Tracheostomy Care and Suctioning - Adult
Contents
1. Suctioning Artificial Airways Learning Package 13 CORRESPONDING SIZES CUFFED UNCUFFED METAL LAERDAL SUCTION SHILEY ADAPTOR CATHETER 00 5 0 8 1 8 2 10 3 10 4 4 5 10 4 5 6 10 4 6 7 12 4 7 8 12 6 8 9 12 8 14 10 14 2 0 PURPOSE 2 1To maintain airway patency by removing secretions or foreign objects from trachea 2 2 To assist the patient in removing airway secretions when the patient is unable to expectorate on his her own 2 3 To stimulate coughing to mobilize secretions 2 4 To decrease the potential for infection that may result from accumulated secretions 2 5 To obtain a sputum specimen for diagnostic purposes 3 0 PROCEDURE 3 1 Endotracheal or Tracheostomy Tube Suctioning Non Ventilated Patients See Nursing Interventions and Clinical Skills Textbook 3 Ed pp 760 762 764 768 3 1 1 Note the following exceptions to the textbook information Suction kits are not routinely used at RUH SCH Suction is pre set on portable suction units Do not use sigh mechanism on mechanical ventilator Sterile Normal Saline may be drawn directly from the 250ml bottle Suction should be continuous while withdrawing suction catheter 3 2 Endotracheal or Tracheostomy Tube Suctioning Ventilated Patients See Nursing Interventions and Clinical Skills Textbook gra Ed pp 766 768 S Nursing Office LEARNING PKG suctioning artificial airways adults doc Suctioning Artificial Airways Lea2. Suction Catheter Closed System In ventilated patients a closed circuit catheter system eliminates the need to disconnect the patient from the ventilator during suctioning The severity of arterial oxygen desaturation can be reduced by using a closed system and unstable patients appear to better tolerate suctioning when not removed from ventilatory Maggione pg 1218 2003 Refer to Policy and Procedure Suctioning Adult Patients With Artificial Airways in Place 1019 for further information S Nursing Office LEARNING PKG suctioning artificial ainways adults doc Suctioning Artificial Airways Learning Package 7 Suction Trap Used to collect sterile sputum specimens when the patient is unable to expectorate sputum or has an artificial airway in place The sputum 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 Setting the Suction Pressure Set suction pressure at 100 120 mmHg for adults Adjust the suction pressure according to the nature of the secretions being removed Use the lowest suction pressure that will be effective Thick secretions or mucous plugs may necessitate higher pressures A physician s order is required to increase the pressure above the limits identified above Rationale Damage to the epithelial and mucosal layers of the
3. Suctioning Artificial Airways Learning Package 4 Comfort measures taken Any other aspects of care regarding the individual needs of the patient The patient may benefit from frequent reassurance and instruction on how to assist the nurse during the procedure Often during the procedure the patient instinctively wants to pull at the catheter especially when the cough reflex is stimulated Warn the patient that the procedure will make him her cough Restraints may be necessary especially in the cognitively impaired patients and with children To allay patient fears suctioning must be performed with confidence and speed Positioning the Patient Position the patient with head of bed elevated or in appropriate position for postural drainage unless medically contraindicated i e unstable spinal fractures Rationale This promotes deep breathing and effective coughing by allowing maximum movement of the diaphragm Oxygenation If required extra oxygen may be given before and after each episode of suctioning This is most often done with ventilated patients In the non ventilated patient extra oxygen can be provided using a manual resuscitation bag attached to oxygen or increase oxygen flow if needed If extra oxygen is not needed encourage the patient to take several deep breaths before and after suctioning Hyperoxygenation Hyperoxygenation refers to the administration of oxygen at a greater concentration than the pat
4. artificial airways are frequently immunocomprimosed and susceptible to infection Since the air is no longer moistened cilia action is depressed leading to thickened secretions that are difficult to clear Strength of cough is depressed due to lack of ability to generate increased intrathoracic pressure against a closed glottis A tacheostomy alters motor and sensory functions responsible for coordinating swallowing causing increased risk of aspiration Endotracheal Tubes Is an airway tube inserted into the trachea to ensure patency of the upper airway It can be inserted through the mouth using an orotracheal tube or through the nose using a nasotracheal tube Adult tubes are almost always cuffed to prevent leakage allowing their use with a mechanical ventilator and decreasing chance of aspiration of orophayngeal fluid 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 This device allows for cuff inflations and quick determination of the cuff pressure Once the cuff is inflated there is not airflow through the trachea other than that going through the endotracheal tube The size and depth of tube insertion depends on the size of the patient SA Nursing Office LEARNING PKG suctioning artificial airways adults doc Suctioning Artificial Airways Learning Package 20 Tracheostomy Tubes Tracheostomy is an incision made into the trache
5. due to deflation of cuff Can eat with plug in place assess swallow first Oxygen given via nasal prongs or mask When not in use put in sterile container Clean with soap amp water rinse thoroughly SA Nursing Office LEARNING PKG suctioning artificial airways adults doc Suctioning Artificial Airways Learning Package 23 5 0 REVIEW QUESTIONS 1 NAME DATE State three reasons for suctioning an artificial airway What signs and symptoms indicate a need for tracheotomy or endotracheal tube suctioning Answer True T or False F to the following questions Tracheostomy ETT suctioning is painless causing no anxiety to the patient Routine suctioning should be avoided Suctioning is effective only for exudate in the upper airways The patient should be positioned at 30 upright if possible during suctioning The suction apparatus may be set at any pressure depending on the viscosity of the secretions Sterile normal saline is routinely instilled prior to each suctioning episode to help loosen secretions List three signs that suctioning has been effective 1 2 SA Nursing Office LEARNING PKG suctioning artificial airways adults doc True True True True True True L False False False L False False False Suctioning Artificial Airways Learning Package 24 5 Complete the following table matching each complication with symptoms and p
6. Hemodynamic instability Recent surgery to the chest and pulmonary structures Pulmonary hemorrhage Extreme reactive bradycardia i e when the heart rate drops dramatically in response to suctioning Hyperactive airways Contraindications to suctioning Epiglottis and or croup are absolute contraindication for nasotracheal suctioning since suctioning can worsen these conditions Nasal bleeding Occluded nasal passages Coagulaopathy or bleeding disorder Laryngospasm Irritable airway Upper respiratory tract infection 2 2 Preparing the Patient and Equipment for Suctioning 2 2 1 Preparing the Patient Suctioning is an uncomfortable and often frightening procedure The patient is intubated and is therefore unable to vocalize The presence of the catheter in the trachea may make the patient highly anxious and restless Suctioning may cause hypoxemia The patient may have a smothered feeling Patients have rated the pain of suctioning at 7 on a pain scale of 1 10 Puntillo 2001 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 Important points to tell the patient and family include Why the patient requires specific aspects of care i e intubation suctioning oxygen before the procedure instillation of saline SA Nursing Office LEARNING PKG suctioning artificial airways adults doc
7. PATIENTS WITH ARTIFICIAL AIRWAYS Title I D Number 1019 Source Nursing Cross Index Date Revised Date Effective June 2005 Scope SASKATOON CITY HOSPITAL ROYAL UNIVERSITY HOSPITAL ST PAUL S HOSPITAL 1 POLICY Types of artificial airways Endotracheal tube Tracheostomy tube Personnel who may suction artificial e airways Certified Registered Nurse and Licensed Practical Nurses for more information refer to Learning Package Suctioning Artificial Airways Registered Respiratory Therapist Physiotherapist Students with supervision RN PT EMT RT Special considerations Suctioning is a sterile procedure The use of protective equipment for staff perfoming suctioning is mandatory Hyperoxygenate patients that require supplemental oxygen Ways to hyperoxygenate include use of manual resuscitation device connected to oxygen flow meter at flush increasing the oxygen flow of oxygen device in use or having the patient take 2 3 deep breaths Hyperoxygenation should be delivered prior to during and post suctioning Sterile Normal Saline instillation is not routinely done Use suction catheter that is no more than 2 the diameter of artificial airway see chart below for appropriate sizes Suction should be continuous while withdrawing suction catheter S Nursing Office LEARNING PKG suctioning artificial ainways adults doc
8. protect themselves from aspiration Cuffless tubes are rarely used in acute care Inner cannula Fits inside the outer cannula and is removed regularly for cleaning if nondisposable If the inner cannula is disposable a new one is inserted each time the old one is removed It has a universal adapter for use with a ventilator and other respiratory equipment Obturator is used during insertion of the tracheostomy tube It is removed following insertion and replaced with the inner cannula It s smooth rounded end makes insertion less traumatic to the tissues SA Nursing Office LEARNING PKG suctioning artificial airways adults doc Suctioning Artificial Airways Learning Package 21 Figure 52 Double Cannula Tracheostomy a ime LA E OL Inner http www cpem org html aiflist html ESN B AAS regal AL S4 Z S amp SAN GILBE Single Cannula Slightly longer than the universal tube It is used for patients who have long or thick necks This tube usually requires additional humidification to prevent the accumulation of secretions which could lead to occlusion Figure S1 Single Cannuls Tracheostomy Tube www cpem org html giflist html S Nursing Office LEARNING PKG suctioning artificial ainways adults doc Suctioning Artificial Airways Learning Package 22 Fenestrated These tubes have an opening on the posterior wall of the outer cannula which allows air to flow through the upper airway and tra
9. to maximize mucocilliary transport in the lower airways Complications of decreased humification are atelectasis tracheitis pulmonary infection obstruction death Complications of over humidification are excessive moisture into dependent bronchi tracheal burns if humidity temperature is excessive infection The need for suctioning varies from patient to patient and with patient condition For example a patient with pneumonia and copious secretions may need to be suctioned every 10 minutes to maintain airway patency and allow for ventilation On the other hand a patient without lung disease who has been intubated only for ventilation i e neuromuscular disease may need to be suctioned only once a shift 2 1 1 Signs and Symptoms Indicating a Need for Suctioning Dyspnea tachypnea apnea Change in respiratory pattern Increased respiratory rate Change in heart rate and rhythm SA Nursing Office LEARNING PKG suctioning artificial airways adults doc Suctioning Artificial Airways Learning Package 3 Restless and agitation Noisy respirations abnormal breath sounds gurgling wheezing crackles Decreased Sp0z or deterioration of blood gases Deterioration in patient s color cool skin Use of accessory muscles nostril flaring Ineffective coughing Patients with the following conditions are more likely to react adversely to suctioning Suction these patients with caution Increased intracranial pressure
10. trachea divides into the right and left mainstem bronchi This bifurcation point is called the carina One mainstem bronchus enters each lung The right bronchus is shorter and wider and extends downward more vertically than the left Therefore aspiration occurs more frequently into the right mainstem bronchus The bronchi are composed of cartilaginous rings and ciliated mucous lining which cleanses the tract by carrying foreign material upward in a blanket of mucous for expectoration or swallowing The mainstem bronchi subdivide in an inverted tree like formation branching through each lung field The bronchioles are the smallest subdivisions of bronchi The bronchioles subdivide further eventually terminating in microsopic alveolar ducts and alveolar sacs called alveoli The walls of these alveoli consist of a single layer of tissue and are the structures that allow the exchange of oxygen and carbon dioxide Figure 2 Tracheo onchial Tree Source adapted from Ames amp Kniesel 1988 Essentials of Adult Health Nursing p 294 Publishing Company Menlo Park Calif SA Nursing Office LEARNING PKG suctioning artificial airways adults doc Suctioning Artificial Airways Learning Package 17 Lungs and Accessory Structures The lungs are located within the thoracic cavity on either side of the heart and extend from the diaphragm to just above the clavicles The lungs inflate with inspiration and deflate with expiration The ma
11. 1 1 2 Criteria for Recertification cccccccccceeeeeeeececcceeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeees 1 PA Mall a 10 AAA E ane Cone ae mtn One Conee REE TEE EOE SRC TAA EAA A 2 2 1 Assessing the Need for SUCtIONING cceeeeeeeeeeeeeeeeeeeeeeeeeeeeeneeees 2 2 2 Preparing the Patient and Equipment for Suctioning 0 0 3 2 3 Complications of Tracheal SUCtIONING cece eeeeeeeeeeeeeeeeeeeeeeeeeeaeees 8 3 0 References ec eee eee eRe ieee Sea Ene bass 11 4 0 Appendix POOP OUCIGS acien na a N naain 12 B Respiratory System Anatomy amp Physiology c ceeeeeeeeeeeeeeeeee 15 C PALI eA PVA Si a AEE EER 19 5 0 Review QUESTIONS ici c2cictacctseieiatisccai att ietal adi siuetateigeeteldsbeplattecealdaeeelatiice 23 SA Nursing Office LEARNING PKG suctioning artificial airways adults doc Suctioning Artificial Airways Learning Package 1 1 0 GENERAL INFORMATION 1 1 Criteria for Certification 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 setting 1 2 Criteria for Recertification Recertification is required annually for LPNs who are not performing the skill regularly Recertification is recommended for RNs annually if the skill is not used regularly Recertification may be done upon the request of the Manager of Nursing Clinical Nurse Educator o
12. SASKATOON HEALTH REGION SUCTIONING ARTIHCIAL AIRWAYS in ADULTS Tracheostomies and Endotracheal Tubes RN AND LPN LEARNING PACKAGE RN SPECIAL NURSING PROCEDURES Suctioning Non Ventiated Adult Patients with an Artificial Airway in Place Suctioning Ventilated Adult Patients amp LPN ADDED SKILL Suctioning a Non ventilated Adult patient via a Tracheostomy Tube ina Well Healed Soma Registered Nursesand Licensed Practical Nurses 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 J une 2005 Pediatic information removed May 2010 This materal was developed forthe use of Saskatoon Regional Health Authority SRHA This maternal may not be suitable forotheragencies 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 i Permission for extensive copying of this leaming package forscholany purposes may be granted It isunderstood that due recognition will be given to the Coordinators of this leaming package and to the Department of Nursing Affairs in any use of thismatenal Copying publication orany other use of this leaming package forfinancial gain without approval is prohibited Requests for permission to copy orto make other use of this material in this leami
13. a A Tracheostomy is the opening or stoma created by a tracheostomy incision Tamburi It is either done open or percutaneously The indications for a tracheostomy are Maintain an open functional airway Bypass an airway obstruction tumors foreign body larynx or tracheal injury soft tissue swelling oral or nasal intubation is not feasible Provide protection from aspiration in patients having difficulty clearing their airway due to head injury CVA progressive neurological disorders myasthenia gravis amolotropic lateral sclerosis Provide mechanical ventilation Remove secretions from tracheobronchial tree Patients with severe pulmonary disease or pulmonary depression with hypoxia or hypercapnia need supplemental oxygen Following prolonged intubation Obstructive sleep apnea Types of Tracheostomy Tubes Universal Also called the double lumen or double cannula tube This is the most common type of tracheostomy tube It has three parts Outer cannula can be either cuffless or with cuff and pilot tube Keeps the airway open Cuffed Tube when inflated this tube seals the airway and prevents the aspiration of oral or gastric secretions The cuff directs air through but not around the tube It is commonly used when mechanical ventilation is required Cuffless Tube Usually double lumen tubes cuffless tubes are used for the long term management of patients The patients must have effective cough and gag reflexes to
14. airways caused by the presence of an artificial airway is magnified with the introduction of a suction catheter Excessive vacuum causes edema hemorrhage and ulceration of tracheal tissue It can pull air from distal airways and contributes to atelectasis and decreased lung compliance It has not been found to increase the amount of secretions retrieved Instillation of Sterile Normal Saline The instillation of sterile NS should not be done on a routine basis Ridling 2003 Instillation can contaminate the lower airways and has an adverse effect on oxygen saturation and arterial blood gases Adequate systemic hydration and airway humidification may accomplish more than instillation see page 2 Normal saline and secretions don t S Nursing Office LEARNING PKG suctioning artificial ainways adults doc Suctioning Artificial Airways Learning Package blend when mixed together and therefore the secretions aren t thinned for easier suctioning Day et al 2001 Assess the need for instillation If required instill sterile Normal Saline into the tube during inspiration 3 5 ml adult Side effects of instillation are Decreased PaOz Failure to remove all saline 7 Increased intracranial pressure n Risk of Infection Hypertension 2 3 Complications of Tracheal Suctioning Symptoms Prevention Hypoxemia Hypoxia Decreased oxygen saturation Sa02 lt 90 or below patient s baseline Cyanosis Ca
15. chesotomy opening This air movement allows the patient to speak and produce a more effective cough The fenestrated tube is often used during weaning to ensure that patients can tolerate breathing through the natural airway before tube removal It carries the significant risk of tissue overgrowth of the fenestrations and subsequent tissue trauma upon removal if left in place too long Neck plate moving around 2 axis Fenestration of tSmrn connector _ outer cannula of inner cannuia p Decannviaton p Mug Wuer Fenestaton of inner cannula _ Outer cannula N is a Base tie to T Outer diameter s of inner cannuta LI Sa enon www kapitex com products trachoestomy2a htm Decannulation Plug tis attaches to the outer cannula after the inner cannula has been removed It blocks air flow through the tracheostomy tube and directs breathing through the mouth and nose To be used only on cuffless tracheostomy tubes or when the cuff is totally deflated Cuffed trachostomy tubes must be totally deflated before decannulation plug is put on Designed to facilitate tracheostomy tube weaning and voice restoration Itis a universal size will fit any tracheostomy tube weaning and voice restoration Itis a universal size will fit any tracheostomy tube Can be difficult to put on patient coughing Can be scary the first time for the patient May have a lot of secretions at first
16. he airway Adults 12 14 Fr catheters CORRESPONDING SIZES CUFFED UNCUFFED METAL LAERDAL SUCTION SHILEY ADAPTOR CATHETER 00 5 00 0 AAA BR OO PO CO NIDIA C 00 NI or N om oO gt A The catheter size should be no more than 1 2 the diameter of the airway If the airway is fully occluded with the catheter it may cause a drop in PaQOz In addition large catheters and small interior diameter of artificial airways when coupled with higher suction flow rates produce the greatest negative airway pressures and alveolar collapse Catheter size can contribute to suction induced atelectasis hypoxia intrapulmonary shunting and decreased lung compliance Catheters with multiple openings versus a single opening produce less tissue trauma Egan 1995 The catheter may also stimulate the vagus nerve resulting in bradycardia and hypotension Paroxysmal coughing due to catheter irritation increases intrathoracic pressure decreases venous return and produces transient hypotension and syncope It also increases intracranial pressure and reduces cerebral blood flow Cardiac arrhythmias may occur due to decrease in myocardial oxygen supply or S Nursing Office LEARNING PKG suctioning artificial ainways adults doc Suctioning Artificial Airways Learning Package 6 increase in oxygen demands in the presence of accompanying tachycardia and elevated blood pressure
17. ican Journal of Critical Care 4 4 pg 267 271 Van Hooser D T 2002 Airway Clearance with Closed System Suctioning American Association of Critical Care Nurses SA Nursing Office LEARNING PKG suctioning artificial airways adults doc Suctioning Artificial Airways Learning Package 15 APPENDIX B Respiratory System Anatomy and Physiology The respiratory system allows the exchange of carbon dioxide produced by cellular metabolism and life sustaining oxygen Interference with the functioning of this system may rapidly result in death Respiratory function is regulated by a center located in the brainstem which detects blood gas concentrations of oxygen and carbon dioxide and adjusts the respiratory rate and depth to maintain homeostasis The respiratory system consists of a network of airways that provide the pathway for the transport and exchange of oxygen and carbon dioxide The respiratory system is divided into the upper and lower airways Upper Airway Consists of the nose pharynx larynx and epiglottis Major functions of the upper airway are Conducting air to the lower airway Protecting the lower airway from foreign matter Warming filtering and humidifying inspired air During inspiration air enters through the nose where the nasal cilia filter out impurities such as small foreign particles dust bacteria some viruses From the nose the air passes into the pharynx The pharynx is
18. ient 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 an assistant giving 5 6 ventilations using a resuscitation bag with supplemental Oz or by the patient taking several large breaths while receiving a higher than normal concentration of oxygen or in the ventilated patient by increasing the ventilator Fi02 Note to hyperoxygenate by ventilator requires 1 2 minutes before dead space in the ventilator is cleared Rationale It is well documented that a decrease in arterial oxygenation occurs during the tracheal suctioning procedure The decreased arterial oxygen tension following tracheal suctioning has been found to lead to SA Nursing Office LEARNING PKG suctioning artificial airways adults doc Suctioning Artificial Airways Learning Package 5 cardiac dysrhythmias hypotension and death Tachycardia may occur as a reflex response to compensate for the suction induced hypoxemia Hyperoxygenation minimizes suction induced hypoxemia by maintaining the PaQz levels throughout the suctioning period Manual ventilation like mechanical ventilation also minimizes hypoxemia due to suctioning induced atelectasis by re expanding sections of the lungs that may have been evacuated or air and collapsed 2 2 2 Preparing the Equipment Suction Catheter The catheter size will vary depending on the size of t
19. instem bronchus pulmonary blood vessels and nerves enter the lungs at the hilum the depression in the medial surface of the lung The lungs are fully moveable within the thoracic cavity except at the hilum the route of the lungs at the level of the 4 amp 5 vertebrae where they are anchored by connective tissue and pulmonary ligaments Each lung is divided into lobes The right lung has three lobes and the left lung has two lobes The lobes of the lung are divided into segments Blood is supplied by the pulmonary and bronchial arteries The lungs are totally enclosed on their outer surfaces by the pleura a two layered membrane The layer lining the chest wall is called the parietal pleura that covering the surface of the lung is the visceral pleura The two layers of pleura are continuous with one another and form a closed sac Normally there is no space between them but rather a potential space called the pleural space A thin film of serous fluid lubricates the pleural surfaces to slide smoothly against each other and creates a cohesive force that causes the lungs to move synchronously with the chest during respiration The thoracic cavity is the area within the chest wall bounded below by the diaphragm above by the scalene muscles and circumferentially by the ribs intercostal muscles vertebra and sternum The thoracic cavity has four subdivisions The right pulmonary space which contains the right lung The left pulmona
20. ng package in whole orin part should be addressed to Department of Nursing Affairs c o Nursing Affairs Office c o Nursing Affairs Office c o Nursing Affairs Office Royal University Hospital Saskatoon City Hospital St Paul s Hospital Saskatoon SK Saskatoon SK Saskatoon SK S7N OW8 S7K 0M7 S7M 02 ACKNOWLEDGEMENTS Coordinated by Chrystal Grant Clinical Nurse Educator Rehabilitation Unit Saskatoon City Hospital Evelyn Seip Clinical Nurse Educator Intensive Care Unit Saskatoon City Hospital Pediatric information removed by Bemie McDonald May 2010 Pediatric information is included in Suctioning Artificial Airways Pediatric Neonate leaming package Special Thanks to Ann Burton Clinical Nurse Specialist Parkridge Centre Margot Hawke Clinical Nurse Educator St Paul s Hospital Royal University Hospital Helen Sabadash Clinical Nurse Educator Royal University Hospital Saskatoon City Hospital Clinical Nurse Educators Acute Care Sector Saskatoon Health Region Site Representativesfor Acute Care Sector Saskatoon Health Region Respiratory Therapy and Physiotherapy S Nursing Office LEARNING PKG suctioning artificial ainways adults doc Suctioning Artificial Airways Learning Package ii TABLE OF CONTENTS 1 0 General INTORMAUON eciies cece ctesencessesencsatetindseentencentateutseded npvedetaudtetatentenss 1 1 1 Criteria for Certification c cc ccccccceeeeeeeeeeeeeneeeeeeeeeeeeeeeeneeeeeeeeeeeeneee
21. r and the blood in the terminal alveolar capillary system is part of the process of respiration Respiration refers to the exchange of Oz and CO in the body within the lungs between the cells and their environment and in intracellular metabolism Normal respiration requires Adequate O2 concentrations in the alveoli Adequate amount of haemoglobin capable of binding with O2 Diffusion of O from the alveoli in concentrations sufficient to saturate the blood adequately before it leaves the lungs Transportation of oxygen to the body cells Ability of the body cells to use the O2 supplied to them Gas exchange occurs in the pulmonary alveoli and in the tissues Pulmonary gas exchange is affected by ventilation perfusion and diffusion Gas exchange is also affected by the availability of an adequate concentration of O2 in the inspired air SA Nursing Office LEARNING PKG suctioning artificial airways adults doc Suctioning Artificial Airways Learning Package 19 APPENDIX C ARTIFICIAL AIRWAYS Overview of Artificial Airways eon os 4 3 E Ma i me N A ee he a ai i i A ae 1 2 r J UI a 2 Es 7 A A i A Position of Endotracheal Tube B Position of Tracheostomy Tube Source adapted from Phipps et al 1995 Medical Surgical Nursing 5 Edition p 1021 Mosby Year Book Inc St Louise Missouri Artificial airways bypass normal mechanisms to prevent infection Patients with
22. r the individual RN or LPN S Nursing Office LEARNING PKG suctioning artificial airways adults doc Suctioning Artificial Airways Learning Package 2 2 0 THEORY 2 1 Assessing the Need for Suctioning A patient with a tracheostomy or endotracheal tube is less able to increase intrathoracic pressure for an effective cough to clear secretions This is because the artificial airway holds the vocal cords open which normally close just prior to a cough Initially a tracheostomy tube may cause increased secretions due to irritation Since tracheal suctioning may cause complications suctioning should be done only when there is exudate present in the upper airways which the patient is unable to clear by coughing Routine suctioning should be avoided as this will increase chance of mucosal trauma and risk of infection Remember that crackles and wheezes are rarely cleared with suctioning because they indicate obstruction or fluid in the lower airways which are inaccessible to suctioning Chest physiotherapy and positioning may move fluid from the lower airways making it more accessible to suctioning Humidification of inspired air and systemic hydration assist to Keep secretions thin easier to move remove Reduce need for suctioning if patient can raise own secretions Prevent tube occlusion from thick dried secretions Counteract insensible fluid losses Compensate for bypass of upper airway Maintain moist mucous membranes
23. rdiac Dysrrhythmias tachycardia or bradycardia Premature ventricular contractions Cardiorespiratory arrest Limit suction pressure to 100 120 mmHg for adults 80 100 mmHg for children 50 80 mmHg for neonates Limit duration of suctioning to 10 15 sec for adults Avoid catheters larger than 1 2 the diameter of the airway Manually ventilate as ordered until pre suction status resumes Hyperoxygenate amp or hyperventilate prior to suctioning Avoid routine suctioning suction only as needed Limit number of catheter passes Cardiac Dysrrhythmias Tachycardia Assess for hypoxemia Cardiac Arrest Death decreased arterial Stop suctioning oxygen content Administer oxygen Bradycardia vagal Manual ventilation as needed response Trauma Aspiration of blood Use lowest level of suction Tracheal mucosal tinged mucous pressure that will be effective damage Decreased air entry Perform suction procedure Pulmonary gently Hemorrhage Bleeding Avoid forcing the catheter SA Nursing Office LEARNING PKG suctioning artificial airways adults doc Suctioning Artificial Airways Learning Package Symptoms Prevention against resistance Do not apply suction while inserting the catheter Withdraw catheter slightly 1 cm before applying suction Lubricate suction catheter with sterile Normal Saline Limit number of catheter passes Avoid routine suction
24. reventive measures in columns 2 and 3 COMPLICATION SYMPTOMS PREVENTION 1 Hypoxemia 2 Trauma of respiratory tract 3 Infection 4 Atelactasis S Nursing Office LEARNING PKG suctioning artificial ainways adults doc
25. rning Package 14 3 3 Documentation e Charting on the Progress Record Flow Sheet or Ventilator Record as per unit policy should be done following the procedure Include the following specifics e Amount consistency colour and odor of secretions e If applicable Hyperoxygenation Hyperventilation Instillation of Sterile Normal Saline Chest Physiotherapy Specimen sent Patient s tolerance of procedure Effectiveness of procedure ie lung auscultation Patient family education provided REFERENCES 1 Ackermann M H amp Mick D J 1998 Instillation of Normal Saline Before Suctioning In Patients With Pulmonary Infections A Prospective Randomized Controlled Trial American Journal of Critical Care 7 4 pg 261 266 Ackerman M H 1993 The Effect of Saline Lavage Prior to Suctioning American Journal of Critical Care 2 4 pg 326 330 Akg l S amp Akyolcu N 2002 Effects of normal saline on endotracheal suctioning Journal of Clinical Nursing 11 pg 826 830 Elkin M Perry A amp Potter P 2004 Nursing Interventions amp Clinical Skills 3 Edtion Philadelphia PA Mosby Pg 760 768 Hagler D A amp Traver G A 1994 Endotracheal Saline and Suction Catheters Sources of Lower Airway Contamination American Journal of Critical Care 3 6 pg 444 447 Raymond S J 1995 Normal Saline Instillation Before Suctioning Helpful Or Harmful A Review of The Literature Amer
26. ry space containing the left lung The pericardial space which contains the heart and pericardial sac The mediastinal space located at the center of the thoracic cavity between the two pulmonary spaces and containing the esophagus trachea heart and great blood vessels The diaphragm is the major muscle of ventilation Relaxed it forms a dome shape beneath the lungs When contracted it pulls downward expanding the thoracic cavity and creating an increased negative pressure which pulls air into the lungs When it relaxes back into its dome shape air is forced out of the lungs The thorax also plays a role in ventilation The elliptical shape formed by the ribs and the angle of their attachment to the spine causes the thorax to expand when the chest is raised diaphragm contracting and become smaller when it is lowered diaphragm relaxing SA Nursing Office LEARNING PKG suctioning artificial airways adults doc Suctioning Artificial Airways Learning Package 18 Mechanism of Ventilation Ventilation is the movement of air in and out of the lungs It occurs in two phases The movement of air into the lungs termed inspiration is an active process involving contraction of the diaphragm and intracostal muscles of the thorax Expiration the movement of air out of the lungs is normally a passive process occurring as the diaphragm and intercostal muscles relax The stimulus to breathe is transmitted to the medulla in the brains
27. subdivided into the nasopharynx the oropharynx and the laryngopharynx These serve as hallways for the respiratory and digestive tracts They also play an important role in phonation The larynx is the upper portion of the trachea and connects the upper and lower airways It is composed of rings of cartilage connected by membranes and muscle One cartilage forms a complete ring and is called the cricoid cartilage located just below the thyroid cartilage The vocal cords lie inside the thyroid cartilage The epiglottis a flexible cartilage attached to the thyroid cartilage functions to prevent the entry of foreign material into the airway when a person swallows The function of the larynx is voice production Lower Airway Also called the tracheobronchial tree the lower airway consists of the tracheal right and left mainstream bronchi segmental bronchi subsegmental bronchi and terminal bronchioles The major functions of the lower airway are Conduction of air through the many branches of the airways to the alveolar level Provision of the functional mechanism for gas exchange SA Nursing Office LEARNING PKG suctioning artificial airways adults doc Suctioning Artificial Airways Learning Package 16 The trachea extends from the larynx to the mainstem bronchi and serves as a passage to and from the lungs Smooth muscle and C shaped rings of cartilage protect the trachea and prevent its collapse At its lower end the
28. suction only as needed Infection patient caregiver Increased abnormal secretions in the trachea Colonization with gram negative organisms Increased heart rate respiratory rate and temperature Use sterile equipment solutions Maintain strict aseptic technique Keep ends of oxygen source clean to reduces possibility of contamination of the oxygen source Use gentle suctioning technique to avoid trauma Optimal hydration nutritional and metabolic status Avoid routine suctioning suction only as needed Wash hands before and after procedure For staff protection use of gloves masks goggles is recommended Hypotension hypertension Significant change from baseline BP Stop suctioning Oxygenate and ventilate Calm manner while suctioning Pain control Atelectasis Decreased air entry Change in chest x ray Limiting amount of negative pressure used see hypoxia section Keep duration of suctioning as short as possible see hypoxia section Provide hyperventilation before and after suctioning Appropriate size of suction catheter S Nursing Office LEARNING PKG suctioning artificial ainways adults doc Suctioning Artificial Airways Learning Package 10 Symptoms Prevention Vagal Stimulation Cardiac dysrhythmias Maximize oxygenation most often before during and after bradycardias suctioning procedure Calmly reassure patient during procedure Bronchocons
29. tem in response to rising blood C02 concentration or falling oxygen concentration The message is then directed down through the vagus nerve to the other central and peripheral mechanisms As the message to inhale is recognized by the receptors in the chest the chest cavity enlarges This occurs by the diaphragm constraint and flattening and the intracostal muscle contracting up and outward The diaphragm is innervated by the fourth cervical spinal nerve Individuals with spinal cord injuries at the level of C4 and higher will be ventilator dependent Individuals with complete injuries at the level of Tg require assisted coughing techniques due to lack of diaphragmatic innervation Increasing the capacity of the thorax provides space for lung expansion Pressure changes in the intrapleural space and within the lung combine to pull the lungs open producing a pressure gradient which causes air to flow into the lungs from the atmosphere Inspiration continues until the pressure gradient between the atmospheric air and the air in the lungs is equal Air flow then ceases and expiration commences as the diaphragm and intracostal muscles relax The amount of ventilation that occurs is affected and regulated by Respiratory centers in the brain and periphery Chemicals in the cerebrospinal fluid m PaQs PaCO gt m pH Other factors such as pain temperature emotions and physical activity Exchange of Gases The exchange of gases between the ai
30. tion suctioning intervention in critically ill patients Heart and lung 17 6 Day T Wainwright S P amp Wilson Barnett J 2001 An evaluation of a teaching intervention to improve the practice of endotracheal suctioning in intensive care units Journal of Clinical Nursing 10 682 696 Maggiore S M Et Al 2003 Prevention of Endotracheal Suctioning Induced Alveolar Decrecruitment in Acute Lung Injury American Journal of Respiratory Critical Care Medicine Vol 167 pg 1215 1224 Puntillo K A et al 2001 Patients perceptions and responses to procedural pain result from Thunder Project Il American Journal of Critical Care Volume 10 4 pp 238 251 Scanlan C L Ed 1995 Egan s Fundamental of Respiratory Care 6 Edition 540 574 Royal University Hospital Nursing Development 1994 Tracheal Suctioning Self Directed Learning Package Author Saskatoon Saskatchewan Sole M L et al 2003 A multisite survey of suctioning techniques and airway management practices American Journal of Critical Care 12 3 220 232 For additional references see policies in Appendix A SA Nursing Office LEARNING PKG suctioning artificial airways adults doc Suctioning Artificial Airways Learning Package 12 4 0 APPENDIX A POLICIES awna Health Authorization x Critical Care Committee x Tri Hospital Nursing Practice Committee POLICIES amp PROCEDURES SUCTIONING ADULT
31. triction Bronchospasm Paroxysmal Coughing Change in air entry Wheezes auscultated Same as for hypoxemia Administer bronchodilators as ordered May need to do prior to suctioning or give routinely Ventilate patient in sync with patient s respiratory effort Talk calmly and slowly to patient to calm them May need to sedate chemically paralyze patient if unable to ventilate Obstruction Unable to ventilate patient Unable to suction patient Call for help Physician Respiratory Therapist other staff stat and prepare to change artificial airway Continue to attempt to ventilate patient until help arrives Increased Intracranial Pressure May correspond with increased BP amp coughing May need to give aerosolized lidocaine physician s order 15 minutes before suctioning SA Nursing Office LEARNING PKG suctioning artificial airways adults doc Suctioning Artificial Airways Learning Package 11 3 0 REFERENCES Akgul S 7 Akyolcu N 2002 Effects of normal saline on endotracheal suctioning Journal of Clinical Nursing 11 826 830 Boutras A R 1970 Arterial blood oxygenation during and after endotracheal suctioning in the apneic patient Anesthesiology 32 114 Buglass E 1999 Tracheostomy Care tracheal suctioning and humidification British Journal of Nursing 8 8 500 504 Chulay M 1988 Arterial blood gas changes with a hyperinflation and hyperoxygena
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