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A Nursing Approach
Mr. Nestlee Sio Cabaccan RN,MSN
• To ensure the highest standards of patient care through theoretical and practical teaching of suction techniques, together with safe and effective use of suctioning equipment, to nursing student.
After This Session Candidates will
• • • • Be familiar with the anatomy and physiology of related structures and have an under standing on nursing procedure. Be able to identify key features in assessing the need of suction. Be able to state ways in reducing Mucosal trauma and preventing Hypoxia Valsalva Maneuver. Be able to identify a safe value for negative suctioning pressure and will be able to dismantle, clean, set up and adjust suction machines accordingly. It is anticipated that student will have the opportunity to demonstrate safe suctioning techniques to a competent student with the supervision of the clinical instructor.
1. 2. 3. 4. 5. Definition of suctioning Brief history Anatomy and Physiology Purpose Guidelines
• Suctioning is a method of removing excessive secretions from the airway. • May be applied to: a. Oral b. Nasopharyngeal c. Tracheal passages
A Brief History Of Suction
• Airway suction was once described as a “surprisingly simple technique” (Thompson, 1936) . • In 1959, Boba et al studied the effects of endotracheal suctioning in paralysed patients. They reported that severe hypoxia resulted from suctioning for one minute. • Shumacker et al (1951), Keown (1960) and Marx et al (1968) reported cardiac arrest associated with endotracheal suction.
A Brief History Of Suction
• Rosen and Hillard (1962) stated that deaths during suctioning procedures have not been reported as often as personal inquiries indicate that they happen.
– “cardiac arrest may arise from the stimulation of respiratory tract reflexes,”
• In 1984, Kergin et al., Using oximetry, again reported reduction in blood oxygen saturation during suctioning.
Anatomy And Physiology Of Related Structures
Nose Pharynx Larynx Trachea Bronchi Lungs – alveoli
Rt Superior Lobe
Lt Superior Lobe
Bronchial Tree Cardiac Notch
RT Middle Lobe
Lt Inferior Lobe Rt Lower lobe Diaphragm
• To provide a patent airway by keeping it clear of excessive secretions.
Vaccum source with adjustable regulator suction jar stethoscope Sterile gloves for open suctioning method Clean gloves for closed suctioning method Sterile catheter Clear protective goggles, apron & mask Sterile normal saline Bain’s circuit or ambu bag for preoxygenate the patient Suction tray with hot water for flushing
The Vagus Nerves
• Have a more extensive distribution than any other cranial nerves. The motor fibres supply the smooth muscles and secretory glands of the pharynx, larynx, trachea, heart, oesophagus, stomach, intestines, pancreas, gall bladder, bile ducts, spleen, kidneys, ureter and blood vessels in the thoracic and abdominal cavities.The sensory fibres convey impulses from the lining membranes of the same structures to the brain.
BRANCHES OF THE VAGUS NERVE
Indications for suction: • Secretions are present which are:– Detrimental to the patient. – Accessible to the catheter. – Neither the patient nor the nurses are able to clear the secretions by any other means.
HAZARDS & COMPLICATIONS Hypoxia / hypoxemia Tracheal and / or bronchial mucosal trauma Cardiac or respiratory arrest Pulmonary hemorrage / bleeding Cardiac dysrhythmias Pulmonary atelectasis Bronchoconstriction / bronchospasm Hypotension / hypertension Elevated ICP Interruption of mechanical ventilation
TYPES OF SUCTIONING
OPEN SUCTION SYSTEM:
Regularly using system in the intubated patients.
CLOSED SUCTION SYSTEM:
This is used to facilitate continuous mechanical ventilation and oxygenation during the suctioning. Closed suctioning is also indicated when PEEP level above 10cmH2O.
The following should be monitored prior to, during & after the procedure:
Breath sounds Oxygen saturation RR & pattern Haemodynamic parameters (pulse rate, Blood pressure) Cough effort ICP (If indicated and available) Sputum characteristics (colour, volume, consistency & odor)
Choosing Correct Gauge Catheter.
• • • • E.G. tracheostomy tube size = 10. Multiply by three = 30. Divide by two = 15. Then choose the nearest, safest or most efficient gauge catheter to that number i.e.
• • • •
For a size 10 tracheostomy tube, use a size 14 fg catheter. “It is essential to use the right size catheter for the lumen of the tracheostomy tube: a 10FG catheter is appropriate for a size 6 tube, a 12FG catheter for a size 8 tube; a 14FG catheter for a size 10 tube, It is occasionally necessary to us a proportionately larger diameter of catheter, especially if secretions are viscous, but this must be done with care.” (Mallet 1985).
Choosing The Correct Amount Of Negative Pressure.
• • Suggestions for minimising the suction-induced hypoxemia include, limiting the negative suction pressure, and the use of hyper oxygenation. Negative suction pressure is also strongly associated with trauma, which as we know leads to infection and increases patient anxiety; the following article is included to demonstrate this.
Achieving the correct depth of insertion.
• Not introducing the catheter too deeply into the tracheo – bronchial tree will reduce the likely hood of vagal stimulation, bronchospasm and trauma. There is a degree of conflict within the research (Kleiber 1986) with suggestions of efficient depths which range from 1cm past the end of the tube to one cm past the carina. A general rule is proceed with the minimum amount of invasion, the recommendation is to advance the catheter slowly until either a
cough reflex is initiated or resistance is felt upon encountering either of these conditions, the nurse should withdraw the catheter 1cm , apply suction and withdraw the catheter.
• For patients with copious or tenacious secretions, who are showing signs of ineffective airway clearance, deeper suctioning is suggested. Care plans should include specific guidelines for catheter insertion and should be updated routinely by the caregiver. Individualisation of the care plan is essential.
Applying Suction Appropriately, For Correct Amount Of Time.
• Insufflation of five litres of O2 down a sidearm during endotracheal suction diminished the rate of decline of pao2 during suction of normal dog lungs. In patients with respiratory insufficiency, the insufflation of O2 during suction did not have any effect on the decreased pao2 seen during the endotracheal suction. The most effective way to prevent hypoxia during endotracheal suction of patients with respiratory failure is to hyperoxygenate for one minute with 100% O2 prior to suction and limit suction to 15 seconds, (fell 1971). To err on the side of caution it is recommended that suctioning is limited to 10 seconds only and that only 3 – 4 passes are completed in any one session.
• The airway mucosa is extremely sensitive to pressure and is easily damaged. Chronic irritation can result in scar formation, which may necessitate surgical intervention and prolonged hospitalisation. Therefore, any suctioning of the airway must be done with extreme gentleness. This again will reduce the likely hood of vagal stimulation, bronchospasm and trauma and will greatly reduce patient anxiety.
Explain the procedure to the patient (If patient is concious). The patient should receive hyper oxygenation by the delivery of 100% oxygen for >30 seconds prior to the suctioning (Either with Bain’s circuit or by increasing the FiO2 by mechanical ventilator). Position the patient in supine position. Auscultate the breath sounds.
Perform hand hygiene, wash hands. It reduces transmission of microorganisms.
Turn on suction apparatus and set vacuum regulator to appropriate negative pressure. For adult a pressure of 100-120 mmHg, 80100/120Lmmhg for children & 60-80/1ooLmmhg for infants.
Place the dominant thumb over the control vent of the suction port, applying continuous or intermittent suction for no more than 10 sec as you withdraw the catheter into the sterile sleeve of the closed suction device Repeat steps above if needed Clean suction catheter with sterile saline until clear; being careful not to instill solution into the ETtube Suction oropharynx above the artificial airway Wash hands
ASSESSMENT OF OUTCOME
Improvement in breath sounds. Decreased peak inspiratory pressure; Increased tidal volume delivery during ventilation. Improvement in arterial blood gas values or saturation as reflected by pulse oximetry. (SpO2) Removal of pulmonary secretions.
Most contraindications are relative to the patient's risk of developing adverse reactions or worsening clinical condition as result of the procedure. Suctioning is contraindicated when there is fresh bleeding. When indicated, there is no absolute contraindication to endotracheal suctioning because the decision to abstain from suctioning in order to avoid a possible adverse reaction may, in fact, be lethal.
LIMITATIONS OF METHOD
Suctioning is potentially an harmful procedure if carriedout improperly. Suctioning should be done when clinically necessary (not routinely). The need for suctioning should be assessed at least every 2hrs or more frequently as need arises.