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Do not exceed 5 seconds per suctioning pass.undefined#ref1">1
Base the frequency of suctioning on the patient’s need. Routine or scheduled suctioning is not recommended.
Stop suctioning if cardiac arrhythmia, hemodynamic instability, or significant changes in oxygenation or ventilation occur.
Refer to the American Heart Association (AHA) interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed coronavirus disease 2019 (COVID-19) (Box 1).2
The upper airway (nose, oropharynx, and trachea) filters, heats, and humidifies inspired air. When an endotracheal (ET) tube is placed, the upper airway is bypassed and the ability to clear secretions is disrupted, placing the patient at a higher risk of secretion retention, infection, and mucus plugging of the ET tube and lungs. Using a humidification device or heat-moisture exchanger optimizes secretion management and keeps secretions thin. Heated humidification is preferred for pediatric patients who are mechanically ventilated because it simulates normal physiologic airway conditions. Proper humidity, hydration, and temperature levels help maintain thinner secretions and facilitate suctioning.6
Suctioning may be performed using the open suctioning technique, which involves a disconnection from the ventilator circuit or oxygen source, or the closed suctioning technique, which involves a sterile, closed, inline suction catheter attached to the ventilator circuit. The closed suctioning technique allows passage of the suction catheter into the airway without disconnection from the ventilator (Figure 1). Disconnecting the patient from the ventilator results in a loss of positive end-expiratory pressure (PEEP) and a risk of system contamination, leading to ventilator-associated pneumonia (VAP). The closed suction system maintains PEEP and prevents contamination.6 Manual ventilation between catheter passes with open suctioning can result in variable tidal volume and barotrauma. The closed system uses the preset ventilator breaths between passes.6 Suctioning using either method can result in tachycardia, hypoxia, and derecruitment of alveoli. The closed suctioning system has been shown to result in much more rapid recovery from these complications.6 Another advantage of closed suctioning is reduced contamination of the health care team member’s gloves and hands, potentially reducing the risk of cross-contamination.
The anatomy and physiology of the pulmonary system and structural characteristics specific to the infant and child include:
Because the ET tube impairs coughing and secretion removal, periodic suctioning is necessary to remove secretions and promote ventilation and oxygenation. To reduce the likelihood of airway contamination and prevent health care–associated infection and VAP, the nurse should perform suctioning using sterile technique. The nurse should also elevate the head of the bed, suction oral secretions that pool above the ET tube cuff, and change the suction setup only when clinically indicated.
Indications for suctioning may include:4
Recommendations and parameters for suctioning include:
Adverse effects of ET suctioning include hypoxemia, atelectasis, elevated pulmonary artery pressure, arrhythmia, trauma to the trachea and bronchi, bronchospasm, infection, increased intracranial pressure (ICP), and elevated blood pressure or hypotension.6
A patient who is especially vulnerable to physiologic changes during suctioning may need premedication.
Rationale: Setting the appropriate suction level minimizes damage to the tracheal epithelium. Sufficient pressure should be applied to remove secretions effectively.
Follow the manufacturer’s directions for suction pressure levels for closed suction systems.
Rationale: Accurate measuring helps avoid tracheal tissue damage from inserting the catheter too deeply. The catheter should not be inserted until resistance is met; this causes damage and scarring to the carina.
Rationale: Preoxygenation may increase the partial pressure of arterial oxygen (PaO2) levels, decreasing the risk of desaturation with suctioning.
Do not preoxygenate with 100% fraction of inspired oxygen (FIO2) if the patient has certain congenital heart defects.6
Suctioning on high frequency oscillation ventilation can result in significant lung derecruitment.
The most efficient catheter advancement occurs when the bag that covers the catheter bunches up behind the fingers.
To reduce the risk of hypoxemia, limit each suction pass to no longer than 5 seconds.6
Rationale: Locking prevents inadvertent suction.
Rationale: Suctioning the oral and nasal pharynx prevents contamination of the lower airways with upper airway organisms.
Reportable conditions: Persistent arrhythmia, hemodynamic instability, significant changes in SpO2 and arterial or venous blood gas values, significant changes in oxygenation or ventilation indices, bronchospasm, unresolved increased work of breathing, changes in peripheral perfusion, cyanosis, increased ICP, anxiety, agitation, changes in mental status
Reportable conditions: Diminished or absent breath sounds, significant changes in SpO2 and arterial or venous blood gas values, increased peak airway pressure, persistent coughing, increased work of breathing
Rationale: Equal breath sounds, equal chest rise, and a visible carbon dioxide waveform indicate correct placement.
Reportable condition: Absent carbon dioxide waveform on the bedside monitor, unequal or no chest rise, unequal breath sounds, change in the position of the ET tube
*In these skills, a "classic" reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.
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