Procedure for tracheal bronchial suctioning in adults.pdf

PROCEDURE FOR TRACHEAL BRONCHIAL
SUCTIONING IN ADULTS
Amendments
Date Page(s) Comments Approved by
Compiled by: Tracheostomy Working Group
Ratified by: Nursing and Midwifery Committee
Date: May 2006
Review Date: May 2007
Comments on this document to: Anil Jaggernath, Specialist Nurse, Critical Care Outreach
Volume 8
Patient Care
Ratified
May 2006
Reviewed Issue 1 Page 1 of 8

Volume 8
Patient Care
ASHFORD AND ST PETER’S HOSPITALS NHS TRUST
PROCEDURE FOR TRACHEAL BRONCHIAL SUCTIONING
See also: Tracheostomy care pictorial guide
Tracheostomy care observation chart
Tracheostomy care competency
Tracheostomy Care Plan
Procedure for removal of inner cannula of a tracheostomy tube
1.0 DEFINITION
Tracheal bronchial suctioning is the removal of sputum via placement of a sterile suction catheter into
a tracheostomy tube using a sterile non-touch technique.
2.0 AIMS
Tracheal bronchial suctioning aims to effectively remove the maximum amount of secretions with
minimal risk of complications to the patient.
3.0 INDICATIONS FOR PROCEDURE
3.1 A tracheostomy provides a patient with a patent airway. If the patient is unable to clear
secretions from the airway independently, suctioning is indicated
3.2 Frequency for tracheal suction is determined by individual clinical assessment of patient need
and should not be considered as a routine procedure. The following are recognised indications
for tracheal suction and include:-
• Patient request of inability to cough up secretion
• Increased coughing of patient
• Audible secretions in chest by listening or chest auscultation
• Secretions felt on chest by resonance on chest wall
• Increased work of breathing and/ or use of accessory muscles
• Tachypnoea / increase in respiratory rate
• Change in skin colour or peripheral desaturation indicated by a significant reduction in
SpO2 from baseline
• Reduction in anticipated ventilatory parameter (if patient receiving non-invasive positive
pressure ventilation)
4.0 EQUIPMENT/ PREPARATION REQUIRED
• Emergency equipment, ambu bag -valve mask, Tracheostomy Emergency Box
• A functional suction unit 13.5 – 20 Kpa (Glass & Graz, 1995 Regan, 1998)
• Correct size sterile catheters (Formula Tracheostomy tube size –2 x2 i.e. size 8 tube : 8 – 2 = 6
x2 = 12)
• Yankeur suction catheter
• Disposable sterile gloves
• Latex universal gloves
• Protective eye wear
• Apron
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May 2006
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• 1 bottle of Sterile Water (To be used for 24 hours, label with change date and ‘For Suction’)
• Connected oxygen delivery supply (tracheostomy mask and tube if patient on air)
5.0 COMPONENTS OF PROCEDURE
• Preparation of patient and equipment
• Suctioning technique
• Evaluation of procedure
6.0 GUIDELINE FOR PROCEDURE
Volume 8
Patient Care
ACTION
Preparation of equipment and patient
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May 2006
RATIONALE
1. Wash hands with liquid soap or alcohol hand gel To reduce the risk of cross-infection
and put on apron.
(Rossoff et al, 1993).
2. Explain procedure to patient. To gain consent, allay any fears and
enable the patient to co-operate.
3. Apply protective eye goggles (to be worn
throughout the suction procedure).
4. Remove inner cannula and replace with clean
inner cannula.
5. Consider pre-oxygenation of patient prior to
procedure.
Indicated if previous evidence of increased work
of breathing, indicators of respiratory distress,
tachypnoea and deoxygenation during or after
previous suctioning procedures.
Pre-oxygenation procedure:
Increase the inspired oxygen concentration by
50% to the patient three minutes prior to
procedure.
NB: For Chronic Obstructive Pulmonary
Disease (COPD) patients; increase the inspired
oxygen with 20% only (Rogge, 1989)
6. Select the appropriate size suction catheter for
patient need.
To calculate correct catheter size
• Subtract 2 from the size of the
tracheostomy tube
• Multiply by 2
(Caroll, 1994).
To reduce the risk of cross infection from
the patient’s secretions.
To avoid passage of potential sputum plug
into patient on suctioning.
To reduce the risk of arrhythmia and
hypoxia (Odell et al, 1993).
COPD patients have an altered serum
carbon dioxide response mechanism and
have a dependent on carbon dioxide
levels to maintain their respiratory drive.
Catheter size should be less than half the
tracheal diameter (Young, 1984).
The lowest possible pressure should be
used to reduce complications (Regan,
1998).
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Volume 8
Patient Care
ACTION
7. Connect suction catheter to suction unit and
check function of suction system.
• Turn on the suction apparatus.
• Attach suitably sized suction catheter end to
suction tubing.
• Ensure that catheter is not removed from
packaging.
• Check that connection is secure. Kink
suction tubing and observe pressure on
gauge.
• Adjust pressure flow to achieve a vacuum
pressure between 13.5-20kPa (Glass & Grap,
1995)
Suctioning technique
8. Put on sterile glove on dominant hand. Avoid
touching anything except the catheter with it.
9. Remove suction catheter from covering ensuring
that the dominant hand with sterile glove only
touches the suction catheter. Avoid touching
anything else but the suction catheter.
10. Hold end of suction catheter with dominant
sterile hand and use other hand to hold the
suction catheter connection site with thumb
accessible to suction port.
11. With suction port uncovered with thumb,
introduce the end suction catheter gently down
tracheostomy tube to a depth of one third of
tracheostomy length (or until length of suction
catheter is at approximately 15 cm mark) or
until patient coughs or resistance felt, then
withdraw approximately 1 cm (Meyer-
Holloway, 1993) before applying suction by
placing thumb over suction port.
12. Apply suction and withdraw the suction catheter
slowly maintaining continuous suction. Avoid
rotation of catheter or intermittent suctioning.
• Do not suction for more than 10-15
seconds Fiorentini,1992; Czarnik RE
et al,1991).
Whilst withdrawing suction catheter observe
patient for signs of complications. Signs
include:-
• Reduced level of consciousness
• Pale and clamminess
Ratified
May 2006
RATIONALE
Check that the suction apparatus is
functioning and that the vacuum pressure
is set between 13 – 20kpa.
To avoid contamination and reduce risk of
cross-infection.
To avoid contamination and reduce risk of
cross-infection.
To enable easy access to passing the
suction catheter.
To prevent trauma and mucosal damage
by the suction catheter contact on mucosa
on insertion.
To ensure suction catheter does not pass
the carina.
To ensure the most effective clearance of
secretions.
To avoid patient developing hypoxaemia
due to removal of oxygen flow by suction.
To detect complications of hypoxaemia
and cardiac arrhythmias.
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Suctioning technique
Volume 8
Patient Care
• Peripheral cyanosis
• Excess coughing
Withdraw suction catheter immediately and
clinically assess patient.
13. When the suction catheter is completely
removed from the tracheostomy tube, release the
thumb from suction port. Wrap the suction
catheter around dominant hand, enclose in glove
and discard.
14. Re-apply the patient’s oxygen supply
immediately.
15. Rinse suction tubing through with water from
bottle.
16. Change suction tubing once a week or when
heavily soiled.
Evaluation of procedure
17. Clinically assess patient for need for further
suctioning.
18. Repeat above with new suction catheter &
gloves until airway clear.
NB: Allow sufficient time for recovery between
each suction episode (particularly if the patient
is in respiratory distress or if there are
indication of a reduction of peripheral
oxygenation during procedure). The number
of suctioning procedures should be limited to
three each episode.
19. Observe and document volume, consistency and
colour on tracheostomy care observation chart.
7.0 TROUBLESHOOTING COMPLICATIONS
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May 2006
To reduce cross infection.
To reduce risk of further hypoxaemia.
To prevent blockage of suction tubing and
prevent cross-infection.
To reduce risk of infection.
To determine need for further suctioning.
To enable time for patient to recover from
trauma of procedure and to prevent
exhaustion and distress for patient.
To minimize potential complications.
To enable detection of chest infection and
care needs.
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Volume 8
Patient Care
Complication Action Rationale
7.1 Respiratory distress • Withdraw suction catheter.
• Monitor vital signs.
• Consider supplementary oxygen.
• Seek medical advice if
7.2 Reduction in level of
consciousness
8. REFERENCES AND BIBLIOGRAPHY
respiratory distress continues.
• Withdraw suction catheter
immediate.
• Assess airway.
• Administer 100% oxygen.
• Call for help.
7.3 Blood stained sputum • Report to medical staff.
• Ensure correct sized suction
catheter used.
• Avoid insertion of catheter until
resistance felt estimate
approximate level of insertion of
suction catheter.
• Ensure suction pressures used
are 13.5-20Kpa.
• Ensure once suction catheter is
inserted into tracheostomy it is
kept moving when suction
7.4 Tenacious Sputum –
minimal amount on
suction
applied.
• Consider use of humidification
• Adjust suction pressure to
maximum of 20kpa
• Take a sample of sputum for
culture and sensitivity
• Inform medical staff
Complication Action Rationale
7.5 Suspected occlusion
or resistance in inner
cannula
• Immediately withdraw suction
catheter.
• Remove inner cannula and
inspect.
• Replace with new inner cannula.
• Seek medical advice.
• If patient exhibits signs of
respiratory distress perform
procedure for suspected blocked
tracheostomy tube.
Carroll PF (1993) Safe suction PRN Registered Nurse, 57,5,32-37.
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May 2006
To avoid hypoxaemia.
To avoid trauma to the
bifurcation of the trachea.
To prevent invagination of
the mucosa through the
catheter end and hole.
To prevent blockage of
tube and subsequent
respiratory arrest.
Reviewed Issue 1 Page 6 of 8

Czarnik RE, Stone KS, Everhart CC, Preusser BA (1991,20,2,144-151.
Fluck RR (1985) Suctioning – Intermittent or continuous? Respiratory Care, 30,837-838
Fiorentini A. (1992) Potential hazards of tracheobronchial suctioning Intensive Care and Critical care
nursing,8,217-226.
Glass CA, Grap MJ (1995) Ten tips for safer suctioning Advanced Journal of Nursing, 5,51-53.
Meyer-Holloway N. (1993) Nursing in the Critically Ill Adult, 4 th edition. California, Addison-Wesley
Odell A, Allder A, Bayne R, Everatt C, Scott S, Still B, West S. (1993) Endotracheal suction of adult,
non-head injured patients: A review of the literature Intensive Care and Critical Care Nursing, 9,274-
278.
Regan M (1988) Tracheal mucosal injury – the nurses role Nursing, 29, 1064-1066
St George’s Healthcare NHS Trust (2000) Guidelines for the Care of Patients with Tracheostomy
Tubes. London: St. George’s NHS Trust, 2000.
Young CS (1984) Recommended guidelines for suction Physiotherapy,3,106-107.
Volume 8
Patient Care
Ratified
May 2006
Reviewed Issue 1 Page 7 of 8