a. Get the necessary equipment for the procedure

Oropharyngeal suctioning is considered a clean (not sterile) procedure. The suctioning device is often originally packaged sterile but may be used more than once. The Yankauer suction catheter is widely used, although several types are available. The Yankauer suction catheter is made of hard plastic and is angled to reach into the back of the mouth. One large opening or several medium-sized openings may be found at the tip of the catheter. The openings are large enough to permit easy suctioning of saliva, food, or vomit. Some handles include a thumb control valve so that suction can be applied to the tip only when wanted. Covering the opening with a thumb creates a vacuum at the tip for suctioning the patient’s mouth (Figure 13-1). The Yankauer may be discarded when no longer needed or sterilized for use with another patient.

Figure 13-1 Features of the Yankauer suction catheter.

A flexible plastic or rubber catheter also can be used. It should be the largest diameter possible to reduce the chance of its becoming plugged. The opening at the catheter tip should be cut straight (perpendicular) across instead of at an angle. No side openings should be present (Figure 13-2). The catheter is discarded when no longer needed.

Figure 13-2 Features of a suction catheter with a cross-cut tip.

b. Put the equipment together and make sure that it works properly

The catheters just mentioned are single pieces with nothing to assemble. They must be attached to a vacuum source by a length of soft rubber tubing. With clean gloves on both hands, attach the Yankauer, plastic, or rubber catheter to the vacuum tubing. The vacuum must be applied to the tip of the catheter for oral secretions to be removed. Check for a vacuum at the tip by any of the following methods:

c. Troubleshoot any problems with the equipment

If no vacuum is felt at the catheter tip, several causes are possible and must be investigated.

a. Calculations related to catheter size (math review)

The following formula can be used to calculate the OD of any suction catheter to determine the endotracheal or tracheostomy tube size with which the suction catheter may be used:

Suction catheter size (Fr) × 0.33=OD(mm) of suction catheter

EXAMPLE 1

Calculate the OD of a 12 Fr suction catheter:

This size catheter, therefore, could be used with an 8-mm ID endotracheal tube. Figure 13-3 shows the relative sizes of this endotracheal tube and catheter.

Figure 13-3 A 12 Fr suction catheter inside an endotracheal tube with an 8-mm internal diameter (ID). The outer diameter (OD) of the suction catheter should be no more than one half the ID of the tube so that the patient can breathe around it.

Use the following formula to estimate the maximum French size suction catheter for the ID of an endotracheal or tracheostomy tube:

b. Get the necessary equipment for the procedure

The term open-airway suctioning is used here to refer to a suctioning procedure on a patient who is spontaneously breathing room air after being disconnected from the source of supplemental oxygen. For example, in a patient with a normal upper airway, the oxygen mask is removed for nasotracheal suctioning. Also, in a patient with an endotracheal or a tracheostomy tube, the aerosol T-piece (Briggs adapter) or ventilator circuit is removed to allow suctioning.

These types of catheters have been in use for many years. The two basic types are shown in Figure 13-4. Closing the thumb control, as shown in Figure 13-5, allows the vacuum to be selectively applied to the secretions when desired. The tips of the catheters can vary greatly. A considerable amount of effort has been spent trying to develop a catheter tip that most effectively removes secretions without damaging the tracheal mucosa. Figure 13-6 shows some of the catheter tips that have been developed to minimize mucosal damage. Note that all feature at least one opening in the catheter that is back from the opening at the tip. Compare this with the single end opening found on the oral suction catheter (see Figure 13-2). The side openings are designed to prevent the vacuum from being applied to the tip when it makes contact with the mucosa.

Figure 13-4 Features of two types of suction catheters with angle-cut tips and side holes. A, This catheter has its own thumb control valve. B, This catheter must have a thumb control valve constructed from a Y-connector.

Figure 13-5 Close-up of a thumb control valve showing how room air is drawn into vacuum tubing when the valve is left open. Closing the valve creates a vacuum at the catheter tip, allowing secretions to be suctioned.

Figure 13-6 Close-ups of the ends of three suction catheters. A, Bevel-cut tip with two offset side holes. B, Ring tip with several side holes around it. C, Coudé (curved-tip) catheter; the curve may help guide the catheter into either the left or right mainstem bronchus.

(From Rarey KP, Youtsey JW: Respiratory patient care, Englewood Cliffs, NJ, 1981, Prentice-Hall.)

Notice in Figures 13-4 and 13-6 that most catheters are straight throughout their length. All of these catheters tend to enter the right mainstem bronchus during deep suctioning. This is because the right mainstem bronchus’s angle off of the trachea is less acute than that of the left mainstem bronchus. Therefore, it is difficult, if not impossible, to use any of these catheters to suction the left mainstem bronchus. The Coudé catheter has an angled tip to make it easier to guide into the left (or right) mainstem bronchus (see Figure 13-6, C). When these catheters are used, the direction of the thumb control valve can help determine the angle of the bent tip.

Use of these traditional types of catheters during open-airway suctioning always results in some level of hypoxemia. The newer, insufflating suction catheter is designed to provide alternatively oxygen through the catheter or vacuum for suctioning. The thumb control end of the catheter is modified with two male-type tubing connectors and a way to switch the lumen of the catheter between them. The thumb control is set to direct the oxygen through the catheter and into the patient as the catheter is advanced. After the catheter has been deeply placed into the trachea for suctioning, the thumb control is switched from delivering oxygen to applying suction.

c. Get the necessary equipment for the procedure

The term closed-airway suctioning is used here to refer to a suctioning procedure in which the patient remains connected to the original source of oxygen. This may be done through a special aerosol T-piece or, more commonly, for an intubated patient receiving mechanical ventilation with positive end-expiratory pressure (PEEP). In addition, closed-airway suctioning may reduce the risk of ventilator-associated pneumonia (VAP). This suctioning method is preferred in patients who are likely to become hypoxic when disconnected from their oxygen source.

In closed-airway suctioning systems, a flexible, clear plastic sheath covers the catheter to maintain its sterility (Figure 13-7). The practitioner does not need gloves. When used for patients who need frequent suctioning, self-contained systems have a financial advantage over the traditional catheter and gloves suctioning method, because they can be reused. Closed-system suction catheters come with either the traditional straight tip or the Coudé tip for selective bronchial suctioning.

Figure 13-7 Self-contained catheter and sheath suctioning system for closed-airway suctioning (based on the Kimberly-Clark/Ballard Trach Care closed endotracheal suction device).

Another device used to create a sealed system for endotracheal tube suctioning consists of an elbow adapter that has an inner plastic sleeve or diaphragm. As the traditional catheter is inserted into the opening on the elbow adapter, the sleeve or diaphragm conforms to the catheter so that no air leakage occurs (Figure 13-8). This ensures that the ventilator-delivered volumes and pressures are not lost through a leak.

Figure 13-8 Features and placement of a special elbow adapter, which allows closed-airway suctioning without loss of tidal volume or pressure during mechanical ventilation.

d. Put the equipment together andmake sure that it works properly

Figure 13-4 shows the attachment of an open-airway suction catheter to the vacuum tubing, and Figure 13-7 shows the attachment of a closed-airway suction catheter to the vacuum tubing. The other end of the vacuum tubing is attached to the vacuum regulator system.

With open-airway suctioning, only a hand covered by a sterile glove can be allowed to touch the area of the catheter that enters the patient’s trachea. The practitioner’s other hand also should be gloved. A clean glove is acceptable for that hand, because it does not touch the part of the catheter that will enter the patient’s trachea.

While holding the body of the catheter, the thumb control valve, and the vacuum connector with the sterile-gloved hand and the vacuum tubing with the cleangloved hand, slip the vacuum tubing over the catheter’s vacuum connector. The seal should be tight so that no vacuum leak occurs. From now on, only the sterile-gloved hand may touch the part of the catheter that makes contact with the patient. The clean-gloved hand may touch only the thumb control valve and vacuum tubing. If the catheter is contaminated, it must be discarded.

The catheter can be tested for patency and vacuum at the tip by the three methods described earlier in the discussion on oropharyngeal suction devices. Note that only a sterile glove may be touched against the tip of the suction catheter to check for a vacuum.

The practitioner does not need gloves when a selfcontained catheter is used for closed-airway suctioning, because the sheath covers the catheter to prevent contamination.

e. Troubleshoot any problems with the equipment

The three common causes of an equipment failure and how to troubleshoot them are described in the earlier discussion on oropharyngeal suction devices. Remember to withdraw the closed-airway suctioning catheter completely from the endotracheal tube into the sheath, or it will partially obstruct the tube.

a. Get the necessary equipment

A variety of specimen collectors (commonly called Lukens traps) are available. They are packaged as sterile so that no contamination of the sputum sample occurs with nonpatient organisms. Figures 13-9 through 13-12 show the key features and functions of several sputum sample collectors. The sputum sample is obtained through a suction catheter or bronchoscope.

Figure 13-9 Features of a collection system for sputum specimens that includes a thumb control valve.

Figure 13-10 Features of a collection system for sputum specimens that does not have a thumb control valve.

Figure 13-11 Features of a collection system for sputum specimens that has a thumb control valve built into catheter.

Figure 13-12 Features of the DeLee collection system for sputum specimens, showing the mouthpiece through which the practitioner can apply suction.

The specimen jar has volume markings. It screws into either a special lid used to suction the specimen or a regular lid. The regular lid is used for shipment to the laboratory. The special lids used in the systems featured in Figures 13-9 and 13-10 must be connected to a sterile catheter. Figure 13-11 shows a system with its own catheter. The vacuum source is provided to these specimen collectors by a length of vacuum tubing, as in the previously described suction catheter systems. Figure 13-12 shows a DeLee system, which is sometimes used in the delivery room. The physician, nurse, or practitioner uses mouth suction to remove secretions from the newborn. In all of these examples, after the sample has been collected, the special lid is unscrewed and replaced with the regular specimen jar lid.

b. Put the equipment together and make sure that it works properly

A properly working specimen collection system provides a vacuum to the tip of the suction catheter when the thumb control valve or mouthpiece is sealed and vacuum is applied. This is tested by dipping the catheter tip into a container of sterile water or saline solution. The liquid is drawn up the catheter and deposited in the specimen jar. (The water can be discarded from the jar.)

c. Troubleshoot any problems with the equipment

Failure to have a vacuum at the tip of the suction catheter may be caused by any of the previously mentioned possibilities. They can be checked and corrected by the methods listed earlier. Two causes of an inability to suction secretions are common. One cause is that the jar is not screwed tightly into the special lid, allowing room air to be drawn in. Simply screw the lid in tightly. The second cause is that the secretion channel is plugged. Discard it and replace it with a new specimen collector.

a. Portable vacuum systems

Portable units are designed to be moved with the patient. They may be mounted on a small platform (Figure 13-13) or on a wheeled cart. The portable systems generally include an electrically powered vacuum pump with an ON/OFF switch and a collection bottle. Some units have a control valve for adjusting the level of negative pressure. A negative-pressure gauge is used to determine how much vacuum is being applied. A length of rubber vacuum tubing is used to pass the negative pressure from the pump to the collection bottle. Another length of vacuum tubing is used to pass the vacuum through to the suction catheter. Portable systems are not as powerful as central vacuum systems. They are not very effective at suctioning out large amounts of thick secretions.

Figure 13-13 Portable suction machine, showing the electrically powered motor, collection bottle and cap, and connecting tubing.

(Courtesy Allied Health Care Products, St Louis, Mo.)

In general, the following steps are followed to make the units operational:

b. Central vacuum systems

Central (wall) vacuum systems usually are available at each patient’s bedside in all special care units. Each of the wall outlets is connected through a hospital-wide piping system to a large, electrically powered vacuum pump. It is capable of generating a negative pressure far greater than that needed in most patient care situations. A regulator is used to reduce the vacuum to the desired clinical level (Figure 13-14). Either a Quick Connect or a Diameter Index Safety System (DISS) connector is used to attach the regulator to the central vacuum system.

Figure 13-14 Features of the Ohmeda central vacuum regulator with a three-position selector knob.

(Courtesy Ohmeda Medical, Columbia, Md.)

Most regulators have a selector knob that allows the user to turn the vacuum off (OFF setting) or to switch between full vacuum (FULL setting) and a regulated level of vacuum (REG setting). The FULL setting opens the unit to the maximum level of vacuum available from the central pump. The REG setting allows the user to adjust the vacuum level through a wide range.

In general, the following steps are followed to make the units operational:

Figure 13-15 The negative pressure level is set on the Ohmeda central vacuum regulator by pinching the vacuum tubing and adjusting the vacuum control knob. The vacuum pressure is displayed on the pressure gauge.

(Courtesy Ohmeda Medical, Columbia, Md.)

c. Troubleshoot any problems with the equipment

a. Vagus or vagal nerve stimulation

Vagal nerve endings are found in the hypopharynx and trachea. When they are mechanically stimulated by a suction catheter, any of the following may be seen:

Listen to the patient’s breath sounds before and after suctioning to determine whether an increase in wheezing is present, which shows bronchospasm. Check the heart rate and rhythm by palpation or cardiac monitor to determine whether the patient is becoming bradycardic. The blood pressure also can be measured to check for hypotension.

Further suctioning should be delayed, if possible, until the patient’s wheezing and vital signs have returned to normal. It may be necessary to modify the suctioning procedure by not going as deeply and striking the carina, not twisting the catheter, or not suctioning for as long to reduce the risk of vagal stimulation. A local anesthetic, such as lidocaine (Xylocaine), can be nebulized (with a physician’s order) to reduce the local reaction to the catheter.

a. Make a change in the size and type of suction catheter (ELE code: IIIF2h2) [ELE Difficulty: R, Ap, An]

As discussed earlier, the OD of the suction catheter should be no more than one-half the ID of the patient’s endotracheal tube. If the secretions are easy to suction out, a smaller catheter may be used. A spontaneously breathing patient is less likely to become hypoxic if the tube is less obstructed.

A catheter with a Coudé tip should be used if the catheter must be directed into one or the other mainstem bronchus (usually the left). Closed-airway catheters, such as those made by Ballard Medical Products, offer two advantages over single-use catheters. First, they are more economical if the patient needs frequent suctioning. Second, a patient using a mechanical ventilator continues to be ventilated and oxygenated and to have PEEP maintained during the suctioning episode. The newer catheters that offer intermittent or continuous insufflation of oxygen may reduce the hypoxemia that many patients experience during the suctioning procedure. However, they can be difficult to use and costly.

b. Change the level of vacuum used when suctioning (ELE code: IIIF2h3) [ELE Difficulty: R, Ap, An]

In general, the lowest possible vacuum level should be used that adequately removes secretions. The AARC Clinical Practice Guidelines on suctioning list appropriate negative pressure ranges for patients based on their age. These are listed in the suctioning procedures given earlier. Be prepared to reduce the suctioning pressure if the patient’s secretions are watery and easy to remove. Conversely, be prepared to increase the suctioning pressure if the patient’s secretions are thick and difficult to remove.

c. Instill an irrigating solution into the trachea (ELE code: IIIF2h4) [ELE Difficulty: R, Ap, An]

Sterile normal saline solution (0.9%) is widely accepted as useful for instilling into the trachea to dilute and mobilize pulmonary secretions. It should be used whenever secretions are difficult to suction out. Because the secretions are easier to remove, the respiratory therapist also can use a lower vacuum level. In adults, about 5 to 10 mL is instilled into the trachea and then suctioned out with any secretions. Less is used with children, but no universal guidelines are available. Neonates reportedly have been given amounts ranging from a few drops to 0.33 mL.

d. Change the frequency of suctioning (ELE code: IIIF2h1) [ELE Difficulty: R, Ap, An]

Secretions obstruct the airways and should be removed if possible. Often this requires more than one suctioning episode. The patient is unlikely to be harmed with repeated suctioning as long as proper technique is followed and the patient is reoxygenated between sessions. Watch for any of the complications listed in Boxes 13-1 and 13-2. Listen to the patient’s breath sounds for crackles (rhonchi) or palpate the chest for secretions (tactile fremitus) between suctioning efforts. Stop suctioning when it is no longer needed.

e. Change the duration of suctioning (ELE code: IIIF2h1) [ELE Difficulty: R, Ap, An]

The entire procedure should take 10 to 15 seconds. Actual suctioning generally takes 5 to 10 seconds. However, some patients may not be able to tolerate it this long because of hypoxemia or unstable vital signs. Be prepared to suction for a shorter period. It is safer to suction repeatedly than to increase the suctioning time.

f. Terminate the procedure based on the patient’s response (Code: IIIF1) [Difficulty: ELE: R, Ap; WRE: An]

Stop the procedure if the patient becomes hypoxic or has tachycardia, bradycardia, arrhythmias, hypotension, bronchospasm, or any of the other hazards or complications listed in Boxes 13-1 and 13-2. Bloody secretions indicate possible mucosal damage and justify stopping the procedure. Hypoxemia can cause unstable vital signs, and vagal stimulation can cause bradycardia and bronchospasm. Be prepared to stop suctioning, give extra oxygen, or get help.

Conscious patients should be able to report how they feel after the suctioning of secretions. Hopefully, a patient’s feeling of dyspnea will have improved. Inform the patient’s nurse or physician and the supervising therapist if the patient has any serious questions or problems. Routine communication should occur as needed between these people and any other caregiver.

g. Recommend discontinuation of the procedure based on the patient’s response (Code: IIIG1i) [Difficulty: ELE: R, Ap; WRE: An]

When hypoxemia, tachycardia, bradycardia, arrhythmias, hypotension, bronchospasm, pneumothorax, or pulmonary hemorrhage occur during endotracheal suctioning, the patient’s life is in danger. If any of these problems arise repeatedly, cancellation of the suctioning order is justified. Once the underlying problem has been corrected and safe suctioning can be performed, the order may be reinstated.

Suctioning should be discontinued when the patient has recovered to the point where it is no longer needed. Either the patient’s secretions have decreased in volume, or the patient now is able to cough them out.

a. Record and interpret the following: heart rate and rhythm, respiratory rate, blood pressure, body temperature, and pain level (Code: IIIA1b4) [Difficulty: ELE: R, Ap; WRE: An]

See the discussion on these topics in Chapter 1 or earlier in this chapter.

b. Record and interpret the patient’s breath sounds (Code: IIIAb3) [Difficulty: ELE: R, Ap; WRE: An]

If suctioning is effective, the patient’s breath sounds will improve. The crackles (rhonchi) that were heard before suctioning should now be absent. Normal breath sounds should be heard.

c. Record and interpret the type of cough the patient has and the nature of the sputum (Code: IIIAb3) [Difficulty: ELE: R, Ap; WRE: An]

The amount and consistency of sputum a patient produces depends on the lung problem and whether it is worsening or improving. For example, if pneumonia or bronchitis is worsening, secretion production is increased. If the patient is dehydrated, the sputum contains less water than normal. The patient may complain that the secretions are thicker and harder to cough out. Airway suction may be needed to remove the secretions. As the patient’s condition improves, a return to normal sputum consistency should occur, and less should be produced. The patient should be able to cough it out effectively.