The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [377]
Postprocedure
8 Monitor patient closely for changes in respiratory rate and pattern of breathing, pulse, dyspnoea. Any procedure to the tracheostomy if not managed correctly may lead to possible dislodgement of tube or secretions, leading to respiratory deterioration or distress. E
Action Figure 6 Sterile tracheostomy dressing or tracheostomy/keyhole dressing.
Tracheostomy: suctioning
Evidence-based approaches
Rationale
An effective cough requires the closure of the glottis, then the reopening of the glottis once an adequate intrathoracic pressure is achieved. When a tracheostomy is in situ the mechanism of closing the glottis is compromised, so the patient’s ability to remove secretions is reduced as they are unable to generate the high flows required for coughing. In addition to this, the natural mechanisms of warming and humidifying the gases are lost, altering the consistency of secretions. Secretions become thick and dry, inhibiting mucociliary transport (Higgins 2009), leading to a potential blocking of the tracheostomy tube. Tracheal suction is an essential component of managing secretions, maintaining respiratory function and a patent airway.
Indications
The use of routine suctioning should be avoided and careful assessment of the patient’s respiratory function should be carried out instead. Inspection, auscultation, percussion and palpation will help to determine the following (Hough 2001, Pryor and Prasad 2008).
The patient’s ability to clear their own secretions.
Location of any secretions.
Whether these secretions could be reached by the catheter.
How detrimental these secretions might be for the patient.
The presence of prominent audible secretions, visible secretions, decreased oxygenation or diminished breath sounds during the assessment would indicate a need for suction (Ireton 2007).
Contraindications
Tracheal suction is an essential component of care for all patients with artificial airways. Most contraindications are relative to the patient’s risk of developing adverse reactions or worsening clinical condition as a result of the procedure. Hence choosing to not suction in order to avoid a potential side-effect may sometimes be more harmful to the patient.
However, despite its necessity, suction may be painful and distressing to the patient and can also be complicated by hypoxaemia, bradycardia and cardiovascular compromise (particularly in patients with autonomic dysfunction such as spinal injuries), alveolar collapse, tracheal mucosal damage, bleeding, and the introduction of infection (Higgins 2009, ICS 2008).
Principles of care
Infection risk
Universal precautions must be used at all times when suctioning; this includes wearing aprons, gloves and eye protection. Both the caregiver and patient are at risk of infection when suctioning is performed and in order to minimize this, examination gloves should be worn and an aseptic technique should be used, decontaminating hands with an alcohol handrub before and after the suction procedure (DH and NHSMA 2005). Suction catheters (see Figure 10.42) are for single use only and should be disposed of after each suction.
Method of suctioning
Shallow suctioning, where the catheter is inserted to a premeasured depth not beyond the distal end of the tracheostomy tube, is preferred to deep suctioning, in which the suction catheter is inserted until resistance is met. Deep suctioning should be avoided as it is associated with increased risks of mucosal damage, inflammation (De Leyn et al. 2007) and bleeding, subsequently increasing the risk of airway occlusion. Always suction with the inner tube in situ and change to a non-fenestrated inner tube before the procedure. The instillation of 0.9% sodium chloride to ‘aid’ suctioning is not recommended (Celik and Kanan 2006, ICS 2008).
Anticipated patient outcomes
Suctioning can cause distress, is uncomfortable and is associated with