Suctioning A Nursing Approach Mr. Nestlee Sio Cabaccan RN,MSN
AimsTo 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.
ObjectivesAfter 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.
Content Definition of suctioning Brief history Anatomy and PhysiologyPurpose Guidelines
Definition Suctioning is a method of removing excessive secretions from the airway. May be applied to:
Oral Nasopharyngeal Tracheal passages
A Brief History Of SuctionAirway 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.
*1 This was around the time that the vacuum cleaner was invented and people were looking for differrent applications in terms of the technology involved and equipment used, it is. However, there are many variables associated with suctioning which affect the degree of trauma to the patient. It is vital that medical, nursing and paramedical staff using this procedure appreciate the possible dangers accompanying it and modify their approach accordingly.2 Using manometric techniques to measure blood oxygen saturation, they reported that severe hypoxia resulted from suctioning for one minute. The incidence and degree of hypoxia were not significantly different from those obtained during a similar period of apnea without suctioning.3 Rosen and Hillard (1962) stated that deaths during suctioning procedures have not been reported as often as personal inquiries indicate that they happen. They feel that an important cause of sudden death during suction might be an increased venous return on a hypoxic or diseased heart. They also recognise that cardiac arrest may arise from the stimulation of respiratory tract reflexes, although the part they play in endotracheal suction was difficult to determine.
A Brief History Of SuctionRosen 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.
*1 The non-infrequent occurrence of cyanosis during endotracheal suctioning, and occasional deaths attributable to the procedure, prompted studies of the subject
Anatomy And Physiology Of Related StructuresNosePharynxLarynxTracheaBronchiLungs alveoli
LarynxRt Superior LobeRT Middle LobeRt Lower lobeLt Superior LobeBronchial TreeCardiac NotchTracheaLt Inferior LobeDiaphragm
Purpose To provide a patent airway by keeping it clear of excessive secretions.
NECESSARY EQUIPMENTVaccum source with adjustable regulator suction jarstethoscopeSterile gloves for open suctioning methodClean gloves for closed suctioning methodSterile catheterClear protective goggles, apron & maskSterile normal salineBains circuit or ambu bag for preoxygenate the patientSuction tray with hot water for flushing
The Vagus NervesHave 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.
*These nerves form an important part of the parasympathetic nervous system.They arise from nerve cells in the medulla oblongata and other nuclei and pass down through the neck into the thorax and abdomen.
VAGUS NERVEBRANCHES 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 & COMPLICATIONSHypoxia / hypoxemiaTracheal and / or bronchial mucosal traumaCardiac or respiratory arrestPulmonary hemorrage / bleedingCardiac dysrhythmiasPulmonary atelectasisBronchoconstriction / bronchospasmHypotension / hypertensionElevated ICPInterruption of mechanical ventilation
TYPES OF SUCTIONINGOPEN SUCTIONCLOSED SUCTION
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.
MONITORINGThe following should be monitored prior to, during & after the procedure:Breath soundsOxygen saturationRR & patternHaemodynamic parameters (pulse rate, Blood pressure)Cough effortICP (If indicated and available)Sputum characteristics (colour, volume, consistency & odor)Ventilator parameters (PIP, Vt & FiO2)
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.
*Effect of Negative Pressure on Tracheobronchial Trauma Barbara M. Kuzenski.Nursing Research Vol 27 No 4.To test the effect of different negative pressures on tracheobronchial trauma in the presence of simulated mucus, measured amounts of simulated mucus were injected into the trachea of two anaesthetised mongrel dogs. Suctioning was performed using a different negative pressure for each animal. To identify the effects of negative pressure alone, endotracheal tube size, suction catheter type, suction duration, and suction procedure were identical for both dogs and were selected based on current practices at the hospital with which the investigator was affiliated. Arterial pressure and electrocardiogram were monitored throughout each experiment. The trachea was excised and examined for pathologic changes. Tracheobronchial trauma occurred with suctioning at negative pressures of 100 mm Hg and 200 mm Hg; damage was greater, however, at 200 mm Hg. Results were consistent with postulates made by other investigators in that the extent of tracheobronchial trauma was directly related to the magnitude of negative pressure applied. Comparison of this study, with studies which omitted mucus stimulation, suggests that the amount of damage is not related to the amount of mucus in the trachea. In addition, aspiration efficiency proved to be the same regardless of the negative pressure used. Suctioning at 200 mm Hg recovered approximately the same amount of mucus as suctioning at 100 mm Hg.Extensive loss of cilia was found in the tissue suctioned at 200 mm Hg. Since ciliary movements normally waft tracheobronchial mucus upward toward the epiglottis, destruction of cilliated epithelium suppresses mucus clearance. This predisposes the tracheobronchial tree to infection. The processes of healing tends to obstruct the passage of mucus, and the loss of cilia resulting from suction has far-reaching effects in that mucus clearance is suppressed not only for a period immediately following suctioning, but also for a lifetime. Repair of tracheobronchial tissue results in the formation of granulation and fibrous tissue, which can lead to obstructive crusting. Eventually flattened stratified epithelium replaces the normal cilliated epithelium (Spencer, 1976).REFERENCES.Berman IR and Stahl WM. Prevention of hypoxia complications during endotracheal suctioning Surgery63; 586-587, Apr 1968.Bucci SL. The Principles of Vacuuum and its Use in the Hospital Environment. Madison, Wics. Ohio Medical Products Corp 1974.Comroe JH Physiology of Respiration 2nd Ed. Chicago, Year Book Medical Publishers 1974.Fell T and Chenly FW. Prevention of hypoxia during endotracheal suction. Ann Surg 174; 24-28 July 71.Kearns B. Tracheotomy suctioning technique Can Nurse 66:4