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Suctioning

Clean vs. Sterile Consensus

  • Clean technique for home care
  • Flush catheters
    —Wipe with alcohol
    —Air dry
    —Store clean, dry covered area
  • Repeated catheter use as long as still clear
  • Insufficient data on different cleaning methods
  • Research needed


Suctioning Depth Consensus

  • Pre-measured technique for routine suctioning
  • Twirl catheter
  • Pre-marked catheters
  • Deep technique increases risk of epithelial damage
    — use only in special circumstances

Frequency Consensus

  • Frequency based on clinical assessment
  • No secretions: minimum suctioning twice each day to evaluate tube patency
  • Special cases: increased frequency —postoperative period —respiratory infection

Bag Ventilation Consensus

  • Initial pass of catheter before bagging
  • Patients on respiratory support should be evaluated for hyperoxygenation/hyperventilation before discharge

Saline Use Consensus

  • Routine use of normal saline is NOT recommended
  • Maintain adequate humidification

Other Factors - Consensus

  • Catheter Size
  • Suction Pressure
  • Duration
  • Largest size that fits
  • Apply both on insertion/removal
  • Check home machine before discharge
  • Rapid technique:
    < 5sec


 


 

CAUTION

  • Elements following meant to be used as a single technique
  • Not meant for orotracheal or nasotracheal tubes

Techniques of suctioning are designed to efficiently clear the airway of mucus while avoiding the potential hazards of suctioning. Traditional recommendations for suctioning techniques in most nursing and respiratory care literature were developed assuming the adult is critically ill and has an artificial airway. Those recommendations are not specific to a child with a chronic tracheostomy.

The consensus recommendations are distinctly different in some areas from traditional suctioning methods and should be considered in their entirety, since these recommendations are interrelated. These recommendations are not to be applied when suctioning a child with an orotracheal or nasotracheal tube.

 

Clean vs. Sterile

Definitions

  • Sterile
  • Modified sterile
  • Clean

Sterile technique is defined as the use of a sterile catheter and sterile gloves for each suctioning procedure.

Modified sterile technique is defined as a sterile catheter with freshly washed, clean hands or nonsterile, gloved hands for the procedure.

Clean technique is defined as the use of a clean catheter and freshly washed, clean hands or nonsterile gloves for the procedure. Care is taken not to allow the portion of the catheter that will be inserted in the tracheostomy tube to contact any unclean surface.

Sterile technique has been the typical method of suctioning in the hospital, although this practice is changing toward a modified sterile technique. Clean technique is the usual method for suctioning in the home setting.

When using clean technique there is variation among care givers regarding the duration of use of a single catheter before it is replaced and cleaned. Some report changing the catheter after each suctioning procedure while others change the catheter from every 8 to 24 hours (should the catheter become "contaminated" i.e. dropped on the floor, it would be changed at this point).

Typical
cleaning
procedure

Wash with hot, soapy water; flush

  • Soak
  • Rinse catheters inside and out with clean water
  • Air dry
  • Store in dry container

A typical cleaning method for catheters often includes the steps described. The catheter is first washed and flushed with hot, soapy water; next, the catheters are soaked in a vinegar-and-water solution or a commercial disinfectant; then, the catheters are rinsed inside and out with clean water; then, air dried and stored in a dry container. Minimal research is available in this area.

Since secretions move through the interior of the catheter in one direction only, the cleanliness of the outside of the catheter is more important than the cleanliness of the internal surface of the catheter. However, dried secretions on the surface of the catheter will interfere with the ability of the catheter to suction optimally.

  • In vitro study
  • 20 catheter samples
  • Three step process
    —flush with 3% H2O2
    —soak in 100oC soapy water overnight —flush with 100oC water
    —air dry/wipe - alcohol
  • Results
    —98% of catheters had sterile exteriors
    —91% had sterile interiors
    —stored for up to 20 days without new bacterial growth


In a study by Shabino described a home cleaning procedure similar to the one just described and demonstrated that 98% of the catheters had sterile exteriors and 91% had sterile interiors after cleaning. These catheters were then stored for 20 days and recultured and showed no new bacterial growth. The catheters tolerated repeated cleaning cycles without any change in integrity or appearance, except for mild cloudiness of the plastic.

Shabino, C., A. Erlandson, and L. Kopta. 1986. Home cleaning-disinfection procedure for tracheal suction catheters. Pediatr. Infect. Dis. 5: 54-58.

Consensus

  • Clean technique for home care
  • Flush catheters
    —Wipe with alcohol
    —Air dry
    —Store clean, dry covered area
  • Repeated catheter use as long as still clear
  • Insufficient data on different cleaning methods
  • Research needed


Clean technique is recommended for home care. The caregiver's hands should be thoroughly washed prior to the procedure. If water is unavailable for washing, alcohol or a disinfectant foam is an acceptable substitute. Nonsterile, disposable gloves should be worn for the protection of any caregiver that is not a family member or by anyone who is concerned about infection.

After suctioning is complete, the catheter is flushed with tap water until the lumen is free of secretions; the outside of the catheter is then wiped with alcohol as a germicidal and allowed to air dry. A hydrogen peroxide flush is useful to clear particularly adherent secretions. The catheters are stored in a clean, dry area.

Individual catheters can be used as long as the catheters remains intact and allows inspection of removed secretions. There are a variety of methods available for "more thorough" cleaning including commercial products (Control IIIâ„¢, Maril Products, Tustin, CA), alcohol, and a vinegar-and-water soak.

There are no data to suggest the frequency of a "more thorough" cleaning or that one method is better than another. Methods that do not unnecessarily burden an already busy family should be considered. Additional research is needed in this area.

 

Suctioning Depth

Definitions

  • Shallow
  • Pre-measured
  • Deep

Shallow suctioning describes the insertion of a catheter just into the hub of the tracheostomy tube so that secretions the child has coughed into the opening of the tracheostomy tube can be removed.

Premeasured technique involves the use of a catheter with side holes close to the distal end (0.5 cm or less) of the catheter tube; the catheter is inserted to a premeasured depth, with the most distal side holes just exiting the tip of the tracheostomy tube. Exact depth of insertion in the premeasured technique is critical to avoid epithelial damage (if inserted too deeply) or inadequate suctioning at the tip of the tracheostomy tube (if not inserted deeply enough). A tracheostomy tube, the same size as the one in the child, may be used to measure the exact depth to which the catheter should be inserted. Premarked catheters are also helpful in assuring accurate insertion depth.

Deep suctioning describes the insertion of the catheter until resistance is met, then withdrawing the catheter slightly before suction is applied. For over the past 10 years, studies using animal models have demonstrated epithelium damage and inflammation where deep suctioning is routinely performed. Although, recent practice surveys describe many care givers continue to deep suction.

In fenestrated tubes, suction catheters may accidentally go through the fenestration. If this happens repeatedly, granulation tissue may occur.

 

Consensus

  • Pre-measured technique for routine suctioning
  • Twirl catheter
  • Pre-marked catheters
  • Deep technique increases risk of epithelial damage
    — use only in special circumstances

Premeasured technique is recommended for all routine suctioning. Suctioning technique should include twirling or rotating the catheter between the fingers, not stirring the catheter with the entire hand. Twirling the catheter reduces friction, so that the catheter is more easily inserted, and moves the side holes of the catheter in a helix, which suctions secretions off all areas of the tube wall.

Additionally, the use of premarked catheters is strongly recommended to ensure insertion of the catheter to the proper depth (not too shallow, not too deep).

Special circumstances may necessitate the occasional use of deep suctioning (i.e. unexplained, sudden respiratory collapse). Be aware that deep technique, especially done routinely, increases the risk to the child of epithelial damage. This is one area for which there is clear research-based evidence supporting change of practice.

 

Frequency

  • Types
    —routine
    —as needed
  • Individual Characteristics
    —age
    —neuromuscular status
    —cough
    —viscosity and amount of mucous
    —activity level
    —stoma maturity
  • Helps assess tube patency

Routine suctioning is performed according to a set schedule, for example, every 2 hours. Suctioning "as needed" or p.r.n. is based on assessment of the patient. Suctioning "as needed" is most frequently recommended. The frequency of suctioning will vary on the basis of individual characteristics including age, muscular and neurological status, activity level, ability to generate an effective cough, viscosity and quantity of mucus, and maturity of the stoma.

In addition to removing secretions, suctioning provides the caregiver to perform the important assessment of tube patency. This is important because tubes can become obstructed without clinical symptoms as demonstrated in the study by Redding et al.

Consensus

  • Frequency based on clinical assessment
  • No secretions: minimum suctioning twice each day to evaluate tube patency
  • Special cases: increased frequency —postoperative period —respiratory infection

The consensus panel recommends a combination of using both routine and "as needed" suctioning. In a child with no clinical evidence of secretions, a minimum suctioning twice each day (morning and bedtime) to evaluate tube patency is recommended. Additional suctioning, beyond this minimum, should be based on the clinical assessment of the child.

The caregiver should anticipate the need for increased frequency of suctioning during the postoperative period and whenever the child has a respiratory infection.

 

Bag Ventilation

  • Hyperoxygenation
  • Hyperinflation
  • Hyperventilation

Bag ventilation is often performed during a typical suctioning procedure. Bag ventilation offers the patient three distinct changes in ventilation parameters: hyperoxygenation (increasing the amount of oxygen delivered to the patient), hyperinflation (increasing the volume of air per breath delivered to the patient), and hyperventilation (increasing the rate of ventilation for the patient).

  • Studies -
    —critical care units
    —mostly adult data
  • Recommendations
    —primarily adult focused
  • Experience
    —Not all patients need it
  • Pediatric studies
    —Kerem 1990
          adequate baseline SpO2
          no change in SpO2
    —Feaster 1985
           7 children with BPD and tracheostomies
           No clear benefit

Current recommendations regarding the use of bag ventilation in nursing and respiratory care literature vary and are primarily adult focused. Studies that evaluate the need for hyperoxygenation, hyperinflation, or hyperventilation during suctioning typically have been done in critical care settings with adult patients. These patients were mainly suctioned via orotracheal or nasotracheal tubes. It should not be assumed children with chronic tracheostomies have the same needs as these critically ill adults without tracheostomies.

Based on clinical experience and practice, stable children with a tracheostomy and no additional respiratory support such as a ventilator, continuous positive airway pressure, or high levels of supplemental oxygen typically do not receive bag ventilation before suctioning, particularly in the home setting. The use of postsuctioning breaths varies.

The primary concern in the administration of an artificial breath before suctioning is that secretions may be forced down the trachea and the more distal airways. Children who are prone to atelectasis may need bag ventilation after the initial "cleaning" pass of the suction catheter. Children receiving a high level of support should be monitored carefully to evaluate their stability and need for additional support during the suctioning procedure.

In both the small-sample, pediatric studies by Kerem and Feaster, there were no clinically significant desaturations in the children who were not given any pre- or post-treatment bag ventilation. No technique was found superior.

Consensus

  • Initial pass of catheter before bagging
  • Patients on respiratory support should be evaluated for hyperoxygenation/hyperventilation before discharge

In patients with secretions, an initial pass of the catheter should be made first to quickly clear the tube of any visible or audible secretions before any bag ventilation breaths are delivered. To deliver a manual breath when secretions are bubbling in the tube only serves to force these secretions into the more distal parts of the airway.

Patients receiving supplemental oxygen should be evaluated for the need of hyperoxygenation when delivering artificial breaths. The patient's need for postsuctioning hyperoxygenation or bag ventilation is best determined in the hospital before discharge. End tidal carbon dioxide measurement and oxygen saturation can guide decision making.

 

Saline Use

  • Reasons for use
    —stimulate a cough
    —loosen or thin secretions
    —lubricate catheter
  • Possible problems
    —oxygen desaturation
    —poor mixing with mucus
    —contamination


Normal saline instillation (NSI) has been considered useful to help stimulate a cough, loosen or thin secretions, lubricate the catheter, or serve as a vehicle for mucus to be removed from the airway. However, the routine use of NSI may be associated with undesirable outcomes such as a decrease in oxygen saturation, an inability to mix with (and therefore thin) mucus, and contamination of the lower airways with unsterile saline. Studies do not demonstrate the efficacy of normal saline in thinning mucus.

Consensus

  • Routine use of normal saline is NOT recommended
  • Maintain adequate humidification

The routine use of normal saline is not recommended. Proper attention to maintenance of adequate humidification will be more successful in maintaining thin mucus than NSI.

 

Other Factors

Consensus

  • Catheter Size
  • Suction Pressure
  • Duration
  • Largest size that fits
  • Apply both on insertion/removal
  • Check home machine before discharge
  • Rapid technique:
    < 5sec

The literature recommends use of a suction catheter size that is one-half the internal diameter of the tracheostomy tube. This is not possible in many of the small pediatric or neonatal tubes. The smaller size suction tube was recommended in the past to allow airflow around the catheter and thus avoid atelectasis during lengthy suctioning. Another consideration in choosing a catheter is the ability to remove secretions adequately and to detect partially obstructed tubes via tactile feedback. A large, firmer catheter can be easily inserted and can quickly remove secretions. The largest size catheter that will fit inside the tracheostomy tube is recommended, because a large-bore tube will remove secretions more efficiently than the previously mentioned smaller size tube. Atelectasis is not likely with the rapid, premeasured technique.

Concern about excessive vacuum pressure in deep suctioning, during which the airway epithelium has more exposure to the suction catheter, has led in the past to recommendations to limit the pressure applied during suctioning. Most important is the ability of the machine to generate adequate vacuum to efficiently suction the mucus in a few seconds. Suction should be applied both while inserting and removing the catheter. The suction should be adequate to efficiently remove secretions with a rapid pass of the catheter. Before discharge, the home suction machine should be used to ensure that it is adequate to clear the patient's secretions. A stationery suction machine that can generate a greater vacuum may be beneficial for a child with thick secretions in addition to the child's portable suction machine.

The current literature suggest limiting deep suctioning to 15 seconds or less and the premeasured technique to 5 seconds or less. With adequate and continuous pressure, the length of time required to perform the premeasured technique should be a few seconds. This is vital when using a larger suction catheter, relative to tracheostomy size, to prevent atelectasis and when suctioning both during insertion and removal of the suction catheter. Remember these suctioning recommendation should be considered and applied in their entirety. To do otherwise, could be dangerous to the child.

Components of Tracheostomy Care