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Table 11.5 Catheter sizes and suction pressures

Patient age Catheter size (French) Suction pressure (mmHg)

Premature infant 6 80–100

Infant 8 80–100

Toddler/preschooler 10 100–120

School age 12 100–120

Adolescent/adult 14 120–150

Procedures that involve suctioning present a risk of suction-induced hypoxaemia, hypertension, cardiac arrhythmias and other problems that warrant patient monitoring, in particular oxygen saturation and cardiac monitoring (Thomson 2000).

Pharmacological support

Adequate analgesia is a key consideration in ensuring that an effective sputum expectoration technique can be achieved. For example, preprocedural analgesia should be given time to be effective, and wounds need to be supported to maximize inhalation and minimize pain (Guest 2008).

Nebulization of 0.9% sodium chloride and/or mucolytic agents, such as N-acetylcysteine, may need to be administered to help loosen tenacious secretions and to elicit an effective cough (Rajiv 2007).

Non-pharmacological support

Collaboration with the physiotherapy team may assist in obtaining a good-quality sample (Hess 2002). For sputum sampling, physiotherapeutic modalities implemented may include appropriate positioning, active cycle of breathing, deep breathing and effective coughing techniques (HPA 2008a).

Specific patient preparation

Patient position is important in optimizing secretion sampling. Patients should be sat upright or on the edge of the bed, if able, or in a high semi-Fowler position (head elevated to 30–45°) in bed supported by pillows (Dulak 2005).

The quality and quantity of secretion production and mucociliary clearance depend on systemic hydration. Patient hydration can boost sputum production to enable a good sample (Dulak 2005). This can be further enhanced with sufficient airway humidity and nebulization.

Procedure guideline 11.18 Sputum sampling

Essential equipment

Universal container

Apron

Non-sterile gloves

Eye protection (e.g. goggles/visor)

Appropriate documentation/form

Optional equipment

Nebulizer

Preprocedure

Action Rationale

1 Explain and discuss the procedure with the patient. To ensure the patient understands the procedure and gives valid consent (NMC 2008b, C).

2 Fully explain the steps of the procedure. The procedure requires the patient to fully understand and co-operate in order to optimize the quality of the sample (Dulak 2005, E).

3 Position patient upright in a chair or in a semi- or high-Fowler position, supported as necessary with pillows. For comfort and to facilitate optimum chest/lung expansion. E

4 If secretions thick/tenacious or having difficulty clearing secretions: administer nebulization therapy and/or enlist help of the physiotherapist. To loosen secretions and to assist in techniques that will optimize sputum sample collection (Hess 2002, C).

5 Wash hands with bactericidal soap/decontaminate physically clean hands with alcohol rub. Don apron, gloves and eye protection. To reduce the risk of cross-infection or splash injury to practitioner and specimen collection (DH 2007a, C).

Procedure

6 Ask patient to take three deep breaths in through their nose, exhale through pursed lips and then force a deep cough. Deep breathing helps loosen secretions and a deep cough will ensure a lower respiratory tract sample is obtained (Dulak 2005, C).

7 Ask patient to expectorate into a clean container and secure lid. To prevent contamination. E

Postprocedure

8 Dispose of waste, remove apron, gloves and eye protection and wash/decontaminate hands. To ensure correct clinical waste management and to reduce the risk of cross-infection (DH 2006, D).

9 Label sample and complete microbiology request form (including relevant information such as indication for sample and current/recent antimicrobial therapy). To maintain accurate records and provide accurate information for laboratory analysis (NMC 2009, C; Weston 2008, E).

10 Dispatch to the laboratory as soon as possible within 2 hours. To increase the chance of accurate organism identification (Higgins