Suctioning

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Suctioning

• Endotracheal
• Nasotracheal
• Open vs Closed Suction Systems
• Sputum sample

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Rationale

• To remove secretions from lower airway when
  patient intubated or trached
• Or cannot cough effectively
• To obtain sputum sample for culture and
  sensitivity

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Indications

• Adults - suction when secretions present
• auscultation
• observed
• Do not suction routinely - except for infants
• Suction catheter passes ensure tube patency
• Infants more susceptible to mucus plugging

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Suctioning

• Advance plastic tube down ETT or trach
• Apply vacuum to evacuate secretions

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Complications of ETT Suctioning

• Hypoxemia
• Atelectasis
• Tracheal damage
• Cross contamination
• Bronchoconstriction
• Cardiac arrhythmias
• Increased intracranial pressure

Fisher JT, Waldron MA, Armstrong CJ. Effects of
hypoxia on lung mechanics in newborn cats.Can J
Physiol Pharmacol 1987 65 1234-1238.
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Hypoxemia

• Most important
• Hypoxemia will cause arrhythmias such as
  tachycardia, PVCs, or v fib
• Anytime arrhythmias occur - STOP SUCTIONING and
  VENTILATE with 100 OXYGEN IMMEDIATELY

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To Prevent Hypoxemia

• Pre and post oxygenate with 100 O2 and limit
  suction pass to 15 seconds or less.
• Can also supply oxygen across mouth of ETT

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Applying O2 Across Mouth of ETT
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Lung Collapse (atelectasis)

• Suctioning air as well as secretions
• If suction catheter too large, room air cannot
  enter ETT
• All suctioned air then comes from the lungs and
  lungs collapse
• Atelectasis worse with 100 compared to
  preoxygenation with 30
• Atelectasis reversed with 20 breaths at 20 ml/kg
  post suctioning. This study used 60 sec suction
  interval to ensure differences.

Qin Lu, Andre Capderou, Philippe Cluzel, Eric
Mourgeon, Lamine Abdennour, et al. A computed
tomographic scan assessment of endotracheal
suctioning-induced bronchoconstriction in
ventilated sheep. Am J Respir Crit Care Med
2000162 1898-1904.
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To Prevent Atelectasis

• SUCTION CATHETER should be NO LARGER than 1/2
  THE INTERNAL DIAMETER OF THE ETT/TRACH TUBE (AARC
  CPG)
• (ETT mm ID/2) x 3 suction catheter size in
  French
• 1 mm 3 French since circumference 3.14 x
  diameter
• HYPERINFLATE after suctioning (or give sigh
  volumes 20 ml/kg)

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SX
SX
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With proper sized suction catheter, catheter
mid-position in ETT draws approximately equal
amounts from both ends of ETT.
X
ETT
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Trauma

• Suction ports will grab mucosa causing tissue
  damage
• Hitting resistance during catheter insertion
  damages tissue, especially with infant trachea

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To Reduce Trauma

• Advance suction catheter gently
• Apply suction intermittently
• Never suction going down
• Use appropriate vacuum pressures
• - 100 torr adults (-100 to -150 - 80 to -100)
• - 100 torr children (-100 to -120)
• - 80 torr infants ( -80 to -100)
• - 60 torr neonates (-60 to -80)
• Use catheters with pre-marked insertion distance
  in infants.

Shapiro, BA. Clinical Application of Respiratory
Care. 3rd ed. Year Book Medical Publishers
1985 251.
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Argyle
whistle tip
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Coudé tip suction catheter
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Cross Contamination

• Natural defense mechanisms by-passed with
  ETT/trach
• Easy to contaminate lower airway through ETT

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To Prevent Cross Contamination

• USE ASEPTIC TECHNIQUE
• Dont touch suction catheter to anything but the
  inside of ETT
• Dont reuse catheter after rinsing
• Glove hand holding catheter

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Bronchoconstriction

• Stimulation of airway irritant receptors causes
  reflex bronchoconstriction
• Hypoxemia may contribute to an increase in
  bronchomotor tone via vagal stimulation and from
  the release of bronchoconstrictor mediators by
  mast cells
• Reduced with preoxygenation of 100 oxygen

Qin (2000)
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To Prevent Bronchoconstriction

• Preoxygenate with 100
• May want to aerosolize lidocaine before
  suctioning or give IV
• Aerosol tx with 200 mg of 5 lidocaine before
  suctioning completely prevented
  bronchoconstriction
• Lidocaine also antitussive so prevented coughing
  (although patient may cough if it is directly
  instilled)
• Cough increases intracranial pressure (want ICP ?
  20 mm Hg) - lidocaine also has direct effect on
  reducing ICP.

Qin (2000) Rudy E, M Baun, K Stone, B Turner.
The relationship between endotracheal suctioning
and changes in intracranial pressure A review of
the literature. Heart Lung. 198615 (5)
488-494.
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Vagal Stimulation

• Vagus innervates entire respiratory tract
• Vagal stimulation causes BRADYCARDIA,
  bronchospasm, cough (or laryngeal spasm with NTS)
• Cough increases intrathoracic pressure which
  increases cerebral venous pressure causing a
  transient increase in intracranial pressure.

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To Reduce Vagal Stimulation

• Advance catheter gently until meet resistance,
  withdraw slightly, then apply suction
• May aerosolize lidocaine if ICP gt 20 mm Hg prior
  to suctioning.
• Use premarked suction catheter with infants.

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Complications Minimized By

• Pre and post oxygenation with 100
• pre gt 30 sec, post gt 1 min (CPG)
• Hyperinflation via bagging
• Aseptic technique
• Proper suction catheter size
• Applying suction on the way out only
• Suctioning to 10 - 15 seconds (CPG)
• Proper vacuum levels
• Gently advancing catheter

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Thumb Control
Connecting tubing to suction
20 - 22 inches long 14 Fr
Coude -
Angled tip
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ETS Infants

• Pneumothorax reported with deep tracheal suction.
• Advance catheter to predetermined depth
• Use suction catheter that has distance markings
  on catheter
• Suction catheter should extend only 0.5 cm beyond
  the tip of ETT

Kleiber C, N Krutzfield, E F Rose. Acute
histologic changes in the tracheobronchial tree
associated With different suction catheter
insertion techniques. Heart Lung, 1988 17 (1)
10-14.
28
Insertion Depth

• Find oral-carinal distance
• Add length of tube extending out from mouth to
  oral-carinal distance insertion depth.
• This will not be the same depth if want suction
  catheter tip to extend only 0.5 cm out from end
  of ETT. Compare markings on suction catheter and
  ETT before using.

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Oral-Carinal Distancefrom Branson,
Hess,Chatburn, Table 6-1
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Differences with infants.

• Stress may cause bradycardia and apnea.
• May take ETT adapter off to suction down tube.

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Nasotracheal Suction (NTS)

• Patients without ETT or Trach
• Need help clearing secretions
• A few differences in technique

32
Differences with NTS

• Lubricate suction catheter with water soluble
  lubricant
• Use smaller sized catheter
• Advance suction catheter without being connected
  to suction
• Apply oxygen via face mask
• Cannot NTS infants
• Trachea positioned more anteriorly than adults
• Will suction nasopharynx, however

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Assessment - Oro-pharynx Trachea
Sinus Turbinate Eustachian Tube Uvula Tongue
Epiglottis Larynx
34
Pathway of NT suction catheter
Sinus Turbinate Eustachian Tube Uvula Tongue
Epiglottis Larynx
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Indications for NTS(AARC 2004 Guidelines)

• Inability to clear secretions evidenced by
• visible secretions in airway
• coarse, gurgling BS
• Increased tactile fremitus
• Suspected aspiration
• Increased work of breathing
• Deteriorating ABGs
• CXR atelectasis/consolidation
• Restlessness
• To stimulate cough
• To obtain a sputum sample

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Contra-indications for NTS(relative unless
indicated)

• Occluded nasal passages
• Nasal bleeding
• Epiglottis or croup (absolute)
• Acute head, facial, or neck injury
• Coagulopathy or bleeding disorder
• Laryngospasm
• Irritable airway
• Upper respiratory tract infection
• Tracheal surgery
• Gastric surgery with high anastomosis
• Myocardial infarction
• Bronchospasm

37
Closed Suction Systems

• Use swivel adapter
• Use Ballard suction catheter

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Swivel Adapter
port
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Problems with Swivel Adapter

• Difficult to prevent port contamination.
• Would have to change frequently, which is costly.
• Does relieve torque on tube, however.

42
Ballard Suction Catheter

• Suction catheter contained within plastic sheath
• System remains closed
• Be sure catheter is completely withdrawn when
  finished
• Suction OFF

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Lock/ Unlock Control Valve
Black Line
To Suction
Patient Wye
ETT
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Lock/ Unlock Control Valve
LOCK
Unlock To Apply Suction
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Open compared to Closed Suctioning
Closed
Open
0 baseline 1 After HIS 2 immediately
after suction 3 30 seconds after suction
Johnson 1994
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Open compared to Closed Suctioning
Closed
Open
0 baseline 1 After HIS 2 immediately
after suction 3 30 seconds after suction
Johnson 1994
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Yankauer (tonsil sucker)
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Obtaining Sputum Sample

• Sputum trap placed in-line between catheter and
  connecting tubing
• Irrigation may be necessary - use sterile saline
  without bacteriostatic agent
• Dont turn trap upside down

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Connecting Tubing
Suction Catheter
Lukens Sputum Trap
Suction Unit
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Charting after Suctioning

• Amount, color, thickness
• How well patient tolerated procedure
• Breath sounds after suctioning
• Any complications

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Summary

• Avoid hazards when suctioning.
• Suction when indicated
• Pre and post oxygenate!
• If PVCs occur, limit suction time, use closed
  suction system.
• Premature babies will drop heart rate when
  stressed.

57
Additional References

• Hyperinflation before and after suctioning
• McIntosh D, Baun MM, Rogge J. Effects of lung
  hyperinflation and presence of positive
  end-expiratory pressure on arterial and tissue
  oxygenation during endotracheal suctioning. Am J
  Crit Care 19932317-325.
• 100 O2
• Goodnough SK. The effects of oxygen and
  hyperinflation on arterial oxygen tension after
  endotracheal suctioning. Heart Lung
  19851411-17.
• Bronchospasm
• Guglielminotti J. Desmonts JM. Dureuil B. Effects
  of trache suctioning on respiratory resistances
  in mechnicaly ventilated patients. Chest
  1998113 1335-1338.
• Nadel JA, Widdicomb JG. Reflex effects of upper
  airway irritation on total lung resistance and
  blood pressure. J Appl Physiol 196217861-865.
• Intracranial pressure
• Rudy E, M Baun, K Stone, B Turner. The
  relationship between endotracheal suctioning and
  changes in intracranial pressure A review of the
  literature. Heart Lung. 198615 (5) 488-494.
• Cardia arrhythmias
• Shim C, Fine N, Fernanandez R, Williams MH.
  Cardiac arrhythmias resulting from tracheal
  suctioning. Ann Intern Med 1969711149-1153.
• Trauma
• Kleiber C, N Krutzfield, E F Rose. Acute
  histologic changes in the tracheobronchial tree
  associated with different suction catheter
  insertion techniques. Heart Lung, 1988 17 (1)
  10-14.
• Closed suction
• Johnson KL, PA Kearney, SB Johnson, J B Niblett,
  NL MacMillan, RE McClain.Closed versus open
  endotracheal suctioning Costs and physiologic
  consequences. Crit Care Med 1994 22(4) 658-666.