Suctioning a Tracheostomy

Suctioning a Tracheostomy

The upper airway warms, cleans and moistens the air we breath. The trach tube bypasses these mechanisms, so that the air via the tube is cooler, dryer and not as clean. In response to these changes, the body produces more mucus. The trach tube is suctioned to remove mucus from the tube and trachea to allow for easier breathing. Generally, the child should be suctioned every 4 to 6 hours and as needed. There may be large amounts of mucus with a new tracheostomy. This is a normal reaction to an irritant (the tube) in the airway. The heavy secretions should decrease in a few weeks. While a child is in the hospital, suctioning is done using sterile technique, however a clean technique is usually sufficient for most children at home. If your child has frequent respiratory infections, trach care and suctioning techniques may need to be addressed. Frequency of suctioning will vary from child to child and will increase with respiratory tract infections. Try to avoid suctioning too frequently. The more you suction, the more secretions can be produced.

Care Techniques

• Sterile Technique: sterile catheters and sterile gloves
• Modified Sterile Technique: sterile catheters and clean gloves
• Clean Technique: clean catheter and clean hands
  

The size of the suction catheter depends on the size of the tracheostomy tube.  Size 6, 8 or 10 French are typical sizes for neonatal and pediatric trach tubes. The larger the number, the larger the diameter of the suction catheter.  Use a catheter with an outer diameter that is about half the inner diameter of the artificial airway this will allow air to enter around it during suctioning.  You can also compute the catheter size with this formula:  Multiply the artificial airways diameter in millimeters by two. For example, 8 mm X 2 = 16, so a 16 French catheter.  Also see Tracheostomy Sizing Chart for recommended catheter sizes for specific Bivona and Shiley pediatric tracheostomy tubes.
Older children may be taught to suction themselves.

Suction Depths

• Shallow Suctioning: Suction secretions at the opening of the trach tube that the child has coughed up.
• Pre-measured Suctioning: Suction the length of the trach tube. Suction depth varies depending on the size of the trach tube. The obturator can be used as a measuring guide.
• Deep Suctioning: Insert the catheter until resistance is felt. (Deep suctioning is usually not necessary. Be careful to avoid vigorous suctioning, as this may injure the lining of the airway).
  

Signs That a Child Needs Suctioning

• Rattling mucus sounds from the trach
• Fast breathing
• Bubbles of mucus in trach opening
• Dry raspy breathing or a whistling noise from trach
• Older children may vocalize or signal a need to be suctioned.
• Signs of respiratory distress under Tracheostomy Complications
  

Equipment

• Suction machine
• Suction connecting tubing
• Suction catheters
• Normal saline
• Sterile or clean cup
• 3cc saline ampules (“bullets”)
• Ambu bag
• Tissues
• Gloves (optional for home care, use powder-free gloves)

 

Illustration courtesy of the Department of Otolaryngology, Cincinnati Children's
Hospital Medical Center, Cincinnati, Ohio

Suctioning a Tracheostomy

Procedure

• Explain procedure in a way appropriate for child's age and understanding.
• Wash hands.
• Set up equipment and connect suction catheter to machine tubing.
• Pour normal saline into cup.
• Put on gloves (optional).
• Turn on suction machine (suction machine pressure for small children 50-100mm Hg, for older children/adults 100-120mm Hg)
• Place tip of catheter into saline cup to moisten and test to see that suction is working.
• Instill sterile normal saline with plastic squeeze ampule into the trach tube if needed for thick or dry secretions. Excessive use of saline is not recommended. Use saline only if the mucus is very thick, hard to cough up or difficult to suction. Saline may also be instilled via a syringe or eye dropper, which is less expensive than single dose units. Recommended amount per instillation is approximately 1cc.
• Gently insert catheter into the trach tube without applying suction. (Suction only length of trach tube - premeasured suctioning. Deeper insertion may be needed if the child has an ineffective cough.)
• Put thumb over opening in catheter to create suction and use a circular motion (twirl catheter between thumb and index finger) while withdrawing the catheter so that the mucus is removed well from all areas. Avoid suctioning longer than 10 seconds because of oxygen loss. Note: Some research has shown that by applying suction both going in and then out of the tube takes less time and therefore results there is less hypoxia. Also, there are now holes on all sides of the suction catheters, so twirling is not necessary.
• Draw saline from cup through catheter to clear catheter.
• For trach tubes with cuffs, it may be necessary to deflate the cuff periodically for suctioning to prevent pooling of secretions above trach cuff.
• Let child rest and breathe, then repeat suction if needed until clear (allow at least 30 seconds between suctioning).
• Oxygenate as ordered (extra oxygen may be given before and after suction to prevent hypoxia).
• Some children need extra breaths with an Ambu bag (approximately 3 - 5 breaths). Purposes of bagging: hyperoxygenation, hyperinflation, and hyperventilation of the lungs. However, this is usually not needed for stable children with no additional respiratory problems.

 

Illustration Source:
The Center for Pediatric Emergency Medicine (CPEM), Teaching Resource for Instructors in Prehospital Pediatrics.  Illustrations by Susan Gilbert. http://www.cpem.org/html/giflist.html

• The child's mouth or nose may also be suctioned, if needed after suctioning the trach, then dispose of that catheter (do not put same catheter back into trach).
• Turn off the machine, dispose of the suction catheter, saline and gloves. In home care, catheters may sometimes be used more than once before disposal or cleaning if the child needs frequent suctioning. Keep the tip of the catheter clean, and store it in the original package. Some catheters have a protective sleeve to help keep it clean.

Bard Medical Division Tracheal Suction Catheter

• A bulb syringe may be used between suctioning if the child is able to cough up some secretions on his/her own.
• Be aware of color, odor, amount and consistency of the secretions and notify doctor of changes in secretions.

Illustration Source:
The Center for Pediatric Emergency Medicine (CPEM), Teaching Resource for Instructors in Prehospital Pediatrics.  Illustrations by Susan Gilbert. http://www.cpem.org/html/giflist.html

Other Suctioning Devices

• A newer suction technique, which is used most often in hospitals for children on ventilator support is a closed multiuse catheter system, also called an "in-line" catheter. This closed system allows suctioning without disconnecting the ventilator. The catheter is protected inside a sleeve and is usually changed only once a day.

Ballard® in-line catheter

• In addition to a stationary suction machine, small, portable, battery-operated suction machines are available for travel. The batteries are rechargeable or the machine can be plugged into a car cigarette lighter.
• The DeLee suction trap is a small plastic suction device. The caregiver sucks on a tube to create a negative suction pressure. (The secretions are collected in a sputum trap and do not come in contact with the caregiver.)

DeLee Suction Trap

• Luer lock syringe with a suction catheter attached. Disconnect the suction catheter from the thumb hole apparatus and attach the end of the catheter to the syringe. (Use size 8 or 10 french suction catheter)
• Bulb syringes can be useful for removing mucus at the opening of the tube, but does not replace routine suctioning of the length of the trach tube.
• Bulb syringe can be modified by cutting off tip of bulb syringe and inserting suction catheter hub into opening. To use, squeeze bulb, insert catheter into trach tube and release bulb (always remove catheter before squeezing bulb).
• The CoughAssist is an alternative to traditional suctioning that is especially helpful for those with an ineffective ability to cough. The CoughAssist assists patients in the removal of bronchial secretions from the respiratory tract. This is a new, vacuum-like, non-invasive technique. (See: Respironics, Inc.)

CoughAssist

•  Hand-operated suction systems such as the RES-Q-VAC provides suction anywhere and anytime and is totally portable.

Hand-powered Suction Device

Encourage your child to cough; this also helps to clear the airway and lungs. Using chest P.T., postural drainage and percussion as needed to maximize airway clearance.  

source:  http://www.tracheostomy.com/care/suction.htm