Suctioning

1. Module 7
Suctioning and Airway
Management

2.  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. 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, 7.0 8.0 & 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:
1. Oropharyngeal
2. Nasopharyngeal
3. Orotracheal
4. Nasotracheal
5. 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. Yankauer
Used primarily for oral suctioning

28. How much pressure? Depends on if
wall or portable unit is used…
Wall Unit Portable Unit
Adult: 100-120 mm Hg Adult: 10-15 mm Hg
Child: 95-110 mm Hg Child: 5-10 mm Hg
Infant: 50-95 mm Hg Infant: 2-5 mm Hg

29.  Procedure 47-4 in Kozier on p. 1288 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 10-15 seconds
 Allow 20-30 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

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

40. SUCTIONING …
Preparation for all types of suctioning.
1. Fill basin or cup with approximately 100 ml of
sterile water.
2. Connect one end of connecting tubing to
suction machine.
3. Check that equipment is functioning properly
by suctioning a small amount of water from
basin.
4. 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.