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Artificial ainvay
Atelectasis
Bronchospasm
Closed system
suction catheter
Endotracheal (Ff)
tube
Hypercapnia
Hypoxemia
Hypoxia
lntubation

Laryngospasm
Obturator
Outer and inner
cannula
Respiratory
distress

sk;ti 25-f
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Oropharyngeal Suctioning, p. 670

Ainruay Suctioning, p. 673
Closed (ln-Line) Suction Catheter, p. 682

Guid*line *5-1

ski'ta*-s

Suction
Suction catheter
Tracheostomy
Yankauer suction

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Endotracheal Tube Care, p. 683

Tracheostomy Care, p. 689

lnflating the Cuff on an Endotracheal

or Tracheostomy Tube, p. 695
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CHAPTER

',4astery of content

.
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in this chapter witt enable the nurse to:

ldentify guidelines used in managing the airway.

Describe the methods for airway management.
Discuss the indications for airway suctioning.
Discuss the indications for tracheostomy care.

tirway management involves maintaining the patency of

a
a
a
a

the

rLrse, upper airway, trachea, and iower airway of the respiratoqr

.'.--,tem. Many courses of action are available to promote
an open or

::tent airway, which has the potential to become obstructed

rucus, mechanical obstruction (i.e., soft tissue

by

in upper airway), or

, ioreign body. These acrions do not always require a physician's

.:Jer. Consult the physician if there are any concerns about the
.:propriateness of the intervention or when an airway obstruction
: present, even when treatment relieves the obstruction. Hydrarn, positioning, nutrition, chest therapy airway clearance techiques, mucous clearance device therapy, deep breathing, coughrg, humidity, and aerosol therapy are noninvasive techniques that
.:e helpful in maintaining a patent airway.
'!7hen
a patienr is unable to clear airway secretions with coughrg, chest physiotherapy, or other noninvasive techniques, more
:r'asive measures, such as suctioning, are needed. These addi.rnal measures directed at maintaining a patent airway are neces,rr1,, especially in a weak, confused, or critically ill patient. This
-lapter focuses on nonemergent, invasive techniques to maintain
:-rway patency, including artificial airways.

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:oxygenation and deep breathing, sometimes referreJ to as hy-

-:r'entilation, assist in reducing suction-induced hvpoxemia

-emir and Drama1i,2005). Preoxygenarion pror.ides a parient

-h a short-term increase in supplemental oxygen, such as in-:asing oxygen flolv rate on a nasal cannula or oxygen mask,
in-.asing the percenr of inspired oxygen of breaths
delivered by the
.=chanical ventilator, or increasing oxygen flow rates to art1ficia1
l.ays. Not every patient requires preoxygenation unless he or she
rvpoxemic before suctioning. Hyperinflarion is the process of
' rviding 100% oxygen to a patient before airu,a1, suctioning
,::uitt,2005).
Following sucrioning, return a patient's oxygen level to presuc.
ning levels to avoid increased risk for oxygen toxicity. In addin, there is also a risk for absorption arelectasls frorn prolonged

i ninistration of high concenrrations of oxygen and

increased
,:bon dioxide retenrion in patients with chronic obstructive lung
. .:ases (Demir and Dramali, 2005).

The practice of normal saline instillation (NSI) into arrilicial

to improve secretion removal is inconclusive. Clinical stud:: comparing the results of suctioning using NSI rvith those of
'.rdard suctioning do nor show any clinical or significant results
-elik and Kanan, 2006). A review of the literature indicates that
-,rioning with or without isoronic normal saline (lNS) produces
:i[ar amounts of secretions and significant decreases in oxygen
:uration. In addition, these studies show increases in heart rate for
- :.l 5 minutes after suctioning with INS as opposed to dry suction.
:. The review also indicates thar the leve1 of a patienr's dyspnea
.er suctioning with or without INS was not significantly different.
-..t, the review nores that the use of INS with suctioning has the
- rential to increase ventilator-associated pneumonia because INS
-.r dislodge bacteria from the upper airway to the lower portions of
-.e airway (Celik and Kanan,
2006; Grap and Munro, Z0O4).
. .vays

I,itiltiititllilllllullllfl#ru

25

Airway Management

Provide oropharyngeal suctioning.

Provide airway suctioning.
Provide endotracheal care.
Provide tracheostomy tube care.
Inflate the cuff on an endotracheal or tracheostomy tube
Change a tracheostomy tube.

Psychosocial consequences of airway suctioning often occur. patients who remember the suctioning report it as painful, suffocating,
or stressful. Patients recalled some of the physiological resulm of
suctioning, such as sleep disturbances, tachycardia, confusion, shortness of breath, and dizziness (Lindgren and Ames, 2005).

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Communication is vital. Arti{icial airways aker patienrs, ability to

communicate. Patients, especially those from other cultures, feel
frightened, frustrated, and vulnerable. In addition, measures used
to maintain airway patency are new and frightening. Assess rhe
meaning of oropharyngeal suctioning ro the parient and family
members. Explain anticipated effects such as gagging and tearing,
which are very disrressing to family members. Many Vietnamese
believe that objects entering the body cause illness, so some may
interpret suctioning as introducing illness to the patient (Edmonds
and Brady,2003). A balance berween positive and negative forces,
or the yin and yang, are important components of Vietnamese

culture and must be maintalned for optimal health.

Provide culturally congruent explanations of the purpose and
therapeutic effects of the procedure. Whenever possible, demonstrate suctioning techniques and enc<turage patient and family
members to parricipare. If available, a professional inrerprerer is a
valuable asset for explanation of procedures, especially those that
are invasive and need to be repeated multiple times, such as suctioning and tracheostomy tube care. If an interpreter is not availab1e, have a family or community member explain invasive procedures such as inserrion of endotracheal tube or trrcheoitomy.
Encourage family members ar rhe bedside to provide support for a
patient who has limited English proficiency. Collaborate with the
family in providing alternarive means of communication for the
patient. Provide educational materials to the parienr and family in
therr native language for maximal understanding.

H
--:+:=

*&*+

Skill Performance Guidelines

Know the patienr's normal range of vital signs and oxygen

saturation ievels. Baseline vital signs serve as a means to identify individual abnormalities and ro recognize the onset of
worsening of an illness.
Know the patienr's medical history. Smoking alters normal

mucociliary clearance. Certain disorders such as chronic

obstructive pulmonary disease (COPD), asthma, cysric fibrosis, pneumonia, thoracic surgery, chest trauma, and abdominal
surgery place the patienr at increased risk for an obstructed
airway.

Identify conditions thar increase the patient's risk for aspira-

tion of gastric contents into the

1ung, resulting in airway obstruction. These include the presence of enteral feeding tubes
or other nasal or oral gastric tubes, a decreased level of consciousness, and a decreased swallowing ability.
Determine if rhe patient has a history of nasal problems, such
as nasal trauma, nasal polyps, deviated nasai septum, or
chronic sinusitis. Allergy problems causing mucosal swelling

hilil,,,,,,,,,

CHAPTER

25

Airway Management

narrow nasal passages, which affect your abiiity to easily pass a

suction catheter.
Review the patient's respiratory assessments. Review the patient's condition from the pasr lZ or 24 hours. These are relative baseline measurements that assisr in distinguishing between gradual and acute changes in the patient's status.
Perform a systematic respiratory assessment of upper and lower
airways, including identifying respiratory rate, respiratory pattern, respiratory muscles used, breath sounds, ability to cough
effectiveiy, integrity of the rib cage, and the characteristics of
sputum production.
Determlne the rype and frequency of intervenrion, based on
assessment flndings. Care that is appropriate for one day or
shift can change, resulting in an increase or decrease in frequency of care or alterations in the type of intervention.
Identify and become familiar with the use of equipment available at the institution. Many types of artificial airways, sucrion
catheters, and suction machines are available. Knowing how
to operate the equipment before using it will benefit both you
and the patient.
Test all equipment before use. Have adequate supplies on hand
at the bedside. Equipment must work properly to provide safe
nursing care. Determine that the suction machine is generating adequate negative suction pressure (Tab1e 25-1) and that
there are suction catheters and appropriate equipment at the

Preterm infants

60-80 mm Hg

lnfants

80-100 mm Hg

Children

100-120 mm Hg

Adults

100-150 mm Hg

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10

Know the patient's home care plan. Absence or interruprior,

ofcertain therapies such as bronchodilators places the patien:
at risk for an obstructed airway during the hospitalization cr:
after dlscharge from the hospital.

11 Know the side effects of medications and other

therapie:
Some medications such as beta-adrenergic blockers have tht
side effect of bronchospasm. An adverse effect of opioids anJ
sedatives is respiratory depression. Similarly, too much oxyger.
reduces the drive to breathe in patienrs with chronic hypercapnia (elevated arterial carbon dioxide tension). Some po.:tion changes affect the patient adversely. For example, in patients with impaired spinal cord innervarions of the respirator,
muscles, supine positions place the diaphragm ar a mechanic.disadvantage and increase the risk for aspiration.

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Yankauer, or tonsillar tip, suction device is used for oropharynA Yankauer sucrion carherer is made of
rigid, minimally flexible plastic. The tip of this suction carherer
usualLy has one large and several small eyelets through which the
mucus enters with application of negative pressure. The Yankauer
suction catheter is angled to faciiitate removal ofpharyngeal secretions through the mouth. This catheter ls used instead of a standard suction catheter when oral secretions are extremely copious
and thick because it can handle large volumes of secretions better
than a standard suction catheter. The Yankauer suction catheter is
not used to suction the nares because of its size.
The Yankauer suction device is useful in the removal of secretions from the mouth in patients after oral and maxiLlofacial surgery,
trauma to the mouth, or neurovascular injury and cerebrovascular
geal suctioning (Fig. 25-1).

accident causing hemiparesis and drooling or impaired swallowins

Patients with artilicial airways and impaired swallowing require u..
ofthe Yankauer suction device to provide oral hygiene.

**3*gati*:: Consideratiens
The skill of performing oropharyngeal (Yankauer) sucrioning ca-r
be delegated to nursing assistive personnel (NAP). Do not routinel.,
delegate this skill for parlents with oral or neck surgery in the ir:mediate postoperative period. The nurse is responsible for assessin.
the patientt respiratory status. The nurse directs rhe NAP about:
o Appropriate suction limits for oropharyngeal suctioning for th.
particular patient, for example, the appropriate suction pre.,
sure, expected frequency of suctioning, and the expected colci
and volume of secretions.
r The risks of applying excessive or inadequate sucrion pressure.
r Avoiding mouth sutures, applying suction against sensitir':
tissues, and dislodging tubes in the patient's nose or mouth.
o Avoiding stimulation of the gag reflex.

Equipri:ent

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2S-1

Data from MRC clinical practice guidelines: nasotracheal suctioning-2Acr

revislon and update, 2OO4, http://www.rclournal.com/cpgs/pdfi09.04. 08:
pdf, accessed September 13,2OO7.

bedside.

,$HELL

Oropharyngeal suctioning.

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tr
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tr
tr
D

Towel, cloth, or disposable paper drape

Clean gloves
Yankauer or tonsillar tip suction catheter
Mask, goggles, or face shield
Disposable cup or nonsterile basin
Thp water or normal saline (about 100 mL)
Suction equipment
Connecting tubing (6 feet)
Oral airway (if indicated)
\Tashclorh (if indicated)
Pulse oximeter

SKlLL25-1

OropharyngealSuctioning

ASSES$t[XHhXT

Assess signs and symptoms of upper airway obstruction requir-

ing oropharyngeal suctioning: gurgling on inspiration or expiration, restlessness, obvious excessive oral secretions, drooling,
gastric secretions or vomltus in mouth, or coughing without
clearing secretions from upper airway.

for signs and symptoms associated with hypoxia (low

oxygen utilization at the cellular or tissue level), hypoxemia
(low oxygen tension in the blood), or hypercapnia (elevated
carbon dioxide tension in the blood) and associated symptoms
of apprehension, anxiety, decreased ability to concentrate,
lethargy, decreased leve1 of consciousness (especially acute),
increased fatigue and dizziness, behavioral changes (especially

Assess

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Physical signs and symptoms result from pooling of secretions in

upper airway. lTorsening secretions may result in total airway
obstruction and hypoxia. The risk for aspiration ofgastric contents and airway obstruction is increased in patients with vomiting, delayed gastric emptying, impaired esophageal sphincter
control, hiatal hernia, impaired cough, impaired swallowing, or
impaired gag reflex.
Suctioning of airways is indicated with alterations in oxygenation
associated with secretion accumulation.

irritability and restlessness), increased pulse rate, increased rate

decreased depth of breathing, elevated blood

of breathing,

pressure, cardiac dysrhythmias, pallor, cyanosis, dyspnea, and

use of accessory muscles for breathing (Considine, 2005).

;c5'
_

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:iji1

Obtain patient's oxygen saturation level via pulse oximetry

(SpOz) (see Chapter 5). Keep oximeter in place.

Provides an objective baseline measure of the oxygen saturation

and provides an early objective indication ofworsening oxygen-

,i
5

Determine patient's knowledge about use of suction catheter.

Identifu risk factors for airway obstruction such as impaired
cough or gag reflex, weakened respiratory muscles, impaired
swallowing, and decreased level of consciousness, as well as
patient's inability to manipulate and use the catheter device.

Reveals need for patient instruction,

Risk factors prevent patient from protecting the airway from aspiration or from clearing secretions safely. Physical factors such as
impaired mobiliry of the upper extremities prevent patient from
using the catheter to help control oral secretions.

Auscuitate for presence of adventitrous sounds.

Determines if lower airway secretions are present (see Skill 25-Z).

:1r.1,

ation status.

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NIJHSIfiIG DIAGT,IOSES

airway .
clearance techniques and devices
'
.
. Impaired gas exchange
.
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:

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Impaired swaliowing
Ineffective airway clearance
Ineffective breathing pattem

.
.

Risk for aspiration

Risk for infection

Indiuidualize related factors based on patient's condition or needs.

5Slrri
':-li.

Defrcient knowledge regarding

Expected outcomes following completion of procedure:

. Upper airway (oral pharynx) is cleared of secretions.
. No gurgling sounds are heard in patient's pharynx on inspi-

ration and expiration.

Drooling is diminished or absent.

Vomitus or gastric secretions are absent from mouth.

SpOz improves or remains the same.

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l':

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secretions.

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lliti*al De*isi** F*int

2

Explain to patient how the procedure helps clear airway secrecoughing, gagging, or (less commonly) sneezing is normal and
iasts only a few seconds. Encourage patient to cough out secretions during procedure. Practice coughing if able. Show patient
how to splint surgical incisions, if necessary.
Position patient (usually semi-Fowler's or sitting upright).
Place towel, cloth, or paper drape across patient's neck and
chest.

Gastric secretions retained in oral cavity increase patient's risk for

aspiration pneumonia.
Removal of secretions helps to improve oxygen saturation level.

ln patients with chronlc pulmonary dlsease, the Sp}z value nay remain the same after suctllnng.

tions and relieves some breathing problems. Explain that

Suctioning is effective.
Presence of secretions in large upper airway produces noisy
respirations.
Excessive drooling indicates that patient is unable to handle oral

Gagging or coughing occurs when the posterior pharynx is deeply

suctioned or as a result of excess secretions. Coughing secretions out of lower airway or posterior pharynx decreases the
amount of suctioning required. Splinting reduces abdominal
incision discomfort during coughing or gagging.
Promotes patient comfort and removal of airway secretions. Towel

protects patient's gown and bed linen from contamination by

secretions.

CHAPTER

25

Airway Management

lfl"rIFL[:{,.;l

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Perform hand hygiene, and apply clean gloves. Apply mask or

face shield if splashing is likely.
Fill cup or basin with approximately 100 mL of warer or normal saline.

Reduces transmission of microorganisms.

Connect one end of connecting tubing to suction machine

and other to Yankauer suction catherer, Tum on suction
equipment, set vacuum regulator to appropriate setting (see

Prepares suction apparatus. Elevated pressure settings increase risk

Aids in cleansing catheter after sucrioning.

for trauma to the oral mucosa.

manufacturer's instructions ).

Check that equipment is functioning properly by suctioning

Ensures equipment

function and lubricates catheter.

smal1 amount of water or normal saline from cup or basin.

Remove patient's oxygen mask, if present. Nasal cannula may

remain in place. Keep oxygen mask near patient's face.

a-

Allows access to mouth. Reduces chance of hypoxia.

a-

.
suctl)ning (Considlne 2005, Pease 2006).

Insert catheter into mouth along gum line to pharynx. Move

catheter around mouth until secretions have cleared. Encour.
age

l{3

patient to cough. Replace oxygen mask.

Rinse catheter with water in cup or basin until connecring

tubing is cleared of secretions. Tirrn off suction. lUash face if
secretions are present on patient's skin.
Observe respiratory status. Repeat procedure, if indicated.
May need to use standard suction catheter to reach into trachea if respiratory status not improved (see Skili 25-2).
Remove towel, cloth, or disposable drape, and place in trash
or in laundry if soiied. Reposition patient; Sims' position encourages drainage and should be used if patient has decreased
level of consciousness.
Discard remainder of water into appropriate receptacle. Rinse
basin in warm soapy water, and dry with paper towels. Discard
disposable cup into appropriate receptacle. Place catheter in
clean, dry area,

catheter where it will come ln contact wlth secretllns

Remove gloves and mask or face shleld, and dispose of in appropriate receptacle. Perform hand hygiene.
11 Position patient, and provide oral hygiene as needed.

oral mucosal surfaces and causing trauma. Coughing moves secretions from lower airway into mouth and upper airway.
Rinses catheter and reduces probability of transmission of microorganisms. Clean suction tubing enhances delivery of set suctior.
pressure. Prevents skin breakdown.
Directs nurse to continue or cease intervention or to choose ar.-

a_

1.

other intervention.
Reduce. rransmission of microorganisms.

Facilitates drainage of oral secretions.

Reduces transmission of microorganisms and maintains medicaasepsis. Moist environment encourages microorganism growth-

excretllns, whlch pronote bacterlal growth

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Movement of catheter prevents the suction tip from invaginatinr

Reduces transmission of microorganisms

equipment.
Promotes patient's comfort.

to other patients an:

"

Compare assessment lindings before and after procedure.

chest and airways for adventitious sounds.

i.;l Auscultate

:*

Obtain postsuction SpO2 measure.

Observe patient or family perform Yankauer suctioning.

Identifies physiological response to the suction procedure.

Presence of lower airway adventitious sounds snggests a need fi-lower airway suctioning.
Provides objective postsuction dara to compare with baseline an:
is another objective measure of the effectiveness of the suctio:.
procedure (AARC, 2004).
Demonstrates learning.

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SKILL

r
.
.
.
.
.
.
.

Worsening respiratory distress.

Return of bloody secretions.

Record the amount, consistency, color, and odor of secretions

and the patient's response to the procedure; document presuction and postsuction cardiopulmonary assessment.
Record instruction to caregivers and ability to correctly perform

r
:',-'-

procedure.

Ieaching Cansiderations

natini
res

sa-

Instrrci family or caregiver not to allow catheter to fall to the

floor.

tcrrti"

Provide information regarding signs and symptoms of worsening

respiratory status.
Asiess knowledge ievel of patient and family caregiver to determine amount of instruction required and frequency of home
health visits necessary to reach goals.

:ucri,l:.

Te el-

Suction further or implement nasal 0r tracheal suctioning.

Evaluate need for other means to protect airway (e.9., oral intubation,
oral airway, positioning).
Provide supplemental oxygen.
Notify physician.
Assess oral cavity for trauma or lesions.
Reduce the amount 0f suction pressure used.
0bserve catheter tip for nicks, which cause mucosal trauma.
lncrease frequency 0f oral hygiene.

Reeordlng and RePcrting

Use bulb syringe. Compress syringe before insertion to prevent

forcing secretions into infant's bronchi (Hockenberry and

\filson, 2007).l{ more forceful suctioning is necessary, use
mechanical suction.

Gerontological 0onsiderations

Some patients with dysphagia benefit from oral suctioning be-

fore, during, and after meals.

Oral mucosa in older adulrs is fragile, and a lower suction pres'

sure is needed.
Older adults are prone to aspiration

oforal secretions because of

decreased cough and gag reflexes (Meiner and Lueckenotte,
2006).

Long-Term and Flome eare Considerations

Pediatric Considerations
r Maintain healthy infant in supine posirion (American Acad'

o
r

neJi;:.

emy of Pediatrics, 2005).

Position infants with breathing problems or excessive vomitus in
prone position (Hockenberry and \Uilson, 2007; Pease, 2006)'
Airways of infants and children are smaller than those of an

adult; even small amounts of mucus cause airway obstruction'

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,uctioning are the depth suctioned, sterile procedure, and the po'
:ential for complications' Oropharyngeal suctioning only removes
,ecretions from the back of the throat. Tiacheai airway suctioning
:rtends into the lower airway. Suctioning is necessary to remove
::spiratory secretions and maintain optimum ventilation and oxyare unable to independentiy remove
"enation in patients who
(Demir
Dramali, 2005). Assess the patient to
and
:rese secretions
:etermine frequency and depth of suctioning. Some patients re'
-uire suctioning every hour or two, whereas others need suctioning
nly once or twice a day (Considine, 2005).
If the secretions are only in the nose and mouth, then only the
:harynx requires suctioning, although in most instances you will
:ction both the pharynx and the trachea. Suction secretions from
.re pharynx as oflen as necessary. Secretions that are not removed
.re more likely to be aspirated into the lungs, increasing the risk
'-.r

chemicals.

nrsol Alivuay I'riarage,{1enl ltiadul*./ Lessons 1' 5, ard 6

','

Ihe major differences between oropharyngeal and tracheal airway

I ic..

In the long-term care or home setting, make sure patient knows

[o clean and disinfect or change the secretion collection container every 24 hours according to home care or institutional
protocol. Many institutions seal and dispose of the entire dis'
posabie secretion collection canister as biohazardous material'
Assess home for the presence of respiratory irritants, including
cigarette smoke, dust, pollen, animal dander, mold, and

Airw:rY Suetir":r:ing

il.r;',-i:,;Ll,ete ,' .fi#*tj=li?isry'

ffi! i"'r' ",, ,

AirwaY Suctioning

Related lnterventions

Unexpected Outcomes

25-2

infection and respiratory failure.

The suctioning procedure has many risks associated with it' The
rost serious relate to hypoxemia, which often results in cardiac

dysrhythmias; laryngeal spasm; bradycardia, which is associated

with stimulation of the vagus nerve; and nasal trauma and bleeding, which can develop from trauma of the suction catheter (Demir
and Dramali, 2005).

NASOPHAHYNGEAL AND NASOTRACHEAL

sucTtoNlNG {ffi**-

lrrlermeciiate r'fiesptrufr:ry *a.re a*d Sucti*nir;g I

Ferfa rrn i n g JVasoliacneai Sucfionrng
t'tso Airway fdart;';gement fv4saule I Lesson 4
Nasopharyngeal and nasotracheal suctioning assist in maintaining
a patent airway by removing secretions from the pharynx or throat
and the trachea. This type of suctioning is used when oral suction'
ing with a Yankauer devlce is ineffective or inappropriate or when
th. lowet airway requires removal of secretions. It involves
inserting a smal1 rubber or soft plastic tube into the nares to the
pharynx or trachea and then applying negative pressure to

withdraw mucus.