VOL: 101, ISSUE: 08, PAGE NO: 36
Dan Higgins, RN, is senior charge nurse, critical care, University Hospital Birmingham, and clinical educator, Specialist Nurse Education Services.
Endotracheal suctioning is performed to maintain a clear airway and optimise respiratory function (Dougherty and Lister, 2004).
It is carried out when a patient with an artificial airway such as a tracheostomy or endotracheal tube cannot cough and void pulmonary secretions.
When a tracheostomy is in place, inspired and expired air bypass the normal humidification and warming processes that occur during passage through the upper airways. This may cause the drying of secretions and decrease mucociliary transport.
The presence of a tracheostomy also impedes the ability to cough, a mechanism that requires glottic closure to generate the high air flow and velocity necessary. While some patients may be able to void secretions via a tracheostomy tube independently, many will require assistance in the form of suction.
The procedure has many complications and many patients find the experience painful and anxiety inducing. Major complications include:
- Hypoxia. This may be related to an interruption in inspired oxygen flow and partial airway obstruction as the catheter passes into the tracheostomy. The procedure may also ‘suck’ oxygen/gas out of the bronchial tree and contribute to alveolar collapse (Griggs, 1998). Simple measures may reduce this, such as encouraging deep-breathing exercises, possibly with an increased concentration of oxygen, if prescribed. It also helps to use an appropriate-sized suction catheter - no more than half the internal diameter of the tracheostomy tube (Griggs, 1998) The procedure should be performed swiftly - certainly in less than 10 seconds.
- Trauma. Direct tracheobronchial trauma may be reduced by using ‘atraumatic’ catheters, which have more than one suction eye. Suction vacuum pressure should also be kept low, at 60-150mmHg (8-20kPa) (Pryor and Prasad, 2001).
- Infection. Suction catheters should be sterile and used once only (Griggs, 1998). However, closed suction systems may be used in mechanically ventilated patients as these may minimise changes in cardio-respiratory parameters. There is controversy over the use of non-sterile gloves. The Department of Health (2001) recommends gloves should be worn as single-use items and not be powdered.
Other complications of suction include haemodynamic instability related to hypoxia and vagal stimulation. Undesirable fluctuations in intracranial pressure may also occur as a result of a reduction in cerebral venous return.
When to perform suction
The decision to perform suction must be based on a comprehensive patient assessment rather than at regimented frequencies. This assessment should include a review of respiratory characteristics, chest excursion, palpation and auscultation.
- Vacuum generator/collection device/tubing.
- Appropriate-sized catheters.
- Eye protection.
- Gallipot/small bowl.
- Saline/water solution.
- Prepare the patient, obtain informed consent and attempt to allay any anxieties.
- Wash hands/don non-sterile gloves, apron and eye protection.
- Employ any measures necessary to reduce the likelihood of hypoxia.
- Select vacuum pressure and catheter (Fig 1).
- Open the end of the catheter package. Attach end of suction tubing to the catheter.
- Put a sterile glove on the dominant hand, remove catheter from packaging, avoiding contamination (Fig 2).
- Introduce the catheter into the tracheostomy to approximately one-third of the catheter length (Fig 3) (Dougherty and Lister, 2004). Introduce the catheter no further than the carina.
- Apply suction and withdraw, rotating the catheter (if suggested by local policy), keeping the time that the catheter is inserted in the tracheostomy to less than 10 seconds (Fig 4).
- Wrap the used catheter round the dominant hand and remove the glove over the catheter to discard (Fig 5).
- Reconnect oxygen/nebulisers that may have been in place prior to the procedure.
- Reassess patient, repeating procedure if necessary.
- Observe cardiorespiratory/haemodynamic signs throughout the procedure.
- Document the procedure, detailing the amount and type of any secretions voided (Fig 6).
All nurses who perform suction must have received approved training and demonstrated competence under supervision. They should ensure that their knowledge and skills are maintained.
Nurses should also make sure they undertake this role in accordance with their organisation’s protocols, policies and guidelines.
This article has been double-blind peer-reviewed. For related articles on this subject and links to relevant websites see www.nursingtimes.net