8- suctioning-updated1444.ppt

Respiratory Care Therapeutics Course (RT 264) Suctioning 1444 (2023) Suctioning Objectives 1- Identify suctioning. 2- List the sites for suctioning. 3- Mention the indications and contraindications for suctioning 4- Explain the deference between oropharengyeal / nasopha...

Respiratory Care Therapeutics Course (RT 264) Suctioning 1444 (2023) Suctioning Objectives 1- Identify suctioning. 2- List the sites for suctioning. 3- Mention the indications and contraindications for suctioning 4- Explain the deference between oropharengyeal / nasopharyngeal suctioning and endotracheal / tracheostomy suctioning as well as choosing the correct size of catheter. 5- Describe Hazards and complications of suctioning and the techniques to minimize those complications. 6- Apply in a proper way the procedure of suctioning. Suctioning Introduction Suctioning : is the application of negative pressure (vacuum) to the airways through a collecting tube (flexible catheter or suction tip) connected either to a suction machine or wall suction outlet for aspirating secretions from the airways The goal of airway clearance techniques is to improve secretions clearance, thereby prevent secretion retention, decreasing obstruction of airways and improve gas exchange. Secretions can be Removed by: - Coughing OR - Suctioning Suctioning may be necessary if the Pts has difficulty in handling their secretions or when an artificial airway is in present. Suctioning can be performed by way of either the upper airway (oropharynx) or the lower airway (trachea and bronchi). Secretions or fluids also can be removed from the oropharynx by using a rigid tonsillar or Yankauer suction tip Suctioning Access to the lower airway is by introduction of a flexible suction catheter through the nose (Nasotracheal suctioning) or artificial airway (endotracheal suctioning). Tracheal suctioning through the mouth should be avoided because it causes gagging. NB; removal of FB, secretions, or tissue masses beyond the main stem bronchi requires bronchoscopy that done by the physician and RTs often assist physician in performing bronchoscopy. Suctioning Upper airways Nasopharyngeal Oropharyngeal Sites for Suctioning Endotracheal Tracheostomy Lower airways Suctioning Indications Need to maintain patency and integrity of the artificial airway Need to remove accumulated pulmonary secretions Need to obtain a sputum specimen to rule out or identify pneumonia or other pulmonary infection or for sputum cytology Contraindications When suctioning indicated, there is no absolute contraindication to endotracheal suctioning Suctioning Equipment: Suction Catheters Suction catheters are either: – Open tipped (more effective with thick plugs but can pull at tissues) or – Whistle tipped (less irritating to respiratory tissues) Most have thumb port to control suction Catheter attached to tubing which then attaches to collection chamber. Sizes of suction catheters: sized in French units (external circumference). - #12 to #18 Fr for adults - #8 to #10 Fr for children - #5 to #8 Fr for infants Most suction catheters for adult general purposes are 22 inches long (sufficient to reach the main stem bronchi) Suctioning Equipment: Suction Catheters Rule of Thumb To estimate quickly the proper size of suction catheter to use with a given endotracheal tube, first multiply the inner diameter(ID) of the tube by 2. then use the next smallest size catheter; Example: 6 mm endotracheal tube: 2 × 6 = 12, so; the next smaller size of catheter is 10 Fr. To avoid atelectasis and hypoxemia that may results from using too large suction catheter combined with negative pressure that quickly evacuates lung volume , the diameter of the catheter should be less than 50% of the internal diameter of the artificial airway in adults. In infants and small children, the diameter of the suction catheter should be less than 70% of the internal diameter of the artificial airway Suctioning Equipment: Suction Catheters Yankauer (Rigid Tonsill-Tip) Catheter Flexible suction catheter for lower airway for Oropharyngeal suctioning suctioning. Suctioning Equipment: Vacuum; How much pressure? Depends on if wall or portable unit is used… Suction pressure should always be checked by occluding the end of the suction tubing before attaching the suction catheter. The suction pressure should be set at the lowest effective level. Negative pressures of 80 to 100 mm Hg in neonates and less than 150 mm Hg in adults are generally recommended. Wall Suction Unit Portable Suction Unit Suctioning The procedure E 1- Sterile Suction Catheter kit 2-Vacuum: portable or wall 7- Sterile gloves, Goggles or Q suctioning machine with face shield. tubing and collection receptor. 8- Water – soluble lubricant U 3- Oxygen (O2) source with a 9- Pulse oximeter I calibrated flowmeter (open 12- Manual resuscitation bag equipped with O2-enrichment suction) or ventilator (closed P suction) device for emergency backup use M 4- Sterile deposable container 11 Stethoscope for fluids Optional Equipment E 5- Sterile normal saline or Electrocardiograph water. N 6- Towel or moisture -resistant Sterile sputum trap for culture specimen T pad & sterile gauzes. Suctioning The procedure Cont’ Position of the patient. Conscious patient Unconscious patient :Semi – Fowler’s position with Lateral position and the patient head turned to one side for oral facing you. suctioning. For nasal suctioning with the neck hyperextended. Suctioning The procedure Cont.,//: Technique for oropharyngeal suctioning - Prepare the equipment as mentioned before then; 1) Check the unit and turn it on and select appropriate negative pressure. 2) Select and measure proper catheter to be used. 3) Open the patient’s mouth and pull the tongue forward. 4), do not apply suction during insertion. Then advance the catheter about 10 to 15 cm along on side of the mouth into oropharynx 4) Suction as you withdraw the catheter. NB; Never suction adults for more than 15 seconds. 1 3 Suctioning The procedure Cont.,//: Technique for Nasopharyngeal Suctioning - Prepare the equipment as mentioned before then; 1) Check the unit and turn it on and select appropriate negative pressure. 2) Select and measure proper catheter to be used. 3) Optimal position of the head to insert catheter in: The neck is flexed, and the head is extended.. 4) Lubricate (with water soluble lubricant) and introduce the catheter into the nasal cavity, do not apply suction during insertion. Never force the catheter against an obstruction. 4) Suction as you withdraw the catheter. NB; Never suction adults for more than 15 seconds. 4 Suctioning Important notes during Suctioning Perform suctioning (not more than 10 – 15 sec) Clean the catheter and apply suction again Flash the catheter with sterile water or saline. Relubricate the catheter and repeat suctioning until the air passage is clear. Allow 20 to 30 second intervals between each suction and limit suctioning to 5 minutes in total. Alternate nares for repeat suctioning. Encourage the Pt to breath deeply and to cough between suctioning.  Obtain specimen if required. - Promote the patient comfort. - Dispose of equipment and ensure availability for the next suction. - Assess the effectiveness of suctioning. Suctioning//: Artificial Airway suctioning ICU Patient in the Simulation Lab Closed suction catheter Suctioning Artificial Airways (Endotracheal or Tracheostomy) Suctioning 1. Physician's order is required. 2. Observe for signs and symptoms of excess secretions in the oral cavity and productive cough without expectoration. 3. Assess lung sounds for labored breathing, restlessness/irritability, color, unilateral breath sounds, and oxygen saturation. There two type of suctioning through artificial airways ( ET or Trach tubes) Deep suctioning: is when the catheter is inserted until meet resistance and then withdrawn approximately 1 cm back before applying suction. Shallow suctioning: is when the catheter is advanced for predetermined depth, which is usually the length of airway plus the adapter. It is recommended in infant and young children (better to avoid deep suctioning) Suctioning Prepare equipment as mentioned before then - Fill sterile basin or cup with approximately 100 ml of sterile water. Be careful not to touch inside of sterile basin - Aseptically open suction kit or catheter. - Apply sterile glove to each hand (or apply non-sterile glove to non-dominant hand & sterile glove to dominant hand). Attach non-sterile suction tubing to sterile catheter, keeping hand holding catheter sterile. - Connect one end of connecting tubing to suction machine. - Check that equipment is functioning properly by suctioning a small amount of water from basin. - Turn suction device on. Set regulator to appropriate negative pressure: Negative pressures of 80 to 100 mm Hg in neonates and less than 150 mm Hg in adults are generally recommended. Suctioning Endotracheal or tracheostomy tube suctioning Hyperinflate and/or hyperoxygenate Pt before suctioning, using manual resuscitation bag or sigh mechanism on mechanical ventilator. Delivery of 100% oxygen (O2) for 30 to 60 seconds to pediatric and adult patients is suggested, especially to patients who are at risk for hypoxemia Open swivel adapter in case of closed suction technique , or, if necessary, remove oxygen or humidity delivery device with non-dominant hand. There are two techniques for endotracheal suctioning: Open and closed. The open technique, sterile technique requires disconnecting the patient from the ventilator. The closed technique, uses a sterile, closed, in-line suction catheter that is attached to the ventilator circuit so that the suction catheter can be advanced into the patient’s endotracheal airway without disconnecting the patient from the ventilator. Suctioning Without applying suction and using dominant thumb and forefinger, gently but quickly insert catheter into artificial airway (best to time catheter insertion with inspiration) until resistance is met or Pt coughs, then pull back 1 cm. In infants the shallow suction method should be used, advancing the catheter just to the end of the artificial airway as recommended to prevent tracheal mucosal trauma. Apply intermittent suction by placing and releasing non-dominant thumb over vent of catheter, then gently and slowly withdraw catheter while rotating it back and forth between dominant thumb and forefinger. The maximum time catheter may remain in airway is 10-15 seconds. Encourage Pt to cough. Close swivel adapter or replace oxygen delivery device. Encourage Pt to deep breathe. Some Pts respond well to several manual breaths from the mechanical ventilator or resuscitation bag. Rinse catheter and connecting tube with NS until clear. Use continuous suction. If the secretions are extremely tenacious, instillation of acetylcysteine or sodium bicarbonate (2%) may be more effective than normal saline; this generally requires a physician’s order. Assess Pt's cardiopulmonary status for secretion clearance and complications. Suctioning Repeat suction if needed. Allow adequate time (at least 1 full minute) between suction passes for ventilation and re-oxygenation. Perform nasopharyngeal and oropharyngeal suctioning to clear upper airway of secretions. After nasopharyngeal and oropharyngeal suctioning is performed, catheter is contaminated; do not reinsert into endotracheal tube (ET) or tracheostomy tube. Reoxygenate Patient: The patient should be hyperoxygenated as mentioned before for at least 1 minute Disconnect catheter from connecting tube. Roll catheter around fingers of dominant hand. Pull glove off inside out so that catheter remains in glove. Pull off other glove in same way. Discard into appropriate receptacle. Turn off suction device. Place unopened suction kit on suction machine or at head of bed for next session. Suctioning Documentation The amount. Consistency. Record the Color. procedure : Odor of the mucus. Pt breathing status before and after. If the technique is carried out frequently it may be appropriate to record only once , however the frequency of suctioning must be record Suctioning Hazards & complications of suctioning Hypoxemia = insufficient oxygen in blood can result if suction maintained without breaks (therefore no longer than 15secs). It can be minimized by pre-oxygenating the patient and used of closed suction technique. Vagal nerve stimulates; stimulation of the vagus nerve by reflex in which irritation of the larynx or trachea results in slowing of the pulse rate (bradycardia), also tachycardia can occur from agitation, so if occur stop suctioning, administer O2 and ventilation, and notify the physician Hypotension or hypertension: may occur as a result of cardiac dysrhythmia, hypoxemia, anxiety, stress, pain, or coughing, so if occur stop suctioning, administer O2 and ventilation, and notify the physician Mucosal damage – may occur due to using suction while inserting a catheter can cause trauma to the mucosa. So limit the amount of pressure and use shallow technique. Micro-atelectasis : if occur: Limit amount of negative suction pressure used, Keep duration of suctioning less than 15 seconds. Use appropriate-size catheter and avoid disconnection from ventilator by using closed suction technique Aspiration – safety for semi-conscious (on their side), conscious should in semi- fowlers with head turned to side Infection – follow protocol for sterile procedure and use closed suction technique. Suctioning Nasotracheal Suctioning Nasotracheal suctioning is indicated for patients who have retained secretions but do not have an artificial airway. It is similar to endotracheal suctioning but the key differences are. In addition to the equipment and supplies used for endotracheal suctioning, sterile water-soluble lubricating jelly is needed to aid catheter passage through the nose. Use of a nasopharyngeal airway should be considered to help reduce mucosal trauma in the nose of patients who require repeated, long-term nasotracheal suctioning. The key aspect of the nasotracheal suctioning procedure is catheter insertion. After lubricating the catheter, the RT inserts it gently through the nostril, directing it toward the septum and floor of the nasal cavity, without applying negative pressure. The catheter is gently twisted if any resistance in the nose is felt. If twisting does not help, the catheter is withdrawn and inserted through the other nostril. Suctioning Nasotracheal Suctioning (cont.,) As the catheter enters the lower pharynx, the patient should assume a “sniffing” position. This position helps align the opening of the larynx with the lower pharynx, making catheter passage through the larynx more likely. The catheter is continually advanced until the patient coughs or a resistance is felt. Suctioning Techniques to Minimize or Decrease the Complications of suctioning 1- Suction only as needed. 2- Sterile technique. 3- Hyperinflation. 4- Hyperoxygenation. 5- Safe catheter size. 6- No saline instillation. 7- Use closed suction technique 8- Never suction while inserting a catheter Suctioning Sputum Induction Indications – Cough without sputum – Negative sputum smear with high clinical suspicion of tuberculosis Technique – Inhalation of hypertonic saline (3%) with ultrasonic or air compressor nebulizer (possible addition of B2 agonist) – Inhalation of vaporized 15 % aqueous saline Yield – Adequate specimen obtained in 85 to 99 % Suctioning What Type of PPE Would You Wear? Suctioning oral secretions and open suctioning of airways? – Gloves and mask/goggles or a face shield – sometimes gown Sputum induction in a patient with suspect TB? – N95 respirator  https://youtu.be/SwoLb3z25fc (oropharyngeal suction) https://youtu.be/979jWMsF62c (nasophryngeal suction) https://youtu.be/iv65ht2y2NI Nasotracheal suctioning https://youtu.be/8nXL4-ZEaUY Suctionining (important)  https://youtu.be/OFC7SL4k3wQ Trach suction https://youtu.be/jOkO2lfny5A Closed suction https://youtu.be/85eraWgiraw Closed suction https://youtu.be/bp0B_rsN9iI RT Asmaa suctioning Suctioning Thank You