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things up. This is one of those procedures that people get vague about: “Did you deep suction her.” “Yeah, with the Yankauer.” (But Yankauer suction isn’t deep suctioning.) “Uh… well, did you blind suction her?” “Yeah, like I said, with the Yankauer!” (Yeah, well, that ain’t right either.) “Well, I mean, did you get into her airway?” “Yeah, in the back of her throat.” (Nope, nope…) So let’s clear things up a little. As always, please remember that these articles are not meant to be official references in any way! This is just what we do, where I work, elsewhere things may be different. Always check with your local policies, procedures, and references! 12345What is suctioning all about? What is “deep” suctioning” Is Yankauer suctioning deep suctioning? What is “blind” suctioning? How do I tell if my patient needs blind suctioning? How do I tell if my patient shouldn’t have blind suctioning? What bad things can happen from blind suctioning? What is a nasal trumpet? How do I place a nasal trumpet? Should I pre-oxygenate my patient for blind suctioning? How high should I set the suction? How does Nurse Markie do it? How do I collect a sputum sample during suctioning?
1- What is suctioning all about? Lots of patients need secretion management. Pneumonia and the like. Seems simple enough – your patient has some secretions that he can’t clear: he can’t cough them up, maybe he’s a bit weak, maybe he just has too much down there to clear on his own – what to do? 2- What is “deep” suctioning? There’s a lot of confusion about this, and as usual, using terms precisely goes a long way towards getting un-confused. Deep suctioning means going past the posterior pharynx with a catheter, through the vocal cords, down into the patient’s airway (trachea!), and applying suction, to remove thick secretions that are making it hard for your patient to breathe. This is a pretty serious maneuver – in essence, it’s the same as intubating someone, except with a skinny catheter, and blindly - wooo…. You need to know exactly how to do this, and safely! 3- Is Yankauer suctioning deep suctioning? No, it isn’t. It doesn’t get into the trachea.
4- What is “blind” suctioning”? The idea is that you can’t really see where you’re going with the catheter, so you have to work “blind”. You need to get past these guys…
With one of these guys… a “whistle-tip” catheter. The suction only comes out of the end of the catheter when you put your finger over the opening at the proximal end… Here… This is a good thing, because you don’t want the suction running while you’re advancing the catheter….
The catheter is lubricated with some of this stuff: Who used to call this “kalubafax”… wow – THAT was a long time ago.
And then the catheter gets passed, up one of the nostrils, along the same path that an NG tube takes, along the curve of the nasopharynx, except not into the esophagus…
…into the trachea. This is a pretty invasive procedure! Actually, you’re intubating him…
5- How do I tell if my patient needs blind suctioning? Your assessment skill don’t need to really be too advanced to notice that your patient is turning kind of blue, can’t cough up the secretions he’s got from his pneumonia, or aspirated ice cream or whatever. It’s usually pretty clear. Was your patient extubated too soon?
You know what this is, right?
Hooked up to something like this? And the numbers should be something like what?
6- How do I tell if my patient shouldn’t have blind suctioning?
Assuming you would, otherwise, you mean? Is he on comfort measures only? Would he be more, or less comfortable if you suctioned him? Would you just have to do it again in a minute? Is he anticoagulated? What’s he going to do if you start inserting things in his nares? Is he a cardiac patient? What nerve runs through the carina? What is the carina? What could happen if you stimulate your patient’s vagus nerve if he’s having – say, an inferior MI? What drug might you want to have at the bedside? Anyway?
7- What bad things can happen from blind suctioning? Not too hard to figure out, but worth mentioning: You can make the patient seriously hypoxic.
You can injure the patient (or get the lung biopsy the surgeons were going to get anyhow), by using suction equipment that’s pulling too hard. You can provoke a serious bradycardia from vagal stimulation. This is pretty rare, but it does happen once in a while. Usually with inferior MI’s . You can infect the patient’s lower airway. You can provoke nasopharyngeal bleeding, and the patient could aspirate blood.
Yup, it’s all true. But if your patient’s airway is almost obstructed with secretions, you need to do something! So learn to do it safely… 8- What is a nasal trumpet? Cute! Nice and soft. Lubricate it up really well with the surgilube stuff. Passing the catheter through this, instead of the patient’s bare nasopharynx, will go a long way towards preventing nasal trauma. Is your patient heparinized? Why am I asking?
9- How do I place a nasal trumpet?
Gently! Remember that some patients have deviated nasal septa, right? One side may let the trumpet pass easily, the other may not. Never force anything, ever! If you can’t pass the trumpet on either side, you may have to try passing the catheter without it. Suctioning any patient repeatedly without a trumpet is almost guaranteed to provoke bleeding…
10- Should I pre-oxygenate my patient for blind suctioning? Good question! The answer is: probably. Usually. Almost always. Ventilated patients should always get pre-oxygenated: there’s a 100% Fi02 button that you can press to do this. But a patient on prongs? Or a mask? Well… hm. Are there situations when it wouldn’t be safe to give a certain patient 100% oxygen? Which patients are those? Why isn’t it safe? In those situations, you have to watch the patient like a hawk, and have mask oxygen at hand. If they desaturate
11- How high should I set the suction?
Not too high! About 140-160mm Hg negative pressure is what we use…
12- How does Nurse Markie do it? Ok, the patient is drowning. Saturation is getting low. He’s clearly in distress. Let’s save him! Gather your equipment: got the trumpet in? Got the catheter? The lube? Sterile gloves? Is the suction setup working? You had all this stuff ready at the bedside, right, because you knew your patient might need this… Let’s see – how do I do this? Been doing it so long… Make sure your patient agrees to this procedure. You are NOT allowed to attack a patient who is competent to refuse things. At the same time, you do need to keep her safe, so it’s best to have things worked out in advance. Patients who aren’t competent to refuse need to have proxy issues worked out… Apologize ahead of time. This is one of the most unpleasant things you’ll ever do to a patient… Try to have a helper on hand to catch flying extremities. It’s not nice to get punched out by an angry, confused patient that you’re trying to help… Sit the patient up. Pillow behind the head. (Assignment for next time: look up the “sniffing position”. Does she have an NG tube? I’d hook it up to suction, try to empty her stomach – if you provoke vomiting while you suction her, you KNOW what’s going to happen, right? Apply the oxygen, in the right amount. If this patient retains carbon dioxide when she gets oxygen, I’d apply just enough for her to resaturate – it’s hyperoxia that’s going to make her stop breathing, right? This is rather a judgment call – what you want to do is assess her oxygenation almost continuously as you do this. Insert the lubricated trumpet. Slide in easily? If it doesn’t, try the other side. You’re watching her sat while you do this, right?
Open the end of the catheter packaging, and tuck the catheter under your arm. Hold it there. Sterile gloves. I squeeze some sterile lube onto the glove paper and leave it there. Suction tubing handy? Set to the right negative pressure? Not too high! Ok – with a sterile gloved hand, reach over to your armpit and pull out the catheter. Don’t get it contaminated on anything – you’ll have to start over if you do, and your patient isn’t breathing too well! (Jayne says: “Are you OUT of your mind? NEVER put anything, even in sterile packaging, under your ARM! Your armpit is DIRTY! Open the end of the package and leave it on the bedside table..”) (Eeek! Eek! She runs an ORbased EP lab, among other things…) Don’t hook up the suction yet. Position the patient’s head at the midline. Start passing the catheter through the trumpet. Now – listen! Literally listen - put your ear to the end of the catheter that you’re holding. You should be able to hear air moving through the catheter. Advance the catheter a bit, on the patient’s inspiration (why?), listening… if it goes into the esophagus, what should you hear? If it goes into the trachea, then what should you hear? What will the patient probably do? In the trachea? Not too hard to tell, is it? Advance the catheter to about ¾ of it’s length. Now attach the suction. Put your finger over the catheter button, and slowly withdraw the catheter, suctioning all the while. Don’t just haul the catheter out at full speed – it needs to stay in long enough for the secretions to get suctioned out. Assess, assess, assess! : o o Look at the patient: is she breathing? Vomiting? Coughing? Look a the monitor: stable rhythm? Slowing? (That’s bad – her airway may be occluded, or you may be poking her carina – back out the catheter while suctioning, to try to open the airway, then get it out of there…) How’s her saturation doing? Look at the catheter: are secretions coming out? That IS the idea, after all – are they coming up the tubing? No? Do you need to turn the suction up? You may have to turn it up to max, if the secretions are really thick, and you have to clear the patient’s airway. Yup, it’s dangerous – turn it back down as soon as you can. Are the secretions bloody, at all? Hmm… Done? Does he need to be suctioned again? Depending, I’ll repeat the process until I think the patient’s really clear. If it was difficult to get into the trachea, I might even leave the catheter in place – not all the way down, but past the cords anyhow, watching the saturation the whole time.
Now, apologize again. Wipe the tears out of your patient’s eyes. Wipe your own eyes.
Re-assess! Is he going to need it again? Is this the second time in the shift that you’ve had to do this? Or the twelfth? Does he need to be intubated? Re-intubated?
13- How do I collect a sputum sample during suctioning? A sputum trap! The catheter plugs into the yellow part, and the suction tubing connects to the white cone thing. Applying suction with this gadget connected draws the sputum into the clear thing, which you then cap off…
… and send to the lab.
Jayne says: “Make sure you tell them that they have to use new, sterile suction tubing to the canister every time they do this, or the specimen will just get contaminated by the nasty old tubing that’s just been hanging off the wall…”
Ok – change that tubing!
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