Information about avoiding the cardiac hazard associated with tracheo-bronchial suctioning

1. Safe Suctioning.
Strategies For Avoiding The Cardiac Hazard
.

2. Aims
• To ensure the highest standards of
patient care through theoretical and
practical teaching of suction
techniques, together with safe and
effective use of suctioning equipment,
to nursing staff.

3. Objectives
After This Session Candidates will
• Be familiar with the anatomy and physiology of related
structures and have an under standing of the role of the
vagus nerve in contributing to the cardiac hazard.
• Be able to identify key features in the assessment of acutely
ill patients and will be able to state the main indications for
suctioning.
• Be able to state nine ways of reducing the cardiac hazard
associated with suctioning.
• Be able to identify a safe value for negative suctioning
pressure and will be able to dismantle, clean, set up and
adjust suction machines accordingly.

4. Anatomy And Physiology Of
Related Structures
• As a refresher please turn to activity 1
in your workbook

5. Larynx Trachea
Lt Superior
Rt Superior Lobe Lobe
Bronchial
Tree
Cardiac Notch
RT Middle Lobe
Lt Inferior Lobe
Rt Lower lobe
Diaphragm

6. The Vagus Nerves
• Have a more extensive distribution than any
other cranial nerves. The motor fibres supply
the smooth muscles and secretory glands of
the pharynx, larynx, trachea, heart,
oesophagus, stomach, intestines, pancreas,
gall bladder, bile ducts, spleen, kidneys,
ureter and blood vessels in the thoracic and
abdominal cavities. The sensory fibres
convey impulses from the lining membranes
of the same structures to the brain.

7. BRANCHES
OF THE
VAGUS NERVE VAGUS
NERVE

9. A Brief History Of Suction
• Airway suction was once described as a
“surprisingly simple technique” (Thompson,
1936) .
• In 1959, Boba et al studied the effects of
endotracheal suctioning in paralysed
patients. They reported that severe hypoxia
resulted from suctioning for one minute.
• Shumacker et al (1951), Keown (1960) and
Marx et al (1968) reported cardiac arrest
associated with endotracheal suction.

10. A Brief History Of Suction
• Rosen and Hillard (1962) deaths
during suctioning procedures have not
been reported as often as personal
inquiries indicate that they happen.
– “cardiac arrest may arise from the
stimulation of respiratory tract reflexes,”
• In 1984, Kergin et al., Using oximetry,
again reported reduction in blood
oxygen saturation during suctioning.

11. We Are Now Aware That :-
• Suctioning of the trachea is a more
hazardous procedure than commonly
appreciated. The insertion of a
catheter into the trachea may produce
cough, laryngospasm, or
bronchospasm as a reaction to the
foreign body and precipitate an acute
hypoxic episode.

12. If
• Patients are unstable or if copious secretions
are present, regard nasotracheal and
oropharygeal suctioning as having the same
hazards as other types of endotracheal
aspiration.

13. Definitions.
Tracheostomy.
A tracheostomy is a surgical opening made
from the skin into the trachea.
Indications:
Tracheostomy may be carried out:
– To provide and maintain a patent airway.
– To enable the removal of tracheobronchial
secretions.
– A tracheostomy may be performed as a
permanent, emergency or elective procedure.

14. Contraindications.
• Suspected CSF leak (BOS fracture) or raised
inter cranial pressure.
• Tracheo/oesophageal fistula.
• Ca in upper GI or respiratory tract.
• Severe bronchospasm.
• Stridor.
• Oesophageal or high GI surgery.
• Some thoracic surgery: - pneumonectomy.
• Acute face, neck or head injury (dependant
upon access).

15. Tracheo - Bronchial Suctioning.
Definition: -.
The insertion of a suction catheter into the trachea, to
remove secretions from the patient’s chest.
– Airway suctioning removes excess secretions from the
respiratory tract by the insertion of a catheter into the area
and the application of a negative pressure. Although a
relatively uncomplicated procedure to perform, which
requires little in the way of sophisticated equipment, it is
associated with well-documented undesirable side effects.
– Therefore, airway suctioning presents as an interesting
anomaly – it may be both life saving and potentially harmful,
particularly in patients who are fragile or likely to require
long-term regular suctioning.

16. Indications for suction: -
• Secretions are present which are:-
– Detrimental to the patient.
– Accessible to the catheter.
– Neither the patient nor the nurses are able to clear
the secretions by any other means.

17. Hazards Of Suctioning.
1. Patient anxiety.
2. Changes in ICP.
3. Trauma.
4. Infection.
5. Pneumothorax.
6. Hypoxia.
7. Cardiac hazard.

18. Patient Anxiety.
• some patients have likened suctioning
to having a red-hot poker put down
their throat.
• Please read activity two in your work
book.

19. Changes In ICP.
• Studies have demonstrated that ETS
will increase ICP. This elevation of
ICP is most pronounced in patients
who have evidence of intracranial
hypertension and are thus the least
able to tolerate such elevations.,
Nurses should be encouraged to
include some method of
preoxygenation in their ETS
procedure.

20. Trauma.
• Plym and dunning first attributed SEVERE
mucosal damage to tracheobronchial suctioning in
1956.
– “If continuous vacuum pressure is applied, the
suction catheter adhered to the mucosa and, if
pulled away from it, the technique was
tantamount to a crude biopsy.”
– “Scattered haemorrhagic areas and oedema were noted
in the right main bronchus. Other areas, which appeared
grossly normal, were found to have extensive damage on
microscopic examination.”

21. Trauma.
• They suggested that the
– “negative tissue pressure caused by the
invaginated mucosa disrupted capillary blood
flow.
– damage attributable to suction:-
• epithelial loss, sub mucosal oedema, lymphatic
distension, sub epithelial cellular proliferation and
fibrinous deposit.
– Since ciliary movements are necessary to
move mucous secretions upward towards the
epiglottis, this destruction of ciliated
epithelium may suppress mucus clearance
and, therefore, predispose the
tracheobronchial tree to infection.

22. Trauma.
• MUCOSAL trauma can be caused simply by catheter
contact during insertion. The number of catheters passed in
a given time is a highly significant factor (Sackner et al, 1973
link et al, 1976).
• Although Jung and Gottlieb (1976) concluded that trauma
due to suctioning was negligible after one catheter insertion,
in clinical practice patients seldom require suctioning only
once. Patients may require suction several times a day.
• If even after just one catheter insertion minor trauma is
observed, this will obviously be enhanced with subsequent
suctioning procedures.
• It is advised that suction should, therefore, be carried out
only when necessary and not on a “routine” basis, that is at
pre-determined intervals, and that careful consideration is
given to the type of catheter used.

23. Infection.
• The tracheal tube has been identified as a source
of trauma as well as a reservoir for bacterial
growth. The tube contributes to a patient’s
susceptibility to respiratory infection because it
causes the air entering the lungs to bypass the
normal filtering mechanisms of the nose and
mouth. Patients requiring assistance in airway
maintenance often have low resistance to infection
because of factors such as poor nutrition, the
presence of chronic disease, or generalised
debility. Having been placed in a vulnerable
situation in which they are exposed to numerous
sources of bacteria, the rate of infection is
extremely high.

24. Pneumothorax.
• We report four instances of pneumothorax
secondary to bronchial perforation by a suction
catheter. Perforation of the bronchial tree should
be suspected in a patient who suddenly
deteriorates during suctioning or who has a
massive persistent air leak. The mechanism of
catheter injury has been confirmed at autopsy.
Thoracotomy with suture of the injured lung may
be life saving and avoid the consequences of
prolonged respirator support. Pre-measurement of
suction catheters will minimise or prevent this
complication.

25. Hypoxia.
• Ambubagging and suctioning were studied in mechanically
ventilated patients to assess the effects these had on the
partial pressure of O2 and CO2 in the arterial blood. No
significant fall in PaCO2 was noted in either of the treatment
groups.
• One the group was suctioned until they were clinically clear
of tracheobronchial secretions, irrespective of the number of
times they were suctioned, there was s highly significant
drop in PaO2 among this group.
• Nurses should be aware of the marked drop of PaO2 during
prolonged suctioning and the potential dangers associated
with this drop.

26. Hypoxia.
• During suctioning, not only are secretions removed from the
airways but gas is also removed from the respiratory tract
and the aspiration of gas may therefore contribute to the
hypoxia that results.
• The duration of suctioning should never exceed 10 seconds
and the smallest possible diameter suction catheter should
be used. As a rule the diameter of the catheter should never
exceed half the diameter of the tracheostomy tube However
in certain circumstances, the viscosity of the secretions will
determine the size of the catheter (Eales 1989).

27. Hypoxia.
• It has been established that pre
suction assessment and pre-
oxygenation if indicated will prevent
the hypoxia, which results from
suctioning.
• Other Suggestions for minimising the
suction-induced hypoxemia include
limiting the duration of suctioning to
10 seconds, limiting the negative
suction pressure to 120 - 150 mm hg.

28. Management Of Secretions.
• Secretion management is a vital part of
tracheostomy care; nurses should aim to
manipulate the viscosity of secretions to
reduce the amount of suction required.
There are various methods of achieving
this:-.
• A sputum assessment should be
undertaken on every shift with any changes
in the nature of secretions documented
nurses should always consider the
possibility of infection when they encounter
marked changes in the nature of
secretions.

29. Management Of Secretions.
• Wet oral or bronchial secretions can be controlled with
prescribed hyoscine patches or sublingual atropine drops.
• Dry secretions can be prevented or controlled with
humidification of oxygen and/or saline nebulisation, P.R.N.
Saline nebulisation can be provided if patients have trouble
in expectorating dry or thick secretions.
• Another important factor is the maintenance of adequate
levels of systemic hydration which will again facilitate the
clearance of secretions.
• The following extract addresses these points:-.
• This extract highlights the importance of individual patient
assessment and specific action planning in the absence of
definitative studies.

30. Cardiac Hazard.
• Endotracheal suctioning of intubated
patients is associated with
hemodynamic complications including
arterial hypoxemia, cardiac
arrhythmias, hypotension and even
death (Walsh 1989).

31. Ways To Avoid The Cardiac
Hazard
(And all the other hazards).
2. Only provide suction on a P.R.N.
Basis.
3. Least invasive first.
4. Prevent hypoxia.
5. Assess and pre-oxygenate.
6. Use correct gauged catheter

32. Only Provide Suction On A
P.R.N. Basis.
• The tube may serve as a major threat to the airway, and
that threat is magnified when tracheal suctioning is
performed. Trauma from insertion of the tube or movement
of the tube after it is in place may result in laryngeal oedema
and mucosal damage. The inflammatory response that
follows results in the formation of an inflammatory exudate
that necessitates tracheal suctioning. It is well known,
however, that numerous complications can result from the
suctioning procedure, including bacterial growth, hypoxemia,
and cardiac dysrhythmias. The risk of these complications
could be reduced by suctioning in response to actual fluid in
the airways rather than routine suctioning every 1 to 2 hours.
• Indications for suction: -.
– Secretions are present which are:-.
» Detrimental to the patient.
» Accessible to the catheter.
– Neither the patient nor the nurses are able to clear the
secretions by any other means.

33. Least Invasive First.
• Before providing suction always attempt a less invasive
procedure. Dual cannulated tubes should be used at all
times. Patients who are able to cooperate should be
encouraged to cough, otherwise remove and replace inner
tube and reassess patient status.

34. Prevent Hypoxia.
• We are aware that hypoxia occurs during tracheo –
bronchial and naso – tracheal suctioning, and that hypoxia in
conjunction with bradycardia and hypotension is the main
contributing factor for cardiac episodes, nurses should be
monitoring patient status on a regular basis, a useful tool in
this assessment is the saturation monitor (pulse oximeter).
As we expect a reduction in saturation of around 4% during
suctioning, we should never attempt if SpO2 is less than 94
– 95%.If a patient requiring suction has a saturation below
94 – 95% it is important to administer oxygen or reposition
patient before providing suction, if this is at all possible.

35. Peoxygenation.
• Seventeen patients with lung disease were monitored with
an ecg during tracheal suctioning after breathing either air or
100% oxygen. Eight of them had a tracheostomy, three had
an orotracheal tube, and six had no intubation.
• The incidence of transient cardiac arrhythmia during tracheal
suctioning was significant while breathing air (35%).
Arrhythmias included frequent atrial premature contractions,
nodal tachyardia, transient sinus arrest, incomplete heart
block, and frequent premature ventricular contractions. After
a brief period of breathing 100%, oxygen tracheal suctioning
was no longer associated with significant arrhythmia (shim et
al 1969).
• Four litres o2 per minute will quite quickly raise o2
saturations to a safe level. Patients presenting with
potentially dangerous cardiac arrhythmias should breathe
100% oxygen in order to avoid complications prior to
tracheal suctioning as long as this is not contraindicated.

36. Choosing Correct Gauge
Catheter.
• Physical effects of endotracheal suctioning as described by
Rosen and Hillard (1962) consisted of flow of air from the tip
of the suction catheter to the suction apparatus and from the
open end of endotracheal tube downwards around the
suction catheter to the tip, resulting in varying degrees of
negative pressure in the lungs. The magnitude of such
effects depended on the extent of air displacement and
negative pressure produced by the suction, the size of the
catheter, and the relationship between the outer diameter of
the endotracheal tube. (Boutros 1970).
• To prevent haemodynamic changes, the outer diameter of
the suction catheter should not exceed half of the inner
diameter of the tracheostomy tube. A way to calculate this is
to multiply the tracheostomy tube size by three and divide
that number by two.

37. Choosing Correct Gauge
Catheter.
• E.G. tracheostomy tube size = 10.
• Multiply by three = 30.
• Divide by two = 15.
• Then choose the nearest, safest or most efficient gauge
catheter to that number i.e.
• For a size 10 tracheostomy tube, use a size 14 fg catheter.
• “It is essential to use the right size catheter for the lumen of
the tracheostomy tube:
• a 10FG catheter is appropriate for a size 6 tube,
• a 12FG catheter for a size 8 tube;
• a 14FG catheter for a size 10 tube,
• It is occasionally necessary to us a proportionately larger
diameter of catheter, especially if secretions are viscous, but
this must be done with care.” (Mallet 1985).

38. Choosing The Correct Amount
Of Negative Pressure.
• Suggestions for minimising the suction-induced hypoxemia
include, limiting the negative suction pressure, and the use
of hyper oxygenation.
• Negative suction pressure is also strongly associated with
trauma, which as we know leads to infection and increases
patient anxiety; the following article is included to
demonstrate this.

39. Achieving the correct depth of
insertion.
• Not introducing the catheter too deeply into the tracheo –
bronchial tree will reduce the likely hood of vagal stimulation,
bronchospasm and trauma. There is a degree of conflict
within the research (Kleiber 1986) with suggestions of
efficient depths which range from 1cm past the end of the
tube to one cm past the carina.
• A general rule is proceed with the minimum amount of
invasion, the recommendation is to advance the catheter
slowly until either a cough reflex is initiated or resistance is
felt upon encountering either of these conditions, the nurse
should withdraw the catheter 1cm , apply suction and
withdraw the catheter.
• For patients with copious or tenacious secretions, who are
showing signs of ineffective airway clearance, deeper
suctioning is suggested. Care plans should include specific
guidelines for catheter insertion and should be updated
routinely by the caregiver. Individualisation of the care plan
is essential.

40. Applying Suction Appropriately,
For Correct Amount Of Time.
• Insufflation of five litres of O2 down a sidearm during
endotracheal suction diminished the rate of decline of pao2
during suction of normal dog lungs. In patients with
respiratory insufficiency, the insufflation of O2 during
suction did not have any effect on the decreased pao2
seen during the endotracheal suction.
• The most effective way to prevent hypoxia during
endotracheal suction of patients with respiratory failure is to
hyperoxygenate for one minute with 100% O2 prior to
suction and limit suction to 15 seconds, (fell 1971).
• To err on the side of caution it is recommended that
suctioning is limited to 10 seconds only and that only 3 – 4
passes are completed in any one session.

41. Being Gentle.
• The airway mucosa is extremely sensitive to pressure and is
easily damaged. Chronic irritation can result in scar
formation, which may necessitate surgical intervention and
prolonged hospitalisation. Therefore, any suctioning of the
airway must be done with extreme gentleness.
• This again will reduce the likely hood of vagal stimulation,
bronchospasm and trauma and will greatly reduce patient
anxiety.

42. Well Done
Any questions
?????????????
Please complete the
course evaluation