Endotracheal Suctioning: In Line ETT

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Lydia Wood
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1 Approved by: Endotracheal Suctioning: In Line ETT Gail Cameron Senior Director Operations, Maternal, Neonatal & Child Health Programs Dr. Paul Byrne Medical Director, Neonatology Neonatal Policy & Procedures Manual : Date Effective Next Review Oct 2018 Dr. Sharif Shaik Medical Director, Neonatology Policy Statement Applicability Use of an in line suction catheter is the preferred method of endotracheal tube suctioning to prevent interruption of ventilation & de-recruitment of alveoli and minimize the risk of ventilator associated pneumonia. Every attempt will be made to have the patient connected to the ventilator for suction procedures Parameters may require adjustment on the ventilator in order for the infant to tolerate the procedure. If the infant does not tolerate the suction procedure after ventilator manipulation, manual ventilation is started. All Covenant Health Employees Equipment Closed Tracheal Suction System Sterile Normal Saline Sterile Scissors Suction set-up with connecting tubing 3 ml syringe Set Up Select catheter that is suitable for the endotracheal tube. Select the matching Y adapter for the endotracheal tube and attach the sheatherd catheter to the appropriate port on the adapter Ensure lavage port is closed Using scissors cut endotracheal tube at an angle proximal to the original connector to accept the new Y adapter and immediately insert Y adapter into endotracheal tube and attach ventilator circuit to large 15mm adapter to continue ventilation Occlude suction tubing and set wall suction to mmhg Attach suction to end of sheathed catheter and lock suction control valve on catheter Procedure This procedure is done ideally with two persons so that ventilation may be adjusted as required. One person is a respiratory therapist who can adjust the ventilator as necessary. Action Rationale 1. Perform hand hygiene. 2. Patient assessment to evaluate need for suction. increased work of breathing rising oxygen requirement or CO 2 level visible secretions in the airway poor chest excursions or lack of chest vibrations with HFO coarse breath sounds by auscultation or noisy breathing suspected aspiration of gastric or upper airway secretions Suctioning an ETT is an extremely stressful procedure and should be done as infrequently as possible. DO NOT proceed with suctioning if infant is cyanosed, bradycardic or hypoxic, unless tube occlusion is suspected.

2 Page 2 of 5 increased peak inspiratory pressures during volumecontrolled mechanical ventilation or decreased tidal volume changes in flow and pressure graphics 3. Ensure nurse responsible for the patient is aware of the procedure. Call Therapist should ventilator parameters need adjustment. 4. Check suction is set to mmhg. Unlock suction valve 5. Fill 3 ml syringe with sterile normal saline and attach to lavage port Use lowest vacuum pressure effective in clearing secretions within a few seconds Saline is used to clear secretions from the collection area of the suction set. 6. Note length of ETT. 7. In case manual ventilation is necessary, the assistant checks that the T-piece resuscitator (or bagger if T-piece is unavailable) has the appropriate FiO 2 8. Advance catheter by gripping Y with one hand while pushing catheter toward patient with thumb and forefinger of other hand. Stop advancement when catheter length markings and length of ETT markings match. 9. To apply suction, hold Y and depress suction control valve while withdrawing suction catheter until black marking on catheter tip is completely within the suction side of the Y. Total procedure time is seconds. Limit time of insertion and suctioning to least time required to remove secretions 10. If the infant doesn t tolerate the suction procedure, the Therapist adjusts the ventilator parameters for the procedure. If a Therapist is not available increase ventilation using the ventilator manual breath key. If the infant remains intolerant of the procedure, the assistant ventilates manually with a T-piece resuscitator) or bagger between catheter passes. Minimum ventilation between catheter passes is 5 breaths. Trauma which can lead to tissue damage and atelectasis is avoided by not passing the catheter beyond the ETT tip. The catheter occludes the airway during suctioning. Guard against over suctioning as the process has adverse effects. Pulling the suction catheter out to far may result in inflation of the catheter sheath. Should this occur carefully push the catheter back inside the Y adapter port to occlude the sheath from the Y adapter.. Initial de-recruitment is not apparent by clinical signs, so the infant has enhanced ventilation between catheter passes.

3 Page 3 of The catheter may be passed two or three times if warranted by secretions obtained. 12. After suctioning, flush catheter through lavage port. Depress suction control valve and then instill saline while continuing to depress suction control valve. Minimize the time suction is applied as it is applied to the airway as well. Close lavage port after flushing 13. Lift and turn suction control valve to Lock Position. Suctioning an ETT is extremely stressful and is done as infrequently as possible. DO NOT suction if infant is cyanosed, bradycardic or hypoxic, unless tube occlusion is suspected. The black mark on the tip of the catheter must be visible in lavage port Y section. Flushing removes secretions from the catheter for a patent lumen but it applies suction to the patient s airway and may result in de-recruitment of alveoli. Guards against accidental application of suction. 14. Gradually reset FiO 2 to pre-procedure levels to prevent hyperoxia. 15. Document procedure in notes. Documentation An absence of detailed documentation indicates tolerance of the procedure and no unusual findings. 1. Tolerance of Suctioning a. Episodes of hypoxia and amount of time to return to baseline. b. Episodes of bradycardia and amount of time to return to baseline. c. Any other physiological changes. 2. Suctioning Effectiveness Evaluation of suctioning effectiveness based on: auscultation and estimation of amount colour and consistency of secretions; a decrease in oxygen requirements; an increase in oxygen saturation; or a decrease in the TcCO2 end tidal CO2, changes in peak inspiratory pressure, changes in tidal volume, or changes in the pulmonary graphics. 3. Date to change In-line suction cartridge. System is changed once weekly and prn. Related Documents Adapted with permission from Stollery Children s Policy and Procedure Manual: In-Line ETT Suction, June 2009 RELATED POLICIES AND PROCEDURES Basic Assessment Ventilated Infant- Care of (Policy) References Acherman, M.H. (1985). The use of bolus normal saline instillation in artificial airways: Is it useful or necessary? Heart & Lung, 14(5), Brodsky, L., Reidy, M., & Stanievich, J.F. (1987). The effects of suctioning techniques on the distal tracheal mucosa in intubated low birth weight infants. International Journal of Pediatric Otorhinolaryngology, 14(1), 1-14.

4 Page 4 of 5 Burton, G.G. & Hodgkin, J.E. (1984). Care (A guide to Clinical Practice) 2 nd Ed., Toronto: Lippincott. Douglas, S. & Larsen, E.L. (1985). The effect of positive end expiratory pressure adaptor on oxygenation during endotracheal suctioning. Heart & Lung, 14(4), MacDonald,M.,G., Ramasethu, J.,Rais-Bahrami, K., (2013) Atlas of Procedures in Neonatology (5 th ed. pp ) Philadelphia: Wolters Kluwer/ Lippincott Williams & Wilkins Perry, A. G., Potter, P.A. Ostendorf, W. R. (2014). Clinical Nursing Skills and Techniques, Chapter 25 Airway Management Page Skill 25-2 Revisions July 2005 July 2011

5 Page 5 of 5 Signing GAIL CAMERON SENIOR DIRECTOR OPERATIONS, MATERNAL, NEONATAL & CHILD HEALTH PROGRAMS GREY NUNS & MISERCORDIA HOSPITALS DR. PAUL BYRNE MEDICAL DIRECTOR NEONATAL PROGRAM GREY NUNS HOSPITAL DR. SHARIF SHAIK MEDICAL DIRECTOR NEONATAL PROGRAM MISERICORDIA HOSPITAL \

Suctioning: Esophageal/Gastric

Approved by: Suctioning: Esophageal/Gastric Gail Cameron Senior Director Operations, Maternal, Neonatal & Child Health Programs Dr. Paul Byrne Medical Director, Neonatology Neonatal Policy & Procedures