Suctioning , Tracheostomy

Anatomy And Physiology

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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 of Tracheostomy

  • 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.

 

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.

 

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.

•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.

 

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

• 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.

• 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

• 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.

 

• 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.”

• 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;

 

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. 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.

 

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,.

• 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.

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