Adult Tracheal Suctioning – Clinical Protocol

• Aims
• Background and indications
• Method (step by step)

Aims

To standardise and optimise the maximum removal of secretions/ specimens from the trachea with the minimum of adverse effects.

Background and indications

Definition
Suctioning is the drawing of air out of a space to create a vacuum that will suck in surrounding liquids e.g. secretions from the tracheal tree

Summary
This protocol is intended to support and inform practitioners performing tracheal suctioning on adults within the acute in-patient setting to improve care and safety.

1.0 Objectives

• To provide patients with robust evidence based care,
• To provide practitioner with graded evidenced based procedures of care
• To enable care to be audited in a meaningful manner

2.0 Scope
2.1 Applies to all adult patients with a Tracheal (endotracheal or tracheostomy) tube in situ.

2.2 Applies to registered Practitioners (including Medical, Nursing, Physiotherapists, Speech and Language Therapists and Operating Department Practitioners) who have demonstrated competency in this procedure.

3.0 Standards
Practitioners will receive training and assessment as part of a competency package (National Competency Framework for Adult Critical care Nurses Step 1 competencies).

Care will be audited annually as part of Critical Care audit programme.

Closed suction is the standard for ventilated critical care patients

4.0 Background and indications for protocol

Evidence for practices
The presence of a Tracheal tube (TT) disrupts the integrity of the mucociliary clearance system and the mechanics of coughing. Sedation, ventilation, coma states, muscle weakness and trauma also affect the mucociliary clearance system and the mechanics of coughing (Ashurst, 1992). Tracheal suction is important in order to reduce the risk of consolidation and atelectasis that may lead to inadequate ventilation (Pederson et al., 2009). Subsequently tracheal suction is a regularly performed procedure; it involves the insertion of a suction catheter into the trachea with the application of negative pressure as it is withdrawn. The negative pressure required to remove secretions also removes oxygen from the lungs and can produce well-documented adverse effects ranging from hypoxemia, cardiovascular instability, tracheal and mucosal trauma, infection, discomfort, arrhythmias, atelectasis, increased venous return and adverse effects on Intracranial pressure (ICP) (Higgins, 2009; MacIntyre and Branson, 2009; Pryor and Prasad, 2008; Blakeman et al., 2022). The major recommendations are (Pederson et al., 2008; Blakeman et al., 2022):

• Suctioning only when necessary
• Using a suction catheter occluding up to 50% of the lumen of the endotracheal tube
• Using the lowest possible suction pressure up to a maximum of 200 mmHg whilst exercising caution
• Inserting the catheter no further than the carina
• Suctioning no longer than 15 seconds
• Performing continuous rather than intermittent suctioning
• Avoiding saline lavage
• Provide hyper-oxygenation pre and post suction procedure
• Provide hyperinflation combined with hyperoxygenation on a non-routine basis
• Always using aseptic non-touch technique using either closed or open suction

Assessing need for suction
Suction should not be carried out routinely and should only occur as indicated following a thorough assessment. This includes observation for abnormal breathing sounds on auscultation such as whistling, crepitus (crackles) or diminished sounds, irregular respiratory pattern, increased peak inspiratory pressures, decreased tidal volumes, an increase in coughing, alteration in the amount or consistency of secretions (Griggs,1998). Unexplained decreases in oxygen saturations, increased airway pressures, diminished breath sounds and visible secretions in the tracheal tube are all indicators for suction (Ireton, 2007).

Closed suctioning
Closed-circuit suction (CCS) is designed to eliminate the need to disconnect the patient from the ventilator during tracheal suction. It maintains ventilator settings and PEEP, reduces staff exposure to respiratory secretions, and reduces potential for translocation of respiratory secretions through ‘ventilator spray’ and enables timely suctioning of patients. When the ventilator circuit is opened spray condensate and tracheal secretions can contaminate the nurse via inhalation and the spraying of clothing and bed area (Blackwood, 1998; Cobley, 1991).

Closed suction system can also be used for non-ventilated intubated patients reducing infection risks for patients and healthcare practitioners whilst maintaining respiratory support. It is also of invaluable use for those patients with active high risk infection status.

Open suction with single use catheters and ventilation interruption has its place. Care has to be taken to limit the disconnection time and to monitor the suction pressure in use. Sterile single use co-polymer over gloves are used over examination gloves for the hand controlling the suction catheter.

Frequency and Timing
Secretion volume, patient’s stability and accurate assessment of the situation will determine how many passes are required. Each pass of a catheter can adversely affect oxygen saturation, cerebral blood flow, ICP, arterial pressure or cardiac output (Pryor and Prasad 2008).

Time should be allowed in-between passes in order to pre-oxygenate, assess the patient’s respiratory symptoms and address any hazardous effects that may have occurred.

Suction time in total should not exceed 15 seconds (Blakeman et al., 2022). Longer suction times increase risk of adverse effects. Suction during inspiration allows the ventilator to provide some of the gas that will be evacuated during the suctioning event, reducing the possible generation of suction atelectasis (McElvie, 1998).

Suction Catheters / Design / Insertion / Length of insertion
Ideally catheters should be sterile, flexible and clear so that secretions are easily visible and removed causing the least mucosal damage. Link (1976) demonstrated that the physical act of inserting a catheter into the trachea damages the mucosa and that single side hole catheters produce more damage than catheters with multiple side holes. Suction catheters with two or more side holes dissipate the focus of the suction pressure reducing mucosal contact and trauma. Although tissue trauma may be negligible during a single suction procedure, poor technique and repeated suctioning will increased mucosal damage (Kleiber,1998).

Larger catheters increase the risk of mechanical trauma due to greater mucosal contact. A greater amount of air may be evacuated with larger catheters and the risk of hypoxia increases as oxygen flow to the lungs is reduced. The AARC (Blakeman et al., 2022) recommend that catheter size should allow adequate oxygen flow to the lungs, and should not exceed 50%of the internal diameter of the tracheal tube.

The widely accepted formula for calculating catheter size is:

Pederson et al (2009)

It is recommended to use minimally invasive tracheal suctioning. The suction catheter should be inserted to the carina and then retracted 1-2cm before suctioning. Alternatively, the length of the suctioning catheter is estimated by measuring an identical tracheal tube (Pederson et al 2009). Carinal stimulation by using a suction catheter which is too long in length is associated with arrhythmias especially bradycardia (MacIntyre and Branson 2009).

Difficulty in passing a suction catheter may indicate a potential blockage of the tracheal tube and is therefore important that this is recognised and reported immediately.

Subglottic drainage port
The use of endo-tracheal tubes and tracheostomy tubes with subglottic drainage ports can reduce Ventilator Acquired Pneumonia (VAP) by preventing contaminated oral secretions that accumulate above the tracheal cuff in intubated patients leaking past the cuff into the lungs (Muscedere et al. 2011). Maintaining an appropriate inflation pressure in the tracheal cuff is important, since under inflation (<20cm H2O) is associated with VAP. Over inflation (>30cm H2O) is also harmful and contributes to long-term tracheal damage (DoH 2010). A cuff pressure of 25 cm H20 is therefore recommended (Lorente et al 2007). Suctioning via the subglottic port would be done according to the manufacturer’s instructions but usually through aspiration with a syringe. Please refer to ‘Sub-glottic aspiration via a tracheal tube - adults in critical care’ guideline: SOP ID5299 for further information.

When deflating the tracheostomy cuff the suction port should be aspirated prior to cuff deflation. If a tracheostomy tube does not have a sub-glottic port simultaneous deep suction should be carried out whilst the cuff is deflated. If it is suspected that the sub-glottic port is not fully clearing secretions accumulating above the cuff, simultaneous deep suction should be performed during cuff deflation.

Pre and post oxygenation
Hypoxia and hypoxemia are among the most common complications of endotracheal suctioning and can be mitigated by the administration of oxygen prior and post procedure (Pedersen et al., 2008; Tavangar et al., 2016; Rodrigues et al., 2017). Tracheal suctioning affects the respiratory mechanics and gas exchange therefore pre-and post-oxygenation is required. Rodrigues (2017) found little difference for pre and post oxygenation of FiO2 0.20 above baseline and FiO2 1.0 in preventing hypoxemia and hypoxia. Previous reviews of this evidence base have suggested using the latter (FiO2 1.0) for 30 seconds prior to tracheal suctioning (Pederson, 2008). Subsequent research has also suggested that the administration of supplemental oxygen pre-and post- procedure should be between 1-2 minutes in duration (Tavangar, 2016). Exercising clinical judgement and caution is advised when administrating pre-and post-oxygen for patients requiring tracheal suctioning.

Suction Pressures
The negative pressure used can affect the amount of secretions removed and cause additional tracheal mucosa damage and hypoxia. If suction pressure is too low the patient’s airway is not cleared. If it is too high the suction catheter can adhere to the tracheal wall damaging the tracheal mucosa (Griggs, 1998).

The lowest amount of suction pressure needed to remove secretions should be used. The recommended pressure for adults has been suggested to be 80-120mmHg (Pederson et a,l 2009; Blakeman et al., 2022) although clinically this level is often insufficient to evacuate thick mucoid secretions. In this situation negative pressure of up to 200mmHg may be needed to clear the airways adequately whilst exercising caution. Humidification and hydration need to be reviewed if secretions are tenacious. The AARC (Blakeman et al., 2022) recommend not exceeding 200mmHg of negative pressure and efforts to clear secretions should be made by using as low as possible suction pressure.

Suctioning and Intra Cranial Pressure (ICP)
Direct tracheal stimulation, increased paCO₂, interruptions in ventilation, impaired cerebral venous return due to coughing, increased heart rate (HR) and increased blood pressure (BP) (Pryor and Prasad, 2008) can all cause rises in ICP however raised ICP does not directly correlate with low cerebral perfusion pressure (CPP). Additional sedation can be used to moderate these rises in ICP due to cares with further cares/procedures being avoided for at least 10 minutes following tracheal suction to allow stabilisation of ICP and a return to baseline figures (Ellen, 1991). Pre-oxygenation for at least 3 minutes mediates the risk of suction induced hypoxia and the associated effects on ICP. Suctioning should be limited to no more than 2 suction passes of less than 15 seconds. Increases in ICP, secondary to suctioning, usually resolve to baseline levels within a few minutes (White, 1982; Fisher ,1982; Imle, 1988). Transient rises in ICP are considered permissible if baseline levels are achieved quickly and if CPP is maintained.

Use of sodium chloride 0.9% bolus and sodium chloride 0.9% nebulisation
The practice of sodium chloride 0.9% bolus instillation is not advised on a routine basis. (Celik and Kanan, 2006; Halm & Krisko-Hagel, 2008; Blakeman et al. 2022). Its use may be advocated clinically but this assessment should be noted. If a bolus of sodium chloride 0.9% is used, it must be the sodium chloride 0.9% ampoules from the closed circuit suction package. If this is not used the sodium chloride 0.9% must be prescribed. Sodium chloride 0.9% instillation has been noted to have an adverse effect on oxygen saturation that worsens over time. It does not increase the efficacy of secretion removal (Ackerman, 1993). It can increase the risk of infection by dislodging bacteria on the inside of the airway and can create a physical barrier to gas exchange (Hagler, 1994; Ackerman, 1993). When used to produce a cough, it is no stronger than that produced by the introduction of a suction catheter (Hudak, 1996). Bolus instillation results in preferential patterns of deposition in the gravity dependant regions of the lungs, this can have adverse implications for the sedated ventilator dependant patient. Sodium chloride 0.9% nebulisation can help sputum production and cough clearance by generating droplets small enough to penetrate deep into the lung (Hough 1992). The best known interventions for managing thick tenacious secretions and preventing mucus plugs in ventilator dependent patients are hydration, adequate humidification, use of mucolytic agents and effective mobilization (Halm & Krisko-Hagel, 2008). Although, Strickland et al. (2015) found no high level evidence related to the use of bronchodilators, mucolytics, mucokinetics to promote airway clearance in these patients.

Oral suctioning
Oral hygiene and suctioning is an important component secretion management and can reduce the risk for ventilator associated pneumonia (Sole et al., 2011), especially the removal of oral secretions prior to position changes (Chao et al., 2008). The oral hygiene protocol can be found on Leeds Health Pathways.

Infection control

• Open suction is a single use event, with new sterile gloves and catheter used for each pass of the suction catheter.
• Dependant on model used closed suction systems can be changed 24hourly, 72 hourly or as indicated (soiled or malfunction) (Saving Lives, 2007). Closed suction catheters must be rinsed after each set of suction passes using individual 20ml ampoules of sterile sodium chloride 0.9% and removed after use.
• 1L bottles of sterile water used for rinsing suction tubing should be dated and changed every 24hrs (Billau, 2004).
• Single patient use disposable suction liners and tubing located at patients’ bedside are changed when indicated or canister is ¾ full.
• Hospital suction side tubing and suction filters (fitted to underside of suction generator) are changed per patient or monthly (filters and tubing to be dated) (Oxylitre, 2006).
• Staff should adhere to the LTHT hand hygiene policy and use universal precautions. Whenever splashing is a possibility goggles or visors should be worn.

Evidence Base
There are limitations to the evidence based supplied in this protocol. Much of the evidence is beyond 10 years of age thus highlighting a potential gap in research where procedure is discussed and set. Significant attempt has been used to gain relevant and up-to-date research to support this protocol. Research relating to physiology has not been updated as this is regarded as unchanging.

Back to top

Procedure method (step by step)

Closed suction pictorial aids

	Catheter is stored with black mark inside plastic sleeve. This ensures the suction catheter is not interrupting air flow when not in use.
	The suction catheter is advanced into the trachea whilst pushing the plastic sleeve behind.
	Suction is applied by pressing and depressing the button located at the distal end of the suctioin catheter.
	Lifting and turning the control button locks the closed suction catheter to prevent inadvertent use.

Back to top