Steps

Rationale/Points of Emphasis 1

1 Verify that the suction equipment is attached appropriately to the suction machine and the collection container for secretions. Turn on the suction, using the lowest effective pressure when suctioning:

60-80 mm Hg (8-10 kPa) for neonates

80-100 mm Hg (10-13 kPa) for children

80-120 mm Hg (10-16 kPa) for adolescents

Pressure that is too great may cause a change in the negative pressure of the lungs, leading to pneumothorax.

2 Perform hand hygiene. Gather the necessary supplies. Decontaminate and disinfect procedure tray/trolley/surface to create a “general aseptic field.” Assemble supplies on aseptic field near child’s bed.

Reduces transmission of microorganisms. Promotes efficient time management and provides an organized approach to the procedure.

caREminder

The suction catheter should be one half the internal diameter of the tracheostomy tube. Large-bore tube removes secretions more efficiently than a smallbore catheter. Using the correct size minimizes the chance of creating negative pressure that could lead to atelectasis.

3 Place the infant or child in supine position with neck slightly extended. If the child is old enough, have him or her raise the head into a “sniffing” position.

Extension of neck enables the suction catheter to more easily follow the natural curve of the trachea.

KidKare To increase the comfort level of the child, a family member may want to hold the infant or child during the procedure or provide some distraction measures.

4 Open sterile supplies (if used).

Healed tissue is less susceptible to infection.

caREminder

If this is not a new tracheostomy, the suctioning may be done using a modified clean procedure as opposed to a sterile procedure.

5 Pour a small amount of sterile normal saline into a disposable container.

Sterile normal saline is used to lubricate the tip of the suction catheter and to cleanse the suction catheter of mucus between passes.

6 Don appropriate PPE (optional) and gloves based on type of aseptic technique used (e.g., sterile technique, ANTT).

Face shield should be used if the child is infectious or has copious secretions that may come in contact with the caregiver. Reduces transmission of microorganisms.

7 Determine the length of catheter to be inserted in the tracheostomy tube during suctioning. A tracheostomy tube of the same size as the one in the child may be used to measure the exact depth to insert the catheter.

Ensures that the catheter is not inserted too far during suctioning (Chart 103-1 ).

8 Pick up the sterile suction catheter and attach to the suction tubing. The hand grasping the suction catheter at the point that it connects with the suction tubing is now no longer considered sterile and should not be used to insert the catheter down the tracheostomy tube.

Designating one hand as sterile and using only this hand to pass the catheter into the tracheostomy assists in minimizing transmission of organisms.

9 Using the sterile (aseptic) dominant hand, lubricate catheter with normal saline.

Small amount of lubricant eases the passage of the catheter into the tracheostomy tube.

caREminder

Hyperventilation or hyperoxygenation breaths are not recommended before initiating suctioning. Delivering a manual breath when secretions are bubbling in the tube only serves to force these secretions into the more distal parts of the airway. 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 require extra breaths or oxygenation before suctioning.

10a If the child has a mask applied over the tracheostomy tube to deliver oxygen and humidification, move the mask aside at this time.

Mask must be moved to access entrance to tracheostomy tube.

10b Preoxygenation or preventilation before the suctioning procedure is determined on an individual basis, and may be initiated if warranted based on the child’s clinical status.

Hyperventilation can help to minimize the risk of hypoxia. Hyperventilation may also serve to push mucous further down the tracheostomy tube, and may not be implemented.

10c Using the gloved dominant hand, grasp the catheter; insert the catheter by gently twirling or rotating the catheter between the fingers and thumb.

Twirling the catheter reduces friction so that the catheter can be more easily inserted.

10d Use the premeasured technique to insert the catheter to ensure it is not more than half a centimeter beyond the end of the tracheostomy tube.

The premeasured technique ensures that the catheter is not inserted too far thus preventing deep suctioning from happening. Deep suctioning can cause epithelial damage.

10e Do not apply suction while the catheter is being inserted.

The American Thoracic Society (2000) consensus document recommends applying suction while inserting the catheter in the tracheostomy tube. More evidence is needed to determine the effects on the child’s oxygen saturation and blood gas levels. One study has demonstrated that 90 minutes after using the ATS method, subjects had less secretions than those children who were suctioned using the traditional method of only applying suctioning as the catheter is removed.

11a As the catheter is removed, apply intermittent suction as you gently rotate or twirl the catheter between the thumb and forefinger and withdraw the catheter.

Removes secretions. The catheter should not be stirred with the entire hand. Twirling the catheter between the fingers reduces friction so that the catheter is more easily removed. This method also moves the side holes of the catheter in a helix, thereby helping to remove secretions off all areas of the tracheostomy tube wall.

11b Using the premeasured technique, complete suctioning in 5 seconds or less. If deep suctioning is used, complete suctioning in 15 seconds or less.

Prolonging suctioning results in hypoxia and can lead to atelectasis.

11c Do not introduce saline into the tracheostomy tube in an attempt to loosen the mucus.

Studies have shown that instilling saline before suctioning has an adverse effect on oxygen saturation, which may last up to 5 minutes. Also, instilling saline during suctioning dislodges bacteria into the lower airway. Studies do not demonstrate the efficacy of normal saline in thinning mucous secretions.

11d In children with secretions, an initial pass of the catheter should be made first to quickly clear the tube of any visible or audible secretions.

Quickly clears the tube of loose secretions.

12 Rinse the catheter tip in a container of sterile water.

Aids in unclogging tube of mucus.

13 Assess respiratory status and determine the need for postsuctioning hyperventilation or hyperoxygenation breaths.

13a Assess breath sounds after suctioning or assess for other signs of improved respiratory status (e.g., pinker skin color, decreased “gurgling” sounds when the child is breathing, no expelling of mucus from the tube during respirations, end-tidal CO₂ measurements, increased oxygen saturation).

Bag ventilation support may be required if the suctioning caused decreased breath sounds. If the child is hypoxic or if the heart rate is highly elevated, further suctioning should not be attempted until the child’s status is stable.

13b If the child was receiving oxygen and humidification by mask before the suctioning, reapplication of the mask between passes may be warranted (Figure 103-1).

Figure 103-1 Providing humidified oxygen/air helps thin secretions.

Assists child in maintaining adequate levels of oxygenation. Humidification assists in thinning secretions.

13c Provide hyperventilation or hyperoxygenation breaths using bag ventilation if indicated.

The use of postsuctioning breaths varies depending on the child’s needs. Children who are prone to atelectasis may need bag hyperinflation after the passes of the catheter.

14 Repeat procedure until breath sounds are relatively clear.

Too many suction attempts can irritate the mucosal lining of the trachea.

15 Cleanse the suction catheter and tubing one more time by placing the tip in a container of sterile water and applying suction pressure. Detach suction catheter from suction tubing.

Clears suction tubing of mucus and allows mucus to collect in suction collection receptacle. Cleansing the tube helps prevent contaminates from remaining in the tube.

16 Remove gloves and PPE and dispose of waste in appropriate trash receptacle. Turn off suction equipment. Return reusable supplies to safe storage area. Perform hand hygiene.

Reduces transmission of microorganisms. Suction equipment should not remain running when not in use.

17 Remove shoulder roll and place the child in position of comfort with head elevated 30 degrees.

This position facilitates ease of breathing.