Tracheostomy Suctioning

Introduction

Tracheostomy suctioning involves passing a suction catheter though a tracheostomy and

applying suction to clear tracheobronchial secretions and maintain a patent airway. This procedure
should only occur when clinically indicated due to its potential complications.

Indications for tracheostomy suctioning include:

•visible secretions in the airway

•need to maintain the patency and integrity of the artificial airway
•coarse crackles over the trachea
•deterioration of the oxygen saturation level, arterial blood gas values, or both
•inability to generate an effective spontaneous cough
•acute respiratory distress
•suspected aspiration of gastric or upper airway secretions
•need to obtain a sputum specimen to identify infection or for cytology.

Performance of tracheostomy suctioning can use open or closed technique.

The open technique requires disconnection of the patient from any oxygen source present; the
closed technique does not. However, studies that have compared open and closed suction systems have
shown no difference in patient outcomes or patient-to-patient transmission of pathogens. Various
clinical trials have reached different conclusions about the cost-effectiveness of the two techniques.

Equipment

 Oxygen source (or humidification device) and tubing

 Handheld resuscitation bag
 Suction apparatus with collection container
 Oral suction device
 Suction tubing
 Suction catheter (open or closed tracheostomy system)
 Gloves
 Sterile solution (sterile water or sterile normal saline solution)
 Sterile solution container
 Stethoscope
  Vital signs monitoring equipment
 Disinfectant pad
 Spare tracheostomy tubes (patient's size and one size smaller)
 Obturator
 Optional: sterile gloves, suction catheter kit (includes a sterile suction catheter, sterile gloves,
and disposable sterile solution container), gown, mask, goggles, mask with face shield, pulse
oximeter and probe, nonfenestrated inner cannula, specimen collection container, label,
laboratory transport bag, laboratory request form, cardiac monitor

Preparation of Equipment

 Choose an appropriately sized suction catheter. The catheter diameter should be no larger than
half the inside diameter of the tracheostomy tube (such as using a #12 or #14 French catheter
for an 8-mm or larger tube) to minimize hypoxia during suctioning. Make sure that spare
tracheostomy tubes and an obturator are readily available in case the tracheostomy tube
becomes dislodged.
 Inspect all equipment and supplies. If a product is expired or defective or has compromised
integrity, remove it from patient use, label it as expired or defective, and report the expiration
or defect as directed by your facility.
 For open suctioning
o Connect the suction tubing to the suction catheter and then turn on the suction
apparatus. Occlude the end of the suction tubing to make sure that the suction
apparatus is functioning properly.
o For closed suctioning
o If a closed tracheostomy suctioning system isn't already attached to the patient's
tracheostomy tube, attach it following the manufacturer's instructions. Attach the end
of the suction catheter to the suction tubing and then depress the thumb suction
control to make sure that the suction apparatus is functioning properly.

Implementation

o Verify the practitioner's order, if needed.

o Gather and prepare the necessary equipment.
o Perform hand hygiene.
o Confirm the patient's identity using at least two patient identifiers.
o Provide privacy.
o Explain the procedure to the patient and family (if appropriate), according to their individual
communication and learning needs to increase their understanding, allay their fears, and
enhance cooperation.
o Raise the bed to waist level before providing care to prevent caregiver back strain.

IMPLEMENTATION
1. Perform hand hygiene.
2. Put on gloves and as needed, other personal protective equipment to comply with standard
precautions.
3. Assess the patient's vital signs, breath sounds, respiratory effort, and general appearance to
determine the need for suctioning and establish baselines for comparison.
4. Position the patient upright in a comfortable position with the head in neutral alignment.
5. Attach the patient to a pulse oximeter, as needed, to evaluate oxygenation before, during, and
after the procedure. Make sure that the alarm limits are set appropriately for the patient's
current condition and that the alarms are turned on, functioning properly, and audible to staff. If
the patient has a fenestrated inner cannula in place, change to a nonfenestrated inner cannula
for suctioning because the suction catheter could puncture the small opening of the fenestrated
tube.
6. Assess the patient's ability to cough and breathe deeply to help mobilize secretions up the
tracheobronchial tree.
7. For an open suction system
1. Remove and discard your gloves.
2. Perform hand hygiene.
3. Remove the lid from the sterile solution and place it upside down on a clean surface.
4. Open the package containing the disposable sterile solution container.
5. Using sterile no-touch technique, open the suction catheter kit and put on gloves. If
using individual supplies, open the suction catheter and the gloves. Then put on the
gloves by first placing the nonsterile glove on your nondominant hand and then placing
the sterile glove on your dominant hand.
6. Open the catheter kit and put on gloves
7. Using your nondominant (nonsterile) hand, pour a small amount of sterile solution into
the sterile solution container. Pour sterile solution into sterile solution container
8. Close the solution bottle using your nondominant hand to prevent contamination and
spillage of the solution.
9. Close solution bottle
10. Pick up the sterile suction catheter with your dominant (sterile) hand. Coil the catheter
around your hand to prevent contamination that could occur if the catheter accidently
touched another object.
11. Coil catheter around sterile hand
12. Using your nondominant (nonsterile) hand, attach the catheter to the tubing (as shown
below). Using non-sterile hand, attach to suction tubing
13. Attaching the catheter to the tubing
14. Turn the suction control valve to the ON position and set the suction pressure to the
lowest possible vacuum pressure needed to effectively clear secretions (less than 150
mm Hg). Higher pressures do not enhance secretion removal and can cause traumatic
injury. Turn suction ON and set to proper pressure
15. Using your dominant (sterile) hand, lubricate the outside of the catheter by dipping it
into the sterile solution (as shown below) to ease catheter insertion into the
tracheostomy tube.
 16. Lubricate outside of the catheter by dipping it into the sterile solution
17. Lubricating the outside of the catheter, With the suction catheter tip in the sterile
solution, occlude the suction control valve with the thumb of your nondominant hand.
Suction a small amount of solution through the catheter to lubricate the inside of the
catheter, which facilitates the passage of secretions through it.
18. Occlude control valve and suction sterile solution to lubricate inside of catheter
19. If the patient has a collar over the tracheostomy tube to deliver oxygen or
humidification, move it with your nonsterile hand. Alternatively, open the T-piece
adapter.
20. Move collar with non-sterile hand or open T-piece adapter
21. Preoxygenate the patient with 100% oxygen for 30 to 60 seconds using a handheld
resuscitation bag, if needed. Alternatively, ask the patient to take two or three deep
breaths, if able.
22. Disconnect the handheld resuscitation bag if you used it to preoxygenate the patient.
23. Insert the suction catheter into the tracheostomy tube; do not apply suction while
inserting the catheter to prevent hypoxia. For deep suctioning, insert the suction
catheter until you meet resistance and then withdraw the catheter 1 cm. For shallow
suctioning, insert the catheter to a predetermined length, usually the length of the
tracheostomy (plus the adapter, if present).

Clinical alert: Research hasn't shown deep tracheal suctioning to be more effective than shallow tracheal
suctioning and has shown that it may be associated with more adverse events.

24. Withdraw the catheter. While withdrawing the catheter, apply suction and rotate the
catheter between your fingertips to clear secretions from the sides of the tracheostomy
tube. Ensure that the suctioning event lasts for no longer than 15 seconds to prevent
hypoxia. To apply suction, place your nondominant thumb over the control valve.
Suction can be applied continuously or intermittently because tracheal damage from
suctioning is similar with continuous or intermittent suction.
25. Withdraw the catheter
26. Reapply the tracheostomy collar or close the T-piece adapter between suctioning passes
to maintain the patient's oxygen saturation level. Reapply tracheostomy collar or close
T-piece
27. Dip the free end of the suction catheter into the sterile solution and apply suction until
the catheter is clear of secretions.
28. Assess the patient's response to suctioning. If you're monitoring the heart rate and
rhythm, observe for arrhythmias; if they occur, stop suctioning the patient.
29. Hyperoxygenate the patient for at least 1 minute after suctioning to minimize hypoxia.
30. Use the same method to hyperoxygenate that you used to preoxygenate.
31. Let the patient rest.
32. After the patient's oxygen saturation level returns to the baseline, repeat suctioning, if
clinically indicated. Encourage the patient to cough between suctioning attempts to
enhance secretion removal.
33. Reapply the oxygensource or humidification device.
 34. Inspect the secretions:
a.Normal sputum tends to be watery and white or translucent.
b.Tenacious or thick secretions may indicate dehydration.
c. Yellow, tan, or green secretions may indicate infection
d.Brown sputum may indicate prior bleeding.
e.Red sputum indicates active bleeding.
35. Obtain a specimen for culture and sensitivity testing, if indicated. Label the specimen in
the presence of the patient to prevent mislabeling.
36. Place the specimen in a laboratory transport bag, attach the completed laboratory
request form, and send it to the laboratory.
37. Flush the suction catheter and tubing with sterile solution to prevent contaminants from
remaining in the tubing.
38. Turn off the suction apparatus
39. Remove the suction catheter from the suction tubing.

For a closed suction system

1. If a closed suction system isn't attached to the patient's tracheostomy tube, attach it
following the manufacturer's instructions.
2. Preoxygenate the patient with 100% oxygen for 30 to 60 seconds using a handheld
resuscitation bag, if needed. Alternatively, ask the patient to take two or three deep
breaths, if able.23Disconnect the handheld resuscitation bag, if you used it to
preoxygenate the patient.
3. Steadying the T-piece with one hand, use the thumb and index finger of your other hand
to advance the catheter through the tracheostomy tube until you meet resistance or the
patient coughs. Note that you may have to gently retract the catheter sleeve as you
advance the catheter.
4. Steady T-piece with one hand, advance catheter through tube, retract catheter sleeve
5. While continuing to hold the T-piece and suction control valve and applying suction,
withdraw the catheter until it reaches its fully extended length in the sleeve. Suction can
be applied continuously or intermittently because tracheal damage from suctioning is
similar with continuous or intermittent suction.
6. Hold T-piece and suction control valve, apply suction and withdraw catheter until fully
extended
7. Repeat the procedure only if necessary.
8. Inspect the secretions:
a.Normal sputum tends to be watery and white or translucent.
b.Tenacious or thick secretions may indicate dehydration.
c. Yellow, tan, or green secretions may indicate infection
d.Brown sputum may indicate prior bleeding.
e.Red sputum indicates active bleeding.
9. Obtain a specimen for culture and sensitivity testing, if indicated. Label the specimen in
the presence of the patient to prevent mislabeling.10 Place the specimen in a laboratory
transport bag, attach the completed laboratory request form, and send it to the
laboratory.
 10. After you've finished tracheal suctioning, flush the catheter by maintaining suction while
slowly introducing sterile solution into the irrigation port.
11. Place the suction control valve in the OFF position.

8. Completing the procedure

9. Remove and discard your gloves.
10. Perform hand hygiene.
11. Obtain the patient's vital signs and assess respiratory status to evaluate the effectiveness and
the patient's tolerance of the procedure
12. Make sure that the patient is comfortable and that necessary personal items and the call light
are within easy reach.
13. Return the bed to the lowest position to prevent falls and maintain patient safety.
14. Perform hand hygiene.
15. Clean and disinfect your stethoscope using a disinfectant pad.
16. Perform hand hygiene.
17. Document the procedure.

Special Considerations

 Note that instillation of sterile normal saline solution before suctioning has been associated with
increased hypoxia, deterioration in lung mechanics, and infection. Therefore, guidelines don't
recommend its use.
 Change an inline suction catheter only when it's visibly soiled to avoid frequent disruptions in
the closed circuit, which increase the risk of health care–associated pneumonia.

Complications

Complications of tracheostomy suctioning include decreased lung compliance, decreased functional

residual capacity, hypoxemia, tissue trauma, bronchospasm, colonization of the lower airway, increased
intracranial pressure, hypertension, hypotension, and cardiac arrhythmias.

Documentation

Record the date and time of the procedure; the presuctioning assessment findings that resulted in the
suctioning procedure; the technique you used; the amount, color, and consistency of the secretions;
collection and transport of a specimen to the laboratory for testing; any complications that occurred and
actions you took; and the amount of time the patient took to recover. Also document postsuctioning
vital signs, breath sounds, and other assessment findings. Document teaching provided to the patient
and family (if applicable), their understanding of that teaching, and any need for follow-up teaching.

Reference: Lippincott Manual of Nursing Procedures