MODULE #1: Suctioning
------------- || AUGUST 9 2022
NCM 112 RLE
Transcriber: MARK VINCENT POQUITA SUMABONG
Editor: MARK VINCENT POQUITA SUMABONG
10. Vital signs monitoring equipment
11. Disinfectant pad Spare tracheostomy tubes (patient's size
and one size smaller)
12. Obturator
OUTLINE
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II.
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VI.
VII.
VIII.
IX.
X.
Introduction
Indications
Equipment
Preparation of Equipment
a. For Open Suctioning
b. For Closed Suctioning
Secretion Inspection
Implementation
a. For Open Suctioning
b. For Closed Suctioning
Completing the Procedure
Special Considerations
Complications
Documentation
Optional: sterile gloves, suction catheter kit (includes a sterile
suction catheter, sterile gloves, and disposable sterile solution
container), gown, mask, goggles, mask with face shield, pulse
oximeter and probe, non-fenestrated inner cannula, specimen
collection container, label, laboratory transport bag, laboratory
request form, cardiac monitor
PREPARATION OF EQUIPMENT
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Choose an appropriately sized suction catheter. The catheter
diameter should be no larger than half the inside diameter of
the tracheostomy tube (such as using a #12 or #14 French
catheter for an 8-mm or larger tube) to minimize hypoxia
during suctioning.13 Make sure that spare tracheostomy tubes
and an obturator are readily available in case the
tracheostomy tube becomes dislodged.
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Inspect all equipment and supplies. If a product is expired or
defective or has compromised integrity, remove it from patient
use, label it as expired or defective, and report the expiration
or defect as directed by your facility.
INTRODUCTION
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Tracheostomy suctioning involves passing a suction catheter
though a tracheostomy and applying suction to clear
tracheobronchial secretions and maintain a patent airway.
This procedure should only occur when clinically indicated due
to its potential complications.
INDICATIONS
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visible secretions in the airway
need to maintain the patency and integrity of the
artificial airway
coarse crackles over the trachea
deterioration of the oxygen saturation level, arterial
blood gas values, or both
inability to generate an effective spontaneous cough
acute respiratory distress
suspected aspiration of gastric or upper airway
secretions
need to obtain a sputum specimen to identify
infection or for cytology.
Performance of tracheostomy suctioning can use open or closed
technique. The open technique requires disconnection of the
patient from any oxygen source present; the closed technique
doesn't. However, studies that have compared open and closed
suction systems have shown no difference in patient outcomes or
patient-to-patient transmission of pathogens. Various clinical trials
have reached different conclusions about the cost-effectiveness of
the two techniques
EQUIPMENT
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6.
7.
8.
9.
Oxygen source (or humidification device) and tubing
Handheld resuscitation bag
Suction apparatus with collection container
Oral suction device
Suction tubing
Suction catheter (open or closed tracheostomy system)
Gloves Sterile solution (sterile water or sterile normal
saline solution)
Sterile solution container
Stethoscope
For Open Suctioning:
o Connect the suction tubing to the suction catheter and
then turn on the suction apparatus.
o Occlude the end of the suction tubing to make sure that
the suction apparatus is functioning properly
For Closed Suctioning
o If a closed tracheostomy suctioning system isn't already
attached to the patient's tracheostomy tube, attach it
following the manufacturer's instructions.
o Attach the end of the suction catheter to the suction tubing
and then depress the thumb suction control to make sure
that the suction apparatus is functioning properly.
SECRETION INSPECTION
✓ Normal sputum tends to be watery and white or
translucent.
✓ Tenacious or thick secretions may indicate dehydration.
✓ Yellow, tan, or green secretions may indicate infection.
✓ Brown sputum may indicate prior bleeding.
✓ Red sputum indicates active bleeding.
IMPLEMENTATION
Verify the practitioner's order, if needed.
Gather and prepare the necessary equipment.
Perform hand hygiene.
Confirm the patient's identity using at least two patient
identifiers.
Provide privacy.
Explain the procedure to the patient and family (if appropriate),
according to their individual communication and learning
needs to increase their understanding, allay their fears, and
enhance cooperation.
Raise the bed to waist level before providing care to prevent
caregiver back strain.
Perform hand hygiene.
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[NCM 112 ] SUCTIONING
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Put on gloves and, as needed, other personal protective
equipment to comply with standard precautions.
Assess the patient's vital signs, breath sounds, respiratory
effort, and general appearance to determine the need for
suctioning and establish baselines for comparison.
Position the patient upright in a comfortable position with the
head in neutral alignment.
Attach the patient to a pulse oximeter, as needed, to evaluate
oxygenation before, during, and after the procedure.1 Make
sure that the alarm limits are set appropriately for the patient's
current condition and that the alarms are turned on,
functioning properly, and audible to staff.
If the patient has a fenestrated inner cannula in place, change
to a non-fenestrated inner cannula for suctioning because the
suction catheter could puncture the small opening of the
fenestrated tube.
Assess the patient's ability to cough and breathe deeply to
help mobilize secretions up the tracheobronchial tree.
For Open Suctioning
o Remove and discard your gloves.
o Perform hand hygiene.
o Remove the lid from the sterile solution and place it
upside down on a clean surface.
o Open the package containing the disposable sterile
solution container.
o Using sterile no-touch technique, open the suction
catheter kit and put on gloves. If using individual supplies,
open the suction catheter and the gloves. Then put on the
gloves by first
o placing the nonsterile glove on your nondominant hand
and then placing the sterile glove on your dominant hand.
Open the catheter kit and put on gloves
o Using your nondominant (nonsterile) hand, pour a small
amount of sterile solution into the sterile solution
container.1Pour sterile solution into sterile solution
container
o Close the solution bottle using your nondominant hand to
prevent contamination and spillage of the solution. Close
solution bottle
o Pick up the sterile suction catheter with your dominant
(sterile) hand. Coil the catheter around your hand to
prevent contamination that could occur if the catheter
accidently touched another object..Coil catheter around
sterile hand
o Using your nondominant (nonsterile) hand, attach the
catheter to the tubing (as shown below).
o Using non-sterile hand, attach to suction tubing
o Turn the suction control valve to the ON position and set
the suction pressure to the lowest possible vacuum
pressure needed to effectively clear secretions (less than
150 mm Hg). Higher pressures don't enhance secretion
removal and can cause traumatic injury.1Turn suction ON
and set to proper pressure
o Using your dominant (sterile) hand, lubricate the outside
of the catheter by dipping it into the sterile solution (as
shown below) to ease catheter insertion into the
tracheostomy tube. Lubricate outside of the catheter by
dipping it into the sterile solution
o With the suction catheter tip in the sterile solution, occlude
the suction control valve with the thumb of your
nondominant hand. Suction a small amount of solution
through the catheter to lubricate the inside of the catheter,
which facilitates the passage of secretions through it.
Occlude control valve and suction sterile solution to
lubricate inside of catheter
o If the patient has a collar over the tracheostomy tube to
deliver oxygen or humidification, move it with your
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nonsterile hand. Alternatively, open the T-piece adapter.
Move collar with non-sterile hand or open T-piece adapter
Preoxygenate the patient with 100% oxygen for 30 to 60
seconds using a handheld resuscitation bag, if needed.1
Alternatively, ask the patient to take two or three deep
breaths, if able.
Disconnect the handheld resuscitation bag, if you used it
to preoxygenate the patient.
Insert the suction catheter into the tracheostomy tube;
don't apply suction while inserting the catheter to prevent
hypoxia. For deep suctioning, insert the suction catheter
until you meet resistance and then withdraw the catheter
1 cm. For shallow suctioning, insert the catheter to a
predetermined length, usually the length of the
tracheostomy (plus the adapter, if present).
Clinical alert: Research hasn't shown deep tracheal suctioning to
be more effective than shallow tracheal suctioning and has shown
that it may be associated with more adverse events.
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Withdraw the catheter. While withdrawing the catheter,
apply suction and rotate the catheter between your
fingertips to clear secretions from the sides of the
tracheostomy tube. Ensure that the suctioning event lasts
for no longer than 15 seconds to prevent hypoxia. To
apply suction, place your nondominant thumb over the
control valve. Suction can be applied continuously or
intermittently because tracheal damage from suctioning is
similar with continuous or intermittent suction. Withdraw
the catheter
Reapply the tracheostomy collar or close the T-piece
adapter between suctioning passes to maintain the
patient's oxygen saturation level. Reapply tracheostomy
collar or close T-piece
Dip the free end of the suction catheter into the sterile
solution and apply suction until the catheter is clear of
secretions.
Assess the patient's response to suctioning. If you're
monitoring the heart rate and rhythm, observe for
arrhythmias; if they occur, stop suctioning the patient.
Hyper-oxygenate the patient for at least 1 minute after
suctioning to minimize hypoxia. Use the same method to
hyper-oxygenate that you used to preoxygenate.
Let the patient rest.
After the patient's oxygen saturation level returns to the
baseline, repeat suctioning, if clinically indicated.
Encourage the patient to cough between suctioning
attempts to enhance secretion removal.
Reapply the oxygen source or humidification device.
INSPECT THE SECRETIONS
Obtain a specimen for culture and sensitivity testing, if
indicated. Label the specimen in the presence of the
patient to prevent mislabeling. Place the specimen in a
laboratory transport bag, attach the completed laboratory
request form, and send it to the laboratory
Flush the suction catheter and tubing with sterile solution
to prevent contaminants from remaining in the tubing.
Turn off the suction apparatus
Remove the suction catheter from the suction tubing
For Closed Suctioning
o If a closed suction system isn't attached to the patient's
tracheostomy tube, attach it following the manufacturer's
instructions.
o Preoxygenate the patient with 100% oxygen for 30 to 60
seconds using a handheld resuscitation bag, if needed.1
Alternatively, ask the patient to take two or three deep
breaths, if able.
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[NCM 112 ] SUCTIONING
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Disconnect the handheld resuscitation bag, if you used it
to preoxygenate the patient.
Steadying the T-piece with one hand, use the thumb and
index finger of your other hand to advance the catheter
through the tracheostomy tube until you meet resistance
or the patient coughs. Note that you may have to gently
retract the catheter sleeve as you advance the catheter.
Steady T-piece with one hand, advance catheter through
tube, retract catheter sleeve
While continuing to hold the T-piece and suction control
valve and applying suction, withdraw the catheter until it
reaches its fully extended length in the sleeve. Suction
can be applied continuously or intermittently because
tracheal damage from suctioning is similar with
continuous or intermittent suction. Hold T-piece and
suction control valve, apply suction and withdraw catheter
until fully extended.
Repeat the procedure only if necessary.
INSPECT THE SECRETIONS
Obtain a specimen for culture and sensitivity testing, if
indicated. Label the specimen in the presence of the
patient to prevent mislabeling.10 Place the specimen in a
laboratory transport bag, attach the completed laboratory
request form, and send it to the laboratory.
After you've finished tracheal suctioning, flush the
catheter by maintaining suction while slowly introducing
sterile solution into the irrigation port.
Place the suction control valve in the OFF position.
DOCUMENTATION
➢ Record the date and time of the procedure; the presuctioning assessment findings that resulted in the
suctioning procedure; the technique you used; the
amount, color, and consistency of the secretions;
collection and transport of a specimen to the laboratory
for testing; any complications that occurred and actions
you took; and the amount of time the patient took to
recover. Also document post-suctioning vital signs,
breath sounds, and other assessment findings.
Document teaching provided to the patient and family (if
applicable), their understanding of that teaching, and any
need for follow-up teaching.
COMPLETING THE PROCEDURE
➢ Remove and discard your gloves.
➢ Perform hand hygiene.
➢ Obtain the patient's vital signs and assess respiratory
status to evaluate the effectiveness and the patient's
tolerance of the procedure.
➢ Make sure that the patient is comfortable and that
necessary personal items and the call light are within easy
reach.
➢ Return the bed to the lowest position to prevent falls and
maintain patient safety.
➢ Perform hand hygiene.
➢ Clean and disinfect your stethoscope using a disinfectant
pad.
➢ Perform hand hygiene.
➢ Document the procedure
SPECIAL CONSIDERATIONS
➢ Note that instillation of sterile normal saline solution
before suctioning has been associated with increased
hypoxia, deterioration in lung mechanics, and infection.
Therefore, guidelines don't recommend its use.
➢ Change an inline suction catheter only when it's visibly
soiled to avoid frequent disruptions in the closed circuit,
which increase the risk of health care–associated
pneumonia.
COMPLICATIONS
➢ Complications of tracheostomy suctioning include
decreased lung compliance, decreased functional
residual capacity, hypoxemia, tissue trauma,
bronchospasm, colonization of the lower airway,
increased intracranial pressure, hypertension,
hypotension, and cardiac arrhythmias
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