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Suction airways during mechanical ventilation only when clinically indicated and not as a routine, fixed-schedule treatment.
If the patient develops respiratory distress or cardiac decompensation during the suctioning procedure, immediately withdraw the catheter, supply additional oxygen, and deliver manual breaths as needed.
Suctioning can cause elevations in intracranial pressure (ICP) in patients with head injuries.
Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions.
Endotracheal (ET) and tracheostomy tubes are used to maintain a patent airway and to facilitate mechanical ventilation. ET or tracheostomy tube suctioning is performed to maintain the patency of the artificial airway and to improve gas exchange, decrease airway resistance, and reduce infection risk by removing secretions from the trachea and mainstem bronchi. Suctioning also may be performed to obtain samples of tracheal secretions for laboratory analysis.
ET and tracheostomy tubes prevent effective coughing and natural secretion removal, which necessitates the need for periodic suctioning to remove pulmonary secretions. In acute care situations, suctioning is always performed as a sterile procedure to prevent hospital-acquired pneumonia.
Indications for suctioning include:
There are two basic methods of suctioning. In the open-suction technique, after disconnection of the ET or tracheostomy tube from any ventilatory circuit or oxygen sources, a sterile single-use suction catheter is inserted into the open end of the tube.
In the closed-suction technique, also referred to as “in-line suctioning,” a multiuse suction catheter inside a sterile plastic sleeve is inserted through a special diaphragm attached to the end of the ET or tracheostomy tube (Figure 1). The closed-suction technique allows for the maintenance of oxygenation and ventilation support, which may be beneficial in patients with moderate to severe pulmonary insufficiency. In addition, the closed-suction technique decreases the risk for aerosolization of tracheal secretions during suction-induced coughing. Use of the closed-suction technique should be considered in patients who develop cardiopulmonary instability during suctioning with the open-suction technique; in patients who have high levels of positive end-expiratory pressure (PEEP), inspired oxygen, or both; or in patients who have grossly bloody pulmonary secretions or in whom airborne transmission of disease, such as active pulmonary tuberculosis, is suspected.
100% oxygen should always be provided before and after each pass of the suction catheter into the ET tube, whether suctioning is done with the open- or the closed-suction method.3
The suction catheter should not be any larger than one half of the internal diameter of the ET or tracheostomy tube.3 Closed or in-line suction catheters are available in two lengths: a longer one for ET tubes and a shorter one for tracheostomy tubes.
Adequate systemic hydration and supplemental humidification of inspired gases help thin secretions for easier aspiration from airways. Instillation of a bolus of sterile 0.9% sodium chloride solution is not a recommended routine practice.2
Complications associated with artificial airway suctioning during mechanical ventilation include:
Tracheal mucosal damage (e.g., epithelial denudement, hyperemia, loss of cilia, edema) occurs during suctioning when tissue is pulled into the catheter-tip holes. These areas of damage increase the risk of infection and bleeding.
Suctioning is a necessary procedure for patients with artificial airways. No absolute contraindication to suctioning exists when clinical indicators point to the need for it.
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Rationale: The amount of suction applied should be only enough to effectively remove secretions. High negative-pressure settings may increase tracheal mucosal damage.
If one sterile glove and one nonsterile glove are used, don the nonsterile glove on the nondominant hand and the sterile glove on the dominant hand. Handle all nonsterile items with the nondominant hand.
Do not allow the dominant hand to come in contact with the connecting tubing. Wrap the suction catheter around the sterile dominant hand to prevent inadvertent contamination of the catheter.
Rationale: The administration of 100% oxygen helps prevent a decrease in arterial oxygen levels during the suctioning procedure.
Return the FIO2 to the baseline level after completing suctioning.
Rationale: Some models of MRBs (without reservoirs) entrain room air and deliver lower levels of oxygen.
Do not instill 0.9% sodium chloride solution into the artificial airway before suctioning.2
In select patient populations (those with a lung transplant or pulmonary surgery), the depth of suctioning may be restricted. Advance the catheter to the identified depth using the markings on the catheter.
Rationale: In most cases, the catheter meets resistance at the carina. Acute onset of coughing is one indication the catheter is at the carina because it contains many cough receptors.
Rationale: Suction should be applied only as needed to remove secretions and for as short a time as possible to minimize decreases in arterial oxygen levels.
Keep suction periods brief to keep decreases in oxygen saturation to a minimum.1
Rationale: The number of suction passes should be based on the amount of secretions and the patient’s clinical assessment. Arterial oxygen desaturation and cardiopulmonary complications increase with each successive suction catheter pass.
Rationale: Use of a different suctioning technique may be physiologically less demanding.
Rationale: Rinsing the catheter removes secretion buildup in the connecting tubing and, when using the closed-suction catheter system, in the in-line suction catheter.
Rationale: Solutions and catheters, which come in direct contact with the lower airways during suctioning, must be sterile to decrease the risk for hospital-acquired pneumonia. Devices that are not in direct contact with lower airways have not been shown to increase infection risk.
*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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