1. NUR 232: SKILL 25-2 AIRWAY SUCTIONING

2. INTRODUCTION
The major differences between oropharyngeal and tracheal airway suctioning are the depth suctioned, the potential for complications, and the need for it to be a sterile procedure.
Oropharyngeal suctioning only removes secretions from the back of the throat.
Tracheal airway suctioning extends into the lower airway and it is indicated to remove respiratory secretions and maintain optimum ventilation and oxygenation in patients who are unable to independently remove those secretions.
When a patient’s oxygen saturation falls below 90% this is a good indicator of the need for suctioning.
Some patients require suctioning every hour or two, whereas others need it only once or twice a day.

3. Introduction – cont’d
If the secretions are only in the nose and mouth, only the pharynx requires suction. However, in most instances you will suction both the pharynx and the trachea. Suction secretions from the pharynx as often as necessary using oropharyngeal or nasopharyngeal suctioning. Secretions that are not removed are more likely to be aspirated into the lungs, increasing the risk for infection and respiratory failure. This requires tracheal suction.
Tracheal suctioning has many risks, including hypoxemia, which often results in cardiac dysrhythmias, laryngeal spasm, or bradycardia. Bradycardia is associated with stimulation of the vagus nerve. Nasal trauma and bleeding can develop from trauma from a suction catheter introduced through the nares.

4. Introduction – cont’d NASOPHARYNGEAL AND NASOTRACHEAL SUCTIONING:
Nasopharyngeal and naso-tracheal suctioning help to maintain a patient airway by removing secretions from the nares, pharynx, throat, and trachea by introducing a suction catheter through the nares.
This type of suctioning is used when oral suctioning (see Skill 25-1) is ineffective or inappropriate or when the lower airway requires removal of secretions.
It involves inserting a small rubber or soft plastic tube into the nares to the pharynx or trachea and applying negative pressure to withdraw mucus.

5. Introduction – cont’d ARTIFICIAL AIRWAY SUCTIONING:
Endotracheal (ET) tubes and tracheostomy tubes (TTs) are artificial airways inserted to relieve airway obstruction, provide a route for mechanical ventilation, permit easy access for secretion removal, and protect the airway from gross aspiration in patients with impaired cough or gag reflexes.
ENDOTRACHEAL TUBES:
ET intubation is a procedure performed by a health care provider or specially trained personnel (e.g., certified registered nurse, anesthesiologist, or respiratory therapist.)
An ET tube is inserted through the nares (nasal ET tube) or the mouth (oral ET tube) past the epiglottis and vocal cords into the trachea.
The length of time that an ET tube remains in place is somewhat controversial; however, in most cases after 2 to 4 weeks, if a patient still requires an artificial airway, a TT is inserted.
Oral ET tubes are usually made of plastic or rubber. Adult sizes of ET tubes have a cuff molded onto the tube to prevent the aspiration of oral secretions or gastric contents into the lung and / or to obstruct the escape of air from mechanical ventilator breaths through the upper airway.

6. INTRODUCTION – CONT’D TRACHEOSTOMY TUBES:
A Tracheostomy Tube can be temporary or permanent, depending on a patient’s condition. It is inserted directly into the trachea through a small incision made in a patient’s neck.
Tracheostomy Tubes are made of several different materials, including polyvinyl chloride – or silicone- based plastics and stainless steel or metallic compounds. Metal tracheostomy tubes are thermal sensitive and must be protected from extreme heat and cold to prevent tissue injury in the patient.
Most metal and plastic tracheostomy tubes contain an inner cannula that is temporarily withdrawn for cleaning airway-occluding mucus without removing the entire Tracheostomy Tube.

7. INTRODUCTION – CONT’D
A cuff on a Tracheostomy Tube serves the same purpose as one on an ET tube. Cuffs are made of a balloon like inflatable plastic; usually you manually inflate one with air (see Skill 25-5). Plastic covered foam cuffs are self-air inflating if the inflation port is left open to the atmosphere.
Some agencies use a closed suction catheter system or in- line suction catheter device to minimize infections, especially in critically ill or immunosuppressed patients. Use of a closed-system catheter (in-line) allows quicker lower airway suctioning without applying sterile gloves or a mask and does not interrupt ventilation and oxygenation in critically ill patients (see Procedural Guideline 25-1). With a closed-system method the patient’s artificial airway is not disconnected from the mechanical ventilator.

8. ASSESSMENT
1. Assess for risk factors for upper or lower airway obstruction, including obstructive lung disease, pulmonary infections, impaired mobility, sedation, decreased level of consciousness, seizures, presence of feeding tube, decreased gag or cough reflex, and decreased swallowing ability.
Presence of these risk factors can impair patient’s ability to clear secretions from airway, increase risk for retaining secretions, and necessitate nasopharyngeal or naso-tracheal suctioning.

9. ASSESSMENT – CONT’D
2. Determine presence of apprehension, anxiety, decreased ability to concentrate, lethargy, decreased level of consciousness (especially acute), increased fatigue, dizziness, behavioral changes (especially irritability), pallor, cyanosis, dyspnea or use of accessory muscles.
Signs and symptoms indicate hypoxia (low oxygen at cellular or tissue level), hypoxemia, or hyper-capnia. Anxiety and pain consume oxygen and in turn worsen signs of hypoxia. Patients with conditions such as acute respiratory distress syndrome, pulmonary edema, and heart failure are at particular risk for hypoxia
3. Assess vital signs, including pulse oximetry (SpO2) and, if on ventilator, peak inspiratory pressure and tidal volume.

10. Assessment – cont’d
4. Assess signs and symptoms of upper and lower airway obstruction requiring airway suctioning, including wheezing, crackles, or gurgling on inspiration or expiration; restlessness; tachypnea; hypertension or hypotension; cyanosis; decreased level of consciousness, especially acute; or excess nasal secretions, drooling, or gastric secretions or vomitus in mouth.
5. Assess for additional factors that anatomically influence upper or lower airway function; recent surgery; head, chest, or neck tumors; facial or nasal trauma; and neuromuscular diseases.
6. Assess factors that affect volume and consistency of secretions.
A. Fluid balance
B. Lack of Humidity
C. Infection (e.g., pneumonia)
D. Allergies, sinus drainage

11. Assessment – cont’d
7. For endotracheal suctioning assess patients’ peak inspiratory pressure when on volume-controlled ventilation or tidal volume during pressure-controlled ventilation.
8. Weigh a patient’s need for suction and consider contraindications to naso-tracheal suctioning.
A. Facial or neck trauma / surgery
B. Acute head injuries
C. Bleeding disorders
D. Nasal Bleeding
E. Epiglottis or croup
F. Laryngospasm
G. Irritable Airway
H. Gastric Surgery

12. ASSESSMENT – CONT’D 9. Examine sputum microbiology data.
Clinical Decision Point: Endotracheal Tube suctioning is necessary for patients with artificial airways. Most contraindications are relative to a patient’s risk of developing adverse reactions or a worsening clinical condition as a result of the procedure. The decision to withhold suctioning to avoid a possible adverse reaction may in fact be lethal.
9. Examine sputum microbiology data.
10. Assess patient’s understanding of procedure.

13. planning 1. Expected outcomes following completion of the procedure:
Upper and lower airways demonstrate absent or diminished adventitious sounds, including gurgles, crackles, wheezes on inspiration and expiration.
Heart rate, blood pressure, respiratory rate and effort and SpO2 readings are within normal range.
When airway secretions are removed and oxygenation improves, patient’s vital signs, SpO2 readings, and respiratory assessment findings improve as well.
Absence of drooling, gastric secretions, or vomitus in mouth; nasal secretions.
Patient verbalizes easier breathing if able to.

14. PLANNING – CONT’D
2. Explain to patient how procedure will help clear airway and relieve breathing difficulty. Explain that temporary coughing, sneezing, gagging, or shortness of breath is normal during procedure.
3. Explain importance of and encourage coughing to remove secretions during procedure. Practice coughing, using splinting if appropriate (see Chapter 36).

15. PLANNING – CONT’D
4. Have patient assume position comfortable for nurse and patient (usually semi-Fowler’s or sitting upright with head hyperextended unless contraindicated.)
Reduces stimulation of gag reflex, promotes patient comfort and secretion drainage, and prevents aspiration. Reduces strain on nurse’s back. Hyperextension facilitates insertion of catheter into trachea.
5. Place pulse oximeter on patient’s finger. Take reading and leave oximeter in place.
Provides continuous Sp02 value to determine patient’s response to suctioning.

16. IMPLEMENTATION
1. Identify patient using two identifiers.
2. Perform hand hygiene and apply mask, goggles, or face shield if splashing is likely.
3. Connect one end of connecting tubing to suction machine and place other end in convenient location near patient. Turn suction device on and set suction pressure to as low a level as possible and yet able to effectively clear secretions. Occlude end of suction tubing to check pressure.
Excessive negative pressure damages nasal pharyngeal and tracheal mucosa and induces greater hypoxia. Lowest possible suction pressure is recommended; less than 150 mm Hg in adults.
Clinical Decision Point: After suctioning, readjust ventilator settings to pre-procedural levels to avoid increased risk for oxygen toxicity and absorption, atelectasis from prolonged administration of high concentrations of oxygen, and increased carbon dioxide retention in patients with chronic obstructive lung disease.

17. Implementation – cont’d
4. PREPARE SUCTION CATHETER.
A. ONE-TIME-USE CATHETER:
1. Using aseptic technique, open suction kit or catheter. If sterile drape is available, place it across patient’s chest or on over-bed table. Do not allow suction catheter to touch any non-sterile surfaces.
2. Unwrap or open sterile basin and place on bedside table. Be careful not to touch inside of basin. Fill with about 100 mL sterile normal saline solution or water.
3. Open lubricant. Squeeze small amount onto open sterile catheter package without touching package. Note: Lubricant is not necessary for artificial airway suctioning.
Prepare lubricant while maintaining sterility. Using water- soluble lubricant helps avoid lipoid aspiration pneumonia. Excessive lubricant occludes catheter.
B. Closed (in-line) suction Catheter: See Procedural Guideline 25-1 : I did not write a power point presentation on this.

18. Implementation – cont’d
5. Apply sterile glove to each hand or apply non-sterile glove to non-dominant hand and sterile glove to dominant hand.
6. Pick up suction catheter with dominant hand without touching non-sterile surfaces. Pick up connecting tubing with non-dominant hand. Secure catheter to tubing.
7. Check that equipment is functioning properly by suctioning small amount of normal saline solution from basin.

19. Implementation – cont’d
8. Suction Airway:
A. NASOPHARYNGEAL AND NASOTRACHEAL SUCTIONING:
1. Increase oxygen flow rate for face masks as ordered by the health care provider. Have patient deep breathe slowly, if possible.
2. Lightly coat distal 6 to 8 cm (2.4 to 3.2 inches) of catheter with water-soluble lubricant.
3. Remove oxygen delivery device, if applicable, with non-dominant hand. Without applying suction and using dominant thumb and forefinger, gently but quickly insert catheter into nares. Instruct patient to deep breathe and insert catheter following natural course of nares. Slightly slant catheter downward or through mouth. Do not force through nares.
Application of suction pressure while introducing catheter into trachea increases risk for damage to mucosa and increases risk for hypoxia. Passing catheter during inhalation improves likelihood of entering trachea.

20. Implementation – cont’d
Clinical Decision Point: Be sure to insert catheter during patient inhalation, especially if inserting it into trachea, because epiglottis is open. Do not insert during swallowing or catheter will most likely enter the esophagus. Never apply suction during insertion. Patient should cough. If patient gags or becomes nauseated, catheter is most likely in esophagus, and you need to remove it.
A. Nasopharyngeal (without applying suction): In adults insert catheter about 16 cm (6.4 inches); in older children, 8 to 12 cm (3 to 5 inches); in infants and young children, 4 to 7.5 cm (1.6 to 3 inches). Rule of thumb is to insert catheter distance from tip of nose (or mouth) to angle of mandible.
(i) Apply intermittent suction for no more than 15 seconds by placing and releasing non-dominant thumb over catheter vent. Slowly withdraw catheter while rotating it back and forth between thumb and forefinger.

21. Implementation – cont’d
(b) Naso-tracheal (without applying suction): In adults insert catheter about 20 cm (8 inches); in older children about 16 to 20 cm (6 to 8 inches); and in young children and infants, 8 to 14 cm (3 to 5 ½ inches).
(i) Apply intermittent or continuous suction for no more than 10 seconds by placing non- dominant thumb over vent of catheter and slowly withdrawing catheter while rotating it back and forth between dominant thumb and forefinger. Encourage patient to cough. Replace oxygen device, if applicable and have patient deep breathe.

22. Implementation – cont’d
4. Positioning: In some instances turning patient’s head helps you suction more effectively. If you feel resistance after insertion of catheter, use caution; it has probably hit carina. Pull catheter back 1 to 2 cm (0.4 to 0.8 inches) before applying suction.
Turning patient’s head to the side elevates bronchial passage on opposite side. Turning head to right helps with suctioning of left main-stem bronchus; turning head to left helps you suction right main-stem bronchus. Suctioning too deep may cause tracheal mucosa trauma.
5. Rinse catheter and connecting tubing with normal saline or water until cleared.

23. Implementation – cont’d
6. Assess for need to repeat suctioning procedure. Do not perform more than two passes with catheter. Observe for alterations in cardiopulmonary status. When possible, allow adequate time (at least 1 minute) between suction passes for ventilation and oxygenation. Encourage patient to deep breathe with oxygen mask in place (if ordered) and cough.
Clinical Decision Point: When using the nasal approach, perform tracheal suctioning before pharyngeal suctioning whenever possible. The mouth and pharynx contain more bacteria than the trachea. If copious oral secretions are present before beginning the procedure, suction mouth with oral suction.

24. Implementation – cont’d
Clinical Decision Point: When there is difficulty passing the catheter, ask patient to cough or say “ahh” or try to advance the catheter during inspiration. Both measure help to open the glottis to permit passage of the catheter into the trachea.
Clinical Decision Point: Monitor patient’s vital signs and oxygen saturation throughout suction procedure. If the patient’s pulse drops more than 20 beats/min or increases more than 40 beats/min or if SpO2 falls below 90% or 5% from baseline, Stop Suctioning.
B. ARTIFICAL AIRWAY SUCTIONING:
1. Hyper-oxygenate patient with 100% oxygen for 30 to 60 seconds before suctioning by adjusting fractional inspired oxygen (FiO2) setting on a mechanical ventilator or using an oxygen-enrichment program on microprocessor ventilators. Manual ventilation of a patient is not recommended; it is ineffective for providing FiO2 of 1.0.

25. IMPLEMENTATION – CONT’D
2. If patient is receiving mechanical ventilation, open swivel adapter or, if necessary, remove oxygen or humidity delivery device with non-dominant hand.
3. Without applying suction, gently but quickly insert catheter into artificial airway using dominant thumb and forefinger (it is best to try to time catheter insertion into artificial airway with inspiration) until you meet resistance or patient coughs; then pull back 1 cm (0.4 inch).
Application of suction pressure while introducing catheter into trachea increases risk for damage to tracheal mucosa and increased hypoxia. Pulling back stimulates cough and removes catheter from mucosal wall so catheter is not resting against tracheal mucosa during suctioning. Shallow suctioning is recommended to prevent tracheal mucosa trauma.

26. IMPLEMENTATION – CONT’D
Clinical Decision Point: If unable to insert catheter past the end of the ET tube, the catheter is probably caught in the Murphy eye (i.e., side hole at the distal end of the ET tube that allows for collateral airflow in the event of tracheal main-stern intubation). If this happens, rotate the catheter to reposition it away from the Murphy eye or withdraw it slightly and reinsert with the next inhalation. Usually the catheter meets resistance at the carina. One indication that the catheter is at the carina contains many cough receptors. Pull the catheter back 1 cm (0.4 inch).
2. If patient is receiving mechanical ventilation, open swivel adapter or, if necessary, remove oxygen or humidity delivery device with non- dominant hand.

27. IMPLEMENTATION – CONT’D
3. Without applying suction, gently but quickly insert catheter into artificial airway using dominant thumb and forefinger (it is best to try to time catheter insertion into artificial airway with inspiration) until you meet resistance or patient coughs; then pull back 1 cm (0.4 inch).
Application of suction pressure while introducing catheter into trachea increases risk for damage to tracheal mucosa and increased hypoxia. Pulling back stimulates cough and removes catheter from mucosal wall so catheter is not resting against tracheal mucosa during suctioning. Shallow suctioning is recommended to prevent tracheal mucosa trauma.

28. Implementation – cont’d
4. Apply continuous suction by placing non-dominant thumb over vent of catheter; slowly withdraw catheter while rotating it back and forth between dominant thumb and forefinger. Encourage patient to cough. Watch for respiratory distress.
Continuous suction and rotation of catheter are recommended because studies show that tracheal tissue damage from intermittent and continuous suctioning is similar. If catheter “grabs” mucosa, remove thumb to release suction.
5. If patient is receiving mechanical ventilation, close swivel adapter or replace oxygen delivery device.
This reestablishes artificial airway.
Clinical Decision Point: If patient develops respiratory distress during the suction procedure, immediately withdraw catheter and supply additional oxygen and breaths as needed. In an emergency, administer oxygen directly through the catheter. Disconnect suction and attach oxygen at prescribed flow rate through the catheter.

29. IMPLEMENTATION – CONT’D
6. Rinse catheter and connecting tube with normal saline until clear. Use continuous suction.
7. Assess patient’s vital signs, cardiopulmonary status, and ventilator measures for secretion clearance. Repeat Steps (1) through (6) once or twice more to clear secretions. Allow adequate time (at least 1 full minute) between suction passes.
8. Encourage patient to deep breathe if able. Hyper- oxygenate for at least 1 minute following same technique used to pre-oxygenate.
9. When pharynx and trachea are sufficiently cleared of secretions, perform oropharyngeal suctioning to clear mouth of secretions. Do not suction nose again after suctioning mouth.

30. IMPLEMENTATION – CONT’D
9. When suctioning is complete, disconnect catheter from connecting tubing. Roll catheter around fingers of dominant hand. Pull glove off inside out so catheter remains coiled in glove. Pull off other glove over first glove in same way. Discard in appropriate receptacle. Turn off suction device.
Seals contaminants in gloves. Reduces transmission of microorganisms.
10. Remove towel, place in laundry or appropriate receptacle, and reposition patient. (Apply clean gloves to continue personal care).
11. If indicated, readjust oxygen to original level because patient’s blood oxygen level should have returned to baseline.
Prevents absorption atelectasis (i.e., tendency for airways to collapse if proximally obstructed by secretions). Prevents oxygen toxicity while allowing patient time to re-oxygenate blood.

31. IMPLEMENTATION – CONT’D
12. Discard remainder of normal saline into appropriate receptacle. If basin is disposable, discard into appropriate receptacle. If basin is reusable, rinse it out and place it in soiled utility room.
13. Remove face shield and discard into appropriate receptacle. Perform hand hygiene.
14. Place unopened suction kit on suction machine table or at head of bed.
Provides immediate access to suction catheter for next procedure.
15. Help patient to a comfortable position and provide oral hygiene as needed.

32. Evaluation
1. Compare patient’s vital signs, cardiopulmonary assessments, and Spo2 values before and after suctioning. If on ventilator, compare FiO2 and tidal volumes.
Identifies physiologic effects of suction procedure to restore airway patency.
2. Ask patient if breathing is easier and if congestion is decreased.
Provides subjective confirmation that suctioning procedure has relieved airway.
3. Observe character of airway secretions.
Provides data to document presence or absence of respiratory tract infection or thickened secretions.

33. Unexpected outcomes 1. Patient’s respiratory status does not improve.
Limit length of suctioning.
Determine need for more frequent suctioning, possibly of shorter duration.
Determine need for supplemental oxygen. Supply oxygen between suctioning passes
Notify health care provider.
2. Bloody secretions are returned after suctioning.
Determine amount of suction pressure used. May need to be decreased.
Ensure that suction is completed correctly using intermittent suction and catheter rotation.
Evaluate suctioning frequency.
Provide more frequent oral hygiene.

34. Unexpected outcomes – cont’d
3. Unable to pass suction catheter through naris at first attempt.
Try other naris or oral route.
Increase lubrication of catheter.
Insert nasal airway, especially if suctioning through patient’s nares frequently.
If obstruction is mucus, apply suction to relieve obstruction but not to mucosa. If you think obstruction is a blood clot, consult with health care provider.
4. Patient has paroxysms of coughing.
Administer supplemental oxygen.
Allow patient to rest between passes of suction catheter.
Consult with health care provider regarding need for inhaled bronchodilators or topical anesthetics.

35. UNEXPECTED OUTCOMES – CONT’D
5. No secretions obtained during suctioning.
Evaluate patient’s fluid status and adequacy of humidification on oxygen delivery device.
Assess for signs of infection.
Determine need for chest physiotherapy (see Chapter 24).

36. Recording and reporting
Record the amount, consistency, color, and odor of secretions; size of catheter; route of suctioning; and patient’s response to suctioning.
Document patient’s pre-suctioning and post- suctioning vital signs, cardiopulmonary status, and ventilation measures (see Chapter 6).
SPECIAL CONSIDERATIONS – TEACHING:
Instruct patient that coughing increases during the procedure.
Explain why supplemental oxygen is given before and after suctioning if indicated.

37. End of skill
This is the end of your skill.
Your book has provided a video for this skill and the link is as follows:
Elsevier: Perry-Potter: Clinical Nursing Skills and Techniques, , Airway Suctioning.
While you may view this power point presentation several times, as well as watch the video several times, it is vital that you practice in the skills lab in order to pass this skill.