Oral / Nasopharyngeal Suctioning and Tracheostomy Care By Prof. Unn Hidle Updated Spring 2010

Recommended: Video: Respiratory: Concepts and Techniques Part 4: “Chest Therapy – Suctioning” Professor Hidle’s Skills Tracheostomy Care Oro-pharyngeal Suctioning

Oral/Nasopharyngeal suctioning Suctioning = aspiration of secretions through a catheter connected to a suction machine or wall suction outlet Rational for suctioning include: to remove secretions that obstruct the airway to facilitate ventilation (either via nasopharynx, oropharynx, tracheostomy or endotracheal tube) to obtain secretions for diagnostic purposes to prevent infection that may result from accumulated secretions

Although the upper airways (oropharynx and nasopharynx) are not sterile, sterile technique is recommended for all suctioning to avoid introducing pathogens into the airways Suction catheters may be either open tipped or whistle tipped. The whistle-tipped catheter may be more effective for removing thick mucous plugs. Most suction catheters have a thumb port on the side to control the suction.

Open tip suction catheter

Whistle tip suction catheter

The openings on the tip of the catheter distributes negative pressure over a wide area. This prevents irritation to any one area of the mucous membrane. An oral suction tube (Yankauer device) is used to suction the oral cavity.

Yankauer device

Measure the depth for insertion (tip of nose to earlobe) which usually measures approximately 5” or 13 cm. Rotate the catheter when suctioning (not when inserting the catheter) Encourage deep breathing and coughing Always use the least amount of pressure necessary when suctioning (use appropriate suction settings)

Assessing the need for suctioning Oropharyngeal and nasopharyngeal suctioning removes secretions from the upper respiratory tract Endotracheal suctioning is used to remove secretions from the trachea and bronchi. The nurse should auscultate the lung fields and note any adventitious sounds (crackles, rhonchi, rales, wheezing), NOT “coarse” breath sounds. Also, upper airway needs to be adequately assessed for any obstruction by secretions

Other clinical signs indicating the need for suctioning may include: restlessness gurgling sounds during respiration skin color (pallor, cyanosis) rate and pattern of respirations (retractions, use of accessory muscles, flaring, grunting, etc.) pulse rate and rhythm decreased SaO2 levels (O2 saturation) change in mental status

Too frequent suctioning may cause irritation of mucous membranes and increase secretions. A suction attempt should last =< 10 seconds. There should be 20-30 second intervals between each suction (non-respiratory or O2 dependent) Limit suctioning to 5 minutes in total Applying suction for too long may cause increased secretions &/or decrease the client’s oxygen demand.

Complications of suctioning Hypoxemia Trauma to the airway Nosocomial infection Cardiac dysrhythmia (related to the hypoxemia)

Preventing complications with oral/nasopharyngeal suctioning Pressure on the suction gauge (used in LaGCC lab): ** Note: different institutions may use different settings Wall unit: Adult 100-120 mmHg Child 95-110 mmHg Infant 50-95 mmHg (*same for ET/Tracheostomy suctioning) Portable unit: Adult 10-15 inchesHg Child 5-10 inchesHg Infant 2-5 inchesHg

Oro / nasopharyngeal suctioning Perform vital signs pre-suctioning (baseline) and post-suctioning Positioning: Conscious person (+ gag reflex): Oropharyngeal suctioning: in semi-Fowler’s position with head turned to one side Nasopharyngeal suctioning: with the neck hyper-extended (nasopharyngeal suctioning). This will facilitate insertion of the catheter and help prevent aspiration. Unconscious client should be placed in a lateral position, facing you (risk for vomiting).

Suctioning Endotracheal or Tracheostomy tubes Positioning: Semi-Fowler’s position to promote deep breathing, maximum lung expansion, and productive coughing. Deep breathing oxygenates the lungs, counteracts the hypoxic effects of suctioning, and may induce coughing which helps to loosen and move secretions Assess for need of analgesia Oxygen flow via bag-valve-mask (Ambu) should be set at 100%

Sterile technique “Lubricate” with sterile NS (to be used for suctioning) Unless contraindicated, hyperventilate the lungs prior to suctioning. Oxygen should be set to 12-15L/min (FiO2 100%) Suctioning should last no longer than 10 sec in order to minimize oxygen loss

Hyperventilate between suctioning attempts and allow 2-3 minutes between suctioning. Monitor O2 saturations of pt which should be maintained between 95-100% Clients with ET or trach tubes should receive mouth care Q3-4 hours.

Sources of oxygenation Ambu (bag-valve-mask): 100% Respirator (different FiO2 settings) CPAP / BiPAP Face masks: Simple face mask (varies in % of O2 delivery) Partial face-tent (varies in % of O2 delivery) Non-rebreather (close to 100% oxygen delivery) Oxyhood Oxygen tent Nasal Cannuli (delivery of O2 in liters)

Preventing complications of suctioning with ETT or trach. Hyperinflation: Giving the client breaths that are 1-1.5 times the tidal volume (TV) set on the ventilator through the ventilator circuit or via a manual resuscitation bag (Ambu bag). Three to five breaths are delivered before and after each pass of the suction catheter Hyperoxygenation: This can be done with a manual resuscitation bag; bag-valve-mask (Ambu bag) or through the ventilator. It is performed by increasing the oxygen flow (usually to 100%) before suctioning and between suction attempts

For ET and Trach suctioning, the diameter of the suction catheter should be about half the inside diameter of the Trach or ET tube so that hypoxia can be prevented. To determine suction catheter size, multiply the artificial airway’s diameter X 2 (i.e. # 8 ET tube, use #16 French suction catheter) Cuffed versus uncuffed ET tube. Does it matter? Sterile technique is again used

Endotracheal tubes - uncuffed

Endotracheal tube - uncuffed

Endotracheal tube - cuffed

Closed suction system

Closed airway/tracheal suction system, also called in-line suction: Open method: Disconnecting the client from the ventilator, suction and reconnect. Drawbacks include extensive protective gear for the nurse in order to avoid exposure to the client’s sputum. Also, increased cost as disposable, one-time catheters are used Closed airway/tracheal suction system, also called in-line suction: The suction catheter attaches to the ventilator tubing and the client does not need to be disconnected from the ventilator. The nurse does not need protective gear and the suction catheter be reused as it is enclosed in a plastic sheath. This method is becoming more popular.

Promoting Oxygenation Deep breathing and coughing: The nurse can facilitate respiratory functioning by encouraging deep breathing exercises and coughing to remove secretions from the airways. When coughing raises secretions high enough, the client may either expectorate = spit out, or swallow them (not harmful but does not allow for viewing secretions for documentation purposes or obtain sputum specimen). Splinting = using counter-pressure with i.e. a pillow decreases the pain when coughing. Abdominal (diaphragmatic) breathing permits deep full breaths with little effort. Pursed-lip breathing helps the client develop control over breathing by creating resistance to the air flowing out (prolonging exhalation) and preventing airway collapse by maintaining positive airway pressure.

Incentive spirometer: or sustained maximal inspiration devices (SMIs) = measures the flow of air inhaled through the mouthpiece. It is used to: 1) Improve pulmonary ventilation 2) Counteract the effects of anesthesia or hypoventilation 3) Loosen respiratory secretions 4) Facilitate respiratory gaseous exchange 5) Expand collapsed alveoli They offer an incentive to improve inhalation

PEDIATRICS If the child is too young to use incentive spirometry, deep breathe & cough, etc., what should be used???? Lets play!

Physiotherapy: percussion, vibration, and postural drainage Percussion = “clapping” a forceful striking of the skin with cupped hands. Mechanical percussion cups and vibrators are also available (see demonstration). Percussion over congested lung areas can mechanically dislodge tenacious secretions from the bronchial walls. Cupped hands trap the air against the chest and the trapped air sets up vibrations through the chest wall to the secretions

Postural drainage (PVD): drainage by gravity of secretions from various lung segments. Secretions that remain in the lungs or respiratory airways promote bacterial growth and subsequent infections. They can obstruct the smaller airways and cause atelectasis. Careful assessment of the client’s tolerance for PVD is necessary prior to the procedure. The usual sequence for PVD is usually: 1) Positioning (usually Trendelenburg) 2) Percussion 3) Vibration 4) Removal of secretions: coughing or suctioning

Medications: Will be covered in SG#11 in lecture Bronchodilators: Albuterol (Proventil): bronchodilator (MDI, nebulizer, or liquid form beta2-adrenergic agonist) Usually first line of treatment with asthma/wheezing/reactive airway disease Ipratropium (Atrovent): bronchodilator (MDI, nebulizer, or nasal spray)

anti-inflammatory activity. Inhaled/nebulizer corticosteriods: Budesonide (Pulmicort) Beclomethasone (Beclovent) Fluticason (Flonase; Flovent) The above corticosteroids have potent anti-inflammatory activity.

Prophylactic Medications Cromolyn sodium (Intal) Different forms of the drug are used to manage bronchial asthma, to prevent asthma attacks, and to prevent and treat seasonal and chronic allergies. NOT USED IN ACUTE ASTHMA! The drug works by preventing certain cells in the body from releasing substances that can cause allergic reactions or prompt too much bronchial activity. It also helps prevent bronchial constriction caused by exercise, aspirin, cold air, and certain environmental pollutants such as sulfur dioxide.

Tracheostomy Indicated for clients with long-term airway support. A surgical incision in the trachea just below the larynx; curved tracheostomy tube (excellent tracheostomy teaching site) inserted to extend through the stoma into the trachea.

Tracheostomy tubes consist of an outer cannula (inserted into the trachea) and a flange that rests against the neck and allows the tube to be secured in place with trach-ties. All tubes also have an obturator (used to insert the outer cannula and then is removed) which is kept at the clinet’s bedside in case the tube becomes dislodged and needs to be reinserted. Some tracheostomy tubes have an inner cannula that can be removed for periodic cleaning.

Tracheostomy

Pediatric Tracheostomy Tube

Cuffed tracheostomy tube: has an inflatable cuff that produces an airtight seal between the tube and the trachea. The seal prevents aspiration of oropharyngeal secreations and air leakage between the tube and the trachea. Cuffed tubes are usually used in adults Uncuffed tracheostomy tube: no cuff present; used in children < 5 years of age (general rule, however, depends on their size). Due to the anatomical difference in childrens’ airway, their trachea s are resilient enough to seal the airspace around the tracheostomy tube. Low-pressure cuffs: commonly used to distribute a low, even pressure against the trachea. This decreases the risk of tracheal tissue necrosis (do not need to be deflated)

Checking the pressure cuff In cuffed tracheostomy tubes, the cuff pressure needs to be periodically checked The pressure should never exceed 25 mm/hg

Tracheostomy care To maintain airway patency To maintain cleanliness and prevent infection at the tracheostomy site To facilitate healing and prevent skin excoriation around the tracheostomy incision To promote comfort

Hints during tracheostomy care Semi-Fowler or Fowler’s position whenever possible to promote lung expansion Suction before starting tracheostomy care Using Hydrogen peroxide solution (half-strength), will loosen secretions when soaking inner cannula. However, always rinse thoroughly Always use 4X4 gauze and not cotton lint for dressing Always leave the old trach-ties in place when applying the new ones to maintain security of the trach You should be able to place 2 fingers between trach-ties and the client’s neck

Peak Flow Meter A peak flow meter is a small, easy-to-use instrument that measures your peak expiratory flow (how fast you or your child can blow out air after a maximum inhalation). It reveals how well your or your child's lungs are working ("looks" at how narrow your airways are before you have an asthma attack). Used by adults and children (over 5 years of age) who require medication for asthma on a daily or near-daily basis Personal Best = The highest number regularly blown is your personal best. This is done by recording the peak flow values for two weeks first thing in the morning before taking any medications and late afternoon when your asthma is under control. Treatment "zones“ = based on personal best. Zones will help you decide what to do when you have changes with your asthma The zone system can be compared to the colors of a traffic light.

How do I use a peak flow meter? Stand up or sit up straight. Slide indicator to base of meter. Take in deep breath. Place mouthpiece in mouth and seal lips around it. Blow out as hard and fast as you can (one quick blow). Repeat process 2 more times. Select highest number of the 3 efforts. Record this number on your peak flow diary or on a graph.

Peak flow meters

Peak Flow Meter Chart

THE END!