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EasternRegionalNeonatalBenchmarkingGroup

SuctioningGuideline
ReasonforDevelopment: Tostandardiseandimprovepatientcare Toincorporatenewevidenceintopractice. Auditstandards: 1. Suctionisonlyperformedasaresultofassessmentofanidentified need. 2. Suctionpressuresaresetat50100mmHg(810kpa). 3. Preoxygenationisnotperformedunlesstheoxygensaturationhas fallen. 4. Suctioncathetersaremeasurepriortoendotrachealsuctiontoensure thatthecatheterdoesnotpasstheendoftheendotrachealtube (ETT). 5. Salineuseislimitedtothoseinfantswhosesecretionsmayblockthe airway. 6. Suctioningpreferablynotperformedaspartofcaresbutasaseparate procedureorattheendofcares. Scope ForuseinneonatalunitsintheEasternRegion Aim Airwaysuctionisnecessarytoremovesecretionsandprevent 1 obstruction .Seriouscomplicationssuchashypoxaemia,raisedblood pressure,raisedintracranialpressuresandpneumothoraxmayresultfrom thisintervention.Weaimtoachieveabalancebyhelpingwithout 2 harming .
3 Indicationsforsuctioning Coarsebreathsoundsonchestauscultation Lackofbreathsoundsonchestauscultation Reducedchestmovement Audibleorvisiblesecretions Increasingairwaypressures Deterioratingoxygensaturationlevelsorarterialbloodgases Suspectedaspirationofmeconiumorgastriccontents TheneedforETsuctionshouldbebasedonassessmentoftheinfant's clinicalstatus.Tohelpwiththisclinicaldecisionmaking,theoxygen saturation,inspiredoxygenconcentrationtrend,bloodgases,chest movementandtidalvolume(Vt)canbeassessed,aswellastakinginto considerationtheamountandtypeofETsecretionsremovedduring suctionperformedinthepast12hours.

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Complications Atelectasis 4,5,6 Hypoxia 7 Bradycardia 8 Bloodpressurechanges 9 Airwaytraumanecrotisingtracheobronchitis 10,11 Pneumothorax (afterclosedcircuitsuction) 12 Raisedintracranialpressure 13 Nosocomialinfection 14 Discomfort Precautions Saline Salinesolutionadministeredwithsuctioningresultsinundesirable alterationsinoxygensaturationandarterialbloodgaslevels.Insteadof usingnormalsalinetodecreasetheviscosityofsecretionspriorto suctioning,effortsshouldbemadetoensureadequatehumidificationin 4,15,16 themechanicalventilation . Preoxygenation Althoughthereappearstobeevidencesuggestingthatpreoxygenation cansignificantlyreducehypoxaemiarelatedtoETsuction,thisprocedure hasinfactbeenfoundtohavelongtermadverseeffectsontheinfant. Theselongtermeffectsincluderetinopathyofprematurity,parenchymal 17 lungdamageandoxygenfreeradicaldamage . Cathetersize&length 8 Ideallythesuctioncathetershouldnottotallyoccludetheairway .The recommendationforsizeofcatheterisoneofnotmorethanhalfthe insidediameteroftheendotrachealtube(OD:IDof2:1)8,18 .Thisisto preventatelectasis.Thisguidemaybedifficulttoadheretointhe neonatalpopulationbecauseofthesmallinternaldiameterofasize2.5 endotrachealtube,butthesmallestsuctioncathetershouldbeusedforan ETT<3.0. Closedversusopensuctiontechnique Closedcircuitsuctionpreventssomeofthephysiologicalproblemsof disconnectingfromtheventilatorforsuction,whichcanleadtopotential 7,20,21. atelecticcollapse,hypoxia,bradycardiaandincreasesinfectionrisk Durationandtimingofsuction Whenundertakenaspartofaclusteredcareepisode,anysuctioning shouldbeperformedattheendofthecareepisode,allowingtheinfant adequatetimetorecoverbeforeotherroutineproceduresarecarriedout. 8 5 Asitcommonlytakesbetween30minutes and1hour torecoverfrom endotrachealsuctioning,minimalhandlingshouldbeobservedforthis 23 lengthoftimefollowingETsuction

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EndotrachealSuction
Equipment Stethoscope Gloves(forprotectionofthewearer) Suctioncatheters e.g.PaediatricYankeurformeconium 6fgfora2.5mmendotrachealtube 8fgfora3.0mm4.00mmendotrachealtube 6fg10fg(fororalornasalsecretionsdependingonthethicknessof secretionsandthesizeandgestationofthebaby). Suctionconnectingtube Suctionbottleconnectedtosuctionapparatuspressuresset50 24 100mmHg(810kpa) Salineifrequired Rubbishbag Sterilewater(torinsesuctiontubesaftertheprocedure) Anotherpersontocomfortandcontainthebaby Documentation Preparation: 1. Undertakeanassessmentofneed Havethephysiologicalparameterschanged? Isthechestmoving? Whatwastheresultofthemostrecentbloodgas? Auscultatethechestarethebreathsoundsnoisy,isairentryequal? Hasthetidalvolumeorminutevolumedecreased? Hastheoxygenrequirementincreased? Whatwerethesecretionslikeonthelastsuctionevent? Whenwasthelastsuctionperformed? Hastheinfantrecentlybeenhandled? 2. Iftheparentsarepresentexplainthereasonforsuctionandthe procedure 3. Washhands 4. Prepareequipmentasabove 5. Ifusingsalineinstillationpriortosuctioningdrawup0.250.5ml 25,4 [0.25=<2kginfant0.5mls=>2kginfant ] into2mlsyringe, takingcarenottotouchkeyparts,andreplacesyringebackintopaper packet 6. Attachsuctioncathetertosuctiontubing,leavingcatheterinthe protectivepackagingtopreventcontamination
7.

Checkthevacuumpressureensuringthatthemaximumnegative 24 pressuredoesnotexceed50100mmHg(810kpa)

8. Determinelengthofendotrachealtube(includinganydeadspaceand lengthoftheblueETThub).Thisisthelengthyouwillneedtopass
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thesuctioncathetertoensurethatthecatheterreachestheendofthe 26,27 ETTtip .Thiscanbeachievedbyobservingthemarkingsofthe suctioncatheterorbymeasuringthecatheteragainstaprecuttape measurewhichmaybestucktotheinsideoftheincubator 9. Observepresuctioningsaturation,apexbeatandbloodpressure(if monitored)andensuretheinfantiswelloxygenatedpriortoprocedure 20 without"preoxygenating" . Emergencysuction ForemergencysuctionoftheETT,step9ofthepreparationprocedure maynotbeachievable.Itmaybenecessarytoincreasetheinspired oxygenconcentrationinresponsetodesaturation,butinsomecases (suchasblockedETT)waitinguntiltheoxygensaturationis>90%isnot practical.Suctioninthissituationshouldbeperformedtopreventfurther desaturationorbradycardia. 10.Auscultatethechestpriortosuctioningtohavebaselineinformationon whichtocomparepostsuctioningauscultation 11.Positiontheheadinthemidlineifpossibletoreducechangesto cerebralbloodflow. 12.Wherepossibleorganizeanotherperson/parenttohelpwiththe proceduretoallowtheinfanttobecontainedduringthesuctioningas ithasbeenshowntoaidrecovery. Procedure:

1. Washhandsthoroughlyanddry,applyalcoholhandrubandallowto
dry
31,32,33,34 Salineifrequired Ifthereareindicationsforusingsaline,instilthisintotheETT Reconnecttheventilatorforaminimumof5breathstoensurethatthe salinehasthoroughlymoistenedtheETT

2. Putontwounsterileglovestothedominanthand.Doublegloving
meansthatthetopglovecanberemovedtocontainthecatheterafter thesuctioningiscomplete

3. Withdrawsuctioncatheterfromprotectivepackaging,holdinginhand
withsterileglove

4. Silenceventilatoralarmwithnonsterilehand 5. DetachETTfromventilationtubingwithnondominanthand 6. SteadytheETtubewiththenondominanthandandinsertthesuction

catheterdowntheETTtothepredeterminedlengthwiththegloved 9 hand.ThecathetershouldnotadvancebeyondtheendoftheETT .
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7. Applysuctionbyoccludingthefingertipcontrolwitheitherafingeror
thumb

8. Withdrawcatheter,whilstapplyingsuction.Itshouldtakenolonger
than45secondstocompletelywithdrawcatheter.Thewholeprocess 19. shouldnotexceed1015seconds

9. ReattachventilationtubingtotheETT. 10.Assesstoleranceoftheprocedurebyobservingoxygensaturation,
colour,heartrateandactivity.

11.AdjusttheFiO2 tostabilisetheoxygensaturationsofthebabyand
resettobaselinerequirementswhenthebabyreachespresuction apexandoxygensaturationlevels

12.Auscultatethechestandrepeatsuctionasnecessary 13.Iffurthersuctionisneeded,repeattheprocedurefromstep11using
newsuctioncathetereachtime.Usually12attemptsaresufficientto clearETsecretions

14.Observecolour,quantityandtypeofsecretionsinthesuctioncatheter 15.Continuecontainmentiftheinfanthasnottoleratedtheprocedure
well. Followingprocedure:

1. Removetheglovefromthedominanthandbyinvertingitoverthe
usedcatheter

2. Disposeofwasteinyellowclinicalwastebin 3. UseChlorhexidinesolution/watertocleanthroughsuctiontubingand
leavesuctionswitchedoninincubatorbutawayfrominfant

4. Washhandsanddrythoroughly 5. RecordonITUchartincludingamount,typeandcolourofsecretions.
Iffreshbloodisobtained,reporttomedicalstaffimmediately

6. Documenttoleranceandeffectivenessoftheprocedureinthecare
plan Collectingaspecimen: Additionalequipmentneeded Mucustrap Ampouleofsterilewater

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Procedure Ifaspecimenisrequired,amucustrapshouldbeattachedbetween thesuctiontubingandthesuctioncatheter. ETsuctionshouldthenbeperformedinthesamewayasdetailedin theguideline. Followingsuctionthesterilewatershouldbesuctionedthroughthe catheterintothemucustrapbeforeitissealed.

AdditionalInformation: HFOV&suctioning TheprocedureforETsuctionisexactlythesameforinfantsreceiving HFOVorconventionalventilation. Ifusingthesensormedicsventilator,thealarmshouldbesilencedduring disconnectionfromtheventilatorandthestart/stopbuttonshouldbe depressedtorecommenceventilationoncetheETTisreconnectedtothe ventilatortubing.Afterinstillingthesaline,itmaybenecessaryto oscillateforafewseconds,asthereisnogreatpressureshifttogetthe salineintotheETT. Insomesituationsthemeanairwaypressuremayneedtobebriefly increasedby12cmtorerecruitalveoliandstabiliseventilation,butcare mustbetakentoreducebacktoinitialsettingswithinaspecifictime frame(discussonwardroundwithconsultant)toavoidanyover distensionofalreadydamagedlungs.

Oro/nasopharyngealsuction
Preparation: 1. Aswiththepreparationforendotrachealsuctioningthereshouldbean assessmentofneedpriortoundertakingsuction. 2. Iftheparentsarepresentexplainthereasonforsuctionandthe procedure 3. Washhands 4. Prepareequipmentneededfornasopharyngealsuctionandcheckthat equipmentisworking. 5. Attachsuctioncathetertosuctiontubing,leavingcatheterinthe protectivepackagingtopreventcontamination 6. Checkthevacuumpressureensuringthatthemaximumnegative pressuredoesnotexceed50100mmHg(810kpa). 7. Observepresuctioningsaturation,apexbeatandbloodpressure(if monitored)andensuretheinfantiswelloxygenatedpriortoprocedure without"preoxygenating"

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8. Wherepossibleorganizeanotherperson/parenttohelpwiththe proceduretoallowtheinfanttobecontainedduringthesuctioningasit hasbeenshowntoaidrecovery. Procedure: 1. Washhandsthoroughlyanddry,applyalcoholhandrubandallowto dry 2. Putonsterileglovestoprotectthehandsfromanysecretionsandto keepthecathetercleanpriortoinsertion.

Nasalsuction 3. Measurethecatheterfromthemouthtothesuprasternalnotchto 33 estimatethelengthrequiredforinsertion . 4. Itmaybenecessarytolubricatethetipofthecatheterinsome saline/watertopreventtraumatotheliningofthenose. 5. Introducethecathetergentlyintothenostrilandeaseittothebackof 2 thepharynxapproximately48cm . 6. Applysuctionandgentlywithdrawthecatheternottakingmorethan 10seconds.Suctionshouldnotbeappliedwhilstinsertingthecatheter asthiscausesmucosalirritation,damageandcanpotentiallyleadto hypoxia.

Oralsuction 7. Gentlyinsertthecatheterintothemouthinanupwardandbackward direction,iftheinfanthasagagreflexhe/shemaycough 8. Iftheinfantdoesnothaveagagreflex,measurethecatheterfromthe mouthtothesuprasternalnotchtoestimatethelengthrequiredfor insertionandtheninsertthecatheterasabove 9. Applysuctionandgentlywithdrawthecatheternottakingmorethan 10seconds.Suctionshouldnotbeappliedwhilstinsertingthecatheter asthiscausesmucosalirritation,damageandcanpotentiallyleadto hypoxia.

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Tracheostomysuction
1. Assesstheneedforsuctionexcessivecoughing,cyanosis, tachypnoea,bradycardiaandapnoeaorexcessivesecretions 2. Thesuctionequipmentshouldbepresetat50100mmHg(or8 10kpa)tominimisetheriskoftraumaandatelectasis. 3. Measurethedepthtowhichthesuctiontubeneedstobepassed 34 againstanidenticaltracheostomytube . 4. Washhands,dryandapplyalcoholhandrubtoreducetheriskof infection 5. Openthesuctioncatheterandattachtothetubing,leavingtherestof thecatheterinthepackettokeepthecatheterascleanaspossible 6. Putontwononsterileglovesonyourdominanthandtominimisethe riskofinfection.Theglovesshouldbenonpowderedtopreventthe introductionofpowderintotheairway. 7. Instilsalineifneededduetothepresenceofthickorcopious secretions.Alwaysuseaplasticampoule(glassampoulesshouldnever beusedasthereistheriskthatglassfragmentscouldbeintroduced 35 withthesaline)0.250.5mlissufficienttoloosensecretions . 8. Insertthecatheterintothetracheostomytube.DONOTpasscatheter beyondendoftracheostomytube(checkthelengthbymeasuring againstanothertube). 9. Tominimiseirritationofthemucousmembranesapplysuctiontothe sideportonlyasthecatheterisgentlyremoved.Donotrotatethe catheterasitiswithdrawn. 10. Anypassofthesuctioncathetershouldnottakelongerthan10 seconds. 11. Reassesstheinfanttodeterminewhetherfurthersuctioningis necessary,ensuringinfanthasrecoverytimebetweeneachpass.Use anewsterilecatheteroneachoccasion. 12. Observeforrecoveryofoxygenation,heartrate,respirationaltering FiO2 ifnecessary. 13. Disconnectanddisposeofthecatheter.Clearthesuctiontubingwith aqueousHibisol.Attachanewcatheterreadyforthenextuse. 14. RecordthesuctioningeventontheITUchart,indicatingtheamount, colourandconsistency.Secretionsarelikelytobebloodstainedinthe first24hours.

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Signsthatsuctioninghasbeeneffective Reducedworkofbreathing Reducedrespiratoryrateintheunventilatedinfant Increasedoxygensaturation Chestmovementimproves Mv/Vtimproves Apnoea&bradycardiaeventslessen Visibleevidenceofsecretionremoval Absenceofaudible/visiblesecretionsintheupperairway Othersguidelinesusedinthedevelopmentofthisguideline QueensMedicalCentre.TrachealSuctionPhysiotherapyPractice Guidelines RoyalFree(1999)GuidelinesforTrachealSuction References 1. Levene,TudehopeandThearle(2000)Essentialsofneonatalmedicine rd 3 Ed.p123BlackwellScienceLtd.OxfordandLondon.[III] 2. CzarneckiML,KariacCL.(1999)Infantbasalpharyngealsuctioningis itbeneficial? PediatricNursing.March/April25(2):1936,218.[III] 3. DayT,WainwrightSP,WilsonBarnettJ.(2001)Anevaluationofa teachinginterventiontoimprovethepracticeofendotracheal suctioninginintensivecareunits.JournalofClinicalNursing. September10(5):682696.[IIb] 4. KinlochD(2000)Installationofnormalsalineduringendotracheal suctioning:effectsonmixedvenousoxygensaturation.American JournalofCriticalCare. 5. January9(1):789.[III] 6. EvansJC.(1991)Incidenceofhypoxemiaassociatedwithcaregiving inprematureinfants.NeonatalNetwork.September10(2):1724.[III] 7. EvansJC.(1992)Reducingthehypoxemia,bradycardiaandapnea associatedwithsuctioninginlowbirthweightinfants.Journalof Perinatology.June12(2):13742.[III] 8. TanAM,GomezJM,MathewsJ,WilliamsM,ParatzJ,RajaduraiVS. (2005)Closedversuspartiallyventilatedendotrachealsuctionin extremelypretermneonates:physiologicalconsequences.Intensive CriticalCareNursing.August21(4):23442.Epub.[Ib] 9. SimbrunerG,CoradelloH,FodorM,HavelecL,LubecG,PollakA (1981)Effectoftrachealsuctiononoxygenation,circulationandlung mechanicsinnewborninfants.ArchivesofDiseaseinChildhood.56 (5):326330[Ib] 10. KleiberC,KrutzfeldN,RoseEF.(1988)Acutehistologicchangesin thetracheobronchialtreeassociatedwithdifferentsuctioncatheter insertiontechniques.HeartLung.January17(1):1014.[IIa]
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11. ThakurA,BuchmillerT,AtkinsonJ.(2000)Bronchialperforation afterclosedtubeendotrachealsuction.JournalofPediatricSurgery. September35(9):13535.[III] 12. GarciaAparicoL,CastanonM,TarradoX,RodriguezL,IriondoM, MoralesL.(2002)Bronchialcomplicationofaclosedtubeendotracheal suctioncatheter.JournalofPediatricSurgery.October37(10):14834. [III] 13. DurandM,SanghaB,HoppenbrouwersT,HodgmanJE.(1989) Cardiopulmonaryandintracranialpressurechangesrelatedto endotrachealsuctioninginpreterminfants.CriticalCareMedicine. June17(6):50610.[III] 14. FiorentiniA(1992)Potentialhazardsoftracheobronchialsuctioning. IntensiveCriticalCareNursing.December8(4):21726.[IV] 15. AnandKJS,BartonRA,McIntoshN,LagercrantzH,PelausaE, YoungTE,VasaR.(1999)Analgesiaandsedationinpretermneonates whorequireventilatorysupport:resultsfromtheNOPAINtrial. ArchivesofPediatricandAdolescentMedicine.April153(4):3318.[Ib] 16. AkgulS,AkyolcuN.(2002)Effectsofnormalsalineonendotracheal suctioning.JournalofClinicalNursing.November11(6):826830.[III] 17. RidlingDA,MartinLD,BrattonSL.(2003)Endotrachealsuctioning withorwithoutinstallationofisotonicsodiumchlorideincriticallyill children.AmericanJournalofCriticalCare.May12(3):212219.[Ib] 18. PritchardM,FlenadyV,WoodgateP(2000)Preoxygenationfor trachealsuctioningintubated,ventilatednewborninfants.The CochraneLibrary[Ia] 19. SmithC(1995)Endotrachealsuctioninginchildren:anoverviewof theprincipleproblems.JournalofNeonatalandPaediatricCriticalCare. 1(3):4650.Citedin:WallaceJL(1998)Suctioningatwoedged sword:reducingthetheorypracticegap.JournalofNeonatal Nursing.4(6):12,1417.[IV] 20. MoscaFA,ColnaghiM,LattanzioM,BrayM,PugilieseS,Fumagalli M.(1997)Closedversusopenendotrachealsuctioninginpreterm infants:effectsoncerebraloxygenationandbloodvolume.Biologyof theNeonate.72(1):914. 21. CorderoL,SananesM,AyersLW.(2000)Comparisonofaclosed (TrachCareMAC)withanopenendotrachealsuctionsysteminsmall prematureinfants.JournalofPerinatology.AprilMay20(3):1516.[Ib] 22. WoodgatePG,FlenadyV.(2001)Trachealsuctionwithout disconnectioninintubatedventilatedneonates.CochraneDatabaseof SystematicReviews.(2):CD003065.[Ia]
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23. HodgeD(1991)Endotrachealsuctioningandtheinfant:Anursing careprotocoltodecreasecomplications.NeonatalNetwork.9(5):715 [IV] 24. BernertGetal.(1997)Theeffectofbehaviouralstatesoncerebral oxygenationduringendotrachealsuctioningofpretermbabies. Neuropediatrics.April28(2):1115.[IIb] 25. HowardF.(1994)Endotrachealsuctioningandtheneonate. PediatricNursing.6(7):1417.Citedin:WallaceJL(1998)Suctioning atwoedgedsword:reducingthetheorypracticegap.Journalof NeonatalNursing.4(6):12,1417.[IV] 26. CorderoL,SananesM,AyersLW(2001)Acomparisonoftwo airwaysuctioningfrequenciesinmechanicallyventilated,verylowbirth weightinfants.RespiratoryCare.46(8):783788[IIa] 27. SpenceK,GilliesD,WaterworthL.(2005)Deepversusshallow suctionofendotrachealtubesinventilatedneonatesandyounginfants. CochraneDatabaseofSystematicReviews.2:CD003309.[1a] 28. YoungmeeA,YonghoonJ.(2003)Theeffectsoftheshallowandthe deependotrachealsuctioningonoxygensaturationandheartratein highriskinfants.InternationalJournalofNursingStudies.40:97104. [IIa] 29. ShortenD,ByrneP,JonesR(1991)Infantresponsestosaline instillationsandendotrachealsuctioning.JournalofObstetric, GynecologicalandNeonatalNursing.20(6):464469[IIa] 30. BlackwoodB(1999)Normalsalineinstillationwithendotracheal suctioning:primumnonnocere(firstdonoharm).JournalofAdvanced Nursing.29(4):928934[IV] 31. RaymondSJ(1995)Normalsalineinstillationbeforesuctioning: Helpfulorharmful?Areviewoftheliterature.TheAmericanJournalof CriticalCare.4(4):267271[IV] 32. BeeramMR,DhanireddyR(1992)Effectsofsalineinstillationduring trachealsuctiononlungmechanicsinnewborninfants.Journalof Perinatology12(2):120123[IIb] 33. KayJ.(2000)Ch.36Suctioning.In:HubandS,TriggE.Practicesin ChildrensNursing.ChirchillLivingstone.Edinburgh.[IV] 34. RuntonN.(1992)Suctioningartificialairwaysinchildren: appropriatetechnique.PediatricNursing.April18(2):115118.[IV] 35. ButlerA.(2000)TracheostomyCare.In:HubandS,TriggE. PracticesinChildrensNursing.ChirchillLivingstone.Edinburgh.[IV]

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