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Tracheal Suctioning of the Patient Without an Artificial Airway (7.17)

Tracheal Suctioning of the Patient Without an Artificial Airway (7.17) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Pulmonary

7.17



NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
May 20, 2016

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 7.17AP

Original
Revision

Page
1
of 5

Title: Tracheal Suctioning of the Patient
Without an Artificial Airway (Adult &
Pediatric)

I. PURPOSE

To maintain patency of the larger airways by removing secretions; to assist patients
who have an ineffective cough to mobilize secretions from the lower airway.

II. POLICY

The nurse or respiratory therapist will intervene to safely perform suctioning in
patients without an artificial airway.

III. EQUIPMENT

A. Wall suction gauge and canister or portable suction unit (from CS)
B. Connecting tubing
C. Sterile disposable suction kit (suction catheter, sterile gloves, cup) of appropriate
size

Age Suction Catheter Size
Newborn-6 months 6-8 F
6 months-3 years 8-10 F
3 years-10 years 10 F
10 years-16 years 12 F
Adult 12-14 F
(one size larger and one size smaller should be allowed for individual variations)

D. Sterile normal saline for irrigation
E. Water-soluble lubricant
F. Oxygen device (mask, cannula, or manual resuscitator)
G. Nasal pharyngeal airway (nasal trumpet), recommended
H. Personal protective equipment (gloves, goggles, gown, mask)
I. NeoTech Little Sucker- optional nasal suction device for pediatric patients

IV. PROCEDURE

A. Perform hand hygiene according to UWHC Hospital Administrative Policy 13.08,
Hand Hygiene.

Page 2 of 5

B. Follow standard and transmission based precautions according to UWHC
Hospital Administrative Policy 13.07, Standard Precautions & Transmission-
based Precautions (Isolation).
C. Assess respiratory status to determine whether a patient requires suctioning.
Auscultate bilateral breath sounds.
1. Signs and symptoms indicating a patient may require suctioning:
a. Restlessness, agitation, coughing
b. Dyspnea, tachypnea, retractions
c. Changes in respiratory pattern
d. Inability to expectorate mucus, secretions
e. Increased or decreased heart rate
f. Audible rales, diminished breath sounds
g. Rhonchi and gurgling over large airways
h. Excessive secretions
i. Fatigue from excessive coughing
j. Decrease in oxygen saturation
k. Cyanosis
2. Indication of need and frequency of suctioning is in part determined by
ability of patient to spontaneously expectorate secretions that move into
the larger central airways.
3. Patients in whom suctioning and coughing may be contraindicated and
may require a provider consult include (but are not limited to):
a. Acute neck, facial or head injury, particularly basal skull fracture
or CSF leakage from the ear
b. Increased intracranial pressure
c. Unstable fracture of spinal vertebrae
d. Patient with acute bronchospastic airway disease, e.g., asthma,
asthmatic bronchitis
e. Congenital nasopharyngeal defects
f. Some eye surgeries immediately post-op,
e.g., dacryocystorhinoplasty
g. Some ENT surgical procedures, e.g., tracheal reconstruction
h. Patients post esophageal surgery or perforation
i. Patients predisposed to bleeding, e.g. bleeding disorders,
esophageal varices, anticoagulant therapy, nasal bleeding
j. Patients at risk for vomiting and aspiration, e.g. experiencing
nausea, within 1 hour of eating
k. Occluded nares
l. Epiglottitis or croup
D. Aspirate nasopharyngeal cavities and oropharyngeal cavities prior to deep
tracheal suctioning, if needed. Discard the used suction set and obtain a new
suction set prior to tracheal suctioning.
E. A nasal pharyngeal airway is recommended to decrease trauma when frequent
suctioning is required. For pediatric patients, a provider order is required. Assess
the patient for the presence of septal defects which could prevent passage of an
airway and/or catheter.
1. See Nurses’ Guide to Clinical Procedures (6th Ed.), Inserting and
Maintaining a Nasal Airway, or Respiratory Care Policy 3.41, Insertion,
Use and Care of Nasal Pharyngeal Airway, for sizing and placement.

Page 3 of 5

2. The nasal pharyngeal airway should be removed, cleaned and reinserted in
the opposite naris preferably every 24 hours.
3. When suctioning the patient with a nasal pharyngeal airway, care should
be taken to secure the device so that it doesn’t advance into the
nasopharynx. This may require the assistance of a second clinician.
F. Position patient;
1. The ideal positions for deep tracheal suctioning are semi-Fowler's or near-
sitting (head of bed up all the way).
2. Position the patient's head in a neutral, or slightly forward (sniffing),
position.
G. Preoxygenate patient as appropriate:
1. Ask patient to inhale deeply at least 5 times or use oxygen as ordered by
the provider .
2. Place nasal prongs in the mouth or in the opposite nostril during
suctioning when a patient is on oxygen therapy.
3. Avoid excessive periods of high oxygen concentrations for patients with
lung disorders characterized by chronic hypercapnea and reliance on the
hypoxic drive to breathe.
H. Pour sterile irrigating saline into sterile disposable cup from kit; turn on the wall
gauge suction or aspirator and pinch connecting tube to determine amount of
suction. Average ranges of wall suction:
1. Adults: 80-120 mm Hg
2. Pediatrics: Infants 60-80 mm Hg, Children 80-100 mm Hg, Adolescents
80-120 mm Hg
I. Put sterile gloves on both hands. The glove on the suctioning hand must remain
sterile throughout procedure, other glove can be clean.
J. Suction is created by placing the thumb of the non-sterile gloved hand over the
thumb port of the catheter. Remove thumb from port to discontinue suction.
1. If suctioning equipment doesn't work:
a. Validate that suction switch is turned on.
b. Be sure canister is not full.
c. Check for tight fit on vacuum bottle lid.
d. Make sure tubing and catheter connections are tight.
e. Check for kinks in catheter/tubing.
K. Attach catheter to connecting tubing, Check suctioning unit function by
suctioning a small amount of irrigating saline from the cup.
L. A sterile water-soluble lubricant should be utilized. A thin film should be applied
to the end of the catheter using sterile technique.
M. Select naris.
1. Advance the suction catheter into right or left naris, through nasal
passageway, and into pharynx approximately 8-10 cm. For children, use
the distance from nose to ear.
2. Never force the suction catheter. It should move into oropharyngeal cavity
with minimal resistance. A gentle, rotating motion can be used when
advancing catheter through nares.
3. Do not apply suction when advancing catheter.
N. Tell patient to breathe slowly and deeply as catheter is advanced. Continue to
advance until resistance is met. Catheter will be directly above glottis at point of
resistance.

Page 4 of 5

O. Instruct patient to cough (if a spontaneous cough does not occur), and advance
catheter into larynx quickly.
1. When catheter enters larynx or touches carina (about 3/4 length of
catheter), patient should cough.
2. Maneuvers to facilitate catheter entrance into trachea:
a. Reposition patient's head.
b. Pull mandible forward slightly to lift tongue.
c. Pull tongue forward with gauze.
d. Ask patient to cough.
3. If gastric contents are suctioned, remove catheter and change set-up to
prevent accidental introduction of gastric juices into the airway via
contaminated set-up. Gastric contents may also be suctioned if the patient
has aspirated.
4. If the trachea cannot be accessed after several attempts, ask for assistance
from respiratory therapy. It is recommended that a nasal pharyngeal
airway be inserted if one is not already in place.
P. Assess patient tolerance. (See Potential Complications in chart below.)
1. If no cough reflex is present, check patient's level of consciousness or
position of catheter.
2. In cases of laryngospasm, remove catheter immediately. Give positive
pressure ventilation by mask. Call provider STAT if condition persists or
if patient's condition deteriorates.

POTENTIAL COMPLICATIONS SYMPTOMS
Oxygen desaturation Tachycardias, bradycardias, ectopic rhythms
(specifically PVCs), air hunger, skin color
changes, tachypnea.
Blockage of large bronchi Cyanosis, decreased breath sounds, decreased
chest expansion, shortness of breath, weakness,
restlessness, confusion.
Bronchospasm Shortness of breath, wheezing, tachycardia,
tachypnea, retractions, restlessness, anxiety,
cyanosis, coughing.
Vagal stimulation Bradycardia, PVCs, cardiac arrest.
Laryngospasm Airway obstruction, partial or complete; crowing
sound or an absence of sounds; acute airway
emergency.

Q. Apply suction and withdraw catheter. Observe secretions for amount, character,
odor and presence of blood.
1. Maximum length of time for withdrawal of suction catheter:
a. 10 seconds for adults
b. 5 seconds for small children
2. If patient needs more suctioning, reoxygenate for at least one minute
between suctioning passes.
3. Continuous suction during withdrawal will remove secretions that have
traveled higher in the trachea or into the upper airway.
R. After catheter withdrawal and when suctioning is completed, if appropriate, ask
patient to take 5-6 deep breaths with prescribed oxygen device (cannula or mask),

Page 5 of 5

or provide at a minimum 5-6 deep breaths with a manual resuscitator. Deep
breathing can reduce the potential for suction-induced hypoxia and atelectasis.
S. Repeat suctioning procedure once or twice until patient's upper airway is clear
and/or breathing is improved. If no improvement notify provider.
T. Turn off wall gauge or aspirator; wash hands. Wrap connecting tubing around
suction gauge to keep it out of the way.
U. Assess and document effectiveness of suctioning. Include frequency of
suctioning, type of secretions, amount, color and consistency, breath sounds, and
patient's tolerance of procedure.
V. Date and replace sterile irrigation saline every 24 hours.
W. Suction canister liners are discarded when full or as needed.
X. Drainage bottles and connecting tubing are changed as indicated for aesthetic
reasons.
Y. Resuscitation bag and mask are replaced as needed by Respiratory Therapy.

V. UWHC CROSS REFERENCES

A. Respiratory Care Services Policy 3.20, Pulse Oximetry Check & Continuous
Monitoring (Includes Ambulating SPO2)
B. Respiratory Care Services Policy 3.41, Insertion, Use and Care of Nasal
Pharyngeal Airway
C. Respiratory Care Services Policy 3.42, Suctioning
D. Hospital Administrative Policy 13.08, Hand Hygiene

VI. REFERENCE

Smith-Temple, J., & Young Johnson, J. (2009). Inserting and maintaining a nasal
airway. Nurses’ Guide to Clinical Procedures (6th Ed.). Philadelphia, PA: Lippincott
Williams & Wilkins.

VII. REVIEWED BY

Director, Respiratory Care Services
Clinical Nurse Specialist, Universal Care Unit
Clinical Nurse Specialist, Pediatric Intensive Care Unit
Clinical Nurse Specialist, TLC
Clinical Nurse Specialist, Acute Medicine/Progressive Care Unit
Nursing Patient Care Policy and Procedure Committee, May 2016

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer