Tracheal suction guidelines for caregivers

1.) Gather the following equipment and supplies:

Suction machine
Connecting tubing
Disinfected suction catheter
One non-sterile, clean glove
Distilled water
Clean, small paper cup
Clean basin
2.) Position the patient comfortably with his or her head and neck well-supported.
3.)Wash your hands with soap and water and dry with a clean towel.
4.) Fill the small paper cup about half-way with distilled water.
5.) Place the clean glove on your dominant hand (if you are right-handed, place the glove on your right
hand).
6.) If the patient has a cuffed tracheostomy tube, check to see if the cuff is properly inflated. (See below)
7.) Open the suction catheter package.
8.) Pick up the hard plastic end of the catheter with your gloved hand and attach it to the connecting
tubing. (Only touch the connecting tubing with your ungloved hand since it is not sterile)
9.) Wrap the catheter around your gloved hand when not in use to avoid contamination of the catheter.
10.) Turn on the suction machine with your ungloved hand.
11.) Expose the patient's tracheostomy opening.
12.) With your finger off the suction vent (so that you are not applying suction), gently insert the suction
catheter into the tracheostomy opening. Slowly advance the catheter a maximum of 6 inches or until
you feel resistance. (See below)
13.) Cover the suction vent with the thumb of your ungloved hand to apply suction. (See below)
14.) Withdraw the catheter and rotate, using a slow and even motion. Roll the catheter between the
thumb and forefinger of your gloved hand. Apply suction as you withdraw the catheter.

15.) Do not apply suction for longer than 10 seconds.

16.) Clean the catheter and connecting tubing between each suction pass: dip the catheter into the
small paper cup, place your finger over the suction vent and draw up small amounts of distilled water
through the catheter. Empty the contents of the catheter into the collection basin.
17.) Allow the patient 20 to 30 seconds to rest between suction passes.
18.) When the patient's airway is clear and you are finished suctioning, fill a clean basin with distilled
water.
19.) Thoroughly flush the distilled water through the catheter and connecting tubing.
20.) Turn off the suction machine.
21.) Slide the catheter back into the package and disconnect it from the connecting tubing.

21.) Hang the connecting tubing on the suction machine with the tip pointing up.
22.) Rinse the suction catheter and store it with the other equipment to be disinfected.
23.) Wash the basin with soap and warm water. Dry it with a clean towel and put it away.
24.) Take off your glove and discard it properly, along with the paper cup.
25.) Wash your hands with soap and water and dry with a clean towel.

Do not apply suction for longer than 10 seconds.

 Cardiorespiratory arrest most commonly results from tracheostomy obstructions or accidental

dislodgement of the tracheostomy tube from the airway. 
 Obstruction may be due to thick secretions, mucous plug, blood clot, foreign body, or kinking or
dislodgement of the tube.
Early warning signs of obstruction include tachypnoea, increased work of breathing, abnormal breath
sounds, tachycardia and a decrease in SpO2 levels. 
 Endotracheal intubation is done to: Keep the airway open in order to give oxygen,
medicine, or anesthesia. Support breathing in certain illnesses, such as pneumonia,
emphysema, heart failure, collapsed lung or severe trauma. Remove blockages from the airway
Who can insert an endotracheal tube?
The doctor often inserts the tube with the help of a laryngoscope, an instrument that permits the doctor
to see the upper portion of the trachea, just below the vocal cords. During the procedure the
laryngoscope is used to hold the tongue aside while inserting the tube into the trachea.

Indications
 Provide airway for mechanical ventilatory support.
 Administration of surfactants or other medications directly into the lungs.
 Relieve critical upper airway obstruction.
 Provide route for selective bronchial ventilation.
 Assist in pulmonary hygiene when secretions cannot be otherwise cleared.
 Obtain direct tracheal cultures.

Intubation risks

 injury to teeth or dental work

 injury to the throat or trachea
 a buildup of too much fluid in organs or tissues
 bleeding
 lung complications or injury
 aspiration (stomach contents and acids that end up in the lungs)
If the tube is inadvertently placed in the esophagus (right behind the trachea), adequate respirations will
not occur. Brain damage, cardiac arrest, and death can occur. Aspiration of stomach contents can result
in pneumonia and ARDS. Placement of the tube too deep can result in only one lung being ventilated
and can result in a pneumothorax as well as inadequate ventilation. During endotracheal tube
placement, damage can also occur to the teeth, the soft tissues in the back of the throat, as well as the
vocal cords.

This procedure should be performed by a physician with experience in intubation. In the vast majority of
cases of intubation, no significant complications occur.

Sizes
Endotracheal tubes come in a number of different sizes ranging from 2.0 millimeters (mm) to 10.5 mm
in diameter. In general, a 7.0 to 7.5 mm diameter tube is often used for women and an 8.0 to 9.0 mm
diameter tube for men. Newborns often require a 3.0 mm to 3.5 mm tube, with a 2.5 to 3.0 mm tube
used for premature infants.

In the operating room the size is often chosen based on age and body weight.
HOW IT IS INSERTED
During intubation, a physician usually stands at the head of the bed looking towards the patient's feet
and with the patient lying flat. The positioning will vary depending on the setting and whether the
procedure is being done with an adult or child. With children, a jaw thrust is often used.3

The endotracheal tube with the assistance of a lighted laryngoscope (a Glidescope video laryngoscope is
particularly helpful for people who are obese or if a patient is immobilized with a suspected injury to the
cervical spine) is inserted through the mouth (or in some cases, the nose) after moving the tongue out of
the way.

The scope is then carefully threaded down between the vocal cords and into the lower trachea. When
it's thought that the endotracheal tube is in the proper location, the doctor will listen to the patient's
lungs and upper abdomen to make sure that the endotracheal tube was not inadvertently inserted into
the esophagus.

Other signs that suggest the tube is in the proper position may include seeing chest movement with
ventilation and fogging in the tube. When a doctor is reasonably sure the tube is in position, a balloon
cuff is inflated to keep the tube from moving out of place. (In infants, a balloon may not be needed). The
tube is then taped to the patient's face.

Verifying Proper Placement

Once the tube is in place, it's important to verify that it is truly in the proper location to ventilate the
patient's lungs. Improper positioning is particularly common in children, especially children who have
experienced trauma.

In the field, paramedics have a device that allows them to determine if the tube is in the correct position
by a color change.In the hospital setting, a chest X-ray is often done to ensure good placement, though a
2016 review suggests that a chest X-ray alone is inadequate, as is pulse oximetry and physical
examination.6

In addition to directly visualizing the endotracheal tube pass between the vocal cords with a video
laryngoscope, the authors of the study recommended an end-tidal carbon dioxide detector
(capnography) in patient's that had good tissue perfusion, with continued monitoring to make sure the
tube does not become displaced.

In the setting of a cardiac arrest, they recommended using ultrasound imaging or an esophageal
detector device.

After the Procedure

After the endotracheal tube is in place and a patient connected to a ventilator, health care providers will
continue to monitor the tubing, settings, and provide breathing treatments and suctioning as needed.
Careful attention to oral care will also be provided. Due to the location of the tube, patients who are
conscious will be unable to talk while the tube is in place.7

Feeding During Mechanical Ventilation

As with talking eating will also be impossible while the endotracheal tube is in place. When mechanical
ventilation is needed for only a short period of time, intravenous fluids are usually adequate and can
prevent dehydration.

If the tube must be left in place for more than a few days, some type of feeding tubes will be needed to
provide nutrition and access for oral medications.

Options include a nasogastric tube, a G tube or PEG (PEG or percutaneous endoscopic gastrostomy is
similar to a G tube but placed through the skin of the abdomen) or a J tube (jejunostomy tube). Rarely, a
central line might be considered through which nutrition is provided (total parenteral nutrition).

Complications and Risks

There are both short-term and long-term risks and complications associated with endotracheal tube
placement. Short-term complications may include:8

Bleeding
Esophageal placement of the tube: One of the most serious complications is improper placement of the
endotracheal tube into the esophagus. If this goes unnoticed, the lack of oxygen to the body could result
in brain damage, cardiac arrest, or death.
Temporary hoarseness when the tube is removed
Injury to the mouth, teeth or dental structures, tongue, thyroid gland, voice box (larynx), vocal cords,
windpipe (trachea), or esophagus. Dental injuries (particularly to the upper incisors) occur in around one
in 3000 intubations.
Infection
Pneumothorax (collapse of a lung): If the endotracheal tube is advanced too far such that it only enters
one bronchus (and thus ventilates only one lung), inadequate ventilation may occur or collapse of one
lung.
Aspiration of contents of the mouth or stomach during placement which can, in turn, result in aspiration
pneumonia
Persistent need for ventilatory support (see below)
Atelectasis: Inadequate ventilation (a respiratory rate that is too low) can result in collapse of the
smallest of airways, the alveoli resulting in atelectasis (partial or complete collapse of a lung).
Long term complications that may persist or arise later on may include:8

Tracheal stenosis, or narrowing of the trachea: Most common in people who require prolonged
intubation, and once occurring in around 1% of people who were intubated
Tracheomalacia9
Spinal cord injuries
Tracheoesophageal fistula (an abnormal passageway between the trachea and esophagus)
Vocal cord paralysis: A rare complication that can cause permanent hoarseness
Removing the Endotracheal Tube
Before removing an endotracheal tube (extubation) and stopping mechanical ventilation, doctors
carefully assess a patient to predict whether or not he or she will be able to breathe on her own. This
includes:

Ability to breathe spontaneously: If a patient had anesthesia during surgery, they will usually be allowed
to wean off of the ventilator. If an endotracheal tube is placed for another reason, different factors may
be used to determine if it is time, such as using arterial blood gasses or looking at peak expiratory flow
rate.
Level of consciousness: In general, a higher level of consciousness (Glasgow coma scale over eight)
predicts a greater chance that weaning will be successful.
If it's thought that the tube can be reasonably removed, the tape holding the endotracheal tube on the
face is removed, the cuff is deflated, and the tube is pulled out.

Side Effects After Removal

A sore throat after surgery and hoarseness are common following surgery but usually last only a day or
two. Being on a ventilator for surgery is a major risk factor for atelectasis, and having patients cough
after surgery and become mobile as soon as possible is important.