Suction

Suction is used to clear retained or excessive lower respiratory tract secretions in patients who are unable to do so effectively themselves. This could be due to the presence of an artificial airway, such as an endotracheal or tracheostomy tube, or in patients who have a poor cough due to a variety of reasons such as excessive sedation or neurological involvement. 

Background

Suction is a procedure that is regularly carried out by a variety of professions within health care and in some cases by parents or carers. The aim is to reduce the work of breathing and to reduce the risk of atelectasis, thereby maintaining or improving gas exchange. In self ventilating patients the upper respiratory tract may need to be suctioned, via the oro or nasopharynx, to enable a child to breathe comfortably, particularly in the presence of increased secretions during a respiratory infection. It is performed so that the patient’s airway is not compromised; this is particularly important in young infants who preferentially breathe through their nose, thus enabling natural humidification and reducing resistance (Walsh et al, 2011)
 
In the neonatal and paediatric ICU, suctioning of an artificial airway is likely to be the most common procedure (Argent, 2009). For information on suctioning a nasopharyngeal airway (NPA) please refer to the NPA clinical guideline (GOSH, 2016)
 
Suctioning is a potential hazardous procedure and those performing suction should be aware of the harmful side effects.
 

Training

Those performing suction, both health care professionals and parents or carers, need the knowledge and skills to assess the need for suction, and to perform it safely and effectively while minimising the potential side effects.
 
All individuals performing suction should receive training in (Rationale 1):
  • respiratory assessment
  • indications for suction
  • suction technique
  • potential side effects
  • signs of clinical deterioration
  • basic life support
  • how to document the procedure

Potential Adverse Effects

  • tracheobronchial trauma 
  • atelectasis
  • hypoxia 
  • cardiovascular changes 
  • alterations in intracranial pressure (ICP)
  • pneumothorax 
  • infection 
 
Although every care should be taken to minimise the occurrence of the above side effects it is of paramount importance that the objective, the maintenance of a patent airway, is achieved. (American Association for Respiratory Care, 2010; Davies et al, 2014).

Indications

An appropriate assessment must be undertaken to establish the need for suction (Rational 2, 3 and 4). Evidence of retained secretions will be shown by one or more of the following;
 
  • Increased work of breathing 
    • increased respiratory rate
    • alteration in respiratory pattern
    • recession
    • nasal flaring
    • tracheal tug
    • head bobbing 
    • grunting (non-intubated patients)
    • altered level of consciousness
  • Alteration in gas exchange:
    • decrease in the SaO2 (oxygen saturation)
    • pale and/or mottled appearance
    • cyanosis
    • decreased PaO2 (oxygen levels in arterial blood) and/or increased PaCO2 (carbon dioxide levels in arterial blood) on the blood gas
  • Visible, audible or palpable secretions
  • Examination of the chest x-ray (CXR).
  • Alteration of ventilator parameters.
  • Poor cough and inability to effectively clear secretions independently
It is also important that other causes of respiratory distress and possibly an alteration in blood gases that do not require suction are considered; for example a pneumothorax, fluid overload or a misplaced artificial airway (Rationale 4).
 

Contraindications

Suctioning should not be carried out if any of the contraindications are present, unless assessed on an individual basis and with the agreement of the medical team.
  • Unexplained haemoptysis or deranged clotting
  • Laryngospasm (stridor)
  • Bronchospasm
  • Basal skull fractures and other causes of Cerebrospinal fluid (CSF) leakage (for nasal suction only)
  • Recent oesophageal or tracheal anastomosis
  • Occluded nasal passages
  • Unexplained nasal bleeding
  • Severe hypoxaemia/hypoxia
  • Raised Intracranial pressure (ICP)
  • Cardiovascular system instability
(Association of Paediatric Chartered Physiotherapists (APCP) 2015)
 

Preparation

  • Perform hand hygiene (Rationale 5).
  • Ensure the patient, and the family if they are present, are prepared for the procedure:
    • In a non-emergency situation check they have not just been fed (approx. 30 minutes). If they are on continuous feeds ensure the feed is turned off immediately prior to suction (Rationale 6).
    • In an intubated patient ensure they have adequate sedation running (Rationale 7).
    • In an alert older patient explain what is about to happen (Rationale 8).
    • Although not always required in awake infants, there may be times when it may be advisable to wrap them securely in a sheet or blanket and place them in a side lying position (Rationale 9 and Rationale 10). 
  • Prepare the equipment needed:
    • Only use equipment you are familiar with or have received training on.
    • Use the appropriate suction catheter or yankeur (for oral suction)
      • The catheter should be no more than 50% of the diameter of the airway (Rationale 11). 
      • It should be a graduated catheter with two lateral side holes smaller than the end hole (Rational 12 and 13).
    • If using wall mounted suction check it is connected correctly and the ports are inline.
    • For portable suction please use the instruction manual located on the crash trolley.
    • Turn on the suction and set the negative pressure to the appropriate level (see table). Check the pressure by occluding the end of the suction tubing prior to use (Rationale 14). 
  • There is little evidence to specify the optimal negative pressure. The lowest pressure that will effectively clear secretions should be used: (American Association for Respiratory Care, 2010).

Suction pressure table 1

  • Gather personal protection equipment (PPE); gloves, aprons, mask and eye protection. Adherence to standard infection control policies is essential (Tingay et al, 2010) (Rationale 5).
  • In patients on a ventilator it may be necessary to increase the prescribed FiO2 (the amount of oxygen delivered) prior to suctioning. In a non-intubated patient it may be necessary to deliver some supplemental oxygen, or increase the amount in those patients already on oxygen therapy (Rationale 15).
  • Ensure that emergency equipment is close by and emergency team contact information is known (Rationale 16).
 

The Intervention

  • To ensure effective suction (Rationale 17):
    • Position the patient to enable easy access to the airway.
    • Have all the equipment needed ready for use.
    • Perform the procedure quickly, safely and effectively.
    • Suction to a predetermined length (Rationale 18). 
  • In patients with an ETT it is essential to know where the end of the tube is in relation to the carina. If the tube is sitting on the carina the catheter should not go beyond the end of the tube. In patients with other artificial airways, such as tracheostomy or nasopharyngeal airway, suction to the predetermined length that is documented in the patients notes. If the tube is high in the airway and the patient is not coughing it may be necessary to suction further than the end of the tube (Rationale 19). 
  • For nasopharyngeal suction (without an artificial airway) the catheter is passed to a depth approximately the distance from the nostril to the mid part of the ear lobe and down to the base of the neck. This should be sufficient to pass through the nasopharynx and stimulate a cough. Be cautious in the younger population when/if passing through the larynx. (Rationale 20).
  • Duration of suction:
    • The catheter should be passed as quickly as possible while still clearing the secretions. If ventilated the patient should be disconnected from the ventilator for the shortest time possible but certainly less than 10 seconds (Rationale 21).
  • Continue to observe for signs of increased work of breathing and respiratory distress. Be vigilant for signs of vasovagal response to suctioning.
  • Disposal of equipment
    • The suction catheter should be wrapped around the hand and the glove removed ensuring the catheter is contained inside the glove. This is then disposed of in the appropriate waste bin (Rationale 5).
    • The suction tubing should be rinsed through with sterile water (Rationale 22).
    • Perform a clinical hand wash (Rationale 5).
  • Re-assessment:
    • Assess the patient following the intervention referring to the pre intervention assessment (Rationale 23).
  • Document the suction/intervention as appropriate.
  • Frequency of suction:
    • Suction should not be carried out on a routine basis. The only exception is in a patient with a new tracheostomy (GOSH, 2017). The need for suction should be established each time the patient is assessed thereby ensuring suction is performed only as necessary (Rationale 24 and Rationale 25).

Special considerations

  • Oxygen is frequently given and/or increased, during suction, to minimise hypoxia (American Association for Respiratory Care, 2010). There may be occasions where this may be more harmful than beneficial (Rationale 26).
  • Saline instilled via an artificial airway may be used in an effort to loosen and mobilise secretions. This should be done with caution and only by experienced practitioners (Rationale 27).
  • A saline nebuliser or nasal drops may be beneficial in loosening secretions prior to suctioning (Rationale 27).
  • If suction is not successful or secretions are tenacious consider increasing the suction pressure and/or increasing the size of catheter (APCP 2015).
  • If repeated suction is needed or nasal trauma apparent, moisten the tip of the catheter with sterile water or apply a thin layer of aqua gel (Rational 28).
  • Management of tracheostomies: In the first 12-24 hours the patient must be suctioned every 30 minutes and then regularly (as required) until the first tube change, see Clinical guideline: Tracheostomy: care and management review (GOSH, 2017).
  • Management of nasal stents and nasopharyngeal airways: See the NPA clinical guideline (GOSH, 2016).
  • These guidelines are to help facilitate and guide the care of infants and children but they do not negate the need to assess each case on an individual basis, weighing up the benefits against the potentially harmful effects of this procedure.

Rationale

Rationale 1: To ensure the patient is suctioned appropriately, effectively and safely with minimal side effects.
Rationale 2: To ensure that the signs and symptoms exhibited by the patient indicate the need for suction thus ensuring that this invasive procedure is not carried out unnecessarily.
Rationale 3: Ongoing monitoring of the listed parameters should result in a timely intervention thus minimising risk. This will provide a baseline to use as a comparison when re-assessing the patient at the end of the intervention.
Rationale 4: To ensure that suctioning is not carried out unnecessarily and that the appropriate management is initiated in a timely manner.
Rationale 5: To prevent cross infection.
Rationale 6: To minimise the risk of vomiting and subsequent aspiration.
Rationale 7: To minimise the stress and discomfort caused by the procedure.
Rationale 8: To facilitate the patients and families’ understanding and co-operation.
Rationale 9: To facilitate quick suction with minimal interference from the patient thereby reducing the side effects.
Rationale 10: In the event of vomiting the side lying position will help to reduce the risk of aspiration.
Rationale 11: To facilitate clearance of secretions while reducing the possibility of airway trauma and loss of lung volume
Rationale 12: To reduce the risk of stripping the ciliated epithelium and the formation of granulation tissue, this may lead to obstruction and lobar atelectasis (Morrow and Argent, 2008).
Rationale 13: To reduce the amount of occlusion of the airway caused by the catheter. To reduce the amount of tidal volume and oxygen being removed, thus minimising atelectasis and hypoxia.
Rationale 14: To avoid high pressure and the risk of hypoxia and airway trauma or too low pressure which will result in ineffective suction.
Rationale 15: To prevent hypoxia. 
Rationale 16: To ensure patient safety when undertaking the procedure.
Rationale 17: To minimise the time of disconnection from the ventilator. To reduce the risk of an increased work of breathing, especially in non-intubated patients, and atelectasis thereby ensuring optimal gas exchange.
Rationale 18: To reduce the risk of tracheobronchial trauma, including bleeding, pneumothoraces and the possibility of vagal stimulation leading to bradycardia. 
Rationale 19: To guarantee effective removal of secretions.
Rationale 20: To reduce the risk of inducing laryngospasm (Gillies and Spence, 2011).
Rationale 21: To reduce the amount of trauma, atelectasis and hypoxia and minimise the effect the procedure has on the cardiovascular system and the ICP (Argent, 2009;, American Association for Respiratory Care, 2010; Davies et al, 2014).
Rationale 22: To ensure the tubing is clean and patent.
Rationale 23: To ensure the airway is clear and the patient is breathing/ventilating comfortably.
Rationale 24: To ensure the patient is not suctioned too often and put at risk from the accompanying side effects inappropriately.
Rationale 25: This should also ensure the patient is suctioned when needed so reducing the risk of secretions building up and increasing the patients discomfort and work of breathing.
Rationale 26: Knowing the pathophysiology of the patient will ensure appropriate administration of oxygen. In patients with certain congenital heart defects high levels of oxygen may cause severe cardiovascular instability. In neonatal patients high oxygen levels can cause ROP (Retinopathy of Prematurity).
Rationale 27: There is little evidence to support the use of saline instillation although clinicians using saline will say that they clear more secretions, particularly tenacious secretions, with saline rather than without (Schults et al, 2017).
Rationale 28: To lubricate the tip of the suction catheter for easier insertion.

References

American Association for Respiratory Care (2010) Clinical Practice Guidelines: Endotracheal Suctioning of Mechanically Ventilated Patients with Artificial Airways. Respir Care 55 (6): 758-764

Argent AC (2009) Endotracheal suctioning is basic intensive care or is it? Pedaitr Res 66 (4): 364-367

Association of Paediatric Chartered Physiotherapists (2015) Guidelines for nasopharngeal suction of a child or young adult. http://apcp.csp.org.uk 

Davies K, Monterosso L, Bulsara M, Ramelet AS (2014) Clinical indicators for the initiation of endotracheal suction in children: An integrative review. Australian Critical Care. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24767960 [last accessed 29/01/18]

Gillies D, Spence K (2011) Deep versus shallow suction of endotracheal tubes in ventilated neonates and young infants. Cochrane Database of Systematic Reviews, Issue 7. Art. No.: CD003309. DOI: 10.1002/14651858. CD003309.pub2 
GOSH (2016) Nasopharyngeal airway (NPA). Available at: http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/nasophar... accessed 29/01/18]

GOSH (2017) Tracheostomy: care and management review. Available at: http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/tracheos.... [Last accessed 29/01/18]

Morrow B, Argent AC (2008) A comprehensive review of pediatric endotracheal suctioning: Effects, indications, and clinical practice. Peditr Crit Care Med 9 (5): 465-477

Schults J, Mitchell M, Cooke M, Schibler A, (2017) Efficacy and safety of normal saline instillation and paediatric endotracheal suction: An integrated review. Australian Critical Care http://dx.doi.org/10.1016/J.AUCC.2017.02.069

Tingay DG, Copnell B, Grant CA, Dargaville, PA, Dunster KR, Schibler A (2010) The effect of endotracheal suction on regional tidal ventilation and end expiratory lung volume. Intensive Care Med 36: 888-896

Walsh BK, Hood K, Merritt G (2011) Pedaitric airway maintenance and clearance in the acute care setting: How to stay out of trouble. Respir Care 56 (9): 1424-1444

Document control information

Lead Author(s)

Emma Shkurka and Charlotte Hull (Physiotherapy)

Additional Author(s)

Catherine Spreckley (Practice Educator, CCCR)
Liz Smith (Advanced Nurse Practitioner, CCCR)
Catherine Dunne (Physiotherapy)

Document owner(s)

Catherine Dunne (Physiotherapy)

Approved by

Guideline Approval Group

Reviewing and Versioning

First introduced: 
28 February 2000
Date approved: 
31 January 2018
Review schedule: 
Three years
Next review: 
31 January 2021
Document version: 
3.0
Previous version: 
2.0