Suctioning

Original Editor - Adam Vallely Farrell

Top Contributors - Adam Vallely Farrell, Kim Jackson, Manisha Shrestha, Nikhil Benhur Abburi, Rachael Lowe, Uchechukwu Chukwuemeka, Admin, Vidya Acharya, Candace Goh, Kirenga Bamurange Liliane, Laura Ritchie, Evan Thomas and Karen Wilson

Introduction

Suctioning is 'the mechanical aspiration of pulmonary secretions from a patient with an artificial airway in place. The procedure involves patient preparation, the suctioning event(s) and follow up care'.

Suction is used to clear retained or excessive lower respiratory tract secretions in patients who are unable to do so effectively for themselves. This could be due to the presence of an artificial airway, such as an endotracheal or tracheostomy tube, or in patients who have a poor cough due to an array of reasons such as excessive sedation or neurological involvement. 

Having an artificial airway in situ impairs the cough reflex and may increase mucus production. Therefore, in the neonatal and paediatric ICU, suctioning of an artificial airway is likely to be the most common procedure.

Oropharangeal and nasopharangeal suction is a technique intended to stimulate a cough to remove excess secretions and/or aspirate secretions from the airways that cannot be removed from a patient’s own spontaneous effort. A cough may be stimulated by a catheter in the pharynx (oropharangeal suction) or it by passing a catheter between the vocal cords and into the trachea to stimulate a cough (nasopharangeal suction). The trachea is accessed by insertion of a suction catheter either via nasal passage and pharynx (nasotracheal suction) or via the oral cavity and pharynx (orotracheal suction) using an airway adjunct. Nasotracheal suction may be undertaken directly via the nostril without an airway adjunct. However, in some situations, where repeated suction is anticipated and therefore a nasopharyngeal airway should be utilised. Secretions are removed by the application of sub-atmospheric pressure via wall mounted suction apparatus or portable suction unit.

Terminology

• Airway Suction: The removal of airway secretions/foreign material by artificial means, using an applied negative pressure
• Yankauer Suction Catheter: A rigid suction tip used to aspirate secretions from the oropharynx
• Oropharyngeal Suction: (OP) requires the use of an airway adjunct (Guedel Airway)
• NasopharyngealSuction: (NP) may be undertaken directly via the nostril without an airway adjunct.  If repeated suction is anticipated a nasopharyngeal airway should be utilised. This is inserted only by those that are trained to do so.
• Suction is an invasive procedure and should NOT be carried out on a routine basis. But, suctioning is an integral part of the management of intubated/ventilated patients.

2 Systems used:

• Closed Suction System
  • –Do not disconnect from ventilator. Similar procedure to open technique but no application of sterile glove
  • Enables a clinician to clear the lungs of secretions whilst maintaining ventilation and minimising contamination with the least possible disruption to the patient
  • Helpful in preventing cross contamination and infection

• Open Sterile Technique–
  • Clearing the airways of a mechanically ventilated patient with a suction catheter inserted into the endotracheal tube after the patient has been disconnected from the ventilator circuit.

A Cochrane review that included results from 16 trials concluded that suctioning with either closed or open tracheal suction systems did not have an effect on the risk of ventilator-associated pneumonia or mortality. They reported that more studies of higher methodological quality are required, particularly to clarify the benefits and hazards of the closed tracheal suction system for different modes of ventilation and in different types of patients.

Introduction

• Oral
• Nasal
• ET
• Trache / mini trache
• Yankeur

Airway suction via nasopharyngeal and oropharyngeal airways

Oropharyngeal (OPA) and nasopharyngeal airways (NPA) can be used to:

• Restore airway patency by separating the tongue from the posterior pharyngeal wall
• Help maintain adequate oxygenation through providing an avenue for adequate ventilation
• Provide access for the removal of secretions in the upper airway via suctioning.

The insertion of an NPA or OPA is indicated for secretion removal in patients who have evidence of secretions in their upper airway but have an absent cough reflex or an impaired, ineffective cough. This often reflects patients who have an altered conscious state, are weak, or neurologically impaired.

Indications that secretions are present in the upper airway that may be accessible via suction include:

• Audible, upper airway transmitted sounds
• Muffling of a patient’s voice by secretions
• Transmitted sounds on auscultation of the chest wall
• Tactile fremitus
• Moist, rattling cough.

When these signs are present and the patient is unable to clear secretions via a voluntary, stimulated, or assisted cough - or by other means (e.g. physiotherapy techniques), suction may be indicated.

Stimulating a cough

Assisted cough manoeuvres

During an assisted cough the physiotherapist applies pressure to the chest wall in synchrony with a patient’s cough in order to increase the PEFR achieved. Two common methods include

1. An inwards pressure applied to the lower lateral rib
2. An A-P pressure applied to the upper anterior chest wall.

If a patient does not have a strong, effective, spontaneous cough, several methods can be used to try and stimulate a stronger cough. These include a tracheal rub and catheter stimulation in the oropharynx.

1. Tracheal rub

The physiotherapist uses a finger or thumb to rub using blunt pressure across the trachea above the supra-sternal notch. (i.e. a flat finger/thumb is used, not pointed)

2. Catheter stimulation of a cough

A cough can be stimulated by inserting the tip of a catheter (FG 10 or 12) along the outside of the teeth and around in to the back of the oropharynx. As the catheter is passed along the side of the teeth, a block is commonly felt when the catheter comes in contact with the mandible. Rotating the catheter gently will allow the catheter to move off the mandible and in to the back of the oropharynx where a cough may be stimulated and/or secretions suctioned.

Avoid passing the catheter directly over the tongue, as this can stimulate the gag reflex.

If successful, this technique may prevent the need for suctioning via the nasopharynx or with a Guedel airway. It may also provide information on a patient's tolerance of oropharyngeal stimulation (e.g. stimulation of biting reflexes, gag reflexes) which may bias selection of nasopharyngeal or oropharyngeal airway insertion if required.

Oropharyngeal Suction

Oropharyngeal (OPA) or “Guedels” airways

An OPA is a rigid PVC tube that is flanged at the proximal (mouth) end and is shaped to conform to the curvature of the palate. When inserted properly, the flange sits just outside the lips and the tube keeps the patient's tongue extended and prevents it from opposing against the posterior pharynx.

Choosing the correct OPA size

OPAs are made in various sizes. The correct size OPA should track from the corner of the patient's mouth to the angle of the jaw. Insertion of an OPA of incorrect size may push the tongue back toward the pharynx creating an obstruction.

OPA insertion

Suction the oropharynx and inspect it for possible obstructions e.g. food, tumours, and dentition e.g. false teeth. Select a size ten or twelve suction catheter. Lubricate the tip of the catheter and insert the catheter into the OPA prior to insertion into the patient’s oropharynx (this step is optional but can speed up the process). Ensure the catheter moves easily through the OPA orifice and position its tip to protrude just beyond the end of the OPA.

Initially the airway goes in upside down, with the distal end pointing towards the roof of the mouth or sideways. This prevents pushing the tongue back into the oropharynx during insertion. When the airway reaches the back of the throat, rotate it so that the curved part fits over the tongue. Proceed with airway suction. If the gag reflex is stimulated and the patient vomits, be prepared to suction the patient's mouth with a Yankauer, and turn them onto their side if necessary.

Duration of use

When suctioning via an OPA, the OPA is usually removed when the suctioning is complete.

Guide to figures (Pic on suctioning via OPA)

1. Sizing
2. Position OPA upside down
3. Insertion of an OPA - rotation through 180 degrees
4. Rotation of an OPA - rotation through 180 degrees until positioned in airway
5. Suction via an OPA

a) inserting the airway with a catheter already insitu

Guide to figures (insertion of OPA with catheter already in situ)

1. Size
2. Catheter preparation in airway
3. Insertion
4. Rotation
5. Suction via an OPA

b) inserting the airway into the oropharynx on its side rather than upside down, and twisting the airway 90 degrees rather than through 180 degrees. Inserting the airway on its side may prevent trauma to the posterior oropharynx if the airway is inserted forcefully.

Guide to figures (using an oropharynx)

1. Insertion with airway on its side
2. Rotation through 90 degrees
3. Airway insitu ready for suction

Nasopharyngeal airways

Suction via the nasopharynx can be performed with or without the use of a nasopharyngeal airway (NPA). Use of an NPA may be preferable in patients who have evidence of secretion retention, and where the quantity of secretions would require frequent suctioning to be performed.

The NPA is a robust, supple but kink-resistant tube made of soft rubber. They are flanged at the proximal (nasal) end. When properly placed, the tip rests behind the tongue, just above the epiglottis, having separated the soft palate from the posterior wall of the oropharynx. A suction catheter can be passed through the tube and into the posterior pharynx and trachea.

The NPA has some advantages over the OPA, they include:

• an NPA does not stimulate a patient’s gag reflex
• an NPA is better tolerated than an OPA in conscious patients
• an NPA can often be left in situ for longer periods than an OPA
• even while the NPA is in situ, a patient is still able to speak
• it can be used when access to the mouth is technically difficult (trismus, convulsions).

Choosing the correct NPA size

NPAs are available in a variety of sizes, with variation in both the internal diameters of the airway, and in length.

Research has validated that when sizing an NPA for a patient:

• the length of the NPA is more critical than its diameter
• ideal NPA length is best judged by considering the patient’s height and gender
• estimating NPA length by measuring the distance from the tip of the nose to the tragus of the ear has not been validated in adults. A study in Chinese children found a close association between nares-vocal cord distance and nose tip-earlobe distance, with the ideal NPA length being slightly less than this anthropometric measurement.

Duration of use

There is no clear evidence for the ideal duration of NPA placement. General consensus indicates that if clinically indicated, they can remain in place for up to 24 hours. However, to prevent pressure areas, switching the NPA from one to the other nostril every six to eight hours is recommended. The nose should be inspected regularly for pressure areas around the flange of the NPA.

If a patient requires suctioning relatively infrequently e.g. one to four times a day after physiotherapy treatment, then re-inserting the airway before each suction procedure or performing suction without the NPA may be appropriate.

If the patient has copious pulmonary secretions requiring suction every hour or twice hourly, then inserting an NPA and leaving it in situ is warranted to permit easy access and to minimise trauma to the nasal mucosa from repeated insertion of the suction catheter.

Insertion

Suction the oropharynx and inspect it for obstructions e.g. food, tumours, and dentition e.g. false teeth. Inspect the nose to exclude obvious nasal polyps or septal deviation in either nostril. Determine the length of the NPA to use based on the patient’s gender, height and/or nose-eartip.

Before inserting the NPA, place a large safety pin through the shorter edge of the rubber flange of the NPA. Passing suction catheters through the NPA can exert considerable force. A safety pin aids you in supporting the airway and prevents its migration into the nasopharynx. Do not place the safety pin through the lumen of the tube, which will prevent insertion of suction catheters into the lumen.

Lubricate the outside of the airway with a water soluble/aqueous gel (e.g. KY Jelly). Initially choose the larger nostril that is clear from other tubes (e.g. nasogastric tube). Insert the tip of the NPA into the nostril, then slightly lift the nares up and direct the airway to follow a path along the floor of the nose, parallel to the hard palate. Apply gentle partial rotation to the NPA if resistance is felt during insertion e.g. from opposition against the turbinates. If this does not relieve the resistance / obstruction then withdraw the airway and try the other nostril before selecting a smaller size. Insert the airway until the flange is resting against the nostril. Being able to gently rotate the airway is an indication that the size is correct.

Sequence showing correct insertion of an NPA

Guide to figures

1. Correct insertion of an NPA, lifting the nares to reveal the nasal airway and advancement of the NPA parallel to the nasal floor.
2. Gently rotate the NPA if resistance is felt. It should also rotate easily when correctly placed.
3. NPA in situ.
4. Suction performed via the NPA. Lubricate the catheter prior to insertion.
5. Oxygen can be reapplied while the suction catheter is still in situ - if copious secretions are present, desaturation occurs, or to give the patient a rest during the procedure.

Suction without an NPA

Suction via the nasopharynx can also be performed without the use of a nasopharyngeal airway. This may be preferable in patients who have evidence of secretion retention but where the quantity of secretions may not require frequent suctioning to be performed.

The catheter can be advanced in a similar manner as described above for insertion of a nasopharyngeal airway.

Insertion of a catheter into the nasopharynx involves lifting the nares to reveal the nasal airway and advancing the catheter parallel to the nasal floor.

Considerations for insertion

Process and documentation

Process for inserting and suctioning via an NPA or OPA

Indication	Establish need for airway suction.
Contraindication	Review the patient's medical history and identify contraindications and/or precautions to the insertion of an NPA or OPA SEEK APPROVAL FROM MEDICAL STAFF PRIOR TO INSERTION / SUCTION VIA NASOPHARYNGEAL OR GUEDEL AIRWAYS.
Explanation	Explain the procedure to the patient and family. Explain procedure to patient (even when unconscious). Obtain consent when able.
Infection control	Don gloves, gown, and goggles.
Position	Position the patient in high supported sitting, with the head supported in a neutral position.
Hyper-oxygenate	Hyper-oxygenate the patient if able (e.g. increase mask flow rate or FiO2).
Preparation	Prepare for suction procedure Sterile/clean gloves (refer to local hospital policy). Suction catheters. Suction equipment functioning, turned on, 80-200mmHg. Yankauer sucker available.
Insert the airway	Insert the NPA or OPA (refer to instructions provided previously).
Assess	Look - observe skin colour and respiratory rate. Listen - reassess air entry. Feel – for any improvement in chest wall movement (depth of respiration). Note pulse oximetry.
Suction	Two people may be required - one to hold the airway in situ and reassure the patient, while the other person performs the suction procedure. Pass the suction catheter until a strong cough is stimulated. In some cases a cough may not be stimulated. In these cases the catheter may be inserted further until secretions are tapped. However, it is important to remember the risk of laryngospasm. If the carina is felt, withdraw slightly before applying the suction. Suction should not be longer than 15secs. Slowly intermit the suction as you withdraw the catheter. If the patient appears distressed or large amounts of secretions are being suctioned, the catheter can be partially withdrawn but remain inside the pharynx and oxygen reapplied, until the patient has recovered and is ready to continue. If vomiting occurs, be prepared to suction the patient's oropharynx and turn them on their side if necessary.
Hints on suction	To minimise the chance of entering the oesophagus, position the patient / ask the patient to tilt the head back. If the patient is noted to swallow during insertion of the catheter it may slip into the oesophagus. In these cases, withdraw the catheter slightly, reposition the patient's head into extension and repeat the procedure. The catheter is usually in the trachea if the patient coughs. If difficulty is encountered with the insertion of the airway: reassess the size of the selected airway try extending the patient's neck and/or a head tilt/chin lift manoeuvre to open a patient’s airway lower the head of the bed and remove any pillows from under the patient’s head.
Documentation	Time of insertion. Type and size of airway used. Procedural preparation e.g. use of aqueous lubricant, sterile/clean technique, pre-oxygenation, insertion via left or right nostril. Description of insertion e.g. uncomplicated, epistaxis, difficult insertion, unable to pass NPA via left or right nostril, unable to pass catheter. Results of suction. Instructions for other staff e.g. leave NPA in situ for x hrs before removing.

Precautions, contraindications, and complications of inserting an OPA or NPA

Contraindication Pharyngeal obstruction Acute pulmonary oedema Base of skull fractures (use OPA only, NPA / nasal suction contraindicated) Precautions Bleeding risk (low platelets, raised INR, raised APTT, coagulopathy, warfarin) Haemodynamic instability Haemoptysis Acute face, neck, or head injury Septal deviation and/or prior nasal surgery Children False teeth Recent oral surgery Complications Trauma Bleeding Vomiting and aspiration Transient bradycardia Laryngospasm Airway obstruction Intracranial placement Migration of the airway Epistaxis Stimulation of the gag reflex Stimulation of a biting reflex Dental trauma

contraind

*Frank haemoptysis or severe coagulopathy

*Severe bronchospasm

*Undrained pneumothorax

*Compromised cardiovascular status

*Raised ICP

*Pulmonary oedema – removes surfactant

*Nasal suction - #BOS or facial#, post-nasal   surgery, epistaxis

Hazards

*Hypoxia

*Mucosal trauma

*Cardiac arrythmias, cardiac arrest

*Raised intercranial pressure

*Pneumothorax

*Infection

*Laryngospasm

*Pulmonary atelectasis

*Bronchospasm / constriction

*Infection

*HTN / Hypotension

*Pulmonary haemorrhage

*Elevated ICP

*Mechanical trauma

*Uncontrolled coughing

*Laryngospasma

*Pain

*PTx

*Nosocomial infection

*Remember – IT IS NEVER A ROUTINE PROCEDURE – ASSESS THE NEED EACH TIME (Carroll 1994, Pritchard 1994)

Practical

Preparation of the patient

• Explain the procedure to the patient regardless of their alertness.
  • How long it will last.
  • What it will feel like.
  • Why you are doing it.

• The patient should receive hyper-oxygenation by the delivery of 100% oxygen for > 30 secs prior to the suction event.

• The patient SHOULD be monitored throughout the procedure using a pulse oximeter.

Procedure- sterile technique

1. Position the patient with the backrest elevated if not contraindicated
2. Remember to check for tracheostomy patients that a non-fenestrated inner cannula is in situ
3. Wash hands prior to suction procedure
4. Apply plastic apron & non-sterile gloves to both hands
5. Protective eye shield/full face visor if required
6. Open sterile suction catheter
7. Attach connecting tubing to suction catheter
8. Place folded catheter in the axilla
9. Put on sterile glove on dominant hand over non-sterile glove
10. Pick up catheter with dominant hand. N.B. Sterile Hand
11. With non-dominant hand open the suction port on the ETT or remove HME from tracheostomy
12. Without applying suction via the control port, advance the suction catheter using a pencil grip until cough is stimulated or resistance is felt.
13. Pull back catheter 0.5 cm & then apply continuous suction with non-dominant gloved hand.
14. Suction pressure maximum safe limits 100- 150mmHg or < 20kPa
15. Should last <15seconds
16. Assess the patency of the airway for ease of passage
17. Note the colour, consistency & amount of sputum yield
18. Reconnect the patient to the ventilator
19. Post oxygenate the patient with the delivery of 100% O2 for >1minute
20. Wrap the catheter around dominant hand
21. Pull off glove inside out
22. Dispose of catheter and glove in clinical waste bag

Procedure/follow up care

• If further suctioning required repeat the steps as outlined. Never re-insert the same catheter.
• Allow patient sufficient time to recover, particularly if 02 saturations are low.
• Assess patients clinical and hemodynamic status.
• Yankaeur suction should be performed to remove residual secretions in the oropharynx
• Once finished suctioning, wash hands.
• The patient should be monitored for adverse reactions to the procedure.
• Consider breathing control, positions of ease.
• Document the procedure

Assessment of outcome

• Improvement in breath sounds
• Decrease in work of breathing
• Improvement in ABGS or SaO2
• Removal of pulmonary secretions

Clinical Bottom Line

Nasotracheal and orotracheal suction should only be undertaken when other less invasive techniques have proved unsuccessful, and where the secretions are causing physiological deterioration and/or distress[2] Indications that the patients may need suctioning include audible secretions in upper airway or noisy crackles, on auscultation, palpable secretions, ineffective or weak coughing, desaturation despite increased oxygen requirements or raised respiratory rate.

Nasotracheal and orotracheal suction should only be performed by staff who, have been trained and deemed competent as per local policy with relevant training and education being included in an in-service training programme. In addition, opportunities should be offered locally to competent practitioners at all levels wishing to maintain their skills in tracheal suction.

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