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Gloves minimize the risk of infection transfer to the catheter or from the sputum to the nurse’s hands (Fraise and Bradley 2009, E). Some patients may accidentally cough directly ahead at the nurse; standing to one side with tissues at the patient’s tracheostomy minimizes this risk. E

5 If patient is oxygen dependent, hyperoxygenate for a period of 3 minutes. To minimize the risk of acute hypoxia (Billau 2004, E).

6 Ensure that the suction pressure is set to the appropriate level. Recommended suction pressure is ≤100–120 mmHg (13–16 kPa) to minimize atelectasis (ICS 2008, C).

7 Select the correct size catheter. 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: This ensures that hypoxia does not occur while suctioning: the larger the volume, the greater the bore of the tube. E

Incorrect choice of catheter size can cause mucosal damage. E

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

For example: 8.00 mm ID tube: 2 × (8–2) = 12 Fg (ICS 2008). A tube with a too small diameter may not be able to remove thick secretions. E

8 Open the end of the suction catheter pack and use the pack to attach the catheter to the suction tubing. Keep the rest of the catheter in the sterile packet. Use an aseptic technique throughout. To reduce the risk of transferring infection from hands to the catheter and to keep the catheter as clean as possible. E

9 An additional clean, disposable glove can be used on the dominant hand at this stage. To facilitate easy disposal of the suction catheter after suction. E

10 Remove the catheter from the sleeve and introduce the catheter to about one-third of its length or approximately 10–15 cm (ICS 2008) or until the patient coughs. If resistance is felt, withdraw catheter approximately 1 cm before applying suction by placing the thumb over the suction port control and slowly withdraw the remainder of the catheter (Dean 1997, Wood 1998). Gentleness is essential; damage to the tracheal mucosa can lead to trauma and respiratory infection. E

The catheter should go no further than the carina to prevent trauma. R

The catheter is inserted with the suction off to reduce the risk of trauma (Clotworthy 2006c, C).

11 Do not suction the patient for more than 10 seconds (ICS 2008). Prolonged suctioning may result in acute hypoxia, cardiac arrhythmias (Day et al. 2002, C), mucosal trauma, infection and the patient experiencing a feeling of choking.

12 Wrap catheter around dominant hand, then pull back glove over soiled catheter, thus containing catheter in glove, then discard. Catheters are used only once to reduce the risk of introducing infection. E

13 If the patient is oxygen dependent, reapply oxygen immediately. To prevent hypoxia. E

14 Rinse the suction tubing by dipping its end into the sterile water bottle and applying suction until the solution has rinsed the tubing through. To loosen secretions that have adhered to the inside of the tube. E

15 If the patient requires further suction, repeat the above actions using new gloves and a new catheter. Allow the patient sufficient time to recover between each suction (Billau 2004), particularly if oxygen saturation is low or if patient coughs several times during the procedure. The patient should be observed throughout the procedure. To ensure general condition is stable. E

16 Repeat the suction until the airway is clear. No more than three suction passes should be made during any one suction episode (Day 2000, Glass and Grap 1995) unless in emergency such as tube occlusion (Nelson 1999). To minimize the risk of hypoxaemia (Day 2000, E).

Postprocedure

17 Where appropriate, reconnect the patient to oxygen within 10 seconds post suctioning. To minimize the risk of hypoxaemia (Day 2000, E).

18 Observe patient’s respiratory rate and pattern, oxygen saturations, heart rate and work of breathing