Lippincott-Procedures-Tracheostomy-suctioning

1/29/23, 1:44 PM Lippincott Procedures - Tracheostomy suctioning

Tracheostomy suctioning

Revised: November 28, 2022

Introduction

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 be performed only when clinically

indicated because of its potential complications.

Indications for tracheostomy suctioning include:

visible secretions in the airway

aneed to maintain the patency and integrity of the artificial airway

coarse crackles over the trachea

deterioration of the oxygen saturation level, arterial blood gas levels, or both

inability to generate an effective spontaneous cough

acute respiratory distress

suspected aspiration of gastric or upper airway secretions

the need to obtain a sputum specimen to identify infection or for cytology.

Tracheostomy suctioning can be performed using open or closed technique. Open technique requires

disconnecting the patient from any oxygen source present; closed technique doesn't. Studies that have compared

open and closed suction systems have shown no difference in patient outcomes or patient-to-patient transmission

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of pathogens. Various clinical trials have reached different conclusions about the cost-effectiveness of the two

techniques.

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Equipment

Disinfectant pad

Emergency equipment (code cart with emergency medications, defibrillator, handheld resuscitation bag with

mask, intubation equipment)

Gloves

Handheld resuscitation bag

Obturator

Oxygen source (or humidification device) and tubing

Spare tracheostomy tubes (patient's size and one size smaller)

Sterile solution (sterile water or sterile normal saline solution)

Sterile solution container (disposable)

Stethoscope

Suction apparatus with collection container

Suction catheter (open or closed tracheostomy system)

Suction tubing

Vital signs monitoring equipment

Optional: cardiac monitor with leads and electrodes, gown, label, laboratory request form, laboratory

transport bag, mask with a face shield or a mask and goggles, nonfenestrated inner cannula, pulse oximeter

and probe, specimen collection container, sterile gloves, suction catheter kit (includes a sterile suction

catheter, sterile gloves, and disposable sterile solution container)

Preparation of Equipment

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

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minimize hypoxia during suctioning. Make sure that spare tracheostomy tubes and an obturator are readily

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available in case the tracheostomy tube dislodges.

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Inspect all equipment and supplies. If a product is expired, is 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.

Make sure that emergency equipment is functioning properly and readily available.

For open suctioning

Connect the suction tubing to the suction catheter and then turn on the suction apparatus. Occlude the end of the

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suction tubing to make sure that the suction apparatus is functioning properly.

For closed suctioning

If a closed tracheostomy suctioning system isn't already attached to the patient's tracheostomy tube, attach it

according to the manufacturer's instructions. 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.

Implementation

If required by your facility, verify the practitioner's order.

Gather and prepare the necessary equipment and supplies.

Perform hand hygiene.

Confirm the patient's identity using at least two patient identifiers.

Provide privacy.

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Explain the procedure to the patient and family (if appropriate) according to their individual communication

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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.


Put on gloves and, as needed, other personal protective equipment to comply with standard

precautions.

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Assess the patient's vital signs, breath sounds, respiratory effort, and general appearance to determine the

need for suctioning and establish baselines for comparison.

Place 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

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procedure. Make sure that alarm limits are set appropriately for the patient's current condition and that

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alarms are turned on, functioning properly, and audible to staff.

If the patient has a fenestrated inner cannula in place, change to a nonfenestrated inner cannula for

suctioning because the suction catheter could puncture the small opening of the fenestrated tube.

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Assess the patient's ability to cough and breathe deeply to help mobilize secretions up the tracheobronchial

tree.

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For an open suction system

Remove and discard your gloves.


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Remove the lid from the sterile solution and place it upside down on a clean surface.

Open the package containing the disposable sterile solution container.

Using sterile no-touch technique, open the suction catheter kit and put on the sterile gloves. If using

individual supplies, open the suction catheter and the sterile gloves. Then put on the gloves by first placing a

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nonsterile glove on your nondominant hand and then placing the sterile glove on your dominant hand.

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Using your nondominant (nonsterile) hand, pour a small amount of sterile solution into the sterile solution

container.

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Close the solution bottle using your nondominant (nonsterile) hand to prevent contamination and spillage of

the solution.

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 touches another object.

Using your nondominant (nonsterile) hand, attach the catheter to the tubing (as shown below).



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 200 mm Hg). Higher pressures don't enhance

secretion removal and can cause traumatic injury.

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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.

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.

If the patient has a collar over the tracheostomy tube to deliver oxygen or humidification, move it with your

nonsterile hand. Alternatively, open the T-piece adapter.

Preoxygenate the patient with 100% oxygen for 30 to 60 seconds using a handheld resuscitation bag, if

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needed. 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

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the length of the tracheostomy (plus the adapter if present).

Clinical alert: Research hasn't demonstrated deep tracheal suctioning to be more effective than shallow

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tracheal suctioning and has shown that it may be associated with more adverse events.



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

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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 becausetrachealdamage from

suctioning is similar with continuous or intermittent suction.

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Reapply the tracheostomy collar or close the T-piece adapter between suctioning passes to maintain the

patient's oxygen saturation level.

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. Stop suctioning the patient if arrhythmias occur.

Hyperoxygenate the patient for at least 1 minute after suctioning to minimize hypoxia. Use the same

method to hyperoxygenate 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.

Assess the secretions:

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 previous bleeding.

Red sputum indicates active bleeding.

Obtain a specimen for culture and sensitivity testing if indicated. (See the "Sputum collection by tracheal

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suctioning" procedure.) Label the specimen in the presence of the patient to prevent mislabeling. Place

the specimen in a laboratory biohazard transport bag and send it immediately to the laboratory with the

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appropriate laboratory request form (if necessary).

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 a closed suction system

If a closed suction system isn't attached to the patient's tracheostomy tube, attach it following the

manufacturer's instructions.

Preoxygenate the patient with 100% oxygen for 30 to 60 seconds using a handheld resuscitation bag, if

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needed. 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.

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.

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

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becausetrachealdamage from suctioning is similar with continuous or intermittent suction.

Repeat the procedure only if necessary.

Assess the secretions:

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 previous bleeding.

Red sputum indicates active bleeding.


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Obtain a specimen for culture and sensitivity testing if indicated. Label the specimen in the presence of the

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patient to prevent mislabeling. Place the specimen in a laboratory biohazard transport bag and send it

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immediately to the laboratory with the appropriate laboratory request form (if necessary).

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.

Completing the procedure

Remove and discard your gloves and, if worn, other personal protective equipment.


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

reach.

Return the bed to the lowest position to prevent falls and maintain the patient's safety.


Clean and disinfect your stethoscope with a disinfectant pad.


Document the procedure.

Special Considerations

Note that instillation of sterile normal saline solution before suctioning has been associated with increased

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hypoxia, deterioration in lung mechanics, and infection; guidelines don't recommend its use.

Change an in-line suction catheter only when it's visibly soiled to avoid frequent disruptions in the closed

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circuit, which increase the risk of health care–associated pneumonia.

Complications

Complications associated with tracheostomy suctioning may include:

decreased lung compliance

decreased functional residual capacity

hypoxemia

tissue trauma

bronchospasm

colonization of the lower airway

increased intracranial pressure

hypertension

hypotension

cardiac arrhythmias.

Documentation

Documentation associated with tracheostomy suctioning includes:

date and time of the procedure

presuctioning assessment findings that resulted in the suctioning procedure

technique used

secretion assessment

amount

color

consistency

odor (if present)

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collection and transport of a specimen to the laboratory for testing

complications

actions taken

how long the patient took to recover

postsuctioning assessment

vital signs

breath sounds

other assessment findings

teaching provided to the patient and family (if applicable)

understanding of that teaching

follow-up teaching needed.

Related Procedures

Tracheostomy evacuation tube use, respiratory therapy

Tracheostomy suctioning, pediatric

Tracheostomy tube cannula and stoma care

Tracheostomy tube inner cannula cleaning, pediatric

Tracheostomy tube outer cannula and stoma cleaning, pediatric

References

(Rating System for the Hierarchy of Evidence for Intervention/Treatment Questions)

1. American Association for Respiratory Care (AARC). (2010). AARC clinical practice guidelines: Endotracheal

suctioning of mechanically ventilated patients with artificial airways 2010. Respiratory Care, 55(6), 758–764.

Retrieved October 2022 from http://rc.rcjournal.com/content/55/6/758.full.pdf (Level VII)

2. Blakeman, T. C., et al. (2022). AARC clinical practice guidelines: Artificial airway suctioning. Respiratory Care,

67(2), 258–271. Retrieved October 2022 from https://doi-org.library.xu.edu.ph/10.4187/respcare.09548

(Level VII)

3. Klompas, M., et al. (2014). Strategies to prevent ventilator-associated pneumonia in acute care hospitals:

2014 update. Infection Control and Hospital Epidemiology, 35(8), 915–936. Retrieved October 2022 from

http://www.jstor.org/stable/10.1086/677144 (Level I)

Abstract | Complete Reference

4. Wiegand, D. L. (2017). AACN procedure manual for high acuity, progressive, and critical care (7th ed.).

Elsevier.

5. Hyzy, R. C., & McSparron, J. I. (2021). Tracheostomy: Postoperative care, maintenance, and complications in

adults. In: UpToDate, Feller-Kopman, D. J. (Ed.).

UpToDate Full Text

6. Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings:

Recommendations of the Healthcare Infection Control Practices Advisory Committee and the

HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Recommendations and Reports, 51(RR-16), 1–

45. Retrieved October 2022 from https://www.cdc.gov/mmwr/pdf/rr/rr5116.pdf (Level II)

7. World Health Organization (WHO). (2009). WHO guidelines on hand hygiene in health care: First global

patient safety challenge, clean care is safer care. Retrieved October 2022 from

https://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf?sequence=1 (Level IV)

8. The Joint Commission. (2022). Standard NPSG.07.01.01. Comprehensive accreditation manual for hospitals.

(Level VII)

9. Accreditation Commission for Health Care. (2021). Standard 07.01.21. Healthcare Facilities Accreditation

Program: Accreditation requirements for acute care hospitals. (Level VII)



10. DNV GL-Healthcare USA, Inc. (2020). IC.1.SR.1. NIAHO® accreditation requirements, interpretive guidelines

and surveyor guidance – revision 20-1. (Level VII)

11. Centers for Medicare and Medicaid Services. (2020). Condition of participation: Infection control. 42 C.F.R. §

482.42.


(Level VII)

13. The Joint Commission. (2022). Standard RI.01.01.01. Comprehensive accreditation manual for hospitals.

(Level VII)



15. Centers for Medicare and Medicaid Services. (2020). Condition of participation: Patient's rights. 42 C.F.R. §

482.13(c)(1).

16. DNV GL-Healthcare USA, Inc. (2020). PR.2.SR.5. NIAHO® accreditation requirements, interpretive guidelines

and surveyor guidance – revision 20-1. (Level VII)

17. The Joint Commission. (2022). Standard PC.02.01.21. Comprehensive accreditation manual for hospitals.

(Level VII)

18. Waters, T. R., et al. (2009). Safe patient handling training for schools of nursing. Retrieved October 2022

from https://www.cdc.gov/niosh/docs/2009-127/pdfs/2009-127.pdf (Level VII)

19. Siegel, J. D., et al. (2007, revision 2022). 2007 guideline for isolation precautions: Preventing transmission of

infectious agents in healthcare settings. Retrieved October 2022 from

https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf (Level II)



21. Occupational Safety and Health Administration. (2019). Bloodborne pathogens, standard number 1910.1030.

Retrieved October 2022 from https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030

(Level VII)

22. The Joint Commission. (2013). Sentinel event alert 50: Medical device alarm safety in hospitals. Retrieved

October 2022 from https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safetytopics/sentinel-event/sea_50_alarms_4_26_16.pdf

(Level VII)


(Level VII)

24. Graham, K. C., & Cvach, M. (2010). Monitor alarm fatigue: Standardizing use of physiological monitors and

decreasing nuisance alarms. American Journal of Critical Care, 19(1), 28–37. Retrieved October 2022 from

https://doi-org.library.xu.edu.ph/10.4037/ajcc2010651

Abstract | Complete Reference | Full Text

25. American Association of Critical-Care Nurses (AACN). (2018). AACN practice alert: Managing alarms in acute

care across the life span: Electrocardiography and pulse oximetry. Retrieved October 2022 from

https://www.aacn.org/clinical-resources/practice-alerts/managing-alarms-in-acute-care-across-the-life-span

(Level VII)

26. Nance-Floyd, B. (2011). Tracheostomy care: An evidence-based guide. Retrieved October 2022 from

https://americannursetoday.com/tracheostomy-care-an-evidence-based-guide-to-suctioning-and-dressingchanges/

(Level VII)

27. Centers for Disease Control and Prevention. (2004). Guidelines for preventing health-care–associated

pneumonia, 2003: Recommendations of CDC and the Healthcare Infection Control Practices Advisory

Committee. MMWR Recommendations and Reports, 53(RR-3), 1–32. Retrieved October 2022 from

https://www.cdc.gov/mmwr/pdf/rr/rr5303.pdf (Level II)

28. Ganz, D. A., et al. (2013). Preventing falls in hospitals: A toolkit for improving quality of care (AHRQ

Publication No. 13-0015-EF). Agency for Healthcare Research and Quality. Retrieved October 2022 from

https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html (Level VII)

29. Rutala, W. A., et al. (2008, revised 2019). Guideline for disinfection and sterilization in healthcare facilities,

2008. Retrieved October 2022 from https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfectionguidelines-H.pdf

(Level I)





31. The Joint Commission. (2022). Standard RC.01.03.01. Comprehensive accreditation manual for hospitals.

(Level VII)



33. DNV GL-Healthcare USA, Inc. (2020). MR.2.SR.1. NIAHO® accreditation requirements, interpretive

guidelines and surveyor guidance – revision 20-1. (Level VII)

34. Centers for Medicare and Medicaid Services. (2020). Condition of participation: Medical record services. 42

C.F.R. § 482.24(b).

Additional References

Divo, M. J. (2017). Post-tracheostomy care: Bundle up for success! Respiratory Care, 62(2), 246–247.

Retrieved October 2022 from https://doi-org.library.xu.edu.ph/10.4187/respcare.05410

Abstract | Complete Reference | Full Text

Kacmarek, R. M., et al. (2021). Egan's fundamentals of respiratory care (12th ed.). Elsevier.

Rating System for the Hierarchy of Evidence for Intervention/Treatment Questions

The following leveling system is from Evidence-Based Practice in Nursing and Healthcare: A Guide to Best

nd

Practice (2 ed.) by Bernadette Mazurek Melnyk and Ellen Fineout-Overholt.

Level I:

Level II:

Level III:

Level IV:

Level V:

Level VI:

Evidence from a systematic review or meta-analysis of all relevant randomized controlled

trials (RCTs)

Evidence obtained from well-designed RCTs

Evidence obtained from well-designed controlled trials without randomization

Evidence from well-designed case-control and cohort studies

Evidence from systematic reviews of descriptive and qualitative studies

Evidence from single descriptive or qualitative studies

Level VII: Evidence from the opinion of authorities and/or reports of expert committees

Modified from Guyatt, G. & Rennie, D. (2002). Users' Guides to the Medical Literature. Chicago, IL: American Medical

Association; Harris, R.P., Hefland, M., Woolf, S.H., Lohr, K.N., Mulrow, C.D., Teutsch, S.M., et al. (2001). Current Methods of the

U.S. Preventive Services Task Force: A Review of the Process. American Journal of Preventive Medicine, 20, 21-35.

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