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
- tracheobronchial trauma (Brodsky, 1987; Kleiber, 1988; Kuzenski, 1978; Sackner, 1973)
- hypoxia (Boutros, 1970; Karem, 1990; Naigow, 1977; Rindfleisch, 1981)
- atelectasis (Fox, 1977; Nagaraj, 1980)
- cardiovascular changes (Cordero, 1971; Shim, 1969; Simbruner, 1981; Walsh, 1989; Winston, 1987)
- intracranial pressure alterations (Durand, 1989; Perlman, 1983)
- pneumothorax (Alpan, 1984; Anderson, 1976; Vaughan, 1978)
- bacterial infection (Prasad, 1995)
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 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
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).
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
- bowl of clean tap water
- 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 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.
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