1. Suctioning and Airway Management
Module 7
Suctioning and Airway Management

2. More common causes are:
Abnormal increase in respiratory secretions can result from a variety of conditions
More common causes are:
Lung or bronchial infections
Central nervous depression
Exposure to anesthetic gases
In newborns saliva & amniotic fluid which babe cannot expectorate
Premature babes may have absent or decreased cough reflex

3. In a conscious, alert adult the cough reflex is activated and secretions expectorated
Others must rely on suctioning to carry out this function

4. Definitions
Artificial airway = inserted to maintain patent air passage for those whose airway has become or may become obstructed
Loss of consciousness, facial or oral trauma, copious resp secretions, resp distress
Most common:
Oropharyngeal, nasopharyngeal, endotracheal and tracheostomy

5. Indications for Airways
prevent or relieve upper airway obstruction
decrease aspiration
facilitate secretion removal
provide closed system for positive pressure mechanical ventilation

6. The types of Artificial Airways

7. Oropharyngeal Airway
Curved plastic device inserted through the mouth & positioned in the posterior pharynx to move tongue away from the palate and open the airway
Usually for short term use in unconscious pt. May also be used along with an oral endotracheal tube
NOT USED with recent oral trauma, surgery or loose teeth
Does NOT protect against aspiration

9. To insert Oropharyngeal Airway, directions on p. 1283

11. Nasopharyngeal Airway (nasal trumpet)
Made of soft rubber or a plastic tube
Inserted thru nose into posterior pharynx
Facilitates frequent nasopharyngeal suctioning
To be used with EXTREME caution with pts with anticoagulants or bleeding disorders
Size should be slightly smaller than diameter of nostril and slightly longer than distance from tip of nose to earlobe
Check nasal mucous for irritation or ulceration

12. Nasopharyngeal airway in place

13. Endotracheal tube
Flexible tube inserted through mouth or nose into tracheal beyond the vocal cords
Then acts as artificial airway
Allows for deep tracheal suction & removal of secretions
Permits mechanical ventilation
Inflated balloon seals of trachea so aspiration from GI tract CANNOT occur
Generally inserted in emergencies and by physician or specially trained nurses.
Not intended for long term use as maintaining placement difficult

14. Orotracheal insertion easiest as done under direct visualization
Endotracheal tube
Orotracheal insertion easiest as done under direct visualization
Disadvantages are increased oral secretions, more discomfort, difficulty with tube stabilization & inability of pt to talk
Nasotracheal is more comfortable to pt & easier to stabilize.
Disadvantage is blind insertion required and there is possibility of pressure necrosis of nasal airway, sinusitis & otitis media

16. Endotracheal tube
Endotracheal tubes vary according to length, inner diameter, type of cuff & number of lumens
Usual sizes = 6.0, & 9.0mm
Most cuffs are high volume, low pressure with self sealing inflation valves (or cuff may be of foam rubber)
Most are single lumen. But there are dual lumen lumen tubes that can be used to ventilate each lung independently

17. Tracheostomy tube
Firm curved artificial airway inserted directly into trachea at level of 2nd or 3rd tracheal through through surgical incision
Permits mechanical ventilation
Facilitates secretion removal
Can be used long term
Bypasses the upper airway defenses therefore increases susceptibility to infection
Covered in Next Module

19. Nursing Responsibilities with airways
maintain correct tube placement
maintain proper cuff inflation
maintain & monitor ventilation status (including oxygenation & acid-base balance)
providing mouth care
fostering communication & comfort

20. Suctioning

21. Mobilization of secretions
Goal of airway clearance techniques is to improve clearance secretions thereby decreasing obstruction of airways
Secretions can be Removed by
Coughing
Suctioning
Suctioning may be necessary if clt has difficulty handling their secretions or when an airway is in place

22. Suctioning
Is aspirating secretions through a catheter connected either to a suction machine or wall suction outlet.
Primary Suctioning Techniques are:
Oropharyngeal
Nasopharyngeal
Orotracheal
Nasotracheal
Suction of an artificial airway

23. Suction catheters Are either (pic in kozier p. 1288)
Open tipped (more effective with thick plugs but can pull at tissues) or
Whistle tipped (less irritating to resp tissues)
Most have thumb port to control suction (cover to start suction)
Catheter attached to tubing which then attaches to collection chamber
Suction controlled by a gauge

24. Sizes of suction catheters
#12 to #18 Fr for adults
#8 to #10 Fr for children
#5 to #8 Fr for infants

25. Suction Catheters

26. The Yankauer
Yankauer is a rigid plastic catheter with 1 large & several small eyelets through which mucous enters when suction is applied
Used for oral suction
Patients themselves can be taught to use this suction method

27. Used primarily for oral suctioning
              Yankauer                                       
Used primarily for oral suctioning

28. How much pressure? Depends on if wall or portable unit is used…
Wall Unit
Portable Unit
Adult: mm Hg
Adult: mm Hg
Child: mm Hg
Child: mm Hg
Infant: mm Hg
Infant: 2-5 mm Hg

29. Gurgling sounds during respirations
Procedure 47-4 in Kozier on p Suctioning oropharyngeal & nasopharyngeal cavities
Note clinical signs indicating need for suctioning:
Restlessness
Gurgling sounds during respirations
Adventitious breath sounds when chest auscultate
Change in mental status
Change in skin color
Change in rate & pattern of resps
Change in pulse rate & rhythm

30. Oropharyngeal & Nasopharyngeal suctioning
Oropharynx = extends behind mouth from the soft palate above the level of the hyoid bone & contains the tonsils
Nasopharnyx = is located behind the nose & extends to level of soft palate
Used when clt able to cough effectively but is then unable to clear secretions by expectorating or swallowing secretions
Suctioning done after pt has coughed
Done only until pt able to expectorate own secretions

31. All of the techniques are based on common principles:
Oropharynx & tracheal considered sterile, therefore STERILE technique required
Mouth is considered clean therefore suctioning of oral secretions should be performed AFTER suctioning of the oropharynx & trachea
If oropharynx & nasopharnyx to be suctioned, use separate sterile catheter for each
Frequency of suctioning determined upon assessment (via auscultation & inspection)

32. Overview of procedure
DO NOT apply suction during insertion (causes trauma to mucous membranes)
While performing the suction, apply finger over port to start suction action. Rotate catheter gently
Suction attempts should last only seconds
Allow second intervals between attempts
Flush catheter with sterile water or saline in between attempts
Relubricate (with water soluble) with each attempt

33. Notice thumb not
covering hole
Now hole is
covered

34. Evaluation
Compare client's respiratory assessments before & after suctioning.
Ask client if breathing is easier & if congestion is decreased.
Observe client's technique & compliance with suctioning procedures.

35. Record and Report
Record respiratory assessments before and after suctioning.
Size of catheter used.
Route, amount, consistency, and color of secretions obtained.
Frequency of suctioning.
Client's response.

36. Dangers of suctioning
Hypoxemia = insufficient oxygen in blood can result if suction maintained without breaks (therefore no longer than 15secs)
Vagal nerve stimulation (vagovagal reflex) stimulation of the vagus nerve by reflex in which irritation of the larynx or trachea results in slowing of the pulse reate
Mucosal damage – using suction while inserting a catheter can cause trauma to the mucousa
Microatelectasis – is an early manifestation of O2 toxicity
Aspiration – safety for semi conscious (on their side) conscious should in semi fowlers with head turned to side
Infection – follow protocol for sterile procedure
microatelectasis = Microscopic collapse of alveoli that does not involve the airways and may not appear on radiographic examination. Diffuse microatelectasis, an early manifestation of O2 toxicity and the adult and neonatal respiratory distress syndromes, produces dyspnea; rapid, shallow respirations; arterial hypoxemia; decreased lung compliance; and reduced lung volume. Auscultation of the lungs may be normal, or crackles, rhonchi, or wheezes may be heard. Other manifestations depend on the cause of the acute lung injury and the severity of accompanying hemodynamic and metabolic derangements and organ system failure.
Copyright 1997 by F.A.Davis Company

37. Deep suctioning
Tracheal or ‘deep suctioning’ often done by resp therapist, critical care nurse
In tracheal suction the catheter is introduced past the glottis deep into the trachea
Necessary when clt has pulmonary secretions but is unable to cough and does NOT have an artificial airway

38. Orotracheal & Nasotracheal Suctioning
Catheter passed thru nose or mouth into trachea
Nose is preferred route as minimally stimulates gag reflex
Similar to nasopharyngeal except catheter extended further to suction trachea
ENTIRE PROCEDURE CANNOT TAKE MORE THAN 15 SECS (no O2 reaches lungs during suctioning)
Pt should be allowed to rest (unless in resp distress) between passes of catheter and O2 mask/cannula replaced between passes

39. AIRWAY MANAGEMENT: SUCTIONING
Verify nursing intervention using physician's order or nursing care plan.
Observe for signs and symptoms of excess secretions in the oral cavity and productive cough without expectoration.
Assess lung sounds for labored breathing, restlessness/irritability, color, unilateral breath sounds, and oxygen saturation.
Assess client's understanding of procedure and feeling of congestion to indicate that the oral cavity or lower airway needs suctioning.

40. Preparation for all types of suctioning.
Fill basin or cup with approximately 100 ml of sterile water.
Connect one end of connecting tubing to suction machine.
Check that equipment is functioning properly by suctioning a small amount of water from basin.
Turn suction device on. Set regulator to appropriate negative pressure:
wall suction, 80 to 120 mm Hg;
portable suction, 7 to 15 mm Hg for adults.

42. Oropharyngeal suctioning
Attach suction catheter to connecting tubing. Remove oxygen mask if present.
Insert catheter into client's mouth (no suction).
With suction applied, move catheter around mouth, including pharynx and gum line, until secretions are cleared.
Encourage client to cough, and repeat suctioning if needed.
Replace oxygen mask if used.

43. Oropharyngeal suctioning …cont’d
Suction water from basin through catheter until catheter is cleared of secretions.
Place catheter in a clean, dry area for reuse with suction turned off or within client's reach, with suction on, if client is capable of suctioning self.
Discard water if not used by client. Clean basin or dispose of cup.
Remove gloves and dispose.

44. Video on Suctioning covers:
Oropharyngeal
Nasopharyngeal
Nasotracheal

45. Nasotracheal suctioning
Prepare suction catheter.
Open suction kit or catheter using aseptic technique. If sterile drape is available, place it across client's chest. Do table. Be careful not to touch inside of sterile basin not allow suction catheter to touch any nonsterile surfaces.
Unwrap or open sterile basin and place on bedside. Fill with about 100 ml sterile normal saline (NS).

46. Nasotracheal suctioning…
Apply sterile glove to each hand (or nonsterile glove to nondominant hand & sterile glove to dominant hand)
Attach nonsterile suction tubing to sterile catheter, keeping hand holding catheter sterile.
Secure catheter to tubing aseptically. Coat distal 6 to 8 cm (2 to 3 inches) of catheter with water-soluble lubricants.
Remove oxygen delivery device, if present, with nondominant hand.
Use dominant hand to insert catheter into nares during inspiration without applying suction .
Do not force catheter.

47. Nasotracheal suctioning…
Insert catheter approximately 16 cm (6½ inches) in adults.
Apply intermittent suction by placing and releasing nondominant thumb over vent of catheter. Slowly withdraw catheter while rotating it back and forth with suction on for as long as 10 to 15 seconds. Replace oxygen device, if applicable.
Rinse catheter and connecting tubing by suctioning water from the basin until tubing is clear. Dispose of catheter and remaining saline in basin.

48. Endotracheal or tracheostomy tube suctioning
Prepare suction catheter.
Aseptically open suction kit or catheter. If sterile drape is available, place it across client's chest.
Unwrap or open sterile basin and place on bedside table. Be careful not to touch inside of sterile basin. Fill with about 100 ml sterile NS.

49. Endotracheal or tracheostomy tube suctioning
Apply sterile glove to each hand (or apply nonsterile glove to nondominant hand & sterile glove to dominant hand). Attach nonsterile suction tubing to sterile catheter, keeping hand holding catheter sterile.
Check that equipment is functioning properly by suctioning small amounts of saline from basin.
Hyperinflate and/or hyperoxygenate client before suctioning, using manual resuscitation bag or sigh mechanism on mechanical ventilator.
Open swivel adapter, or, if necessary, remove oxygen or humidity delivery device with nondominant hand.

50. Endotracheal or tracheostomy tube suctioning
Without applying suction and using dominant thumb and forefinger, gently but quickly insert catheter into artificial airway (best to time catheter insertion with inspiration) until resistance is met or client coughs, then pull back 1 cm.
Apply intermittent suction by placing and releasing nondominant thumb over vent of catheter, and slowly withdraw catheter while rotating it back and forth between dominant thumb and forefinger. The maximum time catheter may remain in airway is 10 seconds. Encourage client to cough.

51. Endotracheal or tracheostomy tube suctioning
Close swivel adapter or replace oxygen delivery device. Encourage client to deep breathe. Some clients respond well to several manual breaths from the mechanical ventilator or resuscitation bag.
Rinse catheter and connecting tube with NS until clear. Use continuous suction.
Assess client's cardiopulmonary status for secretion clearance and complications. Repeat secretions. Allow adequate time (at least 1 full minute) between suction passes for ventilation and reoxygenation.

52. Endotracheal or tracheostomy tube suctioning
Perform nasopharyngeal and oropharyngeal suctioning to clear upper airway of secretions. After these suctionings are performed, catheter is contaminated; do not reinsert into endotracheal tube (ET) or tracheostomy tube.
Disconnect catheter from connecting tube. Roll catheter around fingers of dominant hand. Pull glove off inside out so that catheter remains in glove. Pull off other glove in same way. Discard into appropriate receptacle. Turn off suction device.
Place unopened suction kit on suction machine or at head of bed.