ALERTSuction the patient’s artificial airway only as clinically indicated and not as a routine, fixed-schedule treatment.undefined#ref1">1 Limit each pass to less than 15 seconds.1 Show
If the patient develops respiratory distress or cardiac decompensation during the suctioning procedure, immediately withdraw the catheter, supply additional oxygen, and deliver manual breaths as needed. Suctioning can cause elevations in intracranial pressure (ICP) in patients with head injuries. Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions. OVERVIEWEndotracheal (ET) or tracheostomy tube suctioning is performed to maintain the patency of the artificial airway and prevent complications. The presence of artificial airways impairs effective coughing and secretion removal, which may result in the need for periodic removal of pulmonary secretions with suctioning. In acute-care situations, suctioning is always performed as a sterile procedure to prevent hospital-acquired pneumonia. Suctioning may result in serious complications, such as hypoxemia, arrhythmias, hypertension or hypotension, increased ICP, bronchospasms, trauma to the mucosa, pain, and anxiety. Evidence shows that ICP can take up to 10 minutes to return to baseline levels after suctioning.3 In brain-injured patients, it is recommended to allow 10 minutes after suctioning before performing other procedures.3 Suctioning is performed by using either an inline (multi-use) suction catheter or a regular (single-use) suction catheter. The patient should be left connected to the ventilator throughout the suctioning procedure.4 The closed-suction technique is the preferred method for suctioning because it facilitates continuous mechanical ventilation and oxygenation during the suctioning procedure. The closed-suction technique allows for a continued tidal volume delivery to the patient with minimal loss of lung volume. Closed suctioning is suggested for an adult patient with high fraction of inspired oxygen (FIO2) or positive end-expiratory pressure (PEEP) or for a patient who is at risk for lung derecruitment.1 An inline suction catheter consists of a catheter inside a sterile plastic sleeve that is attached to the ventilator circuit. It is inserted through a special diaphragm attached to the end of the ET or tracheostomy tube (Figure 1). Sterile technique is used when suctioning with a sterile single-use suction catheter. Suctioning should be ceased immediately if the patient develops any adverse effects. Adverse effects of ET suctioning include:
Adequate systemic hydration and supplemental humidification of inspired gases assist with thinning secretions for easier aspiration from airways. Routine instillation of 0.9% sodium chloride solution before ET suctioning is not recommended.1 Evidence shows an association between instillation of 0.9% sodium chloride solution and ventilator-associated pneumonia (VAP) and hemodynamic changes.2 Administering 100% oxygen presuction and postsuction reduces hypoxemia; however, it is not without risks such as absorption atelectasis. Administering 100% oxygen must be considered if the patient has experienced a clinically significant reduction in oxygen saturation with suctioning, has high oxygen and PEEP requirements, or has a compromised cerebral circulation.2 A decrease in partial pressure of arterial oxygen (PaO2) along with an increased partial carbon dioxide pressure (PaCO2) results in an increase in vasodilatation. This vasodilation can then increase cerebral blood flow and consequently elevate ICP and decrease cerebral perfusion pressure (CPP). For an adult patient, the size of the suction catheter should be one half the inner diameter of the artificial airway, providing a lumen diameter ratio of 0.5.1 Closed-suction catheters are available in two lengths: one for ET tubes (approximately 56 cm [22 inches]), which is sufficient to reach the main stem bronchi, and one for tracheostomy tubes (approximately 30.5 cm [12 inches]).5 A curved tip or coudé catheter is available for selective left main stem bronchial access.5 EDUCATION
ASSESSMENT AND PREPARATIONAssessment
Preparation
PROCEDURESuctioning with an Inline Suction Catheter
Suctioning with a Regular Suction Catheter
MONITORING AND CARE
EXPECTED OUTCOMES
UNEXPECTED OUTCOMES
DOCUMENTATION
REFERENCES
*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice. Adapted from Wiegand, D.L. (Ed.). (2017). AACN procedure manual for high acuity, progressive, and critical care (7th ed.). St. Louis: Elsevier. AACN Levels of Evidence
How do you prevent complications of suctioning?To reduce the risk of hypoxia, pre-oxygenate the patient before suctioning. Never suction longer than 15 seconds. If you must suction the patient again because suctioning has failed, you must pre-oxygenate them again.
What are the risk and complications associated with suctioning?Suctioning can stimulate the vagal nerve, predisposing the patient to bradycardia and hypoxia. Hypoxia can be profound from occlusion, interruption of oxygen supply, and prolonged suctioning. Mucosal trauma, physical injuries, and bleeding can result from blunt or penetrating trauma.
How can the nurse reduce the risk of hypoxia and tissue damage when suctioning a client with a tracheostomy?Immediately reapply oxygen in between suctions to reoxygenate the patient. *Instill sterile normal saline into tracheostomy prior to suction only if prescribed to induce coughing. This reduces risk of tracheal damage and optimizes suction of secretions. Suctioning decreases patient's supply of oxygen.
What are the key techniques used to minimize or decrease complications with endotracheal suctioning?To reduce the risk, preoxygenate the patient before suctioning. If suctioning fails or requires another pass, oxygenate prior to each subsequent suctioning pass. Never suction a patient for longer than 10-15 seconds, because this may increase the risk of both hypoxia and heart rhythm irregularities.
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