Suctioning

Suction is an important skill in health care can be performed by physiotherapist, nursing staff and doctors.

1. Suction Dr. Rekha Marbate [PT] Assistant Professor

2. Content Introduction Purpose Indication Precautions Contraindication

3. Introduction Suction can be used to remove secretions from intubated patients and from infants and children who are unable to cough and expectorate.

4. General principles The technique should be as quick, clean and gentle as possible. Suction is very traumatic to delicate mucosal tissue and it is very easy to introduce infection, especially in intubated patients. Suction should only be carried out as and when necessary, rather than on a routine basis.

5. Equipment

6. Suction tube Suction Catheter Eye Protector ( Face shield) , Face Mask, Gloves

7. Suction trolley: All the equipment needed for airway suction should be set out on a trolley for ease of access: Sterile plastic gloves - disposable. Suction catheters - appropriate sizes for the patient. Lubricating jelly water-based only, not oil-based, for use in nasopharyngeal suction. Sterile gauze swabs - to transfer jelly to tip of catheter. sterile water - to flush the secretions through the catheter and tubing. Sodium bicarbonate acts as a solvent of the secretions. Forceps (if used). Plastic bag for the collection of disposables

8. Indication Whenever secretions can be heard in an intubated patient. For retained secretions in the spontaneously breathing patient who is unable to cough and expectorate efficiently. Before and during the release of the cuff on a tracheostomy tube. If the inflation pressure of the ventilator suddenly' rises. This may indicate the presence of a large plug of mucus in one of the larger bronchi or even within the endotracheal or tracheostomy tube. If the minute volume (MV) drops, this may indicate retained secretions

9. Risks and complications of suction Trauma: Mucosal haemorrhage and erosion frequently occur in the patient who has been suctioned, leading eventually to the formation of granulation tissue. The amount of trauma depends upon the frequency of suction, the amount of negative pressure applied, the size and type of catheter used and the vigour of insertion.

10. 2. Hypoxia. This can occur following suction. To avoid this the suctioning time should be kept to a minimum, particularly in tl ]( ose patients who are dependent on a ventilator, and the inspired oxygen and/or ventilation may be increased prior to suction providing there are no contra-indications.

11. Cardiovascular effects. Cardiac arrhythmias and hypotension can occur during suction due to hypoxia and/or vagal stimulation from direct pharyngeal and tracheal irritation. Particular care should be taken with neonates as bradycardia and apnoea can follow nasopharyngeal suction in these patients

12. Atelectasis. Too large a suction catheter in too small an airway will prevent room air from entering around the catheter during suctioning and atelectasis, in varying degrees, may occur. Too high a negative suction pressure may also cause atelectasis and airway collapse.

13. Pneumothorax. This can occur primarily in premature infants with severe underlying lung disease due to perforation of segmental bronchi by a suction catheter

14. Types Depending on site of Suctioning Nasotracheal suctioning (NT) Oropharyngeal suctioning Tracheostomy suctioning (TT) Endotracheal suctioning Depending upon circuit Open circuit Closed Circuit

15. Procedure:- Suction for intubated patients Wash hands. Prepare equipment: - turn on vacuum, check pressure - attach suction catheter - prepare saline or mucolytic solution - prepare gloves/forceps. Prepare patient - if conscious the patient should be swaddled in a blanket being aware of infusions, drains, tubes, etc ; or he should be held firmly by an assistant. The procedure should be explained to the child and constant reassurance given while suctioning is taking place. Physiotherapy may be carried out at this point if indicated.

16. Place glove on the hand that is to hold suction catheter. Withdraw catheter from its sterile pack with the gloved hand. Disconnect ventilated patient from ventilator. Insert catherter into tube without applying suction. Push catheter gently and quickly down tube until a slight resistance is met. Withdraw catheter 0.5cm. Apply suction. Withdraw catheter quickly, rotating gently between thumb and first finger and interrupting the suction pressure every few seconds.

17. 13. Reconnect patient to ventilator. 14. The same catheter can then be used to clear secretions from the mouth and nose. 15. Discard both the glove and the catheter. 16. Repeat until secretions are cleared.

18. Suction for non-intubated patients Children and infants should always be suctioned in side lying to prevent aspiration of vomit. 1. Wash hands. 2. Prepare equipment: - turn on vacuum, check pressure - attach suction catheter - prepare saline or mucolytic solution - prepare gloves/forceps. 3. Prepare patient - if conscious the patient should be swaddled in a blanket being aware of infusions, drains, tubes, etc ; or he should be held firmly by an assistant. The procedure should be explained to the child and constant reassurance given while suctioning is taking place. 4. Physiotherapy may be carried out at this point if indicated. 5. Place glove on the hand that is to hold suction catheter. 6. Withdraw catheter from its sterile pack with the gloved hand

19. Gently insert catheter into the nose using an upward motion until the nasal septum is passed, then using a downward motion. If a slight resistance is met, withdraw catheter slighdy and try again. Insert catheter to the back of the throat until a cough has been stimulated. It is possible to pass a catheter into the trachea by inserting the catheter during inspiration, but an effective cough can be elicited merely by stimulating the pharynx. Apply suction. Withdraw catheter, rotating slightly between thumb and first finger and interrupting the suction every few seconds. Repeat procedure via other nostril. Discard both the glove and the catheter. Repeat until secretions are cleared.

20. ORAL SUCTION 8. Pass suction catheter to the back of the throat until a cough has been stimulated. Ensure that the catheter is not curling up in the mouth. 9. Apply suction. 10. Withdraw catheter. 11. Repeat until secretions are clear. 12. Discard both the glove and the cathete

21. Contraindications to suctioning the intubated patient Frank haemoptysis Severe bronchospasm Undrained pneumothorax Compromised cardiovascular system.

22. Closed-circuit suction Closed-circuit suction systems are available and consist of a catheter in a protective closed sheath which remains attached to the endotracheal or tracheostomy tube for 24 hours. The indications for use are: immuno-suppressed patients, actively infectious patients (e.g. open TB) and patients with severe refractory hypoxaemia on high levels of PEEP.

23. Precautions 100 — i20mmHg is ideal for most patients although pressure up to —200mmHg may be needed for thick secretions. Nasopharyngeal suction: When introducing a suction catheter via the nose it is helpful if the patient’s neck is extended so that the head is tilted backwards resting on a pillow. If the patient can co-operate the tongue should be protruded, as this helps when attempting to pass the catheter between the vocal cords and into the trachea It must be remembered that nasopharyngeal suction is a very unpleasant experience for the conscious patient and should only be used when absolutely necessary. Nasopharyngeal suction should not be used for patients with head injuries where there is a leak of CSF into the nasal passages.

24. 3. Oropharyngeal suction. A lubricated plastic airway is usually tie eded to prevent the patient biting the catheter and it is difficult to direct the catheter accurately into the pharynx and beyond. 4. Suction via tube Whatever the mode of entry, the physiotherapist must ensure that no suction pressure is applied while the catheter is being introduced. If, during nasopharyngeal suction, the patient becomes cyanosed I and the catheter was difficult to insert, it is acceptable to disconnect the suction, leaving the catheter in situ, while administering oxygen J until the patient recovers and suction can be resumed. No longer than 15 seconds should elapse between the disconnec - I tion and reconnection of the patient to the ventilator, more than adequate time for effective removal of secretions by the experienced I operator. j Where possible, the patient should be suctioned in side lying or 1 with the head rotated to one side to avoid aspiration of gastric contents should vomiting occur.