Section Five Suctioning
PROCEDURE 29 Pharyngeal Suctioning
INDICATIONS
1. To clear the airway of secretions, foreign matter, or blood in patients incapable of clearing their own oropharynx or nasopharynx. Pharyngeal suctioning may be used with conscious or unconscious and intubated or nonintubated patients.
2. To stimulate coughing and deep breathing in the nonintubated patient.
CONTRAINDICATIONS AND CAUTIONS
1. Oropharyngeal secretions may be thick (e.g., blood or vomit). Use a large-bore suction catheter, a tonsillar-pharyngeal suction-tip device (Yankauer), or the suction connecting tubing alone for more effective airway clearance.
2. Excessive suctioning may traumatize the pharyngeal tissue and cause bleeding, swelling, or localized inflammation. Use a beveled tip and limit suctioning to 10 seconds per attempt to help decrease adverse effects.
3. Hypoxemia may result from prolonged suctioning.
4. Suctioning may cause coughing, gagging, or both, which increase intracranial pressure and should be avoided in patients with head injuries. If gagging leads to vomiting, aspiration and respiratory compromise may occur.
5. Suctioning may stimulate the vagal response, leading to bradycardia and hypotension, particularly in infants and younger pediatric patients.
6. If possible, use the less traumatic oropharyngeal route rather than the nasopharyngeal approach.
7. Excessive bleeding may occur in patients who have bleeding disorders or who are receiving anticoagulant therapy. Observe for bleeding and use lower suction pressures for those patients.
8. If epiglottitis is suspected, nasopharyngeal suctioning is contraindicated, because it may precipitate total occlusion of the airway.
9. Pharyngeal suctioning is considered a clean procedure. Regular examination gloves should be worn during the procedure.
EQUIPMENT
Portable or wall continuous-suction unit with regulator
Tonsillar or pharyngeal suction tip or bulb syringe
Suction catheter with an age-appropriate size of French whistle tip with a vent port or Y connector
30 to 60 ml of tap water to clear the connecting tubing and suction tip
Container to hold water (an emesis basin works well)
Water-soluble lubricant for a catheter inserted via the nasopharyngeal route
Supplemental oxygen source and oxygen delivery device
PATIENT PREPARATION
1. For optimal airway alignment, place the patient in semi-Fowler’s position. The sniffing position maximizes alignment of the airway for nasopharyngeal suctioning. Pharyngeal suctioning may be performed in any position.
2. The patient may feel breathless during the procedure. A high-flow oxygen mask may be set up for use between suctioning. Instruct the patient to use the oxygen mask and take deep breaths until he or she feels comfortable.
3. Warn the patient that the suctioning procedure may stimulate the gag or cough reflex. Provide an emesis basin and tissues.
PROCEDURAL STEPS
1. Assemble the suction canister and attach it to the suction unit.
2. Attach the connecting tubing to the suction canister.
3. Select an appropriate catheter or suction device. To prevent hypoxia and trauma, the suction catheter for the nasopharyngeal route should not be greater than half the diameter of the naris to be suctioned.
4. Set the suction gauge between 120 and 200 mm Hg. Full suction assists in the rapid removal of a large amount of fluid or debris from the oropharynx. Occlude the suction tubing to test the level of suction as measured by the suction gauge.
Oropharyngeal Route
1. Attach the catheter or pharyngeal suction tip to the connecting tubing.
2. Insert the catheter or pharyngeal suction tip into the back of the mouth without applying suction. If using a Yankauer tip, gently sweep the posterior pharynx while applying suction for 10 to 15 seconds.
3. If using a catheter, insert it into the area on either side of the glottis. Apply suction intermittently for 10 seconds, gently rotating as you withdraw the catheter.
4. Flush the catheter by aspirating water through the connecting tubing.
Nasopharyngeal Route
1. Nasopharyngeal suctioning is used when the oral route is not accessible (e.g., with clenched teeth or oral trauma).
2. Assess for nasal patency by inspecting each naris for any obstruction, such as polyps, structural deformity, or trauma. Occlude each naris and ask the patient to inhale to determine which side is most patent. Use the most patent naris for suctioning.
3. Attach the suction catheter to the connecting tubing. Apply a small amount of water-soluble lubricant to the catheter or lubricate with water.
4. Instruct the patient to use supplemental oxygen before the procedure and take deep breaths for 30 seconds.
5. Without applying suction, gently insert the lubricated catheter medially into the naris. As you slide the catheter to the back of the naris, instruct the conscious patient to assume the sniffing position. This position assists in passage of the catheter through the larynx and enhances access to the pharyngeal area. Slide the catheter through the naris until resistance is met or coughing is stimulated. If coughing is stimulated, pull back on the catheter slightly.
6. Apply suction intermittently for a maximum of 10 seconds and rotate the catheter slightly while withdrawing.
7. Flush the catheter by aspirating water through the connecting tubing.
8. Offer supplemental oxygen after suctioning.
9. If frequent suctioning is required, a nasopharyngeal airway may be inserted to decrease mucosal trauma and to act as a guide for the catheter. See Procedure 6.
Bulb Syringe
1. Depress the bulb syringe and gently advance into the nose or to the area of pooled secretions and debris in the oropharynx. Release the large bulb syringe to aspirate secretions and debris.
2. When suctioning an infant, insert the tip of the bulb syringe into the side pockets in the cheeks. Never put the tip of the bulb syringe in the back of the throat.
3. Depress bulb syringe into a basin to dispose of secretions and debris.
4. Flush the bulb syringe by aspirating and expelling water until clear.
AGE-SPECIFIC CONSIDERATIONS
COMPLICATIONS
1. Infection is a potential complication of nasopharyngeal suctioning when the correct technique is not used. A new catheter must be used each time for nasopharyngeal suctioning to prevent contamination of the tracheobronchial area.
2. A catheter or pharyngeal suction tip for the oropharynx may be used repeatedly for the same patient unless it is grossly contaminated or becomes clogged with large debris.
3. Excessive suctioning may create irritation to the upper airway and result in bleeding or edema, which may further compromise the airway patency.
PROCEDURE 30 Nasotracheal Suctioning
INDICATIONS
1. To maintain airway patency, maximize oxygenation, and reduce lower airway resistance in the nonintubated patient through removal of secretions when the patient cannot cough effectively. Evidence of secretions includes one or more of the following (AARC, 2004):
2. To stimulate coughing in the weak or debilitated patient who is unable to clear secretions without assistance.
3. To obtain a sputum specimen when the patient is unable to do so without assistance.
CONTRAINDICATIONS AND CAUTIONS
1. Relative contraindications for nasotracheal suctioning include the following (AARC, 2004):
2. Do not suction patients with epiglottitis or croup (AARC, 2004).
3. To prevent hypoxia and tissue trauma, select a suction catheter no more than one half the diameter of the naris to be suctioned.
4. Suctioning may exacerbate increased intracranial pressure or severe hypertension and should be performed with caution in patients with these conditions.
5. Hypoxia may occur during suctioning, particularly in patients with a history of pulmonary or cardiac disease and in infants and small children.
6. Continuous suction may cause trauma to mucosa. Suction should be applied for no longer than 10 seconds (Chulay, 2005).
7. Nasotracheal suction should not be used for patients with severe facial or head trauma. There is risk of penetration of the cranial vault by the suction catheter.
8. Use caution in patients with narrow or obstructed nares and in those who are anticoagulated or who have bleeding disorders.
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