Suctioning

Suctioning

1. JAMIA MILIA ISLAMIA CENTRE FOR PHYSIOTHERAPY & REHABILITATION SCIENCES PRESENTATION OF PHYSIOTHERAPY IN CARDIOPULMONARY CONDITIONS ( BPT-402) TOPIC- SUCTIONING SUBMITTED TO- DR. JAMAL ALI MOIZ SUBMITTED BY- TANVEER BHOLA BPT 4 TH YEAR PRESENTATION DATE- 16.02.2021 1

2. SUCTIONING S uctioning refers to the method of clearing secretions from the airways of patients who can not mobilize and expectorate them without assistance. Suctioning is used to clear retained or excessive lower respiratory tract secretions in patients who are unable to do so effectively for themselves. This could be due to the presence of an artificial airway, such as an endotracheal or tracheostomy tube, or in patients who have a poor cough due to an array of reasons such as excessive sedation or neurological involvement. INDICATIONS- patients incapable of coughing at voluntary or reflex level. ineffective coughing due to weakness and exhaustion in very sick patients. patients who are breathing spontaneously but are unwilling or unable to cough effectively due to confusion , pain. deeply unconscious or, patients with respiratory muscle paralysis A ll intubated patients. 2

3. CONTRAINDICATIONS- Patients with acute head injury or after intracranial surgery Frank hemoptysis Severe bronchospasm Patients with fracture of base of skull or cerebrospinal fluid leak Undrained pneumothorax Compromised cardiovascular system. 3

4. SUCTION EQUIPMENTS- 1. Suction Pumps- it produces the vacuum or suction force needed to aspirate substances . a) Suction apparatus designed to work from a vacuum point close to the patient’s bed . It is most commonly found in hospitals in ICU and wards. It has an on/off switch , control dial, and a manometer. b) Electrical suction apparatus is powered from the mains. It has its own small motor , on/off switch and control dial . c) portable suction apparatus is available powered by rechargeable batteries . All suction pumps have at least one suction bottle (partially filled with antiseptic solution ). 2. Suction Tubing- this leads from the suction bottle to the connection for the suction catheter. Usually made from clear plastic and is disposable (rubber tubing is less used). 4

5. 3 . Connections- made up of clear or semitransparent plastic have 3 holes or 3 arms (Y connector) the catheter and tubing fit on to opposite ends and the third hole is used by operator as control port . To apply suction force to the catheter the operator places a finger or thumb over the opening . 4. Catheters- these are made from soft, clear plastic and are disposable. commonly used sizes for the adult patients are 10,12,14 and 16 FG and are colour coded for size . (6, 8 FG in paediatric , neonates). the size of catheter should not exceed half the diameter of the endotracheal or tracheostomy tube. rubber catheter must be sterilized after use . 5

6. 5. Suction Trolley- all the equipments needed for airway suction should be set out on a trolley for ease of access. sterile plastic gloves (disposable) suction catheters of appropriate size lubricating jelly sterile gauze swabs sterile water plastic bags 6

7. SUCTION SYSTEMS- Closed Suction System- Do not disconnect from ventilator. Similar procedure to open technique but no application of sterile glove Enables a clinician to clear the lungs of secretions whilst maintaining ventilation and minimising contamination with the least possible disruption to the patient Helpful in preventing cross contamination and infection. Open Sterile Technique- Clearing  the airways of a mechanically ventilated patient with a  suction catheter inserted into the endotracheal tube after the patient has been disconnected  from  the  ventilator circuit. 7

8. MODES OF ENTRY- A suction catheter can be introduced into the respiratory tract through the nose, mouth or a tube. NASOPHARYNGEAL SUCTION- The nasopharyngeal airway is a simple airway adjunct that can be used to facilitate ventilation and removal of secretions . The NPA is a robust, supple but kink-resistant tube made of soft rubber. They are flanged at the proximal (nasal) end. When properly placed, the tip rests behind the tongue, just above the epiglottis, having separated the soft palate from the posterior wall of the oropharynx. A suction catheter can be passed through the tube and into the posterior pharynx and trachea . Selection of Nasopharyngeal Airway- The appropriate size of nasopharyngeal airway for average females is a size 6. For average males, the size should be a size 7. The final selection should be based on the patient’s height and clinical condition. Proper sizing for the patient is important. If the nasopharyngeal airway is too short, the airway would not separate the soft palate from the posterior wall of the pharynx. If the airway is too long, it would enter either the larynx and aggravate laryngeal reflexes. The ideal length of the nasopharyngeal airway should have the distal end of the airway within 1 cm of the epiglottis. 8

9. Insertion of Nasopharyngeal Airway- Prior to insertion of a nasopharyngeal airway, the nares should be inspected for obstruction. A local anesthetic spray may be applied to the posterior nares for patient comfort . Prior to insertion, the patient should be in a sitting or semi- Fowler position and the nares are lifted to reveal the nasal airway. Placement of the airway should be parallel to the nasal floor, rather than upwards toward the cribriform plate of the ethmoid bone. Lubrication with a water-soluble lubricant and gentle rotation should facilitate the insertion. 9

10. OROPHARYNGEAL AIRWAY- An OPA is a rigid PVC tube that is flanged at the proximal (mouth) end and is shaped to conform to the curvature of the palate. When inserted properly, the flange sits just outside the lips and the tube keeps the patient's tongue extended and prevents it from opposing against the posterior pharynx . The appropriate size (from flange to distal tip) of an oropharyngeal airway may be estimated based on the length in millimeters from the center of the mouth to the angle of the jaw. Alternatively, the length in millimeters from the corner of the mouth to the earlobe may be used. The third method is to measure the distance from the central incisors to the angle of the jaw. To evaluate the size using this method, place the airway next to the patient’s face . Proper sizing for the patient is important. If the airway is too large, it may push the epiglottis against the larynx leading to airway obstruction. If the airway is too small, the tongue may not be sufficiently moved away from the soft palate leading to airway obstruction by the tongue. 10

11. Insertion of Oropharyngeal Airway- Prior to insertion of an oropharyngeal airway, ensure that the patient is sedated or unconscious. If the patient begins to gag during the procedure , remove the airway immediately and reassess the necessity of an oropharyngeal airway. Sometimes the airway may be opened and maintained by repositioning of the head (e.g., head tilt-chin lift, jaw thrust ). The patient should be in a supine position, and the mouth is opened using the scissors (crosses fingers) technique. If a tongue blade is available , the tongue is depressed and the oropharyngeal airway may be inserted with the pharyngeal curvature. Some practitioners prefer to insert the airway into the patient’s mouth upside down so that the distal end of the airway is facing the hard palate (roof of the patient’s mouth). As the airway is inserted fully, it is turned 180° until the flange (proximal end) rests on the patient’s lips or teeth. 11

12. Sizing Position OPA upside down Insertion of an OPA - rotation through 180 degrees Rotation of an OPA - rotation through 180 degrees until positioned in airway Suction via an OPA 12

13. SUCTION PROCEDURE- 1. Whatever the mode of entry the physiotherapist must ensure that no suction pressure is applied while the catheter is being introduced. It can lead to severe trauma in the mucus layer. 2 . The catheter is inserted until a cough reflex is elicited or some resistance is met in the trachea (Carina ). 3. Suction is then applied by occluding the open hole of control port with the help of thumb . 4. Simultaneously the catheter is withdrawn while gently rolling the catheter between finger and thumb to ensure a continuous rotation to minimise tracheal trauma . 5. Interrupted suction should always be used to avoid a maximum build up of negative pressure 6. Under no circumstances tromboning method should be used, that is, a vigorous up and down movement of the catheter. 13

14. 7. At all times during the procedure observe the patient for signs of hypoxia and if needed administer oxygen or ventilation immediately. 8. Pre-suction oxygenation and Manual hyperinflation can be applied in patients who are at risk of suffering from hypoxia. 9. No longer than 15 seconds should elapse between the disconnection and reconnection of the patient will the ventilator. 10 . If possible patient should be suctioned in side lying or with head rotated to one side to avoid aspiration of gastric contents in case of vomiting. 11. After suctioning patient must be connected to the ventilator or oxygen supply immediately. 12. The therapist should flush the catheter through sterile water, remove the gloves over the catheter and discard both. Suction pump should be switched off. 14

15. HAZARDS OF AIRWAY SUCTIONING- Risk of infection which can be avoided by a good sterile technique. Mucosal trauma- Mucosal trauma is reduced by using an atraumatic catheter, good suctioning technique , and the correct pressures. Cardiac arrhythymias - Direct tracheal stimulation causing a vasovagal reflex can cause arrhythmias. Pre- and post-oxygenation can minimize this effect. Hypoxia - Hypoxia can be caused by the interruption of ventilation, reflex bronchospasm and the removal of the oxygen supply. Pre- and post-oxygenation can minimize this effect . This can occur during nasopharyngeal as well as endotracheal suctioning. Accurate use of applied negative pressure and timing can be helpful in minimising hypoxia, that is, not too powerful or not too long. Raised intracanial pressure- Suction has been proven to increase ICP dramatically, therefore suction should be used only when indicated. 15

16. REFERENCES- Physiotherapy for Respiratory and Cardiac Problems, Edited by Jennifer A Pryor MBA MSc FNZSP MCSP and Barbara A Webber FCSP DSc(Hon ), SECOND EDITION. PRINCIPLES AND PRACTICE OF CARDIOPULMONARY PHYSICAL THERAPY, THIRD EDITION, Edited by: Donna Frownfelter , MA, PT and Elizabeth Dean, PhD, PT. 16