1 SO7. Title of Guideline (must include the word Guideline (not. Oropharyngeal Suctioning Nursing Guideline. Contact Name and Job Title (author)

Transcription

1 Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc) Contact Name and Job Title (author) S07 Tracheal, Nasopharyngeal and Oropharyngeal Suctioning Nursing Guideline Carli Whittaker PICU Nurse Educator Directorate & Speciality Family Health, PICU Date of submission September 2013 Date on which guideline must be reviewed (this should be one to five years) Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) Abstract Key Words Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Evidence base: (1-6) 1 NICE Guidance, Royal College Guideline, SIGN (please state which source). 2a meta analysis of randomised controlled trials 2b at least one randomised controlled trial 3a at least one well-designed controlled study without 3b randomisation at least one other type of well-designed quasiexperimental study 4 well designed non-experimental descriptive studies (ie comparative / correlation and case studies) 5 expert committee reports or opinions and / or clinical experiences of respected authorities 6 recommended best practise based on the clinical experience of the guideline developer Consultation Process 2018 Children and young people This guideline describes indications and methods of suctioning Suction; Children Peer reviewed 1 Expert panel and Nottingham Children s Hospital Clinical Educator Group Target audience Nurses and physiotherapists This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. 1 SO7

2 NOTTINGHAM CHILDRENS HOSPITAL Nursing Guideline S07 Tracheal, Nasopharyngeal and Oropharyngeal Suctioning Standard Statement There will be a consistent and safe method of suctioning with or without an artificial airway as a technique for airway clearance in the paediatric population. This procedure contains information all nursing and Allied Health Professional staff working within the Nottingham Children s Hospital should use when considering the use of suction as an airway clearance technique (ACT) in children with or without artificial airways. Introduction Routes of suction: endotracheal, oropharyngeal, nasopharyngeal (with or without an airway) and tracheostomy. A: Indications for Suction Indications Coughing or poor cough Decreased oxygen saturations Increased PCO 2 Signs of respiratory distress Audible rattle heard without auscultation Reduced breath sounds/movement of chest Increased ventilatory requirements Evidence Based The patient is unable to clear secretions independently, therefore assistance is required to facilitate clearance in order to prevent further infection or compromise of ventilation Retained secretions may compromise gas exchange. This may present as decreased SpO 2 or increased pco 2 Retained secretions may compromise gas exchange. This may present as decreased SpO 2 or increased pco 2. Respiratory distress in a non paralysed patient may occur due to retained secretions impacting on respiratory function (see below). Indicates that secretions are present that the child has not cleared effectively independently Possibility of mucus plugging preventing air entry to a portion of the lung For example. increased ventilator airway pressures, increased oxygen requirements. Retained secretions can reduce lung compliance and therefore impact on overall gaseous 2 SO7

3 Possible aspiration Tracheostomy cuff deflation exchange If aspiration occurs the material needs to be removed promptly to prevent possible airway damage, ventilation compromise and respiratory distress. The oropharynx should be suctioned prior to cuff deflation in order to minimise risk of aspiration. Signs of respiratory distress: Tachypnoea Reduced respiratory rate and/or apnoea Paradoxical breathing Tachycardia/bradycardia Recession (subcostal, intercostal or sternal) Nasal flaring Tracheal tug Grunting/stridor Head bobbing Reduced activity/staring Restlessness/agitation Inability to feed or cry Clammy Cool peripheries B: Contra-Indications General: Oesophageal or tracheal surgery including tracheoesophageal fistula repair (need to be aware of a high anastomosis and the patency of the anastomosis) Severe bronchospasm Stridor Severe pulmonary haemorrhage Epiglotittis When disconnection from oxygen/peep/hfov or similar is detrimental C: Complications Hazard/Complication Paroxysmal coughing Anxiety and pain Action Stop suctioning and allow the patient to settle. You may need to increase the oxygen supply until the patient stops coughing. Explain the procedure clearly to patient (and parents if present and appropriate). Optimise pain control if this is an issue. 3 SO7

4 Formation of granulation tissue/ulceration and tracheobronchial damage Hypoxia Vagal stimulation Intracranial pressure (ICP) Atelectasis Incomplete secretion clearance Cardiovascular changes Risk of pulmonary infection Suction only when indicated. Do not rotate or plunge catheter in and out. Do not exceed suction pressures (see table 1). Increase oxygen. If hypoxia continues despite increase in oxygen use Manual Hyperinflation (MHI). Nb:only individuals trained with completed MHI competencies should use MHI. Pass catheter slowly and stop once cough is stimulated. If resistance is present withdraw catheter prior to applying suction pressure to avoid stimulation to carina. Vaso-vagal response can be due to stimulation of the vaso-vagal reflex which can induce bradycardia, arrhythmia and even cardiorespiratory arrest. When ICP is labile patients should have adequate sedation and paralysis prior to suctioning. ICP should be carefully monitored throughout the procedure. Only suction when indicated with a maximum of 3-4 suctions being completed per treatment session. Atelectasis can occur due to the negative pressure that is applied. Do not exceed recommended suction pressures and only suction when indicated. The combination of nebulisers and other physiotherapy techniques (manual techniques, positioning, MHI) with suctioning may optimise secretion clearance. Monitor the cardiovascular system throughout the suctioning process, avoiding vagal stimulation. Only suction when indicated. For nonimmuno-compromised patients a sterile technique is not required. However the use of good hand hygiene and clean gloves is essential in minimising the risk of pulmonary infection secondary to suctioning. In immuno-compromised patients a sterile technique should be used. Nb: For example, immuno-compromised patients include those post transplant, 4 SO7

5 Apnoea those undergoing chemotherapy or radiotherapy and those patients with a neutropenic status. Stop suctioning immediately and increase the oxygen supply. If the apnoeic episode continues following the cessation of suctioning then the use of MHI is indicated until regular respirations continue. D: Equipment Suction device (wall or portable) Sterile suction catheters (appropriate size) Non sterile boxed gloves for all patients Sterile gloves for immunocompromised patients Oxygen supply with appropriate means of delivery to the patient Airway if required (guedel or nasopharangeal) Yankauer suction connector Water for cleaning tube post treatment Mask and goggles/protective visor E: Procedure Action 1. Assess patient and establish need for suctioning 2. Wash hands, put on disposable gown and non sterile gloves. Use goggles/visor if required 3. Prepare the patient through the provision of adequate information about the procedure and ensuring optimal pain relief is administered. 4. Gain informed consent where possible but do not delay suction episode.. 5. Check correct functioning of suction machine and set pressure to age appropriate value (see table 1). Use the lowest pressure possible to effectively clear secretions. 6. Consider use of positioning, manual techniques, saline Rationale A comprehensive assessment is essential. Suctioning should only completed when clinically indicated (see section A) Minimise risks of infection control Informing the patient about suctioning and encouraging participation is essential in minimising patient discomfort, with the aim of maximising effectiveness of procedure Legal requirement Consider ethics. Minimise risk of mechanical trauma (Boggs, 1993; Glass and Grap, 1995) and unsuccessful suction Optimise success of airway clearance, can facilitate easy access 5 SO7

6 nebulisers, other adjuncts prior to and/or in addition to suction 7. Pre-oxygenate if indicated. The need and extent of this will vary on an individual basis. 8. Attach sterile suction catheter (size appropriate to pt size/airway) to the suction tubing. Ideally choose a catheter that is no greater then ½ the diameter of the ETT /tracheostomy/airway 9. Assess length of airway adjunct (eg pre measure suction catheter against Tracheostomy, ETT length) 10. Put on a second glove-this acts as your clean glove. Suction catheter is removed from the packaging. The sterile catheter should only be touched by the clean glove. Nb. For immunocompromised patients a sterile glove should be used instead of a second glove. If contamination of the catheter occurs, then this should be disposed of and the process repeated. 11. If the patient is ventilated, detach catheter mount from patient at peak of inspiration and introduce the suction catheter into the tube or via catheter mount. Only suction to the end of the ET or tracheostomy tube. Nb.If the patient is on high levels of PEEP consider using a closed suction circuit. Nasopharyngeal without an airway Lubricate catheter with sterile water. Measure the distance between the nose and tragus of the ear. Introduce the catheter to the length measured, to airway, minimise risk of aspiration. MHI and vibrations can be effective in increasing peak expiratory flow rates and optimising PIF:PEF ratios (Gregson, 2007; Shannon, 2010). Normal saline nebulisers can be used to boost humidification (Harkin and Russell, 2001) Minimise risk of hypoxia and cardiac arrhythmias To provide connection between suction unit and the catheter. To ensure suctioning only to the end of the adjunct Minimise risk of cross infection to patient/operator. Minimise risk of infection. Minimise mechanical trauma and patient discomfort. Choong et al.(2003) demonstrated that open suction and therefore ventilator disconnection resulted in a greater loss of volume in comparison to closed circuit suction. Minimising suction depth will reduce the risk of : trauma occurring to the 6 SO7

7 directing it slightly upwards and backwards through the nose into the pharynx. Introduce the catheter on inhalation if possible. If the patient swallows the catheter is likely to pass into the oesophagus-withdraw before applying suction. Nasopharyngeal with an airway Measure the length of the airway and insert the catheter as above but via the airway. Continue to insert catheter until it passes just past the length of the artificial airway. A cough should be stimulated. Oropharyngeal airway Place the airway in the mouth ensuring it sits above the tongue. Keep the airway depressed to avoid stimulation of the soft palate and gagging. Introduce the catheter as above but through the airway. trachea formation of granulation tissue vagal stimulation. 12. Apply suction by placing thumb over valve. Slowly withdraw maintaining the vacuum. Suctioning should be quick but effective, i.e seconds for an infant and 15 seconds for an older child 13. Monitor patients condition throughout the intervention i.e. colour, breathing pattern, RR, hr, secretions, evidence of trauma, distress, cough 14. Wrap the used catheter around the second glove, taking the clean glove off over the catheter. Dispose of both in a clinical waste bag (yellow). 15. If applicable reapply the patients oxygen supply, increasing temporarily if indicated. 16. If possible encourage adequate lung inflation i.e. deep breathing, ACBT etc 17. Clear any additional secretions from the oropharynx gently using Minimise adverse effects/complications of suctioning. i.e. hypoxia, hypoxaemia, cardiac arrhythmias, BP fluctuations, pain, apnoea, atelectasis, raised ICP etc. Reduce the need for a second suction. Optimise patient safety Prevent cross infection. Fulfill waste management criteria. Restoration of optimal oxygen saturations as quickly as possible Minimise atelectasis Avoid secretions from the oropharynx sliding down the respiratory tract 7 SO7

8 the yankauer or a larger size catheter 18. Allow the patient to rest Prevents fatigue 19. Observe the patient and reassess. Is another suction indicated? 20. If the patient has an ineffective cough or secretions have not been adequately removed then a deeper suction may be required. This is not completed routinely. The use of saline nebulisers could be considered to facilitate secretion clearance. Saline should not be used routinely. 21. Clean suction tubing using water 22. Document procedure, effects and response as per documentation policy Minimise risk of mechanical trauma to trachea and carina. To ensure secretions are cleared adequately. Deeper suctions may be required. (Spence et al., 2003) (Halm and Krisko-Hagel., 2008) Reduce the risk of re-introducing infection into the respiratory tract by contamination of tubing. Legal requirement Table 1: Recommended suction pressures CHILD AGE/SIZE (Approx) Infant Child Older child SUCTION PRESSURE RANGE 6-9kPa 9-11kPa 11-15kPa References Boggs, R.L. (1993). Airway management. In: Boggs, R.L., Woodridge-King, M. (eds). AACN Procedure Manual for Critical Care 3 rd Ed, W.B. Saunders, Philadelphia. Choong, K., Chatrkaw, P., Frndova, H. and Cox, P.N. (2003). Comparison of loss in lung volume with open versus in-line cathter endotracheal suctioning. Paediatrc Critical Care Medicine, 4(1) Glass, C. and Grap, M. (1995). Ten tips of suctioning. American Journal of Nursing 5(5) Gregson, RK., Stocks, J., Petley, GW., Shannon, H., Warner, JO., Jagannathan, R. and Main, E. (2007). Simultaneous measurement of force and respiratory profiles during chest physiotherapy in ventilated children. Physiological Measurement. 28(9) SO7

9 Halm, M.A. and Krisko-Hagel, K. (2008). Instilling normal saline with suctioning: beneficial technique or potentially harmful sacred cow. American Journal of Critical Care, 17, Harkin, H. and Russell, C. (2001). Tracheostomy patient care. Nursing Times, 97(25) Shannon, H., Stiger, R., Gregson, RK., Stocks, J., Main, E. (2010). Effect of chest wall vibration timing on peak expiratory flow and inspiratory pressure in a mechanically ventilated lung model. Physiotherapy 96(4) Spence, K., Gillies, D. and Waterworth, L. (2003). Deep versus shallow suction of endotracheal tubes in ventilated neonates and young infants. Cochrane Database Systematic Reviews (3):CD Authors: Ema Swingwood, Physiotherapist and Carli Whittaker, PICU Clinical Educator Date: 2013 Review date: 2018 Consultation: PICU nursing and medical staff, Physiotherapy, Clinical Educators Ratified by: Nottingham Children s Hospital Clinical Educators Group Signed off by: Angela Horsley, Kerry Webb, Rachel Keay 9 SO7