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Airway suction

The aim of airway suction is to clear secretions, thereby maintaining a patent airway and improving ventilation and oxygenation.

Removal of such secretions also minimises the risk of atelectasis (Prasad, 1995).

However it is not a benign procedure and adverse physiological effects directly attributed to airway suction are well documented. These effects can be both immediate and long-term, and therefore a sound knowledge of the procedure and its effects are a pre-requisite for undertaking the procedure, as is the availability of full resuscitation facilities.

Background

The procedure of airway suctioning is a common practice in the treatment of children with a variety of pathologies. Most frequently undertaken to remove excessive or retained secretions from a child’s respiratory tract, it may also be necessary to obtain specimens for laboratory examination.  It may be performed as a single procedure by nursing and medical staff (or occasionally by parents), or it may be incorporated into a chest physiotherapy regime.

The principles are the same whether the suction is of the child’s pharynx or via an artificial airway (eg tracheal tube or tracheostomy).

Children may be unable to clear their own trachebronchial secretions for several reasons, including:

  • Respiratory pathology causing an alteration in type or quantity of secretions, or disruption of the normal mucociliary clearance process.
  • Neurological disorders which inhibit/depress the normal cough reflex.
  • Presence of an artificial airway.

Deleterious effects of airway suctioning

Inform child and family

Explanations appropriate to child’s age and condition must be given even if the child is apparently unconscious. Family members must also receive appropriate explanations (Rationale 1, Rationale 2, Rationale 3, Rationale 4, Rationale 5).

Inform the child and family of the following (Rationale 2, Rationale 6, Rationale 7): 

  • reason(s) for the suction
  • what it entails
  • potential risks of suction
  • duration of the procedure
  • expected outcome from suction
The child and family must be informed that appropriate holding may be required (Rationale 6, Rationale 8, Rationale 9).

Preparation of child

The child must be appropriately positioned and securely held using blankets and/or an assistant as appropriate (Rationale 10, Rationale 11).

Any specific considerations/requirements of individual children should be addressed, for example (Rationale 12, Rationale 13):

  • nebulised medications administered as prescribed
  • pre-oxygenation

Pre-oxygenation prior to suctioning by an appropriate method will be required for children who on individual clinical assessment:

  • are deemed at risk of desaturation during the procedure (Rationale 14)  
  • require > 40% inspired oxygen
Hyperinflation may be required for ventilated children who have reduced lung compliance, eg pulmonary oedema (Rationale 15).

This must only be performed by an experienced nurse or physiotherapist (Rationale 16).

Adequate patient hydration and/or efficient humidification of inspired gases must be ensured (Rationale 17).

Preparation of equipment: negative pressure

The suction unit may be a piped vacuum system or a portable unit. Biomedical Engineering provide a guide to testing the correct set up of suction units.

The negative pressure of the unit must be checked prior to attaching the catheter to the suction tubing (Rationale 18).

This is done by turning on the unit, placing a finger over the end of the suction tubing and then noting the suction manometer reading (Kuzenski, 1978).

If necessary, the pressure must be altered appropriately prior to proceeding.

The suction pressure recommendations are:

  • 60-80 mmHg (8-10 kPa) for neonates
  • up to 120 mmHg (<16 kPa) for older children (Young, 1984)

The vacuum must be checked prior to each procedure (Rationale 19).

Catheters must not be “kinked” prior to insertion in an effort to control the vacuum (Prasad & Hussey, 1995)(Rationale 20).

Preparation of equipment: catheter selection

Rigid suction catheters (ie Yankauer suckers) may be used to clear the mouth of thick and/or particulate matter (Rationale 21).

In all other circumstances, catheters must not exceed more than 50 per cent of the internal diameter of the airway (Glass & Grap, 1995)(Rationale 22).

Catheters must have rounded tips (Link et al, 1976)(Rationale 23).

Catheters must have two or three small lateral holes to provide relief if the distal hole becomes occluded. Catheters must not have more than three lateral holes.

The greater the number of lateral holes the weaker the wall of the suction catheter (Link et al, 1976). Lateral holes of the suction catheters must be smaller than the distal hole (Link et al, 1976; Jung & Gottleib, 1976)(Rationale 24, Rationale 25, Rationale 26).

Whenever possible suction catheters with integrated vacuum controls should be used (Prasad & Hussey, 1995). When these are unavailable a “Y” connector must be incorporated between the suction tubing & catheter (Rationale 27).

Performing suction

The frequency of suctioning is determined by the child’s clinical condition (including chest auscultation) and not pre-determined time intervals (Rationale 28).

Prior to performing suction the following equipment should be gathered (Rationale 29):

  • suction unit
  • suction catheters of appropriate type and size
  • irrigant solution (if considered to be appropriate)
  • specimen container (if required)
  • non-sterile gloves
  • apron
  • bowl of clean tap water
  • tissues
  • blanket (for restraining the child if necessary)

All the equipment must be checked to ensure it is fully operational. Resuscitation equipment should be readily available (Rationale 30, Rationale 31).

Two people may be required for this procedure, ie one to perform suction and the other to restrain the child (Prasad & Hussey, 1995)(Rationale 23, Rationale 32, Rationale 33).

The child should be placed on their side whenever possible (Rationale 33, Rationale 34).

Airway suctioning must be performed as a “clean” procedure (Rationale 35).

A clinical handwash must be performed although in an emergency this may not be practicable.  

Gloves should be worn. There should be no contact between the suction catheter and anything other than the practitioner’s gloved hand and the child’s airway (Rationale 36).

The distance a suction catheter is inserted into the airway is determined by measuring the length of the child’s airway plus connections (Rationale 37). Where there is no artificial airway in situ, the appropriate measurement is determined by the distance from the level of central incisors (or where they would be) to the angle of the lower jaw (Advanced Paediatric Life Support, 2005).

The aim is then to introduce the catheter just beyond this point (Rationale 38). For children who have an artificial airway, the length should be recorded. Catheters are then inserted just beyond this distance, but not as far as the carina (Brodsky et al, 1987; Runton, 1992). The child’s medical team may occasionally instruct a shorter insertion distance, e.g. post-tracheal surgery (Rationale 39).

Suction catheters must be introduced into the airway gently, ensuring no negative pressure is applied (Jung & Gottleib, 1976)(Rationale 40). Catheters must not be rotated on removal but withdrawn straight out of the airway (Rationale 41).

The application of continuous versus intermittent suction is contentious (Czarnik et al, 1991).

The maximum duration of each suction attempt should be determined by the individual child’s clinical response, but should be limited to no more than 10-15 seconds (Sumner, 1990; Young, 1984; Tolles & Stone, 1990)(Rationale 42).

If a child has viscous secretions that are not effectively cleared by suctioning, the use of an irrigant solution may be considered (Prasad & Hussey, 1995)(Rationale 43). However irrigants must not be routinely used (Ackerman, 1993; Hagler & Traver, 1994)(Rationale 44).

The recommended solution for irrigation is 0.9% sodium chloride. Recommended aliquots of irrigants range from 0.5mls in neonates to 2mls for older children (Rationale 45). A greater quantity may be required during physiotherapy treatments.

Whilst performing suction the child must be continuously observed, with particular attention paid to:


If the child’s condition deteriorates, appropriate resuscitation procedures must be initiated immediately (Rationale 50).

Disposable suction catheters are designed for single procedure use only, ie a catheter may be reused only if an immediate further attempt at airway suction is required. Catheters must be changed between suction of an artificial airway and mouth/nostrils (Rationale 35, Rationale 51, Rationale 52, Rationale 53).

Completing the procedure

Suction tubing and flow controls (if appropriate) should be flushed clear with clean tap water. This solution should be discarded and changed four-hourly (Rationale 54, Rationale 55).

The child should be left comfortable (Rationale 56).

All used equipment must be disposed of according to the Trust’s Waste Policy (Rationale 8).

A clinical handwash must be performed (Rationale 54).

The suction procedure must be recorded in the child’s health care records. This should include details of the aspirate obtained as well as any adverse clinical reactions that occurred (Rationale 49, Rationale 55, Rationale 56).

Rationale

Rationale 1: To minimise fear.
Rationale 2: To gain co-operation.
Rationale 3: To provide reassurance and psychological support.
Rationale 4: To gain their assistance as necessary.
Rationale 5: To allay their anxieties & reassure them of the benefits of the procedure.
Rationale 6: To obtain informed consent.
Rationale 7: To minimise anxiety.
Rationale 8: To comply with Trust policy.
Rationale 9: To ensure patient safety.
Rationale 10: To maximise the child’s safety and comfort.
Rationale 11: To minimise the risks of trauma.
Rationale 12: To comply with the child’s treatment plan.
Rationale 13: To assist or potentiate suction procedure by reducing wheezing and/or loosening trachebronchial secretions and minimising hypoxia.
Rationale 14: To minimise hypoxia.
Rationale 15: To maintain distension of the terminal alveoli and enhance oxygenation during procedure.
Rationale 16: This procedure has a high risk of causing cardiac dysrhythmias and reduced cardiac output.
Rationale 17: To reduce the likelihood of thick secretions and therefore maximise airway patency.
Rationale 18: To minimise risks of trauma, hypoxia and atelectasis.
Rationale 19: To ensure the pressure has not been altered.
Rationale 20: To prevent a vacuum build-up which on release causes enormous suction that can result in biopsies of fragile mucosa.
Rationale 21: The relatively wide diameter and rigid design facilitates easier removal of thick secretions/debris.
Rationale 22: To enable gas flow between the catheter and the tracheal wall (or tracheal tube) thus minimising the risks of hypoxia and reducing the likelihood of atelectasis developing.
Rationale 23: To minimise trauma.
Rationale 24: To reduce the risk of tissue biopsies on catheter withdrawal.
Rationale 25: To reduce the risk of the catheter kinking at its tip and damaging the mucosa.
Rationale 26: To ensure that the greatest suction is exerted at the distal end of the catheter, thus minimising the likelihood of lateral invagination of tissue and the potential consequences of tissue trauma.
Rationale 27: To prevent suction being applied to the airway during catheter introduction.
Rationale 28: The frequency of suctioning is determined by the child’s clinical condition (including chest auscultation) and not pre-determined time intervals.
Rationale 29: To enable the procedure to be performed in a timely and safe manner.
Rationale 30: To facilitate safe practice and ensure that procedure is carried out efficiently.
Rationale 31: To facilitate rapid clinical emergency interventions if necessary.
Rationale 32: To provide psychological support.
Rationale 33: To facilitate procedure.
Rationale 34: To minimise risk of aspiration.
Rationale 35: To minimise risks of infection.
Rationale 36: To minimise the risk of contamination.
Rationale 37: To ensure secretions are removed from the child’s entire airway.
Rationale 38: To minimise risk of damage to the carina.
Rationale 39: To prevent damage to lesions or surgical sites.
Rationale 40: To minimise trauma by reducing the direct contact between the catheter and the airway mucosa.
Rationale 41: To minimise hypoxia which is significantly related to duration of suction attempts.
Rationale 42: Inadequately cleared secretions may threaten patency of the child’s airway.
Rationale 43: No conclusive evidence as to efficacy or potential hazards of their use.
Rationale 44: Amounts vary according to the child’s size and specific individual requirements.
Rationale 45: To rapidly recognise any deterioration in the child’s clinical status.
Rationale 46: To influence future suction practices.
Rationale 47: To determine the need for suction.
Rationale 48: To monitor its effectiveness.
Rationale 49: To prevent cardiorespiratory collapse.
Rationale 50: To maximise safety.
Rationale 51: To minimise financial costs.
Rationale 52: For aesthetic reasons.
Rationale 53: To minimise cross-infection.
Rationale 54: To maintain the safety and comfort of the child.
Rationale 55: To provide accurate records.
Rationale 56: To influence future suction practices.

References

Reference 1:
Prasad SA, Hussey J (Ed) (1995) Paediatric Respiratory Care. London, Chapman & Hall

Reference 2:
Sumner E (1990) Artificial ventilation of children Dinwiddie R In: The Diagnosis and Management of Paediatric Respiratory Care. London, Churchill Livingstone.

Reference 3:
Brodsky L, Reidy M, Stanievich J (1987) The effects of suction techniques on the distal tracheal mucosa in intubated low birth weight infants. International Journal of Paediatric Otorhinolaryngology 14(1): 1-14.

Reference 4:
Kleiber C, Krutzfield N, Rose EF (1988) Acute histological changes in tracheobronchial tree associated with difference suction catheter insertion techniques. Heart & Lung 17: 10-14.

Reference 5:
Kuzenski B (1978) Effect of negative pressure in tracheobronchial trauma. Nursing Research 27: 260.

Reference 6:
Sackner MA, Landa JF, Greeneltch N, Robinson MJ (1973) Pathogenesis and prevention of tracheobronchial damage with suction procedures. Chest 64: 284-290.

Reference 7:
Boutros AR (1970) Arterial blood oxygenation during and after endotracheal suctioning in the apneic patient. Anaesthesiology 32: 114-118.

Reference 8:
Kerem E, Yatsiv I, Goitein KJ (1990) Effect of endotracheal suctioning on arterial blood gases in children. Intensive Care Medicine 16: 95-99.

Reference 9:
Naigow D, Powaser MM (1977) The effect of different endotracheal suction procedures on arterial blood gases in a controlled experimental model. Heart & Lung 6: 808-816.

Reference 10:
Rindfleisch S, Tyler M (1981) The effects of duration of endotracheal suctioning on arterial oxygenation in anaesthetised dogs. American Review of Respiratory Disease 123: 1.

Reference 11:
Fox WW, Berman LS, Dinwiddie R et al (1977) Tracheal extubation of the neonate at 2 to 3 cm H2O continuous positive airways pressure. Pediatrics 59: 257-261.

Reference 12:
Nagaraj, HS, Shott R, Fellows R, Yacoub U (1980) Recurrent lobar atelectasis due to acquired bronchial stenosis in neonates. Journal of Pediatric Surgery 15: 411-415.

Reference 13:
Cordero L, Hone EH (1971) Neonatal bradycardia following nasopharyngeal stimulation. Journal of Pediatrics 78: 441-447.

Reference 14:
Shim C, Fernandez R, Fine N, Williams H (1969) Cardiac arrhythmias resulting from tracheal suctioning. American International Medicine 71: 1149-1153.

Reference 15:
Simbruner G, Coradello H et al (1981) Effect of tracheal suction on oxygenation, circulation and lung mechanics in newborn infants. Archives of Disease in Childhood 56: 326-330.

Reference 16:
Walsh JM, Vanderwarf C, Hoscheit D et al (1989) Unsuspected Hemodynamic alterations during endotracheal suction. Chest 95: 162-165.

Reference 17:
Winston SJ, Gravelyn TR, Sitrin RG (1987) Prevention of bradycardic responses to endotracheal suctioning by prior administration of nebulized atropine. Critical Care Medicine 15: 1009-1011.

Reference 18:
Durand M, Sangha B, Cabal LA et al (1989) Cardiopulmonary and intracranial pressure changes related to endotracheal suctioning in preterm infants. Critical Care Medicine 17: 506-510.

Reference 19:
Perlman JM, Volpe JJ (1983) Suctioning in the preterm infant: effects on cerebral blood flow velocity, intracranial pressure and arterial blood pressure. Pediatrics 72: 329-334.

Reference 20:
Alpan G, Glick B, Pele, O et al (1984) Pneumothorax due to endotracheal tube suction. American Journal of Perinatology 1(4): 345-348.

Reference 21:
Anderson K, Chandra K (1976) Pneumothorax secondary to perforation of sequential bronchi by suction catheters. Journal of Paediatric Surgery 11: 687-693.

Reference 22:
Vaughan RS, Menke JA, Giacoia GP (1978) Pneumothorax: a complication of endotracheal tube suction. Journal of Pediatrics 92: 633-634.

Reference 23:
Young CS (1984) Recommended guidelines for suction. Physiotherapy 70: 106-108.

Reference 24:
Glass CA, Grap MJ (1995) Ten tips for safer Suctioning. American Journal of Nursing 9: 51-53.

Reference 25:
Link WJ, Spaeth EE, Wahle WM et al (1976) The influence of suction catheter tip design on tracheobronchial trauma and fluid aspiration efficiency. Anesthetic Analogues 55: 290-297.

Reference 26:
Jung RC, Gottlieb LS (1976) Comparison of tracheobronchial suction catheters in humans. Chest 69: 179-181.

Reference 27:
Advanced Paediatric Life Support (2005) The Practical Approach (5th Ed.). London, BMJ

Reference 28:
Runton N (1992) Suctioning Artificial Airways in Children: Appropriate Technique. Pediatric Nursing 2: 115-118.

Reference 29:
Czarnik RE, Stone KS, Everhart CC, Preusser BA (1991) Differential effects of continuous versus intermittent suction on tracheal tissue. Heart & Lung 20: 144-151.

Reference 30:
Tolles CL, Stone KS (1990) National survey of neonatal endotracheal suctioning practices. Neonatal Network 9: 7-14.

Reference 31:
Ackerman MH (1993) The effect of saline lavage prior to suctioning. American Journal of Critical Care 2(4): 326-330.

Reference 32:
Hagler DA, Traver, GA (1994) Endotracheal saline and suction catheters: Sources of lower airway contamination. American Journal of Critical Care 3: 444-447.


Document control information

Lead author(s)

Sheila Simpson, Resuscitation Services Manager, Training & Development

Document owner
Sheila Simpson, Resuscitation Services Manager, Training & Development

Approved by
Clinical Practice Committee

First introduced: 28 February 2000
Date approved: 26 October 2011
Review schedule: Two years
Next review: 28 October 2013
Document version: 3.0
Replaces version: 2.0

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