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SUCTIONING ARTIFICIAL AIRWAYS

1. bronchiolitis contraction less forceful and ventilation less efficient 3 Airways Pediatric airways have many differences from those of adult 3 Main Areas 1 Supraglottic nose naso oropharynx and epiglottis 2 Glottic vocal cords subglottic area and upper trachea 3 Intrathoracic thoracic trachea mainstem bronchi and lungs Suctioning Artificial Airways Learning Package 36 Supraglottic Area Glottis Ciliated mucous epithelium in nose filter warm and humidify air Infants up to 5 6 months of age are primarily nose breathers due to size and angle of epiglottis so any obstruction of nares secretions edema blood chonal atresia results in respiratory distress Nasopharynx has more lymphoid tissue and large adenoids which can also cause obstruction of airway Tonque of small child is large in relation to mouth and jaw and can obstruct airway in obtunded chilled if their head is too flexed Placing head in sniffing position with small roll under shoulders helps maintain an open airway A jaw thrust maneuver should be used if C spine injury suspected Infants epiglottis is long and floppy attached at a more acute angle and more posterior making it more difficult to visualize airway structures for tracheal intubation It is also susceptible to edema with trauma and infection epiglottitis which can result in complete airway obstruction The larynx funnel shaped structure connecting pharynx and
2. Adequate systemic hydration and airway humidification need to be provided to prevent thick secretions Normal saline and secretions do not mix together Therefore instillation provides a lavage and or stimulates a cough that moves secretions Instillation may have adverse effect on oxygenation and may promote infection by washing bacteria from artificial airway into lower airway tracts Curley amp Thompson 2001 Ridling et al 2003 If required instill sterile 0 9 saline into the tube during inspiration e Neonates 0 3 1 ml Infant 0 5 1 5 ml e Child 1 5 2 mls Adolescents 2 3 mls Instillations must be kept sterile Solutions opened or drawn up at bedside must be discarded after 24 hours NICU 12 hours 2 6 5 Measured Suction Depth All routine suction passes should be to pre measured depth to minimize risk of trauma to delicate tracheal tissues Repeated suctioning past end of endotracheal or tracheostomy tube can result in bronchial perforation hemorrhage histological changes airway inflammation and tracheal stenosis The suction catheter should not pass beyond distal end of endotracheal or tracheostomy tube on a regular basis Curley amp Thompson 2001 Suction Catheters should never be inserted until resistance felt as this causes trauma to carina and may precipitate pulmonary hemorrhage If tube Suctioning Artificial Airways Learning Package 11 obstructed with secretions may suction
3. Airways Artificial Airways discussed in this package are endotracheal tubes and tracheostomy tubes The indications for an artificial airway are Bypass an airway obstruction tumors foreign body larynx or tracheal injury or congenital malformations Provide protection from aspiration in patients having difficulty protecting their airway diminished cough gag swallow due to CNS impairments brain injury progressive neurological or muscle disorder ex muscular dystrophy Note Patients with Glasgow coma scale lt 8 require airway management Provide mechanical ventilation to patient with severe respiratory disease shock or multi system trauma or sepsis Remove secretions from tracheobronchial tree Tracheostomy is usually done for patients requiring prolonged mechanical ventilation months to years or for same indications as an ETT bypass obstruction protect from aspiration and remove secretions A Position Of Endotracheal Tube B Position Of Tracheostomy Tube Source adapted from Phipps et al 1995 Medical Surgical Nursin 5 Edition p 1021 Mosby Year Book Inc St Louis Missouri Suctioning Artificial Airways Learning Package 3 2 1 1 Endotracheal Tubes ETT s An endotracheal tube is a tube inserted into the trachea to ensure patency of the upper airway allow for mechanical ventilation and provide pulmonary hygiene It can be inserted through the mouth orotracheal tube or through the nos
4. Artificial Airways Learning Package 42 Examples Pulmonary emboli pulmonary vasoconstgriciton associated with hypoxia acidosis hypothermia in young infant cardiopulmonary arrest with ineffective compressions c Silent Unit no alveolar ventilation or perfusion Examples cardio respiratory arrest without interventions Normal Ventilation i No Ventilation NI m F Normal Shunt ormal Pertusion N VA d f 1 a le A PX va z LD g 4 y S 2 Dead space Silant Suctioning Artificial Airways Learning Package 43 Appendix C Assessment of Pediatric Respiratory System A B Inspection e Chest shape and anterior posterior diameter compared to lateral diameter Barrel shape Round normal in infant Indicates chronic respiratory problems in child gt 3 yrs Pectus Excavatum Funnel Chest depression of lower portion of sternum Pectus Carinatum Pigeon Chest anterior displacement of sternum Thoracic Kyphosoliosis spinal curvature displaces thorax e Slope of ribs infant ribs more horizontal e Abnormal retractions Suproshenal Glavicular Subasanial e Movement of chest Symmetrical Lag or impairment of movement Synchrony with abdomen use of accessory muscles e Rate amp Rhythm of Breathing Normal rates e Tachynea is non specific sign Concern with RR over 40 min Ominous if RR over 60 min Palpation e Areas of tenderness e Asse
5. SpO coarse breath sounds crackles changes in air entry vibrations of secretions in chest coarse crackles coarse breath sounds changes in air entry coughing visible secretions in airway Suctioning should be done on the basis of clinical assessment with a minimum of morning and bedtime and usually prior to feeds meals to ensure patency of tracheostomy tube 3 2 Ensure that the following equipment is at the bedside and in good working order manual resuscitation bag with reservoir attached to an oxygen flow meter face mask of appropriate size suction regulator suction catheters of appropriate size Neonate 6 8 Fr Pediatrics 8 12 Fr Adolescents 12 14 Fr NOTE Usually a suction catheter of 2 3 diameter of tracheostomy tube is recommended However if secretions are thick or copious use a larger suction catheter to minimize number of suction passes and ensure secretions are cleared e suction canister and connecting tubing e mask face shield e sterile gloves for tracheostomy lt 14 days post op e clean gloves for tracheostomy gt 14 days post op e tonsiller suction for oral secretions e mouth care supplies e stethoscope Suctioning Artificial Airways Learning Package 18 3 3 3 4 3 5 3 6 3 7 3 8 3 9 3 10 3 11 3 12 Wash hands Explain procedure to patient as appropriate to developmental level Position patient with head of bed elevated 30 or in appropriate posi
6. mechanically ventilated patient with an artificial airway ETT or tracheostomy will have the head of bed elevated 30 at all times This is shown to decrease the incidence of ventilator acquired pneumonias VAP S by reducing aspiration For all patients during suctioning position with the head of bed elevated 30 or in appropriate position for postural drainage unless medically contraindicated i e Suctioning Artificial Airways Learning Package 7 unstable spinal fractures This promotes deep breathing and effective coughing by allowing maximum movement of the diaphragm 2 5 3 Hyperoxygenation Hyperoxygenation refers to the administration of oxygen at a greater concentration than the patient is receiving or usually requires It is performed before during and after suctioning based on assessment of the patient s respiratory status Hyperoxygenation can be performed by giving 5 6 ventilations using a manual ventilation bag with supplemental O2 having the patient taking several large breaths while receiving a higher than normal concentration of oxygen In the ventilated patient increasing the ventilator FiO2 prior to suctioning Note To give 100 oxygen by ventilator requires 1 2 minutes before circuit in the ventilator is completely filled with high concentration Oo Rationale It is well documented that a decrease in arterial oxygenation occurs during the tracheal suctioning procedure that may cause cardiac dysr
7. open technique 2 2 1 Open technique patient disconnected from ventilator and suctioned with regular suction catheter 2 2 2 Closed technique utilizes an in line suction catheter with patient remaining attached to ventilator and is recommended for patients with high oxygen requirements or increased levels of PEEP Closed technique reduces recruitment of alveoli and subsequent atelectasis It also minimizes aerosolization of contaminated secretions and may prevent nosocomial infections NICU PICU Closed suctioning is standard of care for endotracheal tube suctioning except for emergency situations where endotracheal tube is obstructed and in line suction has not relieved obstructions or specimen for C amp S is required 3 PROCEDURE 3 1 3 2 Assess the patient s need for suctioning by observing and auscultating for increase RR and work at breathing decreased SpO gt and or increases in ETCO increased heart rate or cyanosis restlessness or agitation coarse breath sounds crackles noisy breathing amp changes in air entry coughing visible secretions in airway increased peak pressures during volume controlled ventilation or decreased tidal volume during pressure controlled ventilation changes in monitored flow or pressure graphics on ventilator Assess the need for instillation with sterile 0 9 saline Instillation may be indicated in patients with tenacious secretions but should not
8. sent Suctioning Artificial Airways Learning Package 20 REFERENCE LIST 1 American Thoracic Society 2000 Care of Child with a Chronic Tracheostomy American Journal of Respiratory Critical Care Medicine 161 297 308 2 Curley M A and Thompson J E 2001 Chapter 8 Oxygenation and Ventilation pp 233 322 In Critical Care Nursing of Infants and Children 2 Edition M A Curley and P A Moloney Harmon editors Philedelphia Saunders 3 Ridling D A Martin L D and Bratton S L 2003 Endotracheal Suctioning with or without instillation or isotonic sodium chloride in critically ill children American Journal of Critical Care 12 3 212 219 4 Singh N C Kissoon N Frewen T amp Tiffin N 1991 Physiological responses to endotracheal and oral suctioning in pediatric patients the influence of endotracheal tube sizes and suction pressures Clinical Intensive Care 2 6 345 50 Suctioning Artificial Airways Learning Package 21 APPENDIX A Endotracheal Tracheostomy Tube and Suction Catheter Chart Endotracheal Tracheostomy Tube inner diameter in mm Suggested Suction Catheter Size French Note Approximate 2X Tube Size 2 5 5 3 0 6 3 5 6 4 0 8 4 5 8 5 0 10 5 5 10 6 0 12 6 5 12 7 0 14 8 0 14 Suctioning Artificial Airways Learning Package 22 APPENDIX B Measured Suction Depth All routine suction passes should be to p
9. to baseline parameters decreasing FiO2 according to SaOz and clinical status 3 8 12 Cap the irrigation port Discard any unused normal saline Disconnect suctioning from in line suction catheter and re cap in line catheter end Provide mouth care per unit policy 3 8 13 Auscultate chest to determine the effectiveness of suctioning ensure patient stability comfort and safety NOTE If Lung Recruitment Measures LRM s have been implemented RRT to return ventilator settings to pre suction baseline as ordered 3 8 14 Document on appropriate record e Amount color and consistency of secretions e Patient s tolerance of procedure vital sign changes e Actions taken if problems encountered during suctioning e Air entry and adventitious breath sounds e If specimen sent Suctioning Artificial Airways Learning Package 29 3 8 15 Change suction catheter PICU When visible debris cannot be cleared with irrigation NICU q weekly as indicated in Patient Care Plan 3 9 Suctioning Patients Receiving High Frequency Ventilation Oscillating HEOV or Jet HF JV 3 9 1 3 9 2 3 9 3 Cues for suctioning and primarily based on visualization of secretions in endotracheal tube changes in vital signs decrease in chest vibrations decreased chest wiggle factor as distinct breath sounds will not be heard due to rapid frequencies or ventilation 3 9 1 1 With HEOV frequency of suctioning should be minimized based on decreased chest wi
10. 0 5 to 1 cm beyond measured depth with caution Endotracheal Tube Measurement Suction depth can be measured by noting cm markings on endotracheal tube visible at teeth or gums then adding length of endotracheal tube external to patient and adapter to this This measurement should not need adjustment with tube depth adjustments as entire tube moves up or down This measure will however need adjustment if endotracheal tube is cut For In line suction catheters size 6 8 10 French measure as above or add 5 cm to last visible cm marking on tube for approximate suction depth to adapter external end Tracheostomy Tube Measurement Use length of tracheostomy tube indicated on box plus measured distance of tracheostomy above stoma add length of adapter if used Length of obturator may also be used calculate suction depth but will be slightly longer than tracheostomy tube Note 2 6 6 Note Suction Depth measurement should be posted at bedside of all pediatric patients and documented on patient care plan Suction catheter should only be inserted to this depth on regular basis Utilize cm markings on catheter bedside measuring tape or color coded bars on in line catheter to determine suction depth Obtaining Specimens A suction trap and straight sterile suction catheter with open suction technique is used to collect sterile sputum specimens from endotracheal or tracheostomy tube for culture and sensitivity C amp S aci
11. SASKATOON HEALTH REGION SUCTIONING ARTIFICIAL AIRWAYS PEDIATRIC NEONATE Tracheostomies amp RN and LPN SA LEARNING PACKAGE e Suctioning Ventilated Conventional and High Frequency Patients Pediatric Neonate RN SPECIAL NURSING PROCEDURE amp e Suctioning Non ventilated and Long term ventilated Patients Via a Tracheostomy Pediatric Neonate RN SPECIAL NURSING PROCEDURE LPN AND SENIOR ASSISTANT ADDED SKILL Registered Nurse LPN SA identified by their Manager will be certified to perform suctioning via endotracheal and or tracheostomy tubes in accordance with the policy of the clinical unit DATE July 2007 This material was developed for the use of Saskatoon Regional Health Authority SRHA This material may not be suitable for other agencies SRHA makes no warranties or representations regarding this information and each agency is urged to update and modify this information for its own use Suctioning Artificial Airways Learning Package as Permission for extensive copying of this learning package for scholarly purposes may be granted It is understood that due recognition will be given to the Coordinator s of this learning package and to the Department of Nursing Development in any use of this material Copying publication or any other use of this learning package for financial gain without approval is prohibited Requests for permission to copy or to make other use of this material in this lea
12. advanced into the ETT or trach The size of catheters will vary depending on the size of the ETT or tracheostomy Size of Catheters Adolescents 12 14 Fr catheters Pediatrics 8 14 Fr catheters Neonates 6 8 Fr catheters Endotracheal Tracheostomy Tube and Suction Catheter Chart Endotracheal Tracheostomy Tube Suction Catheter Size In Line Suction inner diameter in mm French Catheter French 2 5 5 6 3 0 6 6 or 8 3 5 6 8 4 0 8 8 4 5 8 10 5 0 10 10 5 5 10 10 6 0 12 12 6 5 12 12 7 0 14 14 8 0 14 14 These sizes available as In line suction catheters for Tracheostomy tubes The catheter size should be no more than 2 3 of the diameter of the airway to prevent hypoxemia and atelectasis Singh et al 1991 Chong et al 2003 However if secretions are very thick and or copious use larger suction catheter to minimize number of suction passes and ensure secretions are cleared 2 6 2Closed System or In Line In ventilated patients with ETT or tracheostomy a closed circuit catheter system eliminates the need to disconnect the patient from the ventilator during suctioning This system is recommended for patients with high oxygen needs or increased levels of PEEP as the severity of desaturation and derecruitment of alveoli is reduced by providing less interruption to positive ventilatory pressures and PEEP In Line suction also minimizes aresolization of contaminated sec
13. al Coughing Significant change from baseline BP Decreased air entry Change in chest x ray Change in air entry Wheezes auscultated Stop suctioning Oxygenate and ventilate Prepare patient for suctioning Increase analgesic sedation if appropriate Limiting amount of negative pressure used see hypoxia section Keep duration of suctioning as short as possible see hypoxia section Provide Lung Recruitment Maneuvers LRM s after suctioning as ordered Appropriate size of suction catheter Administer bronchodilators as ordered May need to do prior to suctioning or give routinely Ensure manual ventilations in sync with patient s respiratory effort Talk to patient to calm them Obstruction Unable to ventilate patient Unable to suction patient Call for help then ETT e Remove ETT airway and face bag with 100 O2 Tracheostomy e Change tracheostomy tube Use manual ventilation to administer extra O until stable Suctioning Artificial Airways Learning Package 14 Symptoms Prevention e Increased Intracranial Pressure gt 20 mmHg x 5 min or gt 25 mmHg for any time or outside physician established parameters may correspond with increased BP amp coughing Increase analgesia sedation as ordered Give IV Lidocaine prior to suctioning as ordered Give Thiopental IV prior to suctioning as order Considered neuromuscular blocking agent chemical pa
14. asses to provide oxygenation ventilation or use manual ventilation unit with flow oxygen and PEEP valve to oxygenate ventilate between suction passes NICU Use of Neopuff Follow Open Suction procedures per 3 7 However suction should be applied both during insertion and withdrawal of suction catheter unless ordered otherwise Withdrawal of catheter should be in a slow rotating manner 5 to 10 seconds to minimize effects of negative pressure caused by suctioning Suctioning Artificial Airways Learning Package 31 1 REFERENCE LIST Choong K Chartrkaw P Forndova H and Cox P 2003 Comparison of loss of lung volume with open versus in line catheter endotracheal suction Pediatric Critical Care Medicine 4 1 69 73 2 Curley M A and Thompson J E 2001 Chapter 8 Oxygenation and Ventilation pp 233 322 In Critical Care Nursing of Infants and Children 21 Edition M A Curley and P A Moloney Harmon editors Philedelphia Saunders Ridling D A Martin L D and Bratton S L 2003 Endotracheal Suctioning with or without instillation or isotonic sodium chloride in critically ill children American Journal of Critical Care 12 3 212 219 Jackson M R 2005 High frequency ventilation Journal for Respiratory Care Practitioners On line at http www rtmagazine com Articles ASP articleid RO505F05 Singh N C Kissoon N Frewen T amp Tiffin N 1991 Physio
15. ause trauma See Appendix C for how to measure suction depth NOTE n specific circumstances such as suspected endotracheal tube obstruction catheter may be advanced 0 5 cm beyond pre measured depth to remove secretions adhered to distal end of endotracheal tube Apply intermittent suction while slowly withdrawing the catheter rotating catheter between the finger and thumb Continuous suction may be warranted with thick copious secretions or meconium aspiration NOTE Duration of intermittent suction should not exceed 10 seconds in pediatric patients or 5 seconds in neonate Duration of continuous suction should not exceed 5 seconds in neonate or pediatric patient Reoxygenate with the manual resuscitation bag for a minimum of 3 5 breaths at age appropriate rate or until SaO2 returns to baseline for 30 seconds NICU manually ventilate at rate 10 20 higher than ventilation parameters with FiO2 to keep oxygen saturation within ordered parameters between suction passes NOTE A drop in paQOz2 occurs during suctioning and after disconnection from the ventilator Hyperoxygenation and hyperventilation before and after suctioning minimizes this drop If further suctioning is required repeat procedure from 3 7 6 3 7 8 Allow the patient to rest and reoxygenate as necessary Suctioning Artificial Airways Learning Package 27 3 7 10 Clear the catheter and connecting tubing with sterile normal saline as needed and before ins
16. be done routinely as has adverse effect on oxygenation and may promote infection Recommended volumes Neonate 0 3 1ml Infant 1 1 5 ml Child 1 5 2 ml Adolescent 2 3 mls Instillation solutions must be kept sterile Solutions opened or drawn up at bedside must be discarded after 24 hours NICU after 12 hours Suctioning Artificial Airways Learning Package 25 3 3 3 4 3 5 3 6 3 7 Ensure that the following equipment is at the bedside and in good working order e oxygen flow meter e manual resuscitation bag with reservoir and face mask of appropriate size e suction regulator e suction catheters of appropriate size usually 2 times the diameter of the endotracheal or tracheostomy tube in mm equals the appropriate French sized catheter See Appendix A Neonates 5 8 Fr Pediatrics 8 12 Fr Adolescents 12 14 Fr NOTE Catheter should be no more than 2 3 of lumen of tube to prevent hypoxemia and atelectasis However if secretions are very thick and copious use larger suction catheter to minimize number of suction passes and ensure secretions cleared e suction canister and connecting tubing e 0 9 saline for instillation e mask sterile gloves face shield for open suction e clean gloves for closed suction e mouth care supplies e stethoscope e monitoring equipment if possible HR amp SaO2 Wash hands Explain procedure to patient if appropriate incorporating devel
17. changes and airway inflammation and tracheal stenosis Suction catheter should not pass beyond distal end of endotracheal or tracheostomy tube on a regular basis Suction Catheters should never be inserted until resistance felt as this causes trauma to carina Endotracheal Tube e Suction depth can be measured by noting cm markings on endotracheal tube visible at teeth or gums then adding length of endotracheal tube and adapter beyond this This measurement should not need adjustment with the tube depth adjustments as entire tube moves up or down e For In line suction catheters size 6 8 10 French measure as above or add 5 cm to last visible cm marking on tube for approximate suction depth Tracheostomy Tube Use length of tracheostomy tube indicated on box plus measured distance of Tracheostomy above stoma add length of adapter if used Length of obturator may also be used to calculate suction depth but will be slightly longer than tracheostomy tube e Suction Depth measurement should be posted at bedside of all pediatric patients and documented on patient care plan Suction catheter should only be inserted to this depth on regular basis Utilize cm markings on catheter bedside measuring tape or color coded bars on in line catheter to determine suction depth Suctioning Artificial Airways Learning Package 48 5 0 REVIEW QUESTIONS NAME DATE 1 State 2 reasons for suctioning an artificial airway 1 2 2 What signs an
18. d fast bacilli AFB and other diagnostic tests If using in line catheter ensure new sterile catheter utilize for specimen collection SHR Laboratory Manual 2005 The specimen trap is placed between the suction catheter and the suction tubing Please see SHR Infection Prevention and Control Manual and Laboratory Service Manual for further information regarding use of sputum traps Use open suction technique or new in line suction for C amp S specimens from ventilated patients Suctioning Artificial Airways Learning Package 12 2 7 Complications of Tracheal Suctioning Symptoms Prevention e Hypoxemia Decreased oxygen Limit suction pressure to Hypoxia saturation SaO2 lt 90 100 120 mmHg for adults or below patient s 80 100 mm Hg for children baseline 50 80 mmHg for neonates Cyanosis Limit duration of suctioning to Cardiac dysrrhythmias 10 15 sec for adults tachycardia or 10 sec for children bradycardia 5 sec for neonates Premature ventricular Avoid catheters larger than 2 3 the contractions diameter of the airway Cardiorespiratory arrest Hyperoxygenate amp or hyperventilate prior to suctioning Avoid routine suctioning suction only as needed Limit number of catheter passes e Cardiac Tachycardia decreased Minimize hypoxemia by pre Dysrrhythmias arterial oxygen content oxygenating Arrest Bradycardia Vagal Suctioning quickly 5 seconds for response continuou
19. d persons are required to suction to prevent dislodgement of tracheostomy tube 1 2 Senior Assistants and LPN s may suction stable non ventilated and stable long term ventilated patients with an established tracheostomies as assigned by RN once completing unit specific Additional Skills Certification Package in targeted units 1 3 Sterile suction technique must be used for tracheostomies the first 14 days post operative and for obtaining specimens for diagnosis sterile suction catheter and sterile gloves Modified sterile suction technique may be used for established tracheotomies more than 14 days post operative sterile suction catheter and clean gloves without touching portion of suctioning catheter entering tracheostomy tube 1 4 Routine suctioning should be done to premeasured depth This distance in cm should be measured prior to suctioning and documented in Patient Care Plan and posted at bedside Suctioning Artificial Airways Learning Package 17 2 PURPOSE To maintain airway patency by removing pulmonary secretions from the trachea of a patient with a tracheostomy as a component of bronchial hygiene This decreases the risk of hypoxia and potential for infection It also enables collection of sputum for diagnostic purposes 3 PROCEDURE 3 1 Assess the patient s need for suctioning by observing and auscultating for Increased respiratory rate and work of breathing increased heart rate or cyanosis decreased
20. d symptoms indicate that a patient with tracheostomy or endotracheal tube requires suctioning 1 2 3 4 3 Answer True T or False F to the following questions 1 Tracheostomy ETT suctioning is painless causing no anxiety to the patient 2 Suctioning is effective only for secretions in the upper airways 3 The patient should be positioned at 30 upright if possible during suctioning 4 Routine suctioning should be to pre measured depth to prevent trauma to delicate tissues 5 Suctioning should be performed whenever an expiratory wheeze is heard 4 List three signs that suctioning has been effective 1 2 3 Q True Q True Q True Q True Q True False False False False False 20 Suctioning Artificial Airways Learning Package 49 Jimmy a 6 month old baby has a 4 5 Neonatal Tracheostomy in place The length of the tracheostomy tube as indicated on the box 36 mm About 4 cm of the tracheostomy is external to patient With an extension adapter device on tracheostomy tube Routine suction depth is cm When obtaining a tracheal secretion for culture and sensitivity C amp S which of the following best describes the procedure a utilized modified sterile technique and sterile H20 for instillation b utilized sterile technique and open suction method c utilize universal precautions and clean gloves d utilize clean gloves and hyperventilation t
21. dity temperature is excessive infection from contaminated humidity sources 2 3 Signs and Symptoms Indicating a Need for Suctioning Visible secretions in airway Change in respiratory pattern Increased respiratory rate and work of breathing Increased heart rate and cyanosis Restless and agitation Decreased SpO gt and or increased ETCO2 Ineffective coughing Course breath sounds course crackles noisy breathing and changes in air entry Additional cues for Ventilated Patients Increased peak pressures during volume controlled ventilation or decreased tidal volume in pressure controlled ventilation Changes in monitored flow or pressure graphics on ventilator 2 4 Contraindications to Suctioning an Artificial Airwa There are no absolute contraindications to suctioning an endotracheal or tracheostomy tube as secretions need to be removed to prevent obstruction However Neonate and Suctioning Artificial Airways Learning Package 6 Pediatric patients with the following conditions are more likely to decompensate with suctioning Suction these patients with caution and be ready to intervene Increased intracranial pressure cough strain will increase ICP Hemodynamic instability hypoxemia may result in hypotension bradycardia and dysrhythmias Coagulopathy or bleeding disorders suction to pre measured depth only to minimize trauma to trachea Pulmonary hemorrhage Extreme reactive bradycardia i
22. e nasotracheal tube Adults and children over 1 year may utilize cuffed tubes to help seal the airway and aid in mechanical ventilation The cuff is a balloon like device that circles the lower end of the tube It is attached to a very narrow tube which connects to the pilot balloon to a valve allowing access to cuff for filling with air or saline for aeromedical transport Uncuffed or Straight ETT s are usually used in children under 8 years of age as their airways are narrower at the cricoid cartilage which provides a natural seal around the ETT The size of the tube and depth of tube insertion depends on the size of the patient s airway The diameter is measured in millimeters mm and used to describe the endotracheal tube Most ETT s are available cuffed or uncuffed Formula s for ETT size Uncuffed patient age in years 4 Cuffed Patient age 3 4 3 ETT s require insertion by a person specially trained in this skill such as an anesthesiologist respiratory therapist etc and children usually require a regime of medications atropine sedatives analgesics and paralytics to facilitate insertion unless in cardiopulmonary arrest ETT s are designed for short term use hours to few weeks as are uncomfortable to the awake child can traumatize oral and nasal mucos impair oral feeding and vocalizations 2 1 2 Traecheostomy Tubes Tracheotomy is an incision made into the trachea A Tracheostomy is the opening or st
23. e baseline Some patients may require longer duration of reoxygenating to achieve maximum oxygenation NOTE RRT to adjust ventilator settings as ordered for lung recruitment maneuvers LMR S Determine correct color or number for suction depth See Appendix C Suctioning Artificial Airways Learning Package 28 3 8 5 Unlock in line suction Instill if required via Instillation Irrigation port 3 8 6 Stabilize the catheter and endotracheal or tracheostomy tube with non dominant hand 3 8 7 Without suction advance catheter to premeasured depth while pulling plastic sheath back 3 8 8 Depress the control valve to apply suction Maintain suction while withdrawing the suction catheter fully while stabilizing endotracheal or tracheostomy tube to prevent dislodgement Ensure catheter tip fully retracted at end of suctioning to prevent obst5ruction of endotracheal or tracheostomy tube Note Duration of suctioning will not exceed 5 seconds as continuous suction recommended 3 8 9 Check viewing port for secretions and assess patient If further suctioning is required repeat procedure from 3 8 6 3 8 8 Allow the patient to rest and reoxygenate between suction passes 3 8 10 Clean the catheter of debris by flushing sterile 0 9 saline via the irrigation port while simultaneously applying suction Close suction control valve Note Catheter changed when debris cannot be cleared with flushing as above 3 8 11 Return ventilator
24. e when the heart rate drops dramatically in response to vagal stimulation hypoxemia produced with suctioning Provide hyperoxygenation and suction to premeasured depth only Hyperactive airways coughing and irritation of suctioning produces bronchospastic and wheeze Suction to premeasured depth only and give bronchodilators as ordered 2 5 Preparing The Patient And Equipment For Suctioning 2 5 1 Preparing the Patient Suctioning is an uncomfortable and often frightening procedure The patient has an artificial airway and is therefore unable to vocalize Suctioning may cause hypoxemia The patient may have a smothered choking feeling making them anxious and restless combative Patients have rated the pain of suctioning at 7 on a pain scale of 1 10 An explanation regarding the purpose of tracheal suctioning should be given to the patient and or family prior to suctioning and throughout the procedure each time the procedure is done The patient needs frequent reassurance and instruction on how to assist during the procedure Often the patient instinctively will pull at the tube and catheter especially when the cough reflex is stimulated Warn the patient that the procedure will make him her cough A second health care provider may be required to assist with procedure and help to protect artificial airway and manage patient status changes See unit specific policy standards 2 5 2 Positioning the Patient Ideally the
25. echniques Which of the following does not describe suctioning the pediatric airway a Suction pressure should be set as low as possible but able to remove secretions b Instillation of 0 9 saline may be considered when secretions thick and tenacious b Extra oxygen should be given prior to and during suction if patient desaturating c The suction catheter should be advanced until resistance felt withdrawn 1cm then suction applied Which of the following patient conditions warrant extra caution with tracheal suctioning a Those with traumatic brain injury b Those with low platelet count c Those receiving bronchodilators frequently d All of the above Suction policy advocates catheter size no more than 2 3 of diameter of airway What circumstance may warrant a larger catheter and why Suctioning Artificial Airways Learning Package 50 6 0 Definitions Abbreviations PEEP Positive End Expiratory Pressure Pressure exerted by mechanical ventilation at end of expiration to prevent alveoli from complete collapse and aide in gas exchange SpOz2 oxygen saturation ETCO end tidal carbon dioxide spectrometry device attaches to end of endotracheal tube or tracheostomy tube Able to measure CO gt of exhaled gases Normally 35 45 mmHg ETT endotracheal tube S Nursing Office LEARNING PKGisuctioning artificial airways UPDATED doc
26. erting catheter at the end of procedure 3 7 11 Reconnect patient to ventilator wnen suctioning completed 3 7 12 The mouth nose may be suctioned with the same catheter used for tracheal suctioning provided the mouth nose are suctioned last NOTE The mouth nose are considered contaminated with normal bacterial flora Oral nasal suctioning should never proceed tracheal suctioning if the same catheter is used 3 7 13 Auscultate the chest to determine the effectiveness of suctioning and ensure patient comfort and stability 3 7 14 Document on appropriate record amount color and consistency of secretions patient s tolerance of procedure vital sign changes actions taken if problems encountered during suctioning air entry and adventitious breath sounds specimen s obtained and sent 3 8 The Closed Tracheal Suctioning Procedure Pediatrics Neonates 3 8 1 3 8 2 3 8 3 3 8 4 Note for C amp S specimens use new In line suction catheter or open suction technique Note Tracheosotmy specific In line suction catheters may be utilized with tracheostomy tubes Put on clean gloves Set wall suction to Pediatrics 120 mmHg may increase wall suction to 180 mmHg for very thick secretions Neonate 100 mmHg Monitor patient for disrythymias changes in heart rate or SaOz while suctioning Preoxygenate patient for 1 minute using the 100 oxygen key on the ventilator NICU Preoxyenate by increasing F102 0 1 to 0 2 abov
27. fants due to transmission through small chest Vesicular I gt E longer inspiration phase Low pitch and soft Heard normally over peripheral lung fields e Adventitious Sounds Crackle discrete non continuous sound Primarily on expiration Fine High Pitched Crackling Creps hair rolling between fingers Usually heard end of expiration indicating wet lungs pulmonary edema Medium Crackles mid to early inspiration Indicates secretions in bronchioles Suctioning Artificial Airways Learning Package 45 Course Crackles course bubbling usually in larger airways Clear with cough Friction Rub grating low pitched on inspiration and expiration by inflamed pleural surfaces Wheeze indicate partial obstruction of air flow in narrowed passages edema bronchospasm Differences in pitch related to velocity of air flow high pitched musical or low pitched sonorous May be associated with prolonged expiratory time Diminished or absent breath sounds focal or global indicating poor air flow Ominous sign noisy chest is good chest Stridor inspiratory sound produced by narrowing in upper airway structures Crowning or raspy sound Often accompanied by hoarse voice cry or diminished voice cry Suctioning Artificial Airways Learning Package 46 APPENDIX B Developmental Care Practices Suctioning can be a frightening and anxiety producing procedure for all children Develop
28. g Artificial Airways Learning Package 37 e Lung contains little collagen or elastin in newborn infant making premature lung at risk for rupture pneumothorax e Collateral ventilation via Pores of Kohn small holes allowing gas movement between alveoli does not develop until 2 3 years of age Canals of Lambert allow bronchio alveolar communication develop at 6 years of age e Absence of this collateral ventilation makes infants and young children more prone to patchy atelectasis Greater proportion of soft tissue Larynx higher in an infant Loosely attached i 3 gt mucous membranes N Small diameter airway YHOO NT Fewer alveoli Suctioning Artificial Airways Learning Package 38 4 Pulmonary Circulation Both oxygenated and deoxygenated blood is pumped to lungs Left ventricle provides oxygenated blood to lungs via 3 bronchial arteries to bronchi bronchioles lymph nodes and visceral pleura for growth and cell nutrition Right ventricle pumps all of its deoxygenated blood to lungs via pulmonary artery The pulmonary artery then divides into smaller right and left branches that follow airways to alveoli for gas exchange Pulmonary artery pressure PAP is higher in newly born until reactive muscle layers in the pulmonary arterial beds start to thin in response to more oxygen This happens in first 6 8 weeks of life However infants with ongoing hypoxia premature babies or infants wit
29. ggle factor no more than every 12 to 24 hours 3 9 1 2 With HFJV Increase in Servo pressure may indicate need for suction NOTE RRT should be present when patients receiving HFOV or HFJV are suctioned as ventilators put in Standby modes and may require adjustments following suctioning procedure such as increased MAP mean airway pressures to re open collapsed alveoli Pre oxygenation and instillation should be based on patient needs as per 3 7 5 and 3 8 3 Suctioning is done utilizing pre measured suction depth See Appendix C Suctioning Procedures 3 9 3 1 HFOV e In line suction closed suction technique should always be utilized Ventilated disconnects should be avoided to prevent decruitment of alveoli e Ventilator put into Standby more per RRT during suction passess and then turned back on by pressing the Reset button between suction passess to restart ventilator to oxygenate patient e Follow In line suction procedures per 3 8 However suction should be applied both during insertion and withdrawal of suction catheter unless ordered otherwise Withdrawal of catheter should be in a slow rotating manner 5 to 10 seconds to minimize effects of negative pressures caused by suctioning 3 9 3 2 HF JV Suctioning Artificial Airways Learning Package 30 Open suction technique is utilized as per 3 7 as ETT adapter cannot accommodate in line suction catheter HFJV may be reconnected between suction p
30. gus with bronchial buds beginning to shape bronchial branches and main lung lobes Pseudoglandular Period 52 days 16 weeks major conducting airways and terminal bronchi formed Arterial supply increases Diaphragm forms from pleuroperitoneal folds at 8 10 weeks gestation Canalicular Period 17 24 weeks bronchioles develop with 2 3 thin walled terminal sacs primitive alveoli on each Saccular Period 28 36 weeks intense vascularization of lung and loss of glandular appearance Elastic fiber important for alveolar development develop true alveoli present at 34 weeks Contact between air spaces and capillaries established Lymphatic capillaries develop Gas exchange possible but not optimal Alveolar Period 36 weeks term formation of true alveoli occurs with one type of cell for gas exchange 90 and another type for surfactant secretion Surfactant is a complex lipid substance lowering lung surface tension which aids in lung inflation Surfactant production is primarily during 38 40 weeks so opening of alveoli before this may be difficult and traumatic Pulmonary system continues to develop until at least 8 years of age and possibly into adolescence by Increase in size 4 times and number of alveoli 10 times resulting in air surface interface increase of 20 times 24 million alveoli at birth 200 600 million alveoli in adult Tracheal diameter increase 3 times in first 12 mont
31. h congenital heart conditions the muscle layer of vessels may not thin resulting in pulmonary hypertension PHN and pulmonary vascular disease PVD Even in normal infants under 6 8 weeks old hypoxia acidosis hypothermia alveolar hyperinflation and stress can trigger vasoconstriction to lungs and decrease pulmonary blood flow Lymphatic network is present in pleura and around pulmonary arteries and veins 5 Control of Respiration Respiratory rate and depth are under neural and chemical control to maintain oxygen carbon dioxide and pH at levels for optimal cellular functions Central Respiratory Centers in pons and medulla responsible for rhythm of respiration Peripheral Neural Reflexes mechano receptors stretch receptor and C fibers in trachea and lungs transmit impulses to brain stem via vagus nerve altering respiratory rate up or down and increasing volume of breath Also stimulates release of substances like histamine and prostaglandin Chemical Control chemosensitive areas in brain and peripheral chemo receptors in carotid body and aortic arch react to changes in pH carbon dioxide and oxygen as well as circulatory changes to regulate respiration A pediatric patient has higher oxygen demand per kg body weight due to higher metabolic needs O2 consumption in pediatric patient 6 8 ml kg min compared to 3 4 ml kg min in adult Consequently apnea hypoxia and inadequate ventilation develop more rap
32. hs Lung volume increases 4 times Suctioning Artificial Airways Learning Package 34 2 Thoracic Cavity Ribs vertebrae and sternum provide framework for thoracic cavity containing lungs right lung 2 lobes left lung 3 lobes as well as trachea heart great vessels aorta and pulmonary artery and vena cavas and esophagus Thoracic cavity lined with parietal pleura Lungs encased with visceral pleura Lubricating fluid in pleural space between them In disease states pleural space may fill with air pneumothorax blood hemothorax fluid pleural effusion lymph chylothorax or pus empyema Shape of thoracic cavity changes with maturation from round in infant to adult shape at 6 years of age Diaphragm is main respiratory muscle in child producing most of the inspiratory effort Phrenic nerve supplies motor and sensory functions primarily from 3 4 amp 5 cervical spinal nerves Reliance on primarily one muscle for respiratory makes infants and children more prone to fatigue when rapid rates must be sustained Intercostal and accessory muscles poorly developed in infant so contribute little to respiratory effort Infant uses abdominal muscles to assist with breathing Chest wall very compliant as ribs primarily of cartilage and very flexible in infant and young child With increased inspiratory effort downward movement of diaphragm chest wall will move inward on inspiration resulting in indrawing between r
33. hythmias especially bradycardia and hypotension Hyperoxygenation minimizes suction induced hypoxemia by creating an oxygen reservoir in alveoli Note Long term stable tracheostomy patients on low concentrations of oxygen or room air may not require any hyperoxygenation Careful patient assessment needs to be provided during each suctioning procedure 2 5 4 Lung Recruitment Maneuvers LRM s Lung Recruitment Maneuvers are strategies used in critically ill ventilated patients to maintain open alveoli The negative suction pressures applied during suctioning pull air out of aveoli and contribute to collapse and atelectasis Lung Recruitment Maneuvers utilize increased positive airway pressures on inspiration and or expiration eg peak pressures PEEP or increased volumes during and after suctioning to minimize this collapse These parameters are ordered by physician Maggorie et al 2003 6 Preparing the Equipment 2 6 1Suction Catheters Suction catheters come in a variety of sizes and configurations Straight suction catheters are designed for open suction where patient is removed from O2 source or ventilator in order to suction These catheters are equipped with a suction control port which when occluded enables negative pressure from the suction source to be transmitted through the catheter This port usually occluded Suctioning Artificial Airways Learning Package 8 ie suction applied once the catheter has been
34. ibs intercostal below sternum substernal and at base of trachea tracheal tug This is a sign of increasing respiratory effort and distress In extreme circumstances a see saw or paradoxical movement of chest and abdomen may also result an ominous sign of impending respiratory Failure Suctioning Artificial Airways Learning Package 35 Parietal plesira A Left a lung Parietal Coste pericardium diaphrapimatie recess Visceral Visceral pleur mee pericardigm MUILLE Apa vein Anrla Esophagus B Right lung Lefi lung Vieweral pleura hitar l arictal pleura Visceral Parietal pericardium pericardium Anteriar thadiastinuen Fig dl Chest cavity and related structures A Anterior view B Cross section Reproduced with perrnission trom Thompacn 1M and obese Messby s manuel od clinscal murale ef 2 St Louis 149 The CV Mosby Cn Diaphragm movement can be restricted by abdominal contents or gastric distention Elevating head of bed 30 or position of comfort may aid respiratory efforts Insertion of gastric tube for decompression may be required to aspirate air or fluids Note Gastric tube always required with mechanical ventilation and following extended periods of manual ventilation Normally diaphragm is dome shaped to aid in contraction However when it becomes flattened due to lung hyperinflation common with acute asthma and
35. idly 6 Oxygenation amp Ventilation Oz amp CO diffuse across 7 layer alveolar pulmonary capillary membrane in direct proportion to surface area artial pressures of gases and gas solubility CO2 20 times more diffusible than O2 Suctioning Artificial Airways Learning Package 39 6 1 Oxygen Transport O2 carried bound to Hemoglobin 97 and dissolved in plasma 3 SpO2 measures O2 bound to Hemoglobin Blood gases measure Oz in plasma 6 1 2 The Oxygenation Dissociation Curve illustrates the affinity of O2 to Hemoglobin and the relationship between SpO gt and Oz PaOz measured with blood gas On the upper or flat portion of curve PaO2 gt 80 mmHg variances in O2 tension or PaOz produce minimal changes in O2 saturation content Within the steep portion of curve PaO lt 60 mmHg a small variance in Oz tension paOz produces a dramatic drop in O2 saturation content This curve can be shifted to Right reduced Hemoglobin affinity to O2 or shifted Left greater Hemoglobin affinity for O2 by pH COz levels temperature and fetal hemoglobin levels See Physiology or Nursing Texts for more information L shift Larger Hgb 1 neethorn Hyb affinity for Da 2 hypotharma 3 cos i0 i E a a E n i 3 k A shit Aeduces Hgb E ra a ailinety far Gs en ED fie ne go Ne Eh 1 ackiosis mn fe i ay 2 fever ie au CE ae aah g TG g fi i f ar ff i Fa 4 a pr 1 T J 2 J HE a iw om ow While cli
36. ing ce nenea eneneee ee anea 2 2 3 Signs and Symptoms Indicating a Need for Suctioning eee nenea 2 2 4 Contraindications to Suction and Artificial Airway ceea 2 2 5 Preparing the Patient and Equipment for Suctioning 0e 3 2 6 Complications of Tracheal SUCtIONING ceeeeeeeeeeeeeeeeeeeneeeeeeenteeeees 10 3 0 Referenc s secat Iara cas data 0 002 ease ec es ul ee a ua 13 4 0 Appendices Appendix A POlSIES zic potzi to nalt it rile ea alta ba a a a DD pi d 14 Appendix B Essential Anatomy amp Physiology of Pediatric Respiratory System 17 Appendix C Assessment of Pediatric Respiratory System eeaeeee e 26 5 0 Review Questions cc i os eet dies athe eet ee ie hate Ges Suctioning Artificial Airways Learning Package 1 1 0 GENERAL INFORMATION 1 1 Criteria for Certification Completion of Unit Specific Orientation Review of the learning package and completion of the review questions Satisfactory demonstration of the clinical skills to a Clinical Nurse Educator in a patient and or lab simulation setting 1 2 Criteria for Recertification Recertification is required annually for LPNs SA who are not performing the skill regularly Recertification may be done upon the request of the Manager of Nursing Clinical Nurse Educator or the individual RN or LPN SA Suctioning Artificial Airways Learning Package 2 2 0 THEORY 2 1 Artificial
37. ization Source Pediatric Operations Committee Cross Index X Tri Hospital Nursing Practice Date Reaffirmed Committee Date Revised Date Effective March 2006 Scope Saskatoon City Hospital ER OR Royal University Hospital NICU PICU ER OR St Paul s Hospital ER OR 1 POLICY 1 1 The RN RRT experienced PT and their students with direct supervision 1 2 1 3 may perform suctioning of the ventilated pediatric patient who has an endotracheal tube or tracheostomy tube as necessary Pediatric patients are patients under 17 years of age 1 1 1 NICU patients are suctioned by RNs or RRTs 1 1 2 PICU patients require 2 qualified personnel for suctioning unless otherwise ordered second person to monitor vital signs and ensure airways stability Suction depth should be measured prior to suctioning and distance in cm documented in Patient Care Plan and posted at bedside Collection of Specimens for C amp S use an open suction technique or a new in line suction catheter 2 PURPOSE 2 1 To maintain airway patency by removing pulmonary secretions or foreign matter from trachea in patient with an artificial airway as a component of bronchial hygiene and mechanical ventilation This decreases the risk of hypoxemia and potential for infection It also enables collection of sputum for diagnostic purposes Suctioning Artificial Airways Learning Package 24 2 2 Suctioning may utilize closed or
38. l or how much pressure is needed to produce a volume change within lungs Compliance changes with age newborn lungs are relatively tight disease states disease decreasing amount of surfactant such as ARDS decrease compliance lungs more stiff Chest wall thoracic deformilies like scoliosis obesity and muscular dystrophies make it harder to move chest wall Airway Resistance is the pressure needed to move gases into or out of lungs at specific flow rate or time interval Small airway diameters in children contribute up to 50 of resistance compared to 20 in an adult Normally airways are pulled open during inspiration by bronchial smooth muscle and become slightly smaller during the elastic recoil of expiration Bronchial muscle is regulated by autonomic nervous system with sympathetic flight or flight stimulation causing bronchial dilation and parasympathetic stimulation causing constriction Disease states such as asthma and bronchiolitis can cause bronchial constriction resulting in increased work of breathing air trapping and diminished tidal volumes Chemical mediators such as histamine release in anaphylaxis also cause bronchial constriction Medications such as Salvulamol Ventalin via sympathetic receptors to help bronchodilate while medication like Atrovent help block parasympathetic induced bronchial constriction How quickly and easily gases are able to flow in and out of lungs depends upo
39. llow the patient to rest and reoxygenate by reconnecting patient to oxygen source or ventilator Hyperoxygenation with manual resuscitation bag and high flow oxygen may be required if SpO is low patient is cyanotic or showing other signs of severe respiratory distress Patients prone to atelectasis Suctioning Artificial Airways Learning Package 19 3 15 3 16 3 17 3 18 3 19 may benefit from hyperinflation with manual resuscitation bag following removal of secretions as ordered by physician If further suctioning is required repeat procedure from 3 10 3 14 Allow the patient to rest and reoxygenate between suction passes Clear the catheter and connecting tubing with sterile normal saline before reinserting and at the end of procedure The mouth nose may be suctioned with the same catheter used for tracheal suctioning provided the mouth nose is suctioned last NOTE The mouth nose is considered contaminated with normal bacterial flora Oral nasal suctioning should never precede tracheal suctioning if the same catheter is used Auscultate the chest to determine effectiveness of suctioning and ensure patient stability comfort and safety Document on appropriate record e amount color and consistency of secretions e patient s tolerance of procedure vital sign changes e actions taken if problems encountered during suctioning e air entry and breath sounds before and after suctioning e specimen s obtained and
40. logical responses to endotracheal and oral suctioning in pediatric patients the influence of endotracheal tube sizes and suction pressures Clinical Intensive Care 2 6 345 50 Suctioning Ventilated Neonates Policy 1021 2005 Neonatal Intensive Care Unit Policy and Procedure Manual SHR Saskatoon Wright J 1996 Closed Suctioning Procedure in Neonates Neonatal Network Vol 15 No 6 87 90 Wrightson D D 1999 Suctioning Smarter Answers to Eight Common Questions about Endotracheal Suctioning in Neonates Neonatal Network 18 1 51 55 Maggorie S M Lellouche F Pigeot J Taille S Deye N Bouchard L 2003 Prevention of endotracheal suction induced alveolar decruitment in acute lung injury American Journal of Respiratory Critical Care 157 9 1215 24 Suctioning Artificial Airways Learning Package 32 APPENDIX A Endotracheal Tracheostomy Tube and Suction Catheter Chart Endotracheal Tracheostomy Suction Catheter Size In Line Suction Tube French Catheter French inner diameter in mm 2 5 5 6 3 0 6 6 or 8 3 5 6 8 4 0 8 8 4 5 8 10 5 0 10 10 5 5 10 10 6 0 12 12 6 5 12 12 7 0 14 14 8 0 14 14 These sizes available as In line suction catheters for Tracheostomy tubes APPENDIX C Measured Suction Depth All routine suction passes should be to pre measured depth to minimize risk of trauma to delicate tracheal tissues bro
41. mental Care Principles to incorporate during this procedure include Timing procedure to infant s sleep wake cycle whenever possible For older children always tell them what you will be doing before start of procedure and ways they can help you during procedure For example tell them that suctioning will make them cough but that you will let them rest following Provision of containment and support of the infant during the procedure by using positioning flexion and swaddling For older children a second health care provider should be present to help ensure patient does not grab at endotracheal tube or move head excessively Tailoring the pace of the procedure to respond to the infant s cues and allowing the infant to reorganize to a calm state Provision of a 20 to 30 minutes rest post procedure to recover before the next activity for example feeding is especially important in infants Whenever possible suctioning should be done before feeds to minimize risk of vomiting Chest physiotherapy and or positional changes should be done prior to suctioning if possible as these therapies may loosen secretions Suctioning Artificial Airways Learning Package 47 APPENDIX C Measured Suction Depth All routine suction passes should be to pre measured depth to minimize risk of trauma to delicate tracheal tissues Repeated suctioning past end of endotracheal or tracheostomy tube can result in bronchial perforation hemorrhage histological
42. n compliance elasticity of lungs and chest and resistance produced by the size of the patient s own and artificial airways It is therefore extremely important to keep pediatric natural and artificial airways free of secretions Remember that Endotracheal and tracheostomy tubes are always slightly smaller than normal airway This as well as edema and broncho spasm increase the work of breathing required to move air through narrowed airways Addition of airway extenders on ETT s or tacheostomy tubes or some forms of oxygen delivery devices ie Easy Breather on trach tube can Suctioning Artificial Airways Learning Package 41 also increase resistance and work of breathing as extend the length and resistance of external airway 7 Volume of Breath The usual volume of each breath is 6 7 mls kg although larger volume breaths can be generated when bodies gas exchange requirement increase Minute of Ventilation the amount of air moving in and out of lungs in 1 minute and is the product of respiratory rate and volume e Obviously increasing rate and volume increases minute ventilation e Decreasing rate and volume results in decreased minute ventilation a critical situation resulting in hypoxia e However slower large volume breaths may still produce adequate minute ventilation ie When child asleep e Small volume breaths may be tolerated provided the compensatory increase in respiratory rate can be sustained ie asthma
43. nchial perforation hemorrhage histological changes airway inflammation and stenosis Suction catheter should not pass beyond distal end of endotracheal or tracheostomy tube on a regular basis Catheter should never be inserted up to carina For Endotracheal Tube Suction depth can be measured by noting cm markings on endo tracheal tube then adding length of adapter For Tracheostomy Tube Use length indicated on box or length of obturator plus measured distance of tracheostomy above stoma add length of adapter if used This measured depth is posted at bedside and documented on patient care plan Suction catheter should only be inserted to this depth Utilize cm markings on catheter or color coded bars on in line suction catheter Suctioning Artificial Airways Learning Package 33 Appendix B Essential Anatomy amp Physiology of Pediatric Respiratory System Curley amp Thompson 2001 Immaturity of the respiratory system places the infant and young child at risk for respiratory dysfunction with respiratory failure being primary factor in cardiopulmonary arrest 1 Embryology Pulmonary function is immediately essential for extrauterine life Gestational age of premature babies has dramatic influence on immediate and long term respiratory issues Embryological development has 5 stages reflecting histological maturation of lung Embryonic Period Day 26 52 primitive forgut divides into trachea and esopha
44. nical measures of oxygenation SpOz2 and arterial capillary blood gases show O diffusion within the lungs they do not necessarily reflect O2 delivery to tissues effective O2 use by tissues or the work of breathing ventilation O delivery to tissues influenced by cardiac output ie Heart rate volume of blood the amount of Hemoglobin tone in small arterioles that can vasoconstrict or vasodilate and characteristics of capillary wall allowing O2 diffusion Oxygen consumption is amount of oxygen used by tissues is increased in stress states pain fever activity and decreased in sleep relaxation anesthesia sedation and hypothermic states Under optimal conditions O2 delivery matches O2 needs However if O2 needs exceed delivery hypoxia will result Suctioning Artificial Airways Learning Package 40 6 2 Note Ventilation Ventilation is the process of gases moving in and out of lungs inspiration and expiration in response to pressure gradients created by 8 movement of diaphragm and other respiratory muscles that expand thoracic cavity creating a negative pressure that draws pulls gases in through upper airways trachea 9 Positive pressure ventilation manual ventilation with bag valve mask or mechanical ventilator that forces pushes gases into thoracic cavity to expand lungs How easily gases are able to flow into lungs depends upon 6 2 1 6 2 2 Compliance or elasticity of lungs and chest wal
45. oma created by a tracheotomy incision Tracheostomy tubes are often referred to trach for short Types Of Tracheostomy Tubes Pediatric and Neonatal Usually tracheostomy tubes for infants and children up to 6 8 years of age are a single tube uncuffed device Trachesotomy tubes come in different diameters to fit different sized airways This dimension is measured in millimeters mm and used to describe tracheostomy tube ex 3 5 mm just as for ETT s Suctioning Artificial Airways Learning Package 4 Tracheostomy tubes also come in different lengths and optimize pediatric fit This size is listed on product package In general Neonatal tracheostomies are shorter than Pediatric to fit very small infants They are supplied in same diameters as Pediatric ex 3 5 Neonatal and 3 5 Pediatricare same diameter but different length so check carefully Pediatric tracheostomies also come in extra long PDL sizes Older children may have more adult type tracheostomy tubes with cuff that can be inflated to seal airway and decrease air leak around trachesotomy tube Some larger trachesotomy tubes may also have inner cannula or a tube within a tube The inner cannula can be changed without changing the entire tracheostomy Various oxygenation and humidification sources can be used with trachestomy These include trach mask and Easy Breather Special one way speaking valves may also be attached These will have to be removed f
46. opment care practices Appendix B Position patient with head of bed elevated 30 supine and head midline unless contraindicated Note Elevation of head of bed to 30 is recommended for all intubated pediatric patients in supine or side lying positions Open Tracheal Suctioning Procedure 3 7 1 Put on mask and protective eye wear face shield 3 7 2 Setup sterile 0 9 saline for instillation and for flushing of catheter between catheter passes 3 7 3 Open suction catheter package maintaining the sterility of catheter Attach catheter end to connection tubing from the suction apparatus Adjust wall suction Recommended pressures should Suctioning Artificial Airways Learning Package 26 3 7 4 3 7 5 3 7 6 3 7 7 3 7 8 3 7 9 not exceed 80 120 mmHg for pediatrics and 80 100 mmHg for neonates Put on sterile gloves Hyperoxygenation Disconnect the patient from the ventilator ensuring ventilator connections are kept clean Pre oxygenate patient by ventilating for 3 5 breaths using a manual resuscitation bag and 100 oxygen NICU Hyperventilate at rate 10 20 above baseline NOTE Hyperoxygenation provides an oxygen reserve in the alveoli reducing the risks of hypoxemia and bradycardia With sterile gloved hand advance catheter to pre measured depth without applying suction Utilizing measured depth ensures suction catheter does not extend beyond end of endotracheal tube or tracheostomy tube and c
47. or suctioning Manual ventilation bags ex Lardal can be attached to tracheostomy tubes to assist the patient with ventilation and supply increased concentrations of oxygen A mechanical ventilator can also be attached to tracheostomy to provide oxygen humidity and ventilation assistance The ventilator will need to be removed to suction patient unless special in line tracheostomy suction system is used 2 2 Assessing the Need for Suctioning 2 2 1 Pediatric Considerations A patient with a tracheostomy or endotracheal tube ETT is less able to increase intra thoracic pressure needed for an effective cough to clear secretions This is because the artificial airway bypasses the glottis which normally seals the airway allowing patient to exert a forceful cough Consequently suctioning will need to be done when there are secretions present in the upper airways that the patient is unable to clear Literature cautions that routine suctioning should be avoided as increases chances of mucosal trauma and infection However due to the small size of pediatric ETT or tracheostomy tubes pediatric patients needed to be suctioned on a regular basis as small sized tubes are more prone to obstruction from secretions Build up of secretions dramatically increases airway resistance making it more difficult to breath Neonate Pediatrics patients with endotracheal tubes are usually suctioned every 3 4 hours Neonate Pediatric patients with establi
48. ralysis as ordered ventilated patient only Suctioning Artificial Airways Learning Package 15 3 0 REFERENCES REFERENCES Choong K Chartrkaw P Forndova H and Cox P 2003 Comparison of loss of lung volume with open versus in line catheter endotracheal suction Pediatric Critical Care Medicine 4 1 69 73 Curley M A and Thompson J E 2001 Chapter 8 Oxygenation and Ventilation pp 233 322 In Critical Care Nursing of Infants and Children 2 Edition M A Curley and P A Moloney Harmon editors Philadelphia Saunders Ridling D A Martin L D and Bratton S L 2003 Endotracheal Suctioning with or without instillation or isotonic sodium chloride in critically ill children American Journal of Critical Care 12 3 212 219 Jackson M R 2005 High frequency ventilation Journal for Respiratory Care Practitioners On line at http www rtmagazine com Articles ASP articleid R0505F05 Pantillo K A et al 2001 Patient s Perceptions and Responses to Procedural Pain Result from Thunder Project American Journal of Critical Care 10 4 238 251 Singh N C Kissoon N Frewen T amp Tiffin N 1991 Physiological responses to endotracheal and oral suctioning in pediatric patients the influence of endotracheal tube sizes and suction pressures Clincial Intensive Care 2 6 345 50 Suctioning Ventilated Neonates Policy 1021 2005 Neonatal Intensive Care Unit Polic
49. re measured depth to minimize risk of trauma to delicate tracheal tissues Repeated suctioning past end of tracheostomy tube can result in bronchial perforation hemorrhage histological changes airway inflammation and tracheal stenosis Suction catheter should not pass beyond distal end of the tracheostomy tube on a regular basis Special circumstances copious thick secretions or partially obstructed tracheostomy tube may warrant occasional uses of deeper suctioning ie 0 5 past the pre measured depth to remove secretions adhered to tip of tracheostomy tube However avoid inserting suction catheter until resistance is felt as this causes trauma to carina To Measure Use length of tracheostomy tube indicated on box plus measured distance of tracheostomy above stoma add length of tracheostomy adapter if used Length of tracheostomy obturator maybe used however it is slightly longer than tracheostomy tube Suction Depth measurement is posted at bedside and documented on patient care plan Suction catheter should only be inserted to this depth Utilize cm markings on catheter or bedside measuring tape to determine suction depth with each suction pass Suctioning Artificial Airways Learning Package 23 POLICIES amp PROCEDURESS Saskatoon N Title SUCTIONING VENTILATED Health AL AND HIGH CONVENTIONAL AND HIGH ue 4 FREQUENCY PATIENTS VIA ARTIFICIAL AIRWAYS PEDIATRIC NEONATE I D Number 1056 Author
50. retions and may decrease risk of nosocomial infections Curley amp Thompson 2001 Refer to Policy and Procedure Suctioning Ventilated Conventional and High Frequency Patients via Artificial Airways Pediatric Neonate 1056 Appendix A Closed suction systems may require increased suction pressure to effectively remove secretions However suction pressure should not exceed 180mmHg unless ordered by physician Suctioning Artificial Airways Learning Package Fii i gion pante pa Para T mea lar weii circuli Suctioning Artificial Airways Learning Package 10 2 6 3 Suction Pressure Adjust the suction pressure according to the nature of the secretions being removed using the lowest suction pressure that will be effective Set suction pressure at e Pediatrics 100 120 mmHg e Neonates 80 100 mmHg Thick secretions or mucous plugs may necessitate pressures at higher end of range Rationale Damage to the epithelial and mucosal layers of the airways caused by the presence of an artificial airway is magnified with the introduction of a suction catheter Excessive negative pressure causes edema hemorrhage and ulceration of tracheal tissue Negative pressures also pull air from distal airways contributing to atelectasis and decreased lung compliance Chong et al 2003 2 6 4 Instillation The instillation of sterile 0 9 saline should not be done on a routine basis but may be required for tenacious secretions
51. rning package in whole or in part should be addressed to Department of Nursing Development c o Nursing Office c o Nursing Office c o Nursing Office Royal University Hospital Saskatoon City Hospital St Paul s Hospital Saskatoon Sask Saskatoon Sask Saskatoon Sask S7N OW8 S7K 0M7 S7M 0Z9 ACKNOWLEDGMENTS Coordinated by Janlyn Rozdilsky Clinical Nurse Educator Pediatric Intensive Care Unit Royal University Hospital Special Thanks to Dr Gordon Kasian Medical Director Pediatric Intensive Care Unit Royal University Hospital Dr Bryce Lothian Pediatric Respirologist Intensivist Department of Pediatrics Royal University Hospital Lorna Kosteniuk Clinical Nurse Educator Pediatrics 3100 Royal University Hospital Bernie McDonald Clinical Nurse Educator Pediatrics 3000 Royal University Hospital Celeste Heffernan Clinical Nurse Educator Neonatal Intensive Care Unit Royal University Hospital Chris Grant RRT Department of Respiratory Therapy Doug Ellingsen RRT Royal University Hospital Jeff Dmytrowich RRT Suctioning Artificial Airways Learning Package irr TABLE OF CONTENTS 1 0 General Information mmm nenea eee eee nana 1 1 1 Criteria for Certification 2 ee eat pa i lak i eae pate SE 1 1 2 Criteria for Recertification e cs connect ae i 0 alai a ta 1 2 0 Theory eee eee 2 2A ArificialAWayS ssc le asco a iz ou ai ot aia 2 2 2 Assessing the Need for Suction
52. s 10 seconds for intermittent Stop suctioning administer 100 oxygen by manual ventilation or ventilator e Tracheal Aspiration of blood Advance catheter pre measured Mucosal tinged mucous distance only Damage Decreased air entry Use lowest level of suction e Pulmonary Aspiration of frank blood pressure that will be effective Hemorrhage Perform suction procedure gently Avoid forcing the catheter against resistance Limit number of catheter passes Avoid routine suction suction only as needed Assess patient coagulation status e Infection patient Increased secretions in Ensure adequate humidification of caregiver the trachea gases Colonization with gram Wash hands before and after negative organisms procedure Increased heart rate Use sterile equipment and solutions respiratory rate and Maintain strict aseptic technique temperature Suctioning Artificial Airways Learning Package 13 Symptoms Prevention Keep ends of oxygen source clean to reduces possibility of contamination of the oxygen source Use gentle suctioning technique to avoid trauma monitor suction pressure duration and depth Optimal hydration nutritional and metabolic status Avoid routine suctioning suction only as needed For staff protection use of gloves masks goggles is required Change respirate supplies per Infection Control parameters Hypotension hypertension Atelectasis Bronchoconstric tion Bronchospasm Paroxysm
53. shed tracheostomies may be suctioned less frequently but at least in morning and evening to prevent tube obstruction Remember that fine crackles and wheezes are rarely cleared with suctioning because they indicate narrowed bronchial passages secretions or Suctioning Artificial Airways Learning Package 5 edema in the small airways and alveoli which are inaccessible to suctioning Chest physiotherapy and postural drainage positioning may help move secretions from the lower airways to larger upper airways where it more accessible to suctioning 2 2 2 Humidification An ETT or tracheostomy bypasses the upper portions of the airway where inspired gases are normally filtered and humidified Humidification of inspired air and adequate systemic hydration assist to Keep secretions thin easier to move remove by coughing Prevent tube occlusion from thick dried secretions Counteract insensible fluid losses Compensate for bypass of upper airway Maintain moist mucous membranes to maximize mucocilliary transport in the lower airways Humidity can be provided from extended sources such as heated humidifiers on mechanical ventilators or humidified gases via tracheostomy mask Humidity can also be provided by special devised such as Easy Breathers or HME filters that trap exhaled moisture and utilize this to humidify next breath Complications of overhumidification are excessive moisture into dependent bronchi tracheal burns if humi
54. ss respiratory excursion symmetrical e Assess abnormalities Subcutaneous emphysema crepitus course crackly feeling and sound of air in tissues rice krispies indicated air leak into tissues Suctioning Artificial Airways Learning Package 44 a Tactile tremitus Vibrations diminished with poor air entry consolidation Vibrations increased with copious secretions or pleural friction rub Position of trachea eviation may indicate fluid or air collection or collapsed lung ie tension pneumonthorax C Percussion e Normal lungs should have resonance e Dull flat indicates solid organ liver or atelectasis consolidation Hyper resonance tympany indicated air trapping gastric bubble or pneumothorax A feed Flat Over bane Boe oo Cansoldation i i Preumonin Turnar Dull Ovar liver Tympany Gasino me huibhe Resonanca Morral inlercosial spate Hyparrasananea etrusc lung Midclaw kukar liret D Auscultation e Compare symmetrical areas of lung listening anteriorly laterally and posteriorly if possible Note quality intensity and duration of breath sounds in respiratory cycle Adventitious abnormal sounds and timing in respiratory cycle Breath Sounds e Normal Sounds Bronchial I lt E slightly longer expiratory phase High pitch loud blowing Normally over large airways trachea bronchi Broncho vesicular I E high pitched tubular sounds Normal in in
55. tic with air trapping Dead Space not all of the volume of gases entering the respiratory system participates in gas exchange e Gases in nose pharynx trachea and bronchials about 2 mls kg remain unchanged and are referred to as Anatomical Deadspace e Deadspace may be increased with use of artificial airways ETT and tracheostomy tubes especially if extension devices are large in relation to patients tidal volumes These devices can also trap exhaled CO2 and result in rebreathing and increased blood CO levels 8 Ventilation Perfusion Relationships e Optimal gas exchange occurs when ventilation air and perfusion pulmonary blood flow are equally matched However even under ideal circumstances this ventilation perfusion ratio v Q is not 1 1 as gravity draws blood downward while gases tend to rise upward e Patient position whether upright supine or prone changes this relationship In healthy children and adults the body easily compensates and adjusts for the difference and position changes However in the abnormal lung problems may arise a Intrapulmonary Shunt venous deoxygenated blood travels from Right side of heart through lungs and back to Left side of heart without ever coming in contact with ventilated alveoli so no gas exchange occurs Examples ateleclasis pneumonia pneumothorax apnea b Physiological Dead Space alveoli ventilated but not perfused therefore no gas exchange Suctioning
56. tion for postural drainage unless contraindicated Put on mask and protective eye wear face shield Set up sterile saline for instillation if required and flushing of catheter between catheter passes Assess the need for instillation with sterile 0 9 saline Routine instillation is not recommended as has an adverse effect on oxygen saturation but may be required if secretions very thick Recommended volumes Neonate 0 3 1 ml Infant 1 1 5 ml Child 1 5 2 ml Adolescent 2 3 ml NOTE Maintain sterility of instillation solution and change solutions at least q24 hours NICU q 12 hours Open suction catheter package maintaining the sterility of catheter Attach catheter end to connection tubing from the suction apparatus Adjust wall suction to 80 120 mmHg for pediatrics and 50 80 mmHg for neonates Put on gloves sterile or clean as per 1 3 Disconnect the patient from humidity oxygen source or ventilator ensuring the connections are kept clean Preoxygenate patient if requiring high supplemental O or severely desaturating as routine manual ventilation may force secretions back into distal airways Without applying suction advance catheter to pre measured suction depth See Appendix B 3 13 Apply suction while withdrawing and rotating the catheter NOTE Duration of suctioning should not exceed 5 seconds when continuous suction applied or 10 seconds for intermittent suction 3 14 Between passes a
57. trachea is more cephalad towards the head in child resulting in a shorter higher structure at cervical vertebrate 2 3 in child and at cervical vertebrate 4 5 in adult putting them at increased risk for aspiration and making intubation more difficult The cricoid cartilage ring is smallest portion of child s airway and the only part of trachea entirely enclosed with cartilage This ring determines size of endotracheal tube that can be inserted and provides seal around tube in infants and small children Any edema in this area can produce airway obstruction increased airway resistance and work of breathing Intrathoracic Trachea length increases from 4 5 cm in infant to 7 cm in adolescent Thin walled cartilage tube of 16 20 rings which partially encircle trachea Posterior trachea wall is smooth muscle Because of its small diameter even minimal obstruction results in a dramatic increase in airway resistance and increased work of breathing i e 1 mm of swelling in a 4 mm trachea results in a 75 decrease in open area and 16 times increase in resistance Tracheobronchial Tree made of smooth muscle which increase until 1 year of age At 4 5 months of age enough smooth muscle to cause bronchospasm in response to irritant Terminal bronchioles continue to branch until 1 year Alveoli alveoli increase in number and size until child about 8 years to increase surface area for gas exchange Suctionin
58. y and Procedure Manual SHR Saskatoon Wright J 1996 Closed Suctioning Procedure in Neonates Neonatal Network Vol 15 No 6 87 90 Wrightson D D 1999 Suctioning Smarter Answers to Eight Common Questions about Endotracheal Suctioning in Neonates Neonatal Networ 18 1 51 55 Maggorie SM Lellouche F Pigeot J Taille S Deye N Bouchard L 2003 Prevention of endotracheal suction induced alveolar derecruitment in acute lung injury American Journal of Respiratory Critical Care 157 9 1215 24 Suctioning Artificial Airways Learning Package 16 4 0 APPENDICES APPENDIX A Policies pm POLICIES amp PROCEDURESS Saskatoon N Title SUCTIONING NON VENTILATED f He alt q PATIENTS WITH TRACHEOSTOMY i R wm 2 PEDIATRIC NEONATE I D Number 1051 Source Cross Index Date Reaffirmed Date Revised Date Effective May 2006 Scope SASKATOON CITY HOSPITAL ER OR PACU ROYAL UNIVERSITY HOSPITAL 3000 3100 NICU PICU ER OR PACU ST PAUL S HOSPITAL ER OR PACU PARKRIDGE Authorization Pediatric Operations Committee x Tri Hospital Nursing Practice Committee 1 POLICY 1 1 The RN RRT PT and their students with supervision may perform suctioning of the non ventilated patient who has a tracheostomy tube in order to remove airway secretions as necessary For patients with fresh tracheotomies i e tracheostomy tube has not bee changed 2 qualifie

SUCTIONING ARTIFICIAL AIRWAYS

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