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Secretion removal

Secretion removal

Please refer to St George’s Hospital Suction Policy Clin 4.7 v2 ‘Adult, Paediatric and Neonatal Airway Suction Policy (All Routes and Methods)’ for greater detail.

Assessment

Suctioning into the tracheostomy tube should not be a routine procedure. The patient must be assessed for signs of sputum in the airways. Where the patient can cough secretions independently into the top of the tracheostomy tube these secretions can be can be removed with a clean yankauer sucker or tissue.

Equipment

  • Gloves, apron and goggles
  • Functional suction unit (wall or portable)
  • Appropriately sized suction catheters (size of tube -2 x2)1 , this formulation was devised for endotracheal tubes greater than size 6mm assuming the patient was receiving oxygen. Therefore it may be appropriate to adjust the size in patients who have size 6mm or smaller tubes and those without an inflated cuff
  • Water to clean suction tubing

Procedures (adapted from Day et al 20022)

  • Assess patient for signs of airways secretions unable to be independently expectorated
  • Discuss the need for suctioning with the patient gaining consent for the procedure where possible3
  • Pre-oxygenate patients who are receiving supplemental oxygen4 for 30 seconds to 2 minutes5. In COPD patients this should be no more than 20% above baseline.
  • Wash hands, put on goggles6, gloves and an apron
  • Set suction pressures to 10.6-20Kpa (80-150mmHG)7,8. Ensure that applied suction pressure is no greater than 20kpa by occluding the suction tubing with a gloved thumb2
  • Select an appropriately sized catheter. Insert the suction catheter without suction, to the carina to cause a cough and then withdraw 1cm9,10 , if the patient can cough this may not be necessary11 and the catheter need only be inserted to the length of the tracheostomy tube
  • Apply continuous suction12 on withdrawal only13-15, this should take no longer than10-15 seconds
  • Reapply oxygen if required by the patient, within 10 seconds of completing suctioning16, reducing the level of inspired oxygen to pre-suctioning parameters17
  • Reassess patient, reapply suction if required. Ideally suction no more than three times in any one episode12
  • Reassure patient post suctioning
  • Document suctioning and patient response
  • Flush suction tubing with water
  • Wash and gel hands
  • The instillation of normal saline, to facilitate sputum clearance, is not recommended practice, and it may actually be harmful (Blackwood 1999, Kinloch and Rock 1999)18,19. Instead, humidification of inspired gases and saline nebulisers (0.9 or 5%) should be considered.

References

  1. Odell A, Allder, A, Bayne R, Everett C, Scott S, Still B, West S. (1993) Endotracheal suction for adult non-head injured patients. A review of the literature. Intensive Critical Care Nursing. 9: 274-8.
  2. Day T, Farnell S, Wilson-Barnett J (2002) Suctioning: a review of current research recommendations Intensive and Critical care Nursing 18 (2) 79-89
  3. Fiorentini, A. (1992) Potential hazards of tracheo-bronchial suctioning. Intensive and Critical Care Nursing. 8(4): 217-226.
  4. Wainwright S, Gould D. (1996) Endotracheal suctioning: an example of the problems of relevance and rigour in clinical research. Journal of Clinical Nursing. 5(6): 389-398.
  5. AARC American Association of Respiratory Care (1993) Clinical Practice Guidelines: Endotracheal Suctioning of Mechanically ventilated Adults and Children with Artificial Airways. Respiratory Care. 38 (4): 500-504.
  6. Pratt R, Pellowe C, Loveday H, Robinson N, Smith G. (2001) The Epic Project: Developing National Evidence-Based Guidelines for Preventing Healthcare associated Infections. Phase 1: Guidelines for Preventing Hospital-acquired Infections. Journal of Hospital Infection. 47 (supplement): S1-S82.
  7. Luce J, Pierson D, TylerM. (1993) Intensive Respiratory Care. 2nd Edn: Philadelphia, W.B. Saunders Company.
  8. Boggs R. (1993) Airway Management. In Boggs, R.L., Woodridge-King, M. (eds) AACN Procedure manual for critical care. (3rd Edition). Philadelphia: WB Saunders Company.
  9. Dean B. (1997) Evidence based suction management in Accident and Emergency: a vital component of airway care. Accident and Emergency Nursing. 5 (2): 92-98.
  10. Wood C. (1998) Endotracheal suctioning: a literature review. Intensive and Critical Care Nursing. 14: 124-136.
  11. Ashurst S. (1992) Suction therapy in the critically ill patient. British Journal of Nursing.1:10, 485.
  12. Glass C, Grap M. (1995) Ten tips for safe suctioning. American Journal of Nursing. 5(5): 51-53.
  13. DeCarle B. (1985) Tracheostomy care. (Occasional Paper) Nursing Times. 91(40): 50-4.
  14. Allen D. (1988) Making sense of suctioning. Nursing Times. 84(10): 46-7
  15. Gibson I. (1983) Tracheostomy management. Nursing. 18: 538-41.
  16. Day T. (2000) Tracheal suctioning: When, why and how. Nursing Times. 96 (20): 13-15.
  17. Pierce L. (1995) Guide to Mechanical Ventilation and Intensive Respiratory Care. Washington, D.C. W.B. Saunders Company. 92-94.
  18. Blackwood B.(1999) Normal saline instillation with endotracheal suctioning: primum non nocere (first do no harm) J Adv Nurs Apr;29(4):928-34
  19. Kinloch D (1999) Instillation of normal saline during endotracheal suctioning: effects on mixed venous oxygen saturation Am J Crit Care Jul;8(4):231-40