When caring for patients with tracheostomies, you will often find that patients aren't able to clear their own mucus secretions. As nurses, you will be able to remove thick mucus and secretions from the lower airway through suctioning. Some tracheostomies will be set up with a connected in-line suction, and others will require the use of a sterile suction kit.
This video will demonstrate and explain the process of suctioning through a tracheostomy using a sterile suction kit. Let's begin by looking at the tracheostomy setup. The general supplies for a tracheostomy include a venturi setup, attached to the wall oxygen unit.
This attaches to a hose that connects to a collar that sits over the patient's tracheostomy. We'll start with the oxygen. Attached to the wall oxygen unit will be a Venturi setup attached to a sterile water bottle. This device will control the amount of oxygen that is being delivered to the patient. It functions like a Venturi mask.
Room air is mixed with the oxygen delivered from the wall unit. You can control the oxygen delivery by rotating the blue collar around the base of this unit. This collar has markings to deliver 28%, 30%, 35%, 40%, 50%, 70%, or 100% oxygen to the patient by rotating the collar and lining up the markings with the notch above the nozzle. The amount of oxygen that is coming from the wall unit will need to be changed depending on the percentage of oxygen that is being delivered by the Venturi.
The specific liters of O2 for this device are printed on the sterile water bottle that is always attached to the oxygen. Looking at the label on the bottle, you can see that when the Venturi is set to 28% oxygen, the wall oxygen should be set to 6 liters. 8 liters for 30%, 10 liters for 35%, and 12 liters for all higher percentages. To change the wall oxygen delivery, simply turn the knob on the wall unit.
A small metal ball will float to indicate the amount of oxygen being delivered. The center of the ball represents the amount of oxygen being delivered. Do not measure from the top or bottom of the ball. Always measure from the center. A hose is attached to the venturi setup that runs to the patient.
Between the wall oxygen and the patient will be a small canister. This collects condensation in the hose before it reaches the patient and helps to minimize buildup in the airway. It should be positioned to hang below the hose in order for the condensation to fall into the canister. The hose is attached to a collar that sits over the patient's tracheostomy. It delivers oxygen to the trach like a venturi mask delivers oxygen over a patient's nose and mouth.
The collar can be tightened or loosened. and one side of the strap has a snap to allow it to be easily disconnected. The patient's tracheostomy will need to be suctioned periodically. At St. Mary Mercy Hospital, this is done by and at the discretion of either the respiratory therapist or the RN. Therapeutic indications for suctioning include, but are not limited to, visible secretions at the tuborifice, auscultation of coarse crackles over the trachea, deterioration of oxygen saturation levels or arterial blood gas values, inability to produce an effective spontaneous cough, acute respiratory distress, suspected aspiration of gastric or upper airway secretions, the need to obtain a sputum sample, and if the patient is on a mechanical ventilator, increase in peak airway pressure.
When the nurse or respiratory therapist identifies or suspects any of these issues, they should suction the patient. This does not require any physician order to perform. When it has been identified that the patient will require suctioning, you will need to collect some supplies.
First, you will want some PPE. Have a surgical mask and eye protection. It is generally good practice to wear these whenever interacting with a trach patient to protect yourself from any projectile secretions that may exit the trach. You will also need sterile gloves and a suction kit. The suction catheter should not be larger than half the size of the internal diameter of the trach tube.
14 French is stocked in the pod rooms and is suitable for any trach that is larger than a size 7. If the patient has a smaller trach, you may need to contact distribution to get a smaller suction catheter. Sometimes, you may also need sterile water or sterile saline to clean the catheter between suction passes. This is not required for every suction, and is only really necessary when the patient has particularly thick secretions that clog the suction catheter.
The sterile solution can be used to clean the catheter before performing another suction attempt. Suctioning a tracheostomy is completed using sterile technique. The suction kit is sterilely packaged and contains one-size-fits-all sterile gloves, but you may want to use the sized sterile gloves that are available in all the pod rooms.
With your supplies gathered, begin by performing hand hygiene and donning your mask and eye protection. Then, you will need to pre-oxygenate the patient to avoid developing any hypoxia during suctioning. This means supplying the patient with 100% oxygen prior to suctioning. To increase the oxygen delivery, go to the venturi setup.
You will need to turn the collar to 100% oxygen and increase the oxygen delivery from the wall unit to the appropriate level. The table on the bottle shows that 100% oxygen requires 12 liters O2, so twist the collar to 100% and spin the knob on the wall unit to increase the oxygen to 12 liters. Prior to increasing to 100%, be sure to note the original setting the patient was on. In this case, 28% oxygen, requiring 6 liters of O2. After increasing to 100%, leave the collar in place, but you can disconnect the snap on the side to make it easier to move in order to introduce the suction catheter later.
Just make sure the collar remains in place over the trach until that time. Pre-oxygenate for at least one minute. Apply a pulse oximeter to the patient so you can monitor their oxygenation and heart rate during the procedure.
Both can potentially decrease during suctioning. You will be using the wall suction to remove all secretions. Ensure everything is set up appropriately.
Then turn the suction to reg and increase the suction to 150 for adults or 100 for children. Then take the suction tubing and drape it over the bed in a position that will be easily accessed when suctioning. Now open the suction kit and don the sterile gloves. Remove the suction catheter. The suction catheter can be inserted up to 40 centimeters.
though that will not commonly be needed. There are centimeter markings visible for the length of the catheter. At the end is a green adapter with a Christmas tree end that will be inserted into the suction tubing. There is an open port or hole on the adapter as well.
This is how you will control whether suction is being applied or not. When it is covered by your thumb, the suction will be applied through the catheter. But when the hole is uncovered, negative pressure will not reach the end of the catheter, so suction will not be applied.
Hold the green adapter end with your non-down hand. and hold the opposite end with your dominant hand. During the suction procedure, your dominant hand will remain sterile, while your non-dominant hand will become your non-sterile hand. Coil the catheter around your dominant hand.
This will allow you to control the tubing and the adapter with your sterile hand, while your non-sterile hand attaches the suction tubing. Using your non-dominant hand, connect the suction tubing to the adapter end of the suction catheter by pushing the Christmas tree end of the adapter into the tubing. From this point on, that non-dominant hand is no longer sterile. It should not touch the trach or the suction catheter for the remainder of this procedure. With your non-sterile hand, move the collar away from the tracheostomy, and with your sterile, dominant hand, insert the catheter into the patient's trach.
Advance smoothly until you feel resistance or the patient begins to cough. You must not apply suction to the catheter while inserting, so do not cover the hole of the adapter at this time. Also, while inserting, be careful not to let your sterile hand touch the patient or the trach, and to not let the catheter touch the patient.
This could lead to contamination of the catheter and the introduction of infectious agents directly into the airway. When the patient coughs or you meet resistance, retract 1 cm. Now begin suctioning by covering the port on the green adapter with your thumb.
You can apply continuous suction while removing the catheter by holding your thumb over the port during the entire suction attempt, or intermittent suctioning by lifting and replacing your thumb over the port while you retract the catheter. Neither method has proven to present any additional risk of trauma to the patient. While suctioning, slowly pull the catheter out.
With your dominant hand, roll the catheter between your fingers to more evenly apply suction as the catheter is retracted. Keep your dominant hand close to the trach as you remove the catheter, so that you can better control the tip as you remove it from the trach. If you hold the catheter with your hand further back, the catheter tip will likely drop when it leaves the trach and come into contact with the patient, contaminating it.
and if this happens you will need a new catheter for any additional suction attempts. Be aware that while you are suctioning your patient is not able to draw breath so a suction attempt should never last more than 10 to 15 seconds maximum. When the catheter is removed hold it in your dominant hand and replace the collar which should still be delivering 100% oxygen with your non-dominant hand. You can suction up to three times but often one attempt will be enough.
If you are performing multiple attempts Make sure to reapply oxygen between each attempt. If you are finished suctioning at this time, secure the collar to the patient. As stated earlier, sometimes you may need to use sterile saline or sterile water to clean the catheter between attempts.
This will only be necessary if the patient's sputum is particularly thick and clogs the catheter, and you will likely only know this if you have already attempted to suction this patient previously. You can remove a sterile water or sterile saline bottle from the Pyxis, but there will likely be one in the room that the respiratory therapist is using that day. Sterile solution bottles are only good for 24 hours after opening, so be sure to time and date your bottle if you are opening a new one.
Use the catheter kit package to hold the sterile solution. Between passes, simply dip the end of the catheter into the solution and apply suction until the catheter is clear. Then you can attempt to suction the patient again.
If you suction a patient and the catheter clogs, but you do not have sterile solution to clear the catheter, simply use a new catheter if you need to suction an additional time. However, one pass with the suction catheter will often be enough to clear secretions for that patient. You will not always need to complete all three attempts. When you have completed the suctioning process, detach the catheter from the suction tubing and ball it into your hand. Remove your glove, which will contain the catheter in the inside-out glove.
Hold that glove in your remaining gloved hand and remove the remaining glove. Now dispose of the gloves and catheter in the garbage. Turn off the suction. Return the patient to their original oxygen delivery setting. Make sure to not only rotate the venturi setting, but also to adjust the oxygen delivery from the wall unit.
In this case, the patient was receiving 28% oxygen. that required 6 liters of O2 from the wall unit. During suctioning, there are some side effects that may occur. Be aware of these risks and assess your patient appropriately before, during, and after suctioning to ensure their safety. Side effects include hypoxemia, which we try to avoid by pre-oxygenating the patient, arrhythmia, and bradycardia.
And if this is identified on the pulse oximeter during suctioning, suctioning should be stopped and oxygen reapplied. Then the physician should be notified before any additional suctioning is performed. tissue trauma, introduction of pathogens, and atelectasis. When you have completed suctioning, you will need to chart your intervention in Epic. Go to the Basic Assessment tab and navigate to Respiratory Interventions.
Choose Airway Suction from the provided options. Under Airway LDA, identify that it was through a tracheostomy. Then, chart your assessment of secretions and how the patient tolerated the procedure.
Tracheostomy suctioning is a process that will need to be done on patients with trachs throughout the day. It can't be performed by either respiratory therapists or RNs based on their assessments of the patient. It does not require a physician order.