Reprinted from the May 1993 issue of RESPIRATORY CARE [Respir Care 1993;38(5):500–504]
AARC Clinical Practice Guideline
Endotracheal Suctioning of Mechanically Ventilated Adults and Children with Artificial Airways
ETS 2.0 DESCRIPTION:
Endotracheal suctioning is a component of bronchial hygiene therapy and mechanical ventilation and involves the mechanical aspiration of pulmonary secretions from a patient with an artificial airway in place. The procedure includes patient preparation, the suctioning event(s), and follow-up care.
- 2.1 Patient Preparation:
- 2.1.1 In preparation for the suctioning event, the patient should receive hyperoxygenation by the delivery of 100% oxygen for > 30 seconds prior to the suctioning event.(1,2) This may be accomplished by any of the following:
- 126.96.36.199 by adjusting the FIO2 setting on the mechanical ventilator.
- 188.8.131.52 by use of a temporary oxygen-enrichment program available on many microprocessor ventilators.(3)
- 184.108.40.206 by manually ventilating the patient with an increased FIO2. (At least one study suggests that suctioning methods that use the ventilator for oxygenation and hyperinflation may be superior to use of the manual resusci-tator.(4))
- 220.127.116.11.1 This technique has been shown to be ineffective for providing FDO2 of 1.0.(5)
- 18.104.22.168.2 Practitioners should ensure that adequate PEEP levels are maintained while using this technique for patients requiring > 5 cm H2O.
- 22.214.171.124 by the continuous or intermittent insufflation of oxygen through the suction catheter during the suction event(6-8)--Devices designed for this purpose may be difficult to use and are expensive.
- 126.96.36.199 It has been shown that delivery of increased tidal volumes is difficult while using this technique.(9)
- 2.1.2 In preparation for the suctioning event, the patient may be hyperventilated by delivery of an increased rate(1) and/or tidal volume. Hyperventilation may be accomplished by temporarily increasing the mandatory rate on the mechanical ventilator prior to the suctioning event or by increasing the rate of ventilation with a manual resuscitator. (Note: Care should be taken to maintain an adequate expiratory time to allow for complete exhalation of the delivered tidal volume.)(1)
- 2.1.3 In preparation for the suctioning event, the patient may be hyperinflated by the delivery of 'sigh' breaths prior to the suctioning event:
- 188.8.131.52 by increasing the ventilator-set tidal volume to exceed the set tidal volume,
- 184.108.40.206 by manually triggering preset sigh breaths on mechanical ventilators that are equipped with a sigh feature,(10) or
- 220.127.116.11 by manual ventilation with a resuscitation bag.
- 2.1.4 A closed-suction system may be used to facilitate continuous mechanical ventilation and oxygenation during the suctioning event.(1)
- 2.1.5 A patient may be placed on a pulse oximeter to assess oxygenation during and following the procedure.
- 2.1.6 A patient may receive normal saline by instillation through the artificial airway to dilute and mobilize pulmonary secretions.(11,12) The value of instilling other solutions appears to be based on anecdotal reports.
- 2.2 The Suctioning Event: The placement of a suction catheter through the artificial airway into the trachea and the application of negative pressure as the catheter is being withdrawn. Sterile technique should be employed. Each pass of the suction catheter into the artificial airway is considered a suctioning event. The duration of each suctioning event should be approx-imately 10-15 seconds.(13) Suction pressure should be set as low as possible and yet effectively clear secretions. (Experimental data to support an appropriate maximum suction level are lacking. Some textbooks cite maximum safe limits of 100-150 torr but do not reference their recommendations.(14,15))
- 2.3 Follow-Up Care: Following the suctioning event,
- 2.3.1 the patient should be hyperoxygenated by delivery of 100% oxygen for > or = 1 minute by the same technique(s) used to preoxygenate the patient.
- 2.3.2 the patient may be hyperventilated by increasing the respiratory rate and/or tidal volume by the same technique(s) used prior to suctioning.
- 2.3.3 the patient should be monitored for adverse reactions.
ETS 3.0 SETTING:
Endotracheal suctioning may be performed by properly trained persons in a wide variety of settings that include (but are not limited to):
- 3.1 Hospital
- 3.2 Extended care facility
- 3.3 Home
- 3.4 Outpatient clinic
- 3.5 Physician's office
- 3.6 Transport vehicle
ETS 4.0 INDICATIONS:
- 4.1 The need to remove accumulated pulmonary secretions as evidenced by one of the following:
- 4.1.1 Coarse breath sounds by auscultation or 'noisy' breathing
- 4.1.2 Increased peak inspiratory pressures during volume-controlled mechanical ventilation or decreased tidal volume during pressure-controlled ventilation.
- 4.1.3 Patient's inability to generate an effective spontaneous cough.
- 4.1.4 Visible secretions in the airway
- 4.1.5 Changes in monitored flow and pressure graphics
- 4.1.6 Suspected aspiration of gastric or upper airway secretions
- 4.1.7 Clinically apparent increased work of breathing
- 4.1.8 Deterioration of arterial blood gas values
- 4.1.9 Radiologic changes consistent with retention of pulmonary secretions
- 4.2 The need to obtain a sputum specimen to rule out or identify pneumonia or other pulmonary infection or for sputum cytology
- 4.3 The need to maintain the patency and integrity of the artificial airway
- 4.4 The need to stimulate a patient cough in patients unable to cough effectively secondary to changes in mental status or the influence of medication
- 4.5 Presence of pulmonary atelectasis or consolidation, presumed to be associated with secretion retention
ETS 5.0 CONTRAINDICATIONS:
Endotracheal suctioning is a necessary procedure for patients with artificial airways. Most contraindications are relative to the patient's risk of developing adverse reactions or worsening clinical condition as result of the procedure. When indicated, there is no absolute contraindication to endotracheal suctioning because the decision to abstain from suctioning in order to avoid a possible adverse reaction may, in fact, be lethal.
ETS 6.0 HAZARDS/COMPLICATIONS:(1,2)
- 6.1 Hypoxia/hypoxemia(16-23)
- 6.2 Tissue trauma to the tracheal and/or bronchial mucosa(19,24)
- 6.3 Cardiac arrest(22,25)
- 6.4 Respiratory arrest(21)
- 6.5 Cardiac dysrhythmias(2,19,24)
- 6.6 Pulmonary atelectasis(17,19,21)
- 6.7 Bronchoconstriction/bronchospasm(19)
- 6.8 Infection (patient and/or caregiver)(19,26,27)
- 6.9 Pulmonary hemorrhage/bleeding(19,24)
- 6.10 Elevated intracranial pressure(28-30)
- 6.11 Interruption of mechanical ventilation(18)
- 6.12 Hypertension(31)
- 6.13 Hypotension(31)
ETS 7.0 LIMITATIONS OF METHOD:
Endotracheal suctioning is not a benign procedure, and operators should remain sensitive to possible hazards and complications and take all necessary precautions to ensure patient safety. Secretions in peripheral airways are not directly removed by endotracheal suctioning.
ETS 8.0 ASSESSMENT OF NEED:
Qualified personnel should assess the need for endotracheal suctioning as a routine part of a patient/ventilator system check.
ETS 9.0 ASSESSMENT OF OUTCOME:
- 9.1 Improvement in breath sounds
- 9.2 Decreased peak inspiratory pressure (PIP) with narrowing of PIP - Pplateau; decreased airway resistance or increased dynamic compliance; increased tidal volume delivery during pressure-limited ventilation
- 9.3 Improvement in arterial blood gas values (ABGs) or saturation as reflected by pulse oximetry (SpO2)
- 9.4 Removal of pulmonary secretions
ETS 10.0 RESOURCES:
- 10.1 Necessary Equipment:
- 10.1.1 Vacuum source
- 10.1.2 Calibrated, adjustable regulator
- 10.1.3 Collection bottle and connecting tubing
- 10.1.4 Sterile disposable gloves
- 10.1.5 Sterile suction catheter of appropriate caliber. Diameter of the suction catheter should not exceed more than one half of the internal diameter of the artificial airway.(2,21,32) For selective main-stem suction-ing, a curved-tip catheter may be helpful. The information related to the effective-ness of head turning for selective suctioning is inconclusive.
- 10.1.6 Sterile water and cup
- 10.1.7 Sterile normal saline, if instillation is desirable
- 10.1.8 Goggles, mask, and other appropriate equipment for Universal Precautions(33)
- 10.1.9 Oxygen source with a calibrated metering device
- 10.1.10 Manual resuscitation bag equip-ped with an oxygen enrichment device
- 10.1.11 Stethoscope
- 10.2 Optional Equipment:
- 10.2.1 EKG monitor
- 10.2.2 Pulse oximeter
- 10.2.3 Sterile sputum trap for culture specimen
- 10.2.4 Closed suction system
- 10.2.5 Oxygen insufflation device
- 10.2.5.1 Double-lumen suction catheter for continuous oxygen insufflation(4,7,16)
- 10.2.5.2 Control valve device to alternate suction and oxygen insufflation to the suction catheter(7,32)
- 10.3 Personnel: Personnel responsible for performing endotracheal suctioning should demonstrate the following--
- 10.3.1 Knowledge of proper use and assembly of all equipment used
- 10.3.2 Ability to recognize abnormal breath sounds by auscultation
- 10.3.3 Knowledge and understanding of the patient's history, disease process, and goals of treatment
- 10.3.4 Knowledge and understanding of basic physiology and pathophysiology
- 10.3.5 Knowledge and understanding of ventilation, mechanical ventilators, and their alarm systems
- 10.3.6 Knowledge and understanding of all artificial airways and adjuncts used
- 10.3.7 Ability to monitor vital signs, assess the patient's condition, and appropriately respond to complications or adverse reactions to the procedure
- 10.3.8 Ability to modify techniques and equipment in response to complications or adverse reactions
- 10.3.9 Knowledge of basic EKG interpretation
- 10.3.10 Ability to assess the need for and provide cardiopulmonary resuscitation
- 10.3.11 Ability to evaluate and document the effectiveness and patient response to the procedure
- 10.3.12 Knowledge and understanding of the CDC guidelines for Universal Precautions
- 10.3.13 Knowledge of signs and symptoms of decreased cardiac output, oxygenation, and perfusion
- 10.3.14 Ability to teach lay-persons the procedure for home and extended care
- 10.3.15 Lay-persons responsible for endotracheal suctioning outside the hospital should demonstrate:
- 10.3.15.1 Knowledge, skill, and understanding of the assembly, use, maintenance, and cleaning of all equipment used
- 10.3.15.2 Ability to assess the need for and patient response to the procedure
- 10.3.15.3 Ability to perform the proper suctioning technique
- 10.3.15.4 Ability to assess the need for and provide cardiopulmonary resuscitation
ETS 11.0 MONITORING:
The following should be monitored prior to, during, and after the procedure:
- 11.1 Breath sounds
- 11.2 Oxygen saturation
- 11.2.1 Skin color
- 11.2.2 Pulse oximeter, if available
- 11.3 Respiratory rate and pattern
- 11.4 Hemodynamic parameters
- 11.4.1 Pulse rate
- 11.4.2 Blood pressure, if indicated and available
- 11.4.3 EKG, if indicated and available
- 11.5 Sputum characteristics
- 11.5.1 Color
- 11.5.2 Volume
- 11.5.3 Consistency
- 11.5.4 Odor
- 11.6 Cough effort
- 11.7 Intracranial pressure, if indicated and available
- 11.8 Ventilator parameters
- 11.8.1 Peak inspiratory pressure and plateau pressure
- 11.8.2 Tidal volume
- 11.8.3 Pressure, flow, and volume graphics, if available
- 11.8.4 FIO2
- 11.9 Arterial blood gases, if indicated and available
ETS 12.0 FREQUENCY:
Endotracheal suctioning should be performed whenever clinically indicated, with special consideration for the potential complications associated with the procedure. Endotracheal suctioning may be required at some minimum frequency in order to maintain the patency of the artificial airway used.
ETS 13.0 INFECTION CONTROL:
13.1 CDC Guidelines for Universal Precautions should be adhered to.(33)
Mechanical Ventilation Guidelines Committee:
13.2 All equipment and supplies should be appropriately disposed of or disinfected.
Richard D Branson RRT, Chairman, Cincinnati OH
Robert S Campbell RRT, Tampa FL
Robert L Chatburn RRT, Cleveland OH
Jack Covington RRT, San Francisco CA
- Brown SE, Stansbury DW, Merrill EJ, Linden GS, Light RW. Prevention of suctioning-related arterial oxygen desaturation: comparison of off-ventilator and on-ventilator suctioning. Chest 1983;83:621-627.
- Riegel B, Forshee T. A review and critique of the literature on preoxygenation for endotracheal suctioning. Heart & Lung 1985;14:507-518.
- Campbell RS, Branson RD. How ventilators provide temporary O2 enrichment: what happens when you press the 100% suction button? Respir Care 1992; 37:933.
- Baker PO, Baker JP, Koen PA. Endotracheal suctioning techniques in hypoxemic patients. Respir Care 1983;28: 1563-1568.
- Barnes TA, McGarry WP. Evaluation of ten disposable manual resuscitators. Respir Care 1990;35:960-968.
- Smith RM, Benson MS, Schoene RB. The efficacy of oxygen insufflation in preventing arterial oxygen desaturation during endotracheal suctioning of mechanically ventilated patients. Respir Care 1987;32:865-869.
- Langrehr EA, Washburn SC, Guthrie MP. Oxygen insufflation during endotracheal suctioning. Heart Lung 1981;10:1028-1036.
- Kelly RE, Yao FF, Artusio JS Jr. Prevention of suction-induced hypoxemia by simultaneous oxygen insuffla-tion. Crit Care Med 1987;15:874-875.
- Hess D, Spahr C. An evaluation of volumes delivered by selected adult disposable resuscitators: the effects of hand size, number of hands used, and use of disposable medical gloves. Respir Care 1990;35:800-805.
- Branson RD, Campbell RS. Sighs: wasted breath or breath of fresh air? Respir Care 1992;37:462-468.
- Bostick J, Wendelgass ST. Normal saline instillation as part of the suctioning procedure: effects on PaO2 and amount of secretions. Heart Lung 1987;16:532-537.
- Gray JE, MacIntyre NR, Kronenberger WG. The effects of bolus normal-saline.instillation in conjunction with endotracheal suctioning. Respir Care 1990;35:785-790.
- Rindfleisch SH, Tyler ML. Duration of suctioning: an important variable (point of view). Respir Care 1983;28: 457-459.
- Plevak DJ, Ward JJ. Airway management. In: Burton GG, Hodgkin JE, Ward JJ, eds. Respiratory care-a guide to clinical practice, 3rd ed. Philadelphia: JB Lippincott, 1991:501.
- Eubanks DH, Bone RC. Comprehensive respiratory care-a learning system. St Louis: CV Mosby 1985: 517.
- Boba A, Cincotti JJ, Peazza TE, et al. The effects of apnea, endotracheal suction, and oxygen insufflation, alone and in combination, upon arterial oxygen saturation in anesthetized patients. J Lab Clin Med 1959;53: 680-685.
- Boutros AR. Arterial blood oxygenation during and after endotracheal suctioning in the apneic patient. Anesthesiology 1970;32:114-118.
- Craig KC, Benson MS, Pierson DJ. Prevention of arterial oxygen desaturation during closed-airway endotracheal suction: effect of ventilator mode. Respir Care 1984;29:1013-1018.
- Demers RR. Complications of endotracheal suctioning procedures. Respir Care 1982;27:453-457.
- Kergin FG, Bean DM, Paul W. Anoxia during intrathoracic operations. J Thorac Surg 1948;17:709-711.
- Rosen M, Hillard EK. The effects of negative pressure during tracheal suction. Anesth Analg 1962;41:50-57.
- Shim C, Fine N, Fernandez R, Williams MH Jr. Cardiac arrhythmias resulting from tracheal suctioning. Ann Intern Med 1969;71:1149-1153.
- Walsh JM, Vanderwarf C, Hoscheit D, Fahey PJ. Unsuspected hemodynamic alterations during endotracheal suctioning. Chest 1989;95:162-165.
- Sackner MA, Landa JF, Greeneltch N, Robinson MJ. Pathogenesis and prevention of tracheobronchial damage with suction procedures. Chest 1973;64:284-290.
- Shumacker HB, Hampton LJ. Sudden death occurring immediately after operation in patients with cardiac disease, with particular reference to the role of aspiration through the endotracheal tube and extubation. J Thorac Surg 1950;18:48-56.
- Storm W. Transient bacteremia following endotracheal suctioning in ventilated newborns. Pediatrics 1980;65: 487-490.
- Catanzaro A. Nosocomial tuberculosis. Am Rev Respir Dis 1982;125(5):559-562.
- Fisher DM, Frewen T, Swedlow DB. Increase in intracranial pressure during suctioning: infant stimulation vs rise in PaCO2. Anesthesiology 1982;57:416-417.
- Perlman JM, Volpe JJ. Suctioning in the preterm: effects on cerebral blood flow velocity, intracranial pressure, and arterial blood pressure. Pediatrics 1983;72: 329-334.
- Rudy EB, Turner BS, Baun M, Stone KS, Brucia J. Endotracheal suctioning in adults with head injury. Heart Lung 1991;20:667-674.
- Stone KS, Vorst EC, Lanham B, Zahn S. Effects of lung hyperinflation on mean arterial pressure and postsuctioning hypoxemia. Heart Lung 1989;18:377-385.
- Tiffin NH, Keim MR, Frewen TC. The effects of variations in flow through an insufflating catheter and endotracheal-tube and suction-catheter size on test-lung pressures. Respir Care 1990;35:889-897.
- Centers for Disease Control. Update: Universal Precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health care settings. MMWR 1988;37:377-399.
Interested persons may copy these Guidelines for noncommercial
purposes of scientific or educational advancement. Please credit AARC and Respiratory
Reprinted from the May 1993 issue of RESPIRATORY CARE [Respir Care 1993;38(5):500–504]