Suctioning for Beginners
A couple of the newbies were really having trouble with this one, so we decided to clear things
up. This is one of those procedures that people get vague about: “Did you deep suction her.”
“Yeah, with the Yankauer.” (But Yankauer suction isn’t deep suctioning.) “Uh… well, did you
blind suction her?” “Yeah, like I said, with the Yankauer!” (Yeah, well, that ain’t right either.)
“Well, I mean, did you get into her airway?” “Yeah, in the back of her throat.” (Nope, nope…)
So let’s clear things up a little. As always, please remember that these articles are not meant to
be official references in any way! This is just what we do, where I work, elsewhere things may be
different. Always check with your local policies, procedures, and references!
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What is suctioning all about?
What is “deep” suctioning”
Is Yankauer suctioning deep suctioning?
What is “blind” suctioning?
How do I tell if my patient needs blind suctioning?
How do I tell if my patient shouldn’t have blind suctioning?
What bad things can happen from blind suctioning?
What is a nasal trumpet?
How do I place a nasal trumpet?
Should I pre-oxygenate my patient for blind suctioning?
How high should I set the suction?
How does Nurse Markie do it?
How do I collect a sputum sample during suctioning?
1- What is suctioning all about?
Lots of patients need secretion management. Pneumonia and the like. Seems simple enough
– your patient has some secretions that he can’t clear: he can’t cough them up, maybe he’s a
bit weak, maybe he just has too much down there to clear on his own – what to do?
2- What is “deep” suctioning?
There’s a lot of confusion about this, and as usual, using terms precisely goes a long way
towards getting un-confused. Deep suctioning means going past the posterior pharynx with a
catheter, through the vocal cords, down into the patient’s airway (trachea!), and applying
suction, to remove thick secretions that are making it hard for your patient to breathe.
This is a pretty serious maneuver – in essence, it’s the same as intubating someone, except
with a skinny catheter, and blindly - wooo…. You need to know exactly how to do this, and
safely!
3- Is Yankauer suctioning deep suctioning?
No, it isn’t. It doesn’t get into the trachea.
http://www.ssgfx.com/CP2020/medtech/tools/images/yankauer.jpg
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4- What is “blind” suctioning”?
The idea is that you can’t really see where you’re going with the catheter, so you have to
work “blind”.
You need to get past these guys…
With one of these guys… a “whistle-tip” catheter.
The suction only comes out of the end of the
catheter when you put your finger over the opening
at the proximal end…
Here…
This is a good thing, because you don’t want the
suction running while you’re advancing the
catheter….
http://www.medabv.ru/kendall/13-1.jpg
The catheter is lubricated with some of this stuff:
Who used to call this “kalubafax”… wow – THAT
was a long time ago.
http://www.medco-school.com/images/products/88860L.jpg
And then the catheter gets passed, up one of the nostrils,
along the same path that an NG tube takes, along the
curve of the nasopharynx, except not into the
esophagus…
…into the trachea.
This is a pretty invasive procedure! Actually, you’re
intubating him…
http://connection.lww.com/Products/taylor5e/documents/Ch45/jpg/45_001.jpg
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5- How do I tell if my patient needs blind suctioning?
Your assessment skill don’t need to really be too advanced to notice that your patient is
turning kind of blue, can’t cough up the secretions he’s got from his pneumonia, or aspirated
ice cream or whatever. It’s usually pretty clear. Was your patient extubated too soon?
You know what this is, right?
http://www.healthsystem.virginia.edu/internet/periop/images/pacup053.jpg
Hooked up to something like this?
And the numbers should be something like what?
http://www.heska.com/images/g2_230.jpg
6- How do I tell if my patient shouldn’t have blind suctioning?
Assuming you would, otherwise, you mean?
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Is he on comfort measures only? Would he be more, or less comfortable if you
suctioned him? Would you just have to do it again in a minute?
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Is he anticoagulated? What’s he going to do if you start inserting things in his nares?
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Is he a cardiac patient? What nerve runs through the carina? What is the carina?
What could happen if you stimulate your patient’s vagus nerve if he’s having – say,
an inferior MI? What drug might you want to have at the bedside? Anyway?
7- What bad things can happen from blind suctioning?
Not too hard to figure out, but worth mentioning:
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You can make the patient seriously hypoxic.
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You can injure the patient (or get the lung biopsy the surgeons were going to get
anyhow), by using suction equipment that’s pulling too hard.
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You can provoke a serious bradycardia from vagal stimulation. This is pretty rare, but
it does happen once in a while. Usually with inferior MI’s .
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You can infect the patient’s lower airway.
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You can provoke nasopharyngeal bleeding, and the patient could aspirate blood.
Yup, it’s all true. But if your patient’s airway is almost obstructed with secretions, you need to do
something! So learn to do it safely…
8- What is a nasal trumpet?
Cute! Nice and soft. Lubricate it up really well with the
surgilube stuff. Passing the catheter through this, instead
of the patient’s bare nasopharynx, will go a long way
towards preventing nasal trauma. Is your patient
heparinized? Why am I asking?
http://anesthesia.uihc.uiowa.edu/proceduralsedation3/adult/images/nasalairway.jpg
9- How do I place a nasal trumpet?
Gently! Remember that some patients have deviated
nasal septa, right? One side may let the trumpet
pass easily, the other may not. Never force anything,
ever! If you can’t pass the trumpet on either side,
you may have to try passing the catheter without it.
Suctioning any patient repeatedly without a trumpet
is almost guaranteed to provoke bleeding…
http://www.brooksidepress.org/Products/OperationalMedicine/DATA/operationalmed/Procedures/Images/NasalAirway2.jp
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10- Should I pre-oxygenate my patient for blind suctioning?
Good question! The answer is: probably. Usually. Almost always. Ventilated patients should
always get pre-oxygenated: there’s a 100% Fi02 button that you can press to do this.
But a patient on prongs? Or a mask? Well… hm. Are there situations when it wouldn’t be safe to
give a certain patient 100% oxygen? Which patients are those? Why isn’t it safe?
In those situations, you have to watch the patient like a hawk, and have mask oxygen at hand. If
they desaturate
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11- How high should I set the suction?
Not too high! About 140-160mm Hg negative pressure is what we use…
http://www.ecomed.com.au/cat/pimages/31.jpg
12- How does Nurse Markie do it?
Ok, the patient is drowning. Saturation is getting low. He’s clearly in distress. Let’s save him!
Gather your equipment: got the trumpet in? Got the catheter? The lube? Sterile gloves? Is the
suction setup working? You had all this stuff ready at the bedside, right, because you knew your
patient might need this…
Let’s see – how do I do this? Been doing it so long…
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Make sure your patient agrees to this procedure. You are NOT allowed to attack a
patient who is competent to refuse things. At the same time, you do need to keep her
safe, so it’s best to have things worked out in advance. Patients who aren’t
competent to refuse need to have proxy issues worked out…
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Apologize ahead of time. This is one of the most unpleasant things you’ll ever do to a
patient…
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Try to have a helper on hand to catch flying extremities. It’s not nice to get punched
out by an angry, confused patient that you’re trying to help…
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Sit the patient up. Pillow behind the head. (Assignment for next time: look up the
“sniffing position”. Does she have an NG tube? I’d hook it up to suction, try to empty
her stomach – if you provoke vomiting while you suction her, you KNOW what’s
going to happen, right?
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Apply the oxygen, in the right amount. If this patient retains carbon dioxide when she
gets oxygen, I’d apply just enough for her to resaturate – it’s hyperoxia that’s going to
make her stop breathing, right? This is rather a judgment call – what you want to do
is assess her oxygenation almost continuously as you do this.
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Insert the lubricated trumpet. Slide in easily? If it doesn’t, try the other side. You’re
watching her sat while you do this, right?
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Open the end of the catheter packaging, and tuck the catheter under your arm. Hold
it there.
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Sterile gloves. I squeeze some sterile lube onto the glove paper and leave it there.
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Suction tubing handy? Set to the right negative pressure? Not too high!
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Ok – with a sterile gloved hand, reach over to your armpit and pull out the catheter.
Don’t get it contaminated on anything – you’ll have to start over if you do, and your
patient isn’t breathing too well! (Jayne says: “Are you OUT of your mind? NEVER put
anything, even in sterile packaging, under your ARM! Your armpit is DIRTY! Open
the end of the package and leave it on the bedside table..”) (Eeek! Eek! She runs an
OR-based EP lab, among other things…)
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Don’t hook up the suction yet.
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Position the patient’s head at the midline. Start passing the catheter through the
trumpet.
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Now – listen! Literally listen - put your ear to the end of the catheter that you’re
holding. You should be able to hear air moving through the catheter. Advance the
catheter a bit, on the patient’s inspiration (why?), listening… if it goes into the
esophagus, what should you hear? If it goes into the trachea, then what should you
hear? What will the patient probably do?
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In the trachea? Not too hard to tell, is it? Advance the catheter to about ¾ of it’s
length. Now attach the suction. Put your finger over the catheter button, and slowly
withdraw the catheter, suctioning all the while. Don’t just haul the catheter out at full
speed – it needs to stay in long enough for the secretions to get suctioned out.
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Assess, assess, assess! :
o
Look at the patient: is she breathing? Vomiting? Coughing?
o
Look a the monitor: stable rhythm? Slowing? (That’s bad – her airway may
be occluded, or you may be poking her carina – back out the catheter while
suctioning, to try to open the airway, then get it out of there…) How’s her
saturation doing?
o
Look at the catheter: are secretions coming out? That IS the idea, after all –
are they coming up the tubing? No? Do you need to turn the suction up? You
may have to turn it up to max, if the secretions are really thick, and you have
to clear the patient’s airway. Yup, it’s dangerous – turn it back down as soon
as you can. Are the secretions bloody, at all? Hmm…
o
Done? Does he need to be suctioned again? Depending, I’ll repeat the
process until I think the patient’s really clear. If it was difficult to get into the
trachea, I might even leave the catheter in place – not all the way down, but
past the cords anyhow, watching the saturation the whole time.
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Now, apologize again. Wipe the tears out of your patient’s eyes. Wipe your own eyes.
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Re-assess! Is he going to need it again? Is this the second time in the shift that
you’ve had to do this? Or the twelfth? Does he need to be intubated? Re-intubated?
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How do I collect a sputum sample during suctioning?
A sputum trap! The catheter plugs into the
yellow part, and the suction tubing connects
to the white cone thing. Applying suction
with this gadget connected draws the
sputum into the clear thing, which you then
cap off…
http://www.trinitysterile.com/Images/L20510.jpg
… and send to the lab.
http://www.howardmedical.com/Merchant2/graphics/00000001/3843701.jpg
Jayne says: “Make sure you tell them that they have to use new, sterile
suction tubing to the canister every time they do this, or the specimen will
just get contaminated by the nasty old tubing that’s just been hanging off
the wall…”
Ok – change that tubing!
http://www.med-worldwide.com/media/BT-592041.jpg