Nasotracheal Suctioning

CLINICAL GUIDELINES

A registered nurse (RN), licensed practical nurse (LPN), or respiratory therapist may perform nasotracheal suctioning.

Delegation of the skill of nasotracheal suctioning by the RN to the LPN may not be permissible according to the particular state’s scope of nursing practice due to the assessment component required to initiate this procedure.

Nasotracheal suctioning is implemented to remove secretions obstructing the trachea and nasopharyngeal airway that cannot be removed by the child’s spontaneous cough or less invasive procedures, to obtain secretions for diagnostic purposes, or to prevent infection that can occur from accumulated secretions.
Use valid assessment findings (dyspnea, poor skin color, decreased SaO₂ levels, visible or audible secretions, and restlessness) to determine the need for nasotracheal suctioning.
Nasotracheal suctioning is considered a blind highrisk procedure with at times unpredictable outcomes. Nasotracheal suctioning is contraindicated in the child with facial fractures or basilar skull fracture.
Be familiar with the potential risks associated with nasotracheal suctioning before initiating the procedure. These include trauma to the mucosa; cardiac dysrhythmias; changes in heart rate (bradycardia, tachycardia); changes in blood pressure (increase or decrease); respiratory distress (hypoxia, hypoxemia, respiratory arrest); uncontrolled coughing; gagging/vomiting; discomfort and pain; increased intracranial pressure; and nosocomial infection.
Although the upper airways (oropharynx and nasopharynx) are not a sterile environment, it is recommended to use sterile technique for all suctioning to avoid introducing pathogens into the airways. Nasotracheal suctioning should be performed before pharyngeal suctioning.
The appropriate subatmospheric pressures to use when suctioning are :
- Neonates: 60 to 80 mm Hg
- Infants: 80 to 100 mm Hg
- Children: 100 to 120 mm Hg
- Adults: 100 to 150 mm Hg

EQUIPMENT

Portable or wall suction machine with tubing and collection container
Oxygen delivery devices
Receiving blanket
Towel or disposable waterproof pad
Appropriate-sized sterile suction catheter (the catheter diameter should not exceed half the diameter of the airway)

Age	Catheter Size
Neonate to 18 months	5-8 French
18 months to 7 years	8-10 French
7-10 years	10-14 French
11 years to adult	12-16 French

Sterile container for sterile fluids used to lubricate and clear catheter
Water-soluble lubricant and/or normal saline
Sterile gloves
Personal protective equipment
Sterile water

CHILD AND FAMILY ASSESSMENT AND PREPARATION

Assess the child’s respiratory status. Determine the need for suctioning based on clinical findings:
- Breath sounds
- Skin color
- Breathing pattern and rate
- Pulse rate and dysrhythmias
- Color, consistency, and volume of secretions
- The presence of bleeding or evidence of physical trauma
- Cough
- Oxygenation (pulse oximetry)
- Arterial blood gas (if available)
- Laryngospasm
Assess the child’s or the family’s readiness to learn.
Determine whether the child or the family understands the procedure and its significance. Explain in age-appropriate terms to the child that suctioning will relieve breathing difficulty but that it will be uncomfortable and might cause him or her to cough, gag, or sneeze.
Use a doll and a suction catheter in therapeutic play to demonstrate suctioning to the early and middle childhood-aged child to facilitate his or her understanding. Involve a child life specialist to assist in this therapeutic play.

KidKare Encourage a family member to stay with child during the procedure to minimize the child’s stress. If no family member is available, elicit assistance from another staff member.

PROCEDURE
Nasotracheal Suctioning

Steps	Rationale/Points of Emphasis
1 Gather the necessary supplies and equipment and check for proper functioning.	Promotes efficient time management and provides an organized approach to the procedure. Properly functioning equipment and supplies are needed for beneficial results.
2 Place the supplies on a bedside table, turn on the portable or wall suction apparatus, and set the pressure gauge to the appropriate range.	Appropriate suction pressure decreases the chance of mucosal irritation and damage, hypoxemia, and atelectasis.
Test the suction equipment by occluding the connection tubing.	Verifies suction equipment is in good working condition.
3 Perform hand hygiene and don personal protective equipment.	Reduces the transmission of microorganisms and maintains standard precautions. Face shield or goggles are essential to protect splashes from the eyes. Contact and airborne precautions must be used for children with respiratory illnesses such as respiratory syncytial virus (RSV).
4a Assist the conscious child to assume a semi-Fowler’s position. For an infant, place a folded receiving blanket or roll under the shoulders. Place the head in the midline position. Place the unconscious child in the lateral position, facing the person performing the suctioning.	These positions facilitate coughing and the insertion of the catheter in the conscious child. For the unconscious child, the lateral position facilitates drainage of secretions from the pharynx. It also helps to prevent aspiration. KidKare An infant may be swaddled with slightly flexed extremities to provide comfort and assist in the procedure. If remaining present for procedure, position family member at head of bed to keep them within immediate eyesight of their child.
4b Plan method to keep child from touching sterile catheter, such as distraction, swaddling, or obtaining assistance from family member or other staff.	Maintains sterility and prevents introduction of microorganisms.
5 Place a towel or disposable waterproof pad on the child’s chest.	Protects the child’s clothing.
6a Aseptically open sterile suction kit or equipment, using the inside of the wrapping as a sterile field.	Maintains sterility.
6b Set up the sterile cup or container, touching only the outside, and pour sterile water or saline into it, making sure the top of the bottle does not touch the inside of the container.	The inside of the container is considered to be sterile, and your hands are contaminated. The water is used to clear the catheter of secretions.
6c Open lubricant and squeeze onto the sterile field.	The lubricant is used to lubricate the catheter, allowing for easier passage, causing less trauma to the nasal mucosa.
7 Don sterile gloves. The dominant hand must remain sterile, and the nondominant hand is considered clean rather than sterile.	The sterile gloved hand maintains sterility of the catheter, and the unsterile hand maintains standard precautions.
8 With the sterile gloved (dominant) hand, pick up suction catheter, being careful to avoid touching nonsterile surfaces. With the clean (nondominant) glove, pick up the connecting tubing and secure it to the catheter.	Maintains catheter sterility. The nondominant hand controls all nonsterile equipment.
9 Check equipment for proper functioning by placing the catheter in the container of solution while holding a sterile gloved finger or thumb over the port of suction catheter to create suction.	Ensures equipment function. Checks for catheter patency.
10 Make an approximate measure of the depth for the insertion of the catheter by measuring the distance from the tragus of the child’s ear to tip of the nose. Mark the position on the tube by placing the sterile gloved forefinger and thumb at that point on the catheter.	Ensures proper length of catheter to be inserted for nasotracheal suctioning to prevent airway trauma or vagal stimulation.
11 Reassure the child before initiating the procedure. If possible, encourage the child to cough.	Decreases stress. Coughing helps to pool secretions.
12 Dip the catheter tip into the lubricant.	Reduces friction and facilitates insertion of the catheter.
13 Holding the tip of the catheter between the index finger and thumb of the sterile gloved hand, wrap the rest of the catheter around the sterile hand.	Decreases the potential for contamination of the catheter.
14 If child is wearing an oxygen device, use nondominant hand to remove the device.	Provides access to nasotracheal tube.
15 Without applying suction, using dominant hand gently, but quickly, insert the premeasured catheter into either naris along the nasal septum and advance caudally along the floor of the nasal cavity (Figure 74-1).	Applying suction during catheter passage can cause hypoxia and tissue damage. Advancing the catheter along the floor of the nasal cavity avoids the nasal turbinates, which are easily ruptured and bleed.
	Use gentle touch because bradycardia may occur as a result of vagal stimulation at the posterior oropharynx with vigorous suctioning.
	caREminder
	Never force the catheter if resistance is met; simply remove the catheter and attempt passage through the other naris.
Figure 74-1 Suction is not applied while the catheter is gently being inserted into the nares.
16 Apply suction intermittently by occluding the suction control port with the sterile gloved thumb, removing thumb intermittently, and gently rotating the catheter as it is being withdrawn from the naris. Duration of suctioning should be limited to no greater than 15 seconds (Figure 74-2).	Removes secretions. Gentle rotation of the catheter and applying intermittent suction ensures that all surfaces are being reached, avoids tissue trauma to any one area, and prevents hypoxia.

Figure 74-2 During the suctioning process, suction is applied intermittently. The duration of suctioning should be limited to no more than 15 seconds.
17 Irrigate the catheter with the sterile water or saline after each suction pass.	Cleans the catheter of occluding secretions.
18 Relubricate the catheter and repeat suctioning as needed or as tolerated by the child, allowing a 20- to 30-second interval between each suctioning. The nares should be alternated if possible when repeated suctioning is required.	Applying suction for prolonged periods can cause secretions to increase and can decrease the oxygen supply. Alternating the nares can help reduce tissue trauma.
19 Assess the child for color, respiratory rate and effort, and SaO₂ levels (if monitored) during suctioning.	Determines adequacy of oxygenation.
20 Gently clean around the child’s nares once all suctioning has been completed.	Mucus accumulated around the nares is irritating to the mucous membranes and unpleasant for the child.
21 When suctioning is completed, remove gloves inside out. Dispose of gloves, suction catheter, and solution container in proper receptacle. Perform hand hygiene. Place new suction supplies at bedside.	Standard precautions. Reduces transmission of microorganisms. Ensures equipment is available for next time suctioning is needed.
22 Auscultate child’s breath sounds; assess color, secretions, SaO₂ level, dyspnea, and level of anxiety. Ensure child is in position of comfort.	Evaluates effectiveness of suctioning. Supplemental oxygen may be necessary if the child’s clinical status does not improve after suctioning.