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By Root 2018 0

airway changes and cardiovascular instability, and should therefore only be performed when indicated and not at fixed intervals. Frequency should be determined on an individual patient basis and suctioning should aim to clear airway secretions when the patient is not able to, ensuring airway patency and patient safety at all times.

Preprocedural considerations

Equipment

Suction catheter size and suction pressure

Choosing the correct suction catheter size depends on the size of the tracheostomy tube. As a guide, the diameter of the suction catheter should not exceed one-half of the internal diameter of the tracheostomy tube (Griggs 1998, Hough 2001).

The following formula can be used to determine the correct size catheter.

Suction catheter size (Fg) = 2 × (size of tracheostomy tube − 2)

For example: 8.00 mm ID tube: 2 × (8−2) = 12 Fg (ICS 2008)

The incorrect choice of catheter, poor technique and the use of an excessively high suction pressure may all lead to mucosal trauma. The lowest possible vacuum pressure should be used, ≤100–120 mmHg (13–16 kPa), to minimize atelectasis (ICS 2008) and mucosal damage.

Within a critical care setting, a closed-circuit suction system is an alternative method to the open suction system for patients being mechanically ventilated. This closed system has the catheter sealed in a protective plastic sleeve, which is connected permanently into a standard ventilator circuit, thus preventing the catheter becoming contaminated (Figure 10.24). This also reduces the number of times the patient is disconnected from the ventilator, avoiding further hypoxia and cross-infection. Patients who are immunosuppressed, actively infectious patients or those who require high levels of PEEP may in particular benefit from a closed unit (Billau 2004).

Figure 10.24 Components of a closed-circuit catheter. The control valve locks the vacuum on or off. The catheter is protected inside an airtight sleeve. A T-piece connects the device to the tracheal tube. The irrigation port allows saline instillation for irrigating the patient’s airway or for cleaning the catheter.

Procedure guideline 10.4 Suctioning a patient with a tracheostomy

Essential equipment

Suction source (wall or portable), collection container and tubing, changed every 24 hours to prevent growth of bacteria (Billau 2004)

Disposable plastic apron

Eye protection, for example goggles

Bactericidal alcohol handrub

Sterile suction catheters (assorted sizes according to tube size)

A selection of non-sterile, powder-free, clean boxed gloves

Sterile bottled water (labelled ‘suction’ with opening date), changed every 24 hours to prevent the growth of bacteria (Billau 2004)

Preprocedure

Action Rationale

1 If secretions are tenacious, consider using, as prescribed, 2 hourly or more frequently 0.9% sterile sodium chloride nebulizers or other mucolytic agents such as nebulized acetylcysteine. Suctioning may not be as effective if the secretions become too tenacious or dry. Anecdotal evidence through practice suggests that frequent 0.9% sterile sodium chloride or acetylcysteine nebulizers may assist in loosening dry and thick secretions. E

2 Explain procedure to patient and ensure upright position if possible. If the patient is able to perform their own suction, self-suction should be taught. This is not appropriate in critical care settings. To obtain the patient’s co-operation and to help them relax. E

The procedure is unpleasant and can be frightening for the patient (Billau 2004, E). Reassurance is vital. E

Self-control of the patient’s suction is preferable with long-term stomas, if the patient is able to manage it. E

3 If a patient has a fenestrated outer tube, ensure that a plain inner tube is in situ, rather than a fenestrated inner tube (Russell 2005). Suction via a fenestrated inner tube allows a catheter to pass through the fenestration and cause trauma to the tracheal wall (Billau 2004, E).

Procedure

4 Wash hands with bactericidal soap and water or bactericidal alcohol handrub, and put on a disposable plastic apron, disposable