Liverpool Health Service Policy Issued: 5/02
CORPORATE MANUAL PATIENT CARE
Respiratory
P12.09
Tracheostomy Tube Suction
Expected Outcome
The patients airway is cleared effectively through the use of tracheal suction.
Policy Statement
Suctioning will be performed using aseptic technique Suctioning will be attended as clinically indicated on an individual basis Patients will be encouraged to cough and expectorate their own secretions when able Accredited nurses or registered nurses will perform suctioning as required The appropriate sized suction catheter is used
When to Suction: Clinical Indicators1
Coarse breath sounds Noisy breathing Increased or decreased rate of respiration Decreased oxygen saturation Copious secretions Patient attempting to cough
Background
An accredited nurse for the purposes of this protocol is an RN or EN who has completed a Suctioning Competency or is deemed competent by the CNE.
Equipment
Protective eye wear Gloves sterile single use exam gloves or if using Closed Suction System [CSS]; non-sterile gloves Plastic apron or impermeable gown Suction catheter or CSS Portex Blueline Ultra Suction Catheter Size 10 FG 10 FG 10 FG 10 FG 10 FG or 12FG 10 FG or 12FG 12 FG Shiley (traditional) Suction Catheter Size 10 FG
Size 6.0 - inner diameter 5.0 mm Size 7.0 - inner diameter 5.5 mm Size 7.5 - inner diameter 6.0 mm Size 8.0 - inner diameter 6.5 mm Size 8.5 - inner diameter 7.0 mm Size 9.0 - inner diameter 7.5 mm Size 10. - inner diameter 8.5 mm
Size 4.0 inner cannula 5.0 mm
Size 6.0 inner cannula 6.4 mm
10 FG
Size 8.0 inner cannula 7.6 mm Size 10. inner cannula 8.9 mm
10 FG or 12FG 12 FG or 14 FG
Suction catheter size recommendation is that the diameter should be equal or less than half that of the inner cannula diameter1-3, 14). In an emergency, a larger size suction catheter may be used to remove secretions. High pressure wall suction unit and tubing Oxygen outlet and tubing Oxy-Viva bag, tracheostomy oxygen mask for pre-oxygenation, if required Sterile dressing pack (optional) Sterile normal saline to clean used suction catheter Yankeur sucker
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Reviewed: 14 July 2004 Review Date: July 2006
Liverpool Health Service Policy Issued: 5/02
CORPORATE MANUAL PATIENT CARE
Respiratory
P12.09
Procedure
Explain procedure to patient and select appropriately sized suction catheter Oxygen: Patient on oxygen therapy maximal flow rate When using an oxy-viva bag or wall-oxygen humidification unit, flow rate is at 15 litres to supply 100% Oxygen When using a Heat Moisture Exchange unit [HME], use oxygen flow of up to 6 litres Patients not receiving continuous oxygen therapy are assessed for their need for preoxygenation prior to the suction Patients who are not receiving oxygen therapy and are spontaneously breathing are encouraged to do gentle deep breathing exercises prior to suctioning, as appropriate Pre-oxygenate the patient for approximately 3 minutes prior to commencing the suction4, 13 Turn on the suction outlet, ensure there is an adequate seal and vacuum pressure (14 20kP)5 Wash hands, don goggles and apron5 Don appropriate gloves, ensuring that a sterile glove on the dominant hand is used with singleuse suction catheters Introduce catheter into the tracheostomy tube to the approximate location of the carina withdraw 1cm; or at the point where the patient begins to cough; apply suction As continuous suction is applied, withdraw the catheter slowly and smoothly out of the tracheostomy tube - maximum time is 15 seconds7-8 Observe patient response, assess for need for further suctioning episodes; allow patient to rest and receive oxygen, as required, in between suction episodes Rinse the suction catheter in sterile normal saline prior to re-insertion; maintain asepsis1 Allow patient to rest between suction passes, 2-3 passes maximum1, 9. When suctioning is complete; using non-dominant hand - draw the glove on the dominant hand up and over the used suction catheter and dispose of both gloves and catheter appropriately. Document event: CR 168 Tracheostomy Care Chart or flowchart Use a clean yankeur sucker to remove oral secretions
In acute situations only:
When there is difficulty suctioning thickened secretions it may be necessary to use a largersized suction catheter than recommended. After removing secretions with a larger suction catheter; the patient should be reviewed for increased humidification needs - a HME should be used in conjunction with 4/24 normal saline nebulisers (or more frequently). If the secretions are so thick that these methods are not effective, a water bath humidifier should be used, with the base temperature set at 38 - 39O Celsius. When there is suspected obstruction of the airway due to a mucous plug, the tracheostomy tube is at risk of blocking with sputum: 2-5mL sterile normal saline may be used to aid clearance of secretions This is not routine practice and is associated with the potential for hypoxaemia and retention of the saline bolus10-12 If nil response to this technique patient safety is a concern, call MET
Clinical Issues
Other Tracheostomy tubes available on the market: Shiley 'Flextra' - current HME in use does not fit this tube The size of the XLT and Flextra Shiley tubes is the size of the inner cannula. XLT is a proximal or distal extendable tube in both cuffless and cuffed (not fenestrated) combinations. XLT and Flextra use disposable inner cannulae ( do not soak, if crusty or thick secretions discard and obtain replacement) Wards will need to ensure that they have adequate stock of disposable items for all tracheostomy tubes in use.
Reviewed: 14 July 2004 Review Date: July 2006
DN&CS
Tracheostomy Tube Suction Page 2 of 3
Liverpool Health Service
Policy Issued: 5/02 P12.09 References 1. Tracheal suctioning of adults with an artificial airway. Best Practice Evidence Based Information Sheets for Health Professionals. Volume 4, Issue 4, 2000. Joanna Briggs Institute for Evidence Based Nursing and Midwifery. 2. Buglass, E. 1999. Tracheostomy care: Tracheal suctioning and humidification. British Journal of Nursing. 8. 8:500504. 3. Odell, A., Allder, A., Bayne, R., Everett, C., Scott, S., Still. B. and West, S. (1993). Endotracheal suction for adult, nonhead-injured, patients. A review of the literature. Intensive & Critical Care Nursing. 9(4):274-278. 4. Glass, C. and Grap, M. (1995). Ten tips for safer suctioning. Advanced Journal of Nursing. 5:51-53. 5. Rossoff, L., Lam, S., Hilton, E., Borenstein, M. and Isenberg, H. Is the use of boxed gloves in an intensive care unit safe? (1993). American Journal of Medicine. 94(6):602-607. 6. McKelvie, S. (1998). Endotracheal suctioning. Nursing in critical care. 3(5):244-248. 7. Kerr, M., Rudy, E.and Brucia, K. (1993). Head-injured adults: Recommendations for endotracheal suctioning. Journal of Neuroscience Nursing. 25(2):86-91. 8. Day, T. (2000). Best practice for tracheal suctioning. Nursing Times Plus. 96(20):13-15 9. Ackerman, M. (1993). The effect of saline lavage prior to suctioning. American Journal of Critical Care. 2:326-330. 10. Ackerman, M., Ecklund, M. and Abu-Jumah, M. (1996). A review of normal saline instillation: Implications for practice. Dimensions of Critical Care Nursing. 15(1):31-38. 11. Blackwood, B. (1999). Normal saline instillation with endotracheal suctioning: primum non nocere. Journal of Advanced Nursing. 29(4):928-934. 12. Kerr, M., Weber, B., Sereika, S., Darby, J., Marion, D. and Orndoff, P. (1999). Effect of endotracheal suctioning on cerebral oxygenation in traumatic brain-injured patients. Critical Care Medicine. 27(12):2776-2781. 13. Griggs, A. (1998). Tracheostomy: suctioning and humidification. Nursing Standard. 13(2):49-56. 14. Laws-Chapman, C., Rushmer, F., Miller, R., Flanagan, K., Prigmore, S and Chabane, S. 2000. Guidelines for the care of patients with tracheostomy tubes. St Georges Healthcare NHS Trust August, page 32.
CORPORATE MANUAL PATIENT CARE
Respiratory
Authors: Maureen Edgtton-Winn, CNC ICU on behalf of the Trachy Protocol Review Team. Policy Reviewer/s: CNCs for Intensive Care, Neurosciences, Surgery.
Reviewed: 14 July 2004 Review Date: July 2006
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Tracheostomy Tube Suction Page 3 of 3
