Oral Nasopharyngeal Suctioning and Tracheostomy Care

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					Oral / Nasopharyngeal Suctioning
and Tracheostomy Care

    By Prof. Unn Hidle
    Updated Spring 2010

Video: Respiratory: Concepts and Techniques
  – Part 4: “Chest Therapy – Suctioning”
Professor Hidle’s Skills
  – Tracheostomy Care
  – Oro-pharyngeal Suctioning
Oral/Nasopharyngeal suctioning

 Suctioning = aspiration of secretions through a
  catheter connected to a suction machine or wall
  suction outlet
 Rational for suctioning include:
   – to remove secretions that obstruct the airway
   – to facilitate ventilation (either via nasopharynx,
     oropharynx, tracheostomy or endotracheal tube)
   – to obtain secretions for diagnostic purposes
   – to prevent infection that may result from accumulated
 Although the upper airways (oropharynx and
  nasopharynx) are not sterile, sterile technique is
  recommended for all suctioning to avoid
  introducing pathogens into the airways

 Suction catheters may be either open tipped or
  whistle tipped. The whistle-tipped catheter may
  be more effective for removing thick mucous
  plugs. Most suction catheters have a thumb port
  on the side to control the suction.
Open tip suction catheter
Whistle tip suction catheter
The openings on the tip of the catheter
 distributes negative pressure over a
 wide area. This prevents irritation to
 any one area of the mucous
An oral suction tube (Yankauer
 device) is used to suction the oral
Yankauer device
Measure the depth for insertion (tip of nose
 to earlobe) which usually measures
 approximately 5” or 13 cm.
Rotate the catheter when suctioning (not
 when inserting the catheter)
Encourage deep breathing and coughing
Always use the least amount of pressure
 necessary when suctioning (use appropriate
 suction settings)
Assessing the need for suctioning

 Oropharyngeal and nasopharyngeal suctioning
  removes secretions from the upper respiratory
 Endotracheal suctioning is used to remove
  secretions from the trachea and bronchi.
 The nurse should auscultate the lung fields and
  note any adventitious sounds (crackles, rhonchi,
  rales, wheezing), NOT “coarse” breath sounds.
 Also, upper airway needs to be adequately
  assessed for any obstruction by secretions
 Other clinical signs indicating the need for
  suctioning may include:
   – restlessness
   – gurgling sounds during respiration
   – skin color (pallor, cyanosis)
   – rate and pattern of respirations (retractions, use of
     accessory muscles, flaring, grunting, etc.)
   – pulse rate and rhythm
   – decreased SaO2 levels (O2 saturation)
   – change in mental status
 Too frequent suctioning may cause irritation of
  mucous membranes and increase secretions.
 A suction attempt should last =< 10 seconds.
 There should be 20-30 second intervals between
  each suction (non-respiratory or O2 dependent)
 Limit suctioning to 5 minutes in total
 Applying suction for too long may cause
  increased secretions &/or decrease the client’s
  oxygen demand.
Complications of suctioning

Trauma to the airway
Nosocomial infection
Cardiac dysrhythmia (related to the
Preventing complications with
oral/nasopharyngeal suctioning
Pressure on the suction gauge (used in LaGCC lab):
** Note: different institutions may use different settings

 Wall unit:
   – Adult 100-120 mmHg
   – Child 95-110 mmHg
   – Infant 50-95 mmHg (*same for ET/Tracheostomy suctioning)

 Portable unit:
   – Adult 10-15 inchesHg
   – Child 5-10 inchesHg
   – Infant 2-5 inchesHg
Oro / nasopharyngeal suctioning

 Perform vital signs pre-suctioning (baseline) and
 Positioning:
   – Conscious person (+ gag reflex):
      • Oropharyngeal suctioning: in semi-Fowler’s position with
        head turned to one side
      • Nasopharyngeal suctioning: with the neck hyper-extended
        (nasopharyngeal suctioning). This will facilitate insertion of
        the catheter and help prevent aspiration.
   – Unconscious client should be placed in a lateral
     position, facing you (risk for vomiting).
Suctioning Endotracheal or
Tracheostomy tubes
 Positioning:
   – Semi-Fowler’s position to promote deep breathing,
     maximum lung expansion, and productive coughing.
   – Deep breathing oxygenates the lungs, counteracts the
     hypoxic effects of suctioning, and may induce
     coughing which helps to loosen and move secretions
 Assess for need of analgesia
 Oxygen flow via bag-valve-mask (Ambu) should
  be set at 100%
 Sterile technique
 “Lubricate” with sterile NS (to be used for
 Unless contraindicated, hyperventilate the lungs
  prior to suctioning.
 Oxygen should be set to 12-15L/min (FiO2
 Suctioning should last no longer than 10 sec in
  order to minimize oxygen loss
Hyperventilate between suctioning
 attempts and allow 2-3 minutes between
Monitor O2 saturations of pt which should
 be maintained between 95-100%
Clients with ET or trach tubes should
 receive mouth care Q3-4 hours.
Sources of oxygenation

 Ambu (bag-valve-mask): 100%
 Respirator (different FiO2 settings)
 Face masks:
   – Simple face mask (varies in % of O2 delivery)
   – Partial face-tent (varies in % of O2 delivery)
   – Non-rebreather (close to 100% oxygen delivery)
 Oxyhood
 Oxygen tent
 Nasal Cannuli (delivery of O2 in liters)
Preventing complications of
suctioning with ETT or trach.
 Hyperinflation:
  – Giving the client breaths that are 1-1.5 times the tidal
    volume (TV) set on the ventilator through the
    ventilator circuit or via a manual resuscitation bag
    (Ambu bag). Three to five breaths are delivered before
    and after each pass of the suction catheter
 Hyperoxygenation:
  – This can be done with a manual resuscitation bag;
    bag-valve-mask (Ambu bag) or through the ventilator.
    It is performed by increasing the oxygen flow (usually
    to 100%) before suctioning and between suction
 For ET and Trach suctioning, the diameter of the
  suction catheter should be about half the inside
  diameter of the Trach or ET tube so that
  hypoxia can be prevented.

 To determine suction catheter size, multiply the
  artificial airway’s diameter X 2 (i.e. # 8 ET tube,
  use #16 French suction catheter)

 Cuffed versus uncuffed ET tube. Does it matter?

 Sterile technique is again used
Endotracheal tubes - uncuffed
Endotracheal tube - uncuffed
Endotracheal tube - cuffed
Closed suction system
 Open method:
   – Disconnecting the client from the ventilator, suction and
     reconnect. Drawbacks include extensive protective gear for the
     nurse in order to avoid exposure to the client’s sputum. Also,
     increased cost as disposable, one-time catheters are used

 Closed airway/tracheal suction system, also called in-
  line suction:
   – The suction catheter attaches to the ventilator tubing and the
     client does not need to be disconnected from the ventilator. The
     nurse does not need protective gear and the suction catheter be
     reused as it is enclosed in a plastic sheath. This method is
     becoming more popular.
Promoting Oxygenation

 Deep breathing and coughing:
   – The nurse can facilitate respiratory functioning by encouraging deep
     breathing exercises and coughing to remove secretions from the airways.
   – When coughing raises secretions high enough, the client may either
     expectorate = spit out, or swallow them (not harmful but does not allow
     for viewing secretions for documentation purposes or obtain sputum
   – Splinting = using counter-pressure with i.e. a pillow decreases the pain
     when coughing.
   – Abdominal (diaphragmatic) breathing permits deep full breaths with
     little effort.
   – Pursed-lip breathing helps the client develop control over breathing by
     creating resistance to the air flowing out (prolonging exhalation) and
     preventing airway collapse by maintaining positive airway pressure.
Incentive spirometer: or sustained maximal
  inspiration devices (SMIs) = measures the flow
  of air inhaled through the mouthpiece.
 It is used to:
   – 1) Improve pulmonary ventilation
   – 2) Counteract the effects of anesthesia or
   – 3) Loosen respiratory secretions
   – 4) Facilitate respiratory gaseous exchange
   – 5) Expand collapsed alveoli
 They offer an incentive to improve inhalation

If the child is too young to use incentive
  spirometry, deep breathe & cough, etc.,
  what should be used????

Lets play!
Physiotherapy: percussion,
vibration, and postural drainage
 Percussion = “clapping”
  – a forceful striking of the skin with cupped hands.
  – Mechanical percussion cups and vibrators are also
    available (see demonstration).
  – Percussion over congested lung areas can
    mechanically dislodge tenacious secretions from the
    bronchial walls.
  – Cupped hands trap the air against the chest and the
    trapped air sets up vibrations through the chest wall to
    the secretions
 Postural drainage (PVD):
   – drainage by gravity of secretions from various lung segments.
   – Secretions that remain in the lungs or respiratory airways
     promote bacterial growth and subsequent infections.
   – They can obstruct the smaller airways and cause atelectasis.
   – Careful assessment of the client’s tolerance for PVD is necessary
     prior to the procedure.
   – The usual sequence for PVD is usually:
       •   1) Positioning (usually Trendelenburg)
       •   2) Percussion
       •   3) Vibration
       •   4) Removal of secretions: coughing or suctioning
Will be covered in SG#11 in lecture

 Albuterol (Proventil):
  – bronchodilator (MDI, nebulizer, or liquid form
    beta2-adrenergic agonist)
  – Usually first line of treatment with
    asthma/wheezing/reactive airway disease
  Ipratropium (Atrovent):
    bronchodilator (MDI, nebulizer, or nasal
Inhaled/nebulizer corticosteriods:
     Budesonide (Pulmicort)
     Beclomethasone (Beclovent)
     Fluticason (Flonase; Flovent)

     • The above corticosteroids have potent
      anti-inflammatory activity.
Prophylactic Medications

 Cromolyn sodium (Intal)
     • Different forms of the drug are used to manage bronchial
       asthma, to prevent asthma attacks, and to prevent and treat
       seasonal and chronic allergies. NOT USED IN ACUTE
     • The drug works by preventing certain cells in the body from
       releasing substances that can cause allergic reactions or
       prompt too much bronchial activity. It also helps prevent
       bronchial constriction caused by exercise, aspirin, cold air,
       and certain environmental pollutants such as sulfur dioxide.

Indicated for clients with long-term airway
A surgical incision in the trachea just
 below the larynx; curved tracheostomy
 tube (excellent tracheostomy teaching site)
 inserted to extend through the stoma into
 the trachea.
 Tracheostomy tubes consist of an outer cannula
  (inserted into the trachea) and a flange that rests
  against the neck and allows the tube to be secured
  in place with trach-ties. All tubes also have an
  obturator (used to insert the outer cannula and
  then is removed) which is kept at the clinet’s
  bedside in case the tube becomes dislodged and
  needs to be reinserted. Some tracheostomy tubes
  have an inner cannula that can be removed for
  periodic cleaning.
Pediatric Tracheostomy Tube
 Cuffed tracheostomy tube: has an inflatable cuff that
  produces an airtight seal between the tube and the trachea.
  The seal prevents aspiration of oropharyngeal secreations
  and air leakage between the tube and the trachea. Cuffed
  tubes are usually used in adults
 Uncuffed tracheostomy tube: no cuff present; used in
  children < 5 years of age (general rule, however, depends
  on their size). Due to the anatomical difference in
  childrens’ airway, their trachea s are resilient enough to
  seal the airspace around the tracheostomy tube.
 Low-pressure cuffs: commonly used to distribute a low,
  even pressure against the trachea. This decreases the risk
  of tracheal tissue necrosis (do not need to be deflated)
Checking the pressure cuff

In cuffed tracheostomy tubes, the cuff
 pressure needs to be periodically
The pressure should never exceed 25
Tracheostomy care

To maintain airway patency
To maintain cleanliness and prevent
 infection at the tracheostomy site
To facilitate healing and prevent skin
 excoriation around the tracheostomy
To promote comfort
Hints during tracheostomy care

 Semi-Fowler or Fowler’s position whenever possible to
  promote lung expansion
 Suction before starting tracheostomy care
 Using Hydrogen peroxide solution (half-strength), will
  loosen secretions when soaking inner cannula. However,
  always rinse thoroughly
 Always use 4X4 gauze and not cotton lint for dressing
 Always leave the old trach-ties in place when applying
  the new ones to maintain security of the trach
 You should be able to place 2 fingers between trach-ties
  and the client’s neck
Peak Flow Meter

 A peak flow meter is a small, easy-to-use instrument that measures
    your peak expiratory flow (how fast you or your child can blow out
    air after a maximum inhalation).
   It reveals how well your or your child's lungs are working ("looks" at
    how narrow your airways are before you have an asthma attack).
   Used by adults and children (over 5 years of age) who require
    medication for asthma on a daily or near-daily basis
   Personal Best = The highest number regularly blown is your
    personal best. This is done by recording the peak flow values for two
    weeks first thing in the morning before taking any medications and
    late afternoon when your asthma is under control.
   Treatment "zones“ = based on personal best.
     – Zones will help you decide what to do when you have changes with your
     – The zone system can be compared to the colors of a traffic light.
How do I use a peak flow meter?

 Stand up or sit up straight.
 Slide indicator to base of meter.
 Take in deep breath.
 Place mouthpiece in mouth and seal lips around it.
 Blow out as hard and fast as you can (one quick blow).
 Repeat process 2 more times.
 Select highest number of the 3 efforts.
 Record this number on your peak flow diary or on a
Peak flow meters
Peak Flow Meter Chart

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