Safe Suctioning.Strategies For Avoiding The Cardiac Hazard.

Aims

• To 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 staff.

ObjectivesAfter This Session Candidates will

• Be familiar with the anatomy and physiology of related structures and have an under standing of the role of the vagus nerve in contributing to the cardiac hazard.

• Be able to identify key features in the assessment of acutely ill patients and will be able to state the main indications for suctioning.

• Be able to state nine ways of reducing the cardiac hazard associated with suctioning.

• 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 candidates will have the opportunity to demonstrate safe suctioning techniques to a competent practitioner within their practice area, this will involve changing the inner cannula of a tracheostomy tube, in situ, assessing a patient and intervening at an appropriate level.

Anatomy And Physiology Of Related Structures

• As a refresher please turn to activity 1 in your workbook

Larynx

Rt Superior Lobe

RT Middle Lobe

Rt Lower lobe

Lt Superior Lobe

Bronchial Tree

Cardiac Notch

Trachea

Lt Inferior Lobe

Diaphragm

The Vagus Nerves

• Have 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.

VAGUS NERVE

BRANCHES OF THE VAGUS NERVE

A Brief History Of Suction

• Airway 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.

A Brief History Of Suction

• Rosen 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.

We Are Now Aware That :-

• Suctioning of the trachea is a more hazardous procedure than commonly appreciated. The insertion of a catheter into the trachea may produce cough, laryngospasm, or bronchospasm as a reaction to the foreign body and precipitate an acute hypoxic episode.

And We Should Appreciate That.

• Findings that desaturation during tracheal suctioning may be of potentially serious magnitude, and that this desaturation may not be predictable on superficial examination of clinical status, warrant caution during the use of nasotracheal suctioning. When patients are in a clinically unstable condition or if copious secretions are present, regard nasotracheal suctioning as having the same potential hazards as other types of endotracheal aspiration.

Definitions.

Tracheostomy.A tracheostomy is a surgical opening made

from the skin into the trachea.Indications:Tracheostomy may be carried out:

– To provide and maintain a patent airway.– To enable the removal of tracheobronchial

secretions.– A tracheostomy may be performed as a

permanent, emergency or elective procedure.

Contraindications.

• Suspected CSF leak (BOS fracture) or raised inter cranial pressure.

• Tracheo/oesophageal fistula.• Ca in upper GI or respiratory tract.• Severe bronchospasm.• Stridor.• Oesophageal or high GI surgery.• Some thoracic surgery: - pneumonectomy.• Acute face, neck or head injury (dependant

upon access).

Tracheo - Bronchial Suctioning.

Definition: -.

The insertion of a suction catheter into the trachea, to remove secretions from the patient’s chest.

– Airway suctioning removes excess secretions from the respiratory tract by the insertion of a catheter into the area and the application of a negative pressure. Although a relatively uncomplicated procedure to perform, which requires little in the way of sophisticated equipment, it is associated with well-documented undesirable side effects.

– Therefore, airway suctioning presents as an interesting anomaly – it may be both life saving and potentially harmful, particularly in patients who are fragile or likely to require long-term regular suctioning.

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 Of Suctioning.

1. Patient anxiety.2. Changes in ICP.3. Trauma. 4. Infection.5. Pneumothorax.6. Hypoxia.7. Cardiac hazard.

Patient Anxiety.

• some patients have likened suctioning to having a red-hot poker put down their throat.

• Please read activity two in your work book.

Changes In ICP.

• Studies have demonstrated that ETS will increase ICP. This elevation of ICP is most pronounced in patients who have evidence of intracranial hypertension and are thus the least able to tolerate such elevations., Nurses should be encouraged to include some method of preoxygenation in their ETS procedure.

Trauma.

• Plym and dunning first attributed SEVERE mucosal damage to tracheobronchial suctioning in 1956.

– “If continuous vacuum pressure is applied, the suction catheter adhered to the mucosa and, if pulled away from it, the technique was tantamount to a crude biopsy.”

– “Scattered haemorrhagic areas and oedema were noted in the right main bronchus. Other areas, which appeared grossly normal, were found to have extensive damage on microscopic examination.”

Trauma.

• They suggested that the – “negative tissue pressure caused by the

invaginated mucosa disrupted capillary blood flow, and damage attributable to suction includes epithelial loss, sub mucosal oedema, lymphatic distension, sub epithelial cellular proliferation and fibrinous deposit. Since ciliary movements are necessary to move mucous secretions upward towards the epiglottis, this destruction of ciliated epithelium may suppress mucus clearance and, therefore, predispose the tracheobronchial tree to infection.

Trauma.

• MUCOSAL trauma can be caused simply by catheter contact during insertion. The number of catheters passed in a given time is a highly significant factor (Sackner et al, 1973 link et al, 1976). Although Jung and Gottlieb (1976) concluded that trauma due to suctioning was negligible after one catheter insertion, in clinical practice patients seldom require suctioning only once. Patients may require suction several times a day. It is particularly worrying, then, that even after just one catheter insertion minor trauma is observed, this will obviously be enhanced with subsequent suctioning procedures. It is advised that suction should, therefore, be carried out only when necessary and not on a “routine” basis, that is at pre-determined intervals, and that careful consideration is given to the type of catheter used.

Infection.

• The tracheal tube has been identified as a source of trauma as well as a reservoir for bacterial growth. The tube contributes to a patient’s susceptibility to respiratory infection because it causes the air entering the lungs to bypass the normal filtering mechanisms of the nose and mouth. Patients requiring assistance in airway maintenance often have low resistance to infection because of factors such as poor nutrition, the presence of chronic disease, or generalised debility. Having been placed in a vulnerable situation in which they are exposed to numerous sources of bacteria, the rate of infection is extremely high.

Pneumothorax.• We report four instances of pneumothorax

secondary to bronchial perforation by a suction catheter. Perforation of the bronchial tree should be suspected in a patient who suddenly deteriorates during suctioning or who has a massive persistent air leak. The mechanism of catheter injury has been confirmed at autopsy. Thoracotomy with suture of the injured lung may be life saving and avoid the consequences of prolonged respirator support. Pre-measurement of suction catheters will minimise or prevent this complication.

Hypoxia.• Ambubagging and suctioning were studied in mechanically

ventilated patients to assess the effects these had on the partial pressure of O2 and CO2 in the arterial blood. No significant fall in PaCO2 was noted in either of the treatment groups. In the group that was suctioned until they were clinically clear of tracheobronchial secretions, irrespective of the number of times they were suctioned, there was s highly significant drop in PaO2 (p<0.01). Nurses should be aware of the marked drop of PaO2 during prolonged suctioning and the potential dangers associated with this drop.

Hypoxia.• During suctioning, not only are secretions removed from the

airways but gas is also removed from the respiratory tract and the aspiration of gas may therefore contribute to the hypoxia that results.

• The duration of suctioning should never exceed 10 seconds and the smallest possible diameter suction catheter should be used. As a rule the diameter of the catheter should never exceed half the diameter of the tracheostomy tube However in certain circumstances, the viscosity of the secretions will determine the size of the catheter (Eales 1989).

Hypoxia.• It has been established that pre-

oxygenation will prevent the hypoxia, which results from suctioning.

• Suggestions for minimising the suction-induced hypoxemia include limiting the duration of suctioning to 10 seconds, limiting the negative suction pressure to 120 - 150 mm hg, and the use of hyperoxygenation if indicated.

Management Of Secretions.

• Secretion management is a vital part of tracheostomy care; nurses should aim to manipulate the viscosity of secretions to reduce the amount of suction required. There are various methods of achieving this:-.

• A sputum assessment should be undertaken on every shift with any changes in the nature of secretions documented nurses should always consider the possibility of infection when they encounter marked changes in the nature of secretions.

Management Of Secretions.

• Wet oral or bronchial secretions can be controlled with prescribed hyoscine patches or sublingual atropine drops.

• Dry secretions can be prevented or controlled with humidification of oxygen and/or saline nebulisation, P.R.N. Saline nebulisation can be provided if patients have trouble in expectorating dry secretions.

• Another important factor is the maintenance of adequate levels of systemic hydration which will again facilitate the clearance of secretions.

• The following extract addresses these points:-.• This extract highlights the importance of individual patient

assessment and specific action planning in the absence of definitative studies.

Cardiac Hazard.

• Endotracheal suctioning of intubated patients is associated with hemodynamic complications including arterial hypoxemia, cardiac arrhythmias, hypotension and even death (Walsh 1989).

9 Ways To Avoid The Cardiac Hazard

(And all the other hazards).1. Only provide suction on a P.R.N.

Basis.2. Least invasive first.3. Prevent hypoxia.

Only Provide Suction On A P.R.N. Basis.• The tube may serve as a major threat to the airway, and that

threat is magnified when tracheal suctioning is performed. Trauma from insertion of the tube or movement of the tube after it is in place may result in laryngeal oedema and mucosal damage. The inflammatory response that follows results in the formation of an inflammatory exudate that necessitates tracheal suctioning. It is well known, however, that numerous complications can result from the suctioning procedure, including bacterial growth, hypoxemia, and cardiac dysrhythmias. The risk of these complications could be reduced by suctioning in response to actual fluid in the airways rather than routine suctioning every 1 to 2 hours.

• 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.

Least Invasive First.

• Before providing suction always attempt a less invasive procedure. Dual cannulated tubes should be used at all times. Patients who are able to cooperate should be encouraged to cough, otherwise remove and replace inner tube and reassess patient status.

Prevent Hypoxia.

• We are aware that hypoxia occurs during tracheo – bronchial and naso – tracheal suctioning, and that hypoxia in conjunction with bradycardia and hypotension is the main contributing factor for cardiac episodes, nurses should be monitoring patient status on a regular basis, a useful tool in this assessment is the saturation monitor (pulse oximeter). As we expect a reduction in saturation of around 4% during suctioning, we should never attempt if SpO2 is less than 94 – 95%.If a patient requiring suction has a saturation below 94 – 95% it is important to administer oxygen or reposition patient before providing suction, if this is at all possible.

Peoxygenation.

• Seventeen patients with lung disease were monitored with an ecg during tracheal suctioning after breathing either air or 100% oxygen. Eight of them had a tracheostomy, three had an orotracheal tube, and six had no intubation.

• The incidence of transient cardiac arrhythmia during tracheal suctioning was significant while breathing air (35%). Arrhythmias included frequent atrial premature contractions, nodal tachyardia, transient sinus arrest, incomplete heart block, and frequent premature ventricular contractions. After a brief period of breathing 100%, oxygen tracheal suctioning was no longer associated with significant arrhythmia (shim et al 1969).

• Four litres o2 per minute will quite quickly raise o2 saturations to a safe level. Patients presenting with potentially dangerous cardiac arrhythmias should breathe 100% oxygen in order to avoid complications prior to tracheal suctioning as long as this is not contraindicated.

Choosing Correct Gauge Catheter.• Physical effects of endotracheal suctioning as described by

Rosen and Hillard (1962) consisted of flow of air from the tip of the suction catheter to the suction apparatus and from the open end of endotracheal tube downwards around the suction catheter to the tip, resulting in varying degrees of negative pressure in the lungs. The magnitude of such effects depended on the extent of air displacement and negative pressure produced by the suction, the size of the catheter, and the relationship between the outer diameter of the endotracheal tube. (Boutros 1970).

• To prevent haemodynamic changes, the outer diameter of the suction catheter should not exceed half of the inner diameter of the tracheostomy tube. A way to calculate this is to multiply the tracheostomy tube size by three and divide that number by two.

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.

Achieving the correct depth of insertion.

• Not introducing the catheter too deeply into the tracheo – bronchial tree will reduce the likely hood of vagal stimulation, bronchospasm and trauma. There is a degree of conflict within the research (Kleiber 1986) with suggestions of efficient depths which range from 1cm past the end of the tube to one cm past the carina.

• A general rule is proceed with the minimum amount of invasion, the recommendation is to advance the catheter slowly until either a cough reflex is initiated or resistance is felt upon encountering either of these conditions, the nurse should withdraw the catheter 1cm , apply suction and withdraw the catheter.

• For patients with copious or tenacious secretions, who are showing signs of ineffective airway clearance, deeper suctioning is suggested. Care plans should include specific guidelines for catheter insertion and should be updated routinely by the caregiver. Individualisation of the care plan is essential.

Applying Suction Appropriately, For Correct Amount Of Time.• Insufflation of five litres of O2 down a sidearm during

endotracheal suction diminished the rate of decline of pao2 during suction of normal dog lungs. In patients with respiratory insufficiency, the insufflation of O2 during suction did not have any effect on the decreased pao2 seen during the endotracheal suction.

• The most effective way to prevent hypoxia during endotracheal suction of patients with respiratory failure is to hyperoxygenate for one minute with 100% O2 prior to suction and limit suction to 15 seconds, (fell 1971).

• To err on the side of caution it is recommended that suctioning is limited to 10 seconds only and that only 3 – 4 passes are completed in any one session.

Being Gentle.

• The airway mucosa is extremely sensitive to pressure and is easily damaged. Chronic irritation can result in scar formation, which may necessitate surgical intervention and prolonged hospitalisation. Therefore, any suctioning of the airway must be done with extreme gentleness.

• This again will reduce the likely hood of vagal stimulation, bronchospasm and trauma and will greatly reduce patient anxiety.

Well Done

Any questions?????????????

Please complete the course evaluation