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distressSuctionSuction catheterTracheostomyYankauer suction

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Ainruay Suctioning, p. 673

Closed (ln-Line) Suction Catheter, p. 682

Endotracheal Tube Care, p. 683

Tracheostomy Care, p. 689

lnflating the Cuff on an Endotrachealor Tracheostomy Tube, p. 695

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',4astery of content in this chapter witt enable the nurse to:. ldentify guidelines used in managing the airway.. Describe the methods for airway management.. Discuss the indications for airway suctioning.. Discuss the indications for tracheostomy care.

tirway management involves maintaining the patency of therLrse, upper airway, trachea, and iower airway of the respiratoqr.'.--,tem. Many courses of action are available to promote an open or::tent airway, which has the potential to become obstructed byrucus, mechanical obstruction (i.e., soft tissue in upper airway), or

, ioreign body. These acrions do not always require a physician's.:Jer. Consult the physician if there are any concerns about the.:propriateness of the intervention or when an airway obstruction: present, even when treatment relieves the obstruction. Hydra-rn, positioning, nutrition, chest therapy airway clearance tech-iques, mucous clearance device therapy, deep breathing, cough-

rg, humidity, and aerosol therapy are noninvasive techniques that.:e helpful in maintaining a patent airway.

'!7hen a patienr is unable to clear airway secretions with cough-

rg, chest physiotherapy, or other noninvasive techniques, more:r'asive measures, such as suctioning, are needed. These addi-.rnal measures directed at maintaining a patent airway are neces-

,rr1,, especially in a weak, confused, or critically ill patient. This-lapter focuses on nonemergent, invasive techniques to maintain:-rway patency, including artificial airways.

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:oxygenation and deep breathing, sometimes referreJ to as hy--:r'entilation, assist in reducing suction-induced hvpoxemia-emir and Drama1i,2005). Preoxygenarion pror.ides a parient-h a short-term increase in supplemental oxygen, such as in-

-:asing oxygen flolv rate on a nasal cannula or oxygen mask, in--.asing the percenr of inspired oxygen of breaths delivered by the.=chanical ventilator, or increasing oxygen flow rates to art1ficia1l.ays. Not every patient requires preoxygenation unless he or shervpoxemic before suctioning. Hyperinflarion is the process of' rviding 100% oxygen to a patient before airu,a1, suctioning

,::uitt,2005).Following sucrioning, return a patient's oxygen level to presuc.ning levels to avoid increased risk for oxygen toxicity. In addi-n, there is also a risk for absorption arelectasls frorn prolonged

i ninistration of high concenrrations of oxygen and increased,:bon dioxide retenrion in patients with chronic obstructive lung

. .:ases (Demir and Dramali, 2005).The practice of normal saline instillation (NSI) into arrilicial

. .vays to improve secretion removal is inconclusive. Clinical stud-:: comparing the results of suctioning using NSI rvith those of'.rdard suctioning do nor show any clinical or significant results

-elik and Kanan, 2006). A review of the literature indicates that-,rioning with or without isoronic normal saline (lNS) produces:i[ar amounts of secretions and significant decreases in oxygen:uration. In addition, these studies show increases in heart rate for

- :.l 5 minutes after suctioning with INS as opposed to dry suction.- :. The review also indicates thar the leve1 of a patienr's dyspnea.er suctioning with or without INS was not significantly different.

-..t, the review nores that the use of INS with suctioning has the- rential to increase ventilator-associated pneumonia because INS-.r dislodge bacteria from the upper airway to the lower portions of-.e airway (Celik and Kanan, 2006; Grap and Munro, Z0O4).

CHAPTER 25 Airway Management

Provide oropharyngeal suctioning.Provide airway suctioning.Provide endotracheal care.Provide tracheostomy tube care.Inflate the cuff on an endotracheal or tracheostomy tubeChange a tracheostomy tube.

Psychosocial consequences of airway suctioning often occur. pa-tients who remember the suctioning report it as painful, suffocating,or stressful. Patients recalled some of the physiological resulm ofsuctioning, such as sleep disturbances, tachycardia, confusion, short-ness of breath, and dizziness (Lindgren and Ames, 2005).

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Communication is vital. Arti{icial airways aker patienrs, ability tocommunicate. Patients, especially those from other cultures, feelfrightened, frustrated, and vulnerable. In addition, measures usedto maintain airway patency are new and frightening. Assess rhemeaning of oropharyngeal suctioning ro the parient and familymembers. Explain anticipated effects such as gagging and tearing,which are very disrressing to family members. Many Vietnamesebelieve that objects entering the body cause illness, so some mayinterpret suctioning as introducing illness to the patient (Edmondsand Brady,2003). A balance berween positive and negative forces,or the yin and yang, are important components of Vietnameseculture and must be maintalned for optimal health.

Provide culturally congruent explanations of the purpose andtherapeutic effects of the procedure. Whenever possible, demon-strate suctioning techniques and enc<turage patient and familymembers to parricipare. If available, a professional inrerprerer is avaluable asset for explanation of procedures, especially those thatare invasive and need to be repeated multiple times, such as suc-tioning and tracheostomy tube care. If an interpreter is not avail-ab1e, have a family or community member explain invasive proce-dures such as inserrion of endotracheal tube or trrcheoitomy.Encourage family members ar rhe bedside to provide support for apatient who has limited English proficiency. Collaborate with thefamily in providing alternarive means of communication for thepatient. Provide educational materials to the parienr and family intherr native language for maximal understanding.

Skill Performance Guidelines

Know the patienr's normal range of vital signs and oxygensaturation ievels. Baseline vital signs serve as a means to iden-tify individual abnormalities and ro recognize the onset ofworsening of an illness.Know the patienr's medical history. Smoking alters normalmucociliary clearance. Certain disorders such as chronicobstructive pulmonary disease (COPD), asthma, cysric fibro-sis, pneumonia, thoracic surgery, chest trauma, and abdominalsurgery place the patienr at increased risk for an obstructedairway.Identify conditions thar increase the patient's risk for aspira-tion of gastric contents into the 1ung, resulting in airway ob-struction. These include the presence of enteral feeding tubesor other nasal or oral gastric tubes, a decreased level of con-sciousness, and a decreased swallowing ability.Determine if rhe patient has a history of nasal problems, suchas nasal trauma, nasal polyps, deviated nasai septum, orchronic sinusitis. Allergy problems causing mucosal swelling

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CHAPTER 25 Airway Management

narrow nasal passages, which affect your abiiity to easily pass a

suction catheter.Review the patient's respiratory assessments. Review the pa-tient's condition from the pasr lZ or 24 hours. These are rela-tive baseline measurements that assisr in distinguishing be-tween gradual and acute changes in the patient's status.Perform a systematic respiratory assessment of upper and lowerairways, including identifying respiratory rate, respiratory pat-tern, respiratory muscles used, breath sounds, ability to cougheffectiveiy, integrity of the rib cage, and the characteristics ofsputum production.Determlne the rype and frequency of intervenrion, based onassessment flndings. Care that is appropriate for one day orshift can change, resulting in an increase or decrease in fre-quency of care or alterations in the type of intervention.Identify and become familiar with the use of equipment avail-able at the institution. Many types of artificial airways, sucrioncatheters, and suction machines are available. Knowing howto operate the equipment before using it will benefit both youand the patient.Test all equipment before use. Have adequate supplies on handat the bedside. Equipment must work properly to provide safe

nursing care. Determine that the suction machine is generat-ing adequate negative suction pressure (Tab1e 25-1) and thatthere are suction catheters and appropriate equipment at thebedside.

Preterm infants 60-80 mm Hg

lnfants 80-100 mm Hg

Children 100-120 mm Hg

Adults 100-150 mm Hg

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10 Know the patient's home care plan. Absence or interruprior,ofcertain therapies such as bronchodilators places the patien:at risk for an obstructed airway during the hospitalization cr:

after dlscharge from the hospital.11 Know the side effects of medications and other therapie:

Some medications such as beta-adrenergic blockers have thtside effect of bronchospasm. An adverse effect of opioids anJsedatives is respiratory depression. Similarly, too much oxyger.reduces the drive to breathe in patienrs with chronic hyper-capnia (elevated arterial carbon dioxide tension). Some po.:-tion changes affect the patient adversely. For example, in pa-

tients with impaired spinal cord innervarions of the respirator,muscles, supine positions place the diaphragm ar a mechanic.-disadvantage and increase the risk for aspiration.

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A Yankauer, or tonsillar tip, suction device is used for oropharyn-geal suctioning (Fig. 25-1). A Yankauer sucrion carherer is made ofrigid, minimally flexible plastic. The tip of this suction carhererusualLy has one large and several small eyelets through which themucus enters with application of negative pressure. The Yankauersuction catheter is angled to faciiitate removal ofpharyngeal secre-tions through the mouth. This catheter ls used instead of a stan-dard suction catheter when oral secretions are extremely copiousand thick because it can handle large volumes of secretions betterthan a standard suction catheter. The Yankauer suction catheter is

not used to suction the nares because of its size.

The Yankauer suction device is useful in the removal of secre-tions from the mouth in patients after oral and maxiLlofacial surgery,trauma to the mouth, or neurovascular injury and cerebrovascular

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accident causing hemiparesis and drooling or impaired swallowinsPatients with artilicial airways and impaired swallowing require u..ofthe Yankauer suction device to provide oral hygiene.

**3*gati*:: ConsideratiensThe skill of performing oropharyngeal (Yankauer) sucrioning ca-r

be delegated to nursing assistive personnel (NAP). Do not routinel.,delegate this skill for parlents with oral or neck surgery in the ir:-mediate postoperative period. The nurse is responsible for assessin.the patientt respiratory status. The nurse directs rhe NAP about:o Appropriate suction limits for oropharyngeal suctioning for th.

particular patient, for example, the appropriate suction pre.,sure, expected frequency of suctioning, and the expected colciand volume of secretions.

r The risks of applying excessive or inadequate sucrion pressure.r Avoiding mouth sutures, applying suction against sensitir':

tissues, and dislodging tubes in the patient's nose or mouth.o Avoiding stimulation of the gag reflex.

Equipri:entD Towel, cloth, or disposable paper drapefl Clean glovesfl Yankauer or tonsillar tip suction catheterfl Mask, goggles, or face shieldE Disposable cup or nonsterile basintr Thp water or normal saline (about 100 mL)E Suction equipmentE Connecting tubing (6 feet)tr Oral airway (if indicated)tr \Tashclorh (if indicated)D Pulse oximeter

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i Assess signs and symptoms of upper airway obstruction requir-ing oropharyngeal suctioning: gurgling on inspiration or expi-ration, restlessness, obvious excessive oral secretions, drooling,gastric secretions or vomltus in mouth, or coughing withoutclearing secretions from upper airway.

t Assess for signs and symptoms associated with hypoxia (lowoxygen utilization at the cellular or tissue level), hypoxemia(low oxygen tension in the blood), or hypercapnia (elevated

carbon dioxide tension in the blood) and associated symptomsof apprehension, anxiety, decreased ability to concentrate,lethargy, decreased leve1 of consciousness (especially acute),increased fatigue and dizziness, behavioral changes (especially

irritability and restlessness), increased pulse rate, increased rate

of breathing, decreased depth of breathing, elevated bloodpressure, cardiac dysrhythmias, pallor, cyanosis, dyspnea, anduse of accessory muscles for breathing (Considine, 2005).

3 Obtain patient's oxygen saturation level via pulse oximetry(SpOz) (see Chapter 5). Keep oximeter in place.

,i Determine patient's knowledge about use of suction catheter.5 Identifu risk factors for airway obstruction such as impaired

cough or gag reflex, weakened respiratory muscles, impairedswallowing, and decreased level of consciousness, as well as

patient's inability to manipulate and use the catheter device.

6 Auscuitate for presence of adventitrous sounds.

NIJHSIfiIG DIAGT,IOSES. Defrcient knowledge regarding airway . Impaired swaliowing

clearance techniques and devices ' Ineffective airway clearance. Impaired gas exchange . Ineffective breathing pattem

SKlLL25-1 OropharyngealSuctioning

Physical signs and symptoms result from pooling of secretions inupper airway. lTorsening secretions may result in total airwayobstruction and hypoxia. The risk for aspiration ofgastric con-tents and airway obstruction is increased in patients with vom-iting, delayed gastric emptying, impaired esophageal sphinctercontrol, hiatal hernia, impaired cough, impaired swallowing, orimpaired gag reflex.

Suctioning of airways is indicated with alterations in oxygenationassociated with secretion accumulation.

Provides an objective baseline measure of the oxygen saturationand provides an early objective indication ofworsening oxygen-ation status.

Reveals need for patient instruction,Risk factors prevent patient from protecting the airway from aspi-

ration or from clearing secretions safely. Physical factors such as

impaired mobiliry of the upper extremities prevent patient fromusing the catheter to help control oral secretions.

Determines if lower airway secretions are present (see Skill 25-Z).

. Risk for aspiration

. Risk for infection

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1 Expected outcomes following completion of procedure:. Upper airway (oral pharynx) is cleared of secretions.. No gurgling sounds are heard in patient's pharynx on inspi-

ration and expiration.. Drooling is diminished or absent.

. Vomitus or gastric secretions are absent from mouth.

. SpOz improves or remains the same.

2 Explain to patient how the procedure helps clear airway secre-

tions and relieves some breathing problems. Explain thatcoughing, gagging, or (less commonly) sneezing is normal andiasts only a few seconds. Encourage patient to cough out secre-

tions during procedure. Practice coughing if able. Show patienthow to splint surgical incisions, if necessary.

I Position patient (usually semi-Fowler's or sitting upright).Place towel, cloth, or paper drape across patient's neck andchest.

Suctioning is effective.Presence of secretions in large upper airway produces noisy

respirations.Excessive drooling indicates that patient is unable to handle oral

secretions.Gastric secretions retained in oral cavity increase patient's risk for

aspiration pneumonia.Removal of secretions helps to improve oxygen saturation level.

Gagging or coughing occurs when the posterior pharynx is deeplysuctioned or as a result of excess secretions. Coughing secre-

tions out of lower airway or posterior pharynx decreases theamount of suctioning required. Splinting reduces abdominalincision discomfort during coughing or gagging.

Promotes patient comfort and removal of airway secretions. Towelprotects patient's gown and bed linen from contamination bysecretions.

lliti*al De*isi** F*int ln patients with chronlc pulmonary dlsease, the Sp}z value nay remain the same after suctllnng.

CHAPTER 25 Airway Management

lfl"rIFL[:{,.;l ; e r A i, ff i!"'t Perform hand hygiene, and apply clean gloves. Apply mask or

face shield if splashing is likely.* Fill cup or basin with approximately 100 mL of warer or nor-

mal saline.S Connect one end of connecting tubing to suction machine

and other to Yankauer suction catherer, Tum on suctionequipment, set vacuum regulator to appropriate setting (see

manufacturer's instructions ).4 Check that equipment is functioning properly by suctioning

smal1 amount of water or normal saline from cup or basin.F Remove patient's oxygen mask, if present. Nasal cannula may

remain in place. Keep oxygen mask near patient's face.

Reduces transmission of microorganisms.

Aids in cleansing catheter after sucrioning.

Prepares suction apparatus. Elevated pressure settings increase riskfor trauma to the oral mucosa.

Ensures equipment function and lubricates catheter.

Allows access to mouth. Reduces chance of hypoxia.a-

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Insert catheter into mouth along gum line to pharynx. Movecatheter around mouth until secretions have cleared. Encour.age patient to cough. Replace oxygen mask.Rinse catheter with water in cup or basin until connecringtubing is cleared of secretions. Tirrn off suction. lUash face ifsecretions are present on patient's skin.Observe respiratory status. Repeat procedure, if indicated.May need to use standard suction catheter to reach into tra-chea if respiratory status not improved (see Skili 25-2).Remove towel, cloth, or disposable drape, and place in trashor in laundry if soiied. Reposition patient; Sims' position en-courages drainage and should be used if patient has decreasedlevel of consciousness.Discard remainder of water into appropriate receptacle. Rinsebasin in warm soapy water, and dry with paper towels. Discarddisposable cup into appropriate receptacle. Place catheter inclean, dry area,

'!'I Remove gloves and mask or face shleld, and dispose of in ap-propriate receptacle. Perform hand hygiene.

€11 Position patient, and provide oral hygiene as needed.

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! Compare assessment lindings before and after procedure.i.;l Auscultate chest and airways for adventitious sounds.

:* Obtain postsuction SpO2 measure.

.€ Observe patient or family perform Yankauer suctioning.

Movement of catheter prevents the suction tip from invaginatinroral mucosal surfaces and causing trauma. Coughing moves se-

cretions from lower airway into mouth and upper airway.Rinses catheter and reduces probability of transmission of microor-

ganisms. Clean suction tubing enhances delivery of set suctior.pressure. Prevents skin breakdown.

Directs nurse to continue or cease intervention or to choose ar.-other intervention.

Reduce. rransmission of microorganisms.Facilitates drainage of oral secretions.

Reduces transmission of microorganisms and maintains medica-asepsis. Moist environment encourages microorganism growth-

Reduces transmission of microorganisms to other patients an:equipment.

Promotes patient's comfort.

Identifies physiological response to the suction procedure.Presence of lower airway adventitious sounds snggests a need fi--

lower airway suctioning.Provides objective postsuction dara to compare with baseline an:

is another objective measure of the effectiveness of the suctio:.procedure (AARC, 2004).

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Unexpected Outcomes1 Worsening respiratory distress.

2 Return of bloody secretions.

Reeordlng and RePcrting. Record the amount, consistency, color, and odor of secretions

and the patient's response to the procedure; document presuc-

tion and postsuction cardiopulmonary assessment.r Record instruction to caregivers and ability to correctly perform

procedure.

Ieaching Cansiderations. Instrrci family or caregiver not to allow catheter to fall to the

floor.r Provide information regarding signs and symptoms of worsening

respiratory status.. Asiess knowledge ievel of patient and family caregiver to deter-

mine amount of instruction required and frequency of home

health visits necessary to reach goals.

Pediatric Considerationsr Maintain healthy infant in supine posirion (American Acad'

emy of Pediatrics, 2005).o Position infants with breathing problems or excessive vomitus in

prone position (Hockenberry and \Uilson, 2007; Pease, 2006)'r Airways of infants and children are smaller than those of an

adult; even small amounts of mucus cause airway obstruction'

SKILL 25-2 AirwaY Suctioning

Related lnterventionsr Suction further or implement nasal 0r tracheal suctioning.. Evaluate need for other means to protect airway (e.9., oral intubation,

oral airway, positioning).. Provide supplemental oxygen.. Notify physician.

. Assess oral cavity for trauma or lesions.

. Reduce the amount 0f suction pressure used.

. 0bserve catheter tip for nicks, which cause mucosal trauma.

. lncrease frequency 0f oral hygiene.

. Use bulb syringe. Compress syringe before insertion to prevent

forcing secretions into infant's bronchi (Hockenberry and

\filson, 2007).l{ more forceful suctioning is necessary, use

mechanical suction.

Gerontological 0onsiderationso Some patients with dysphagia benefit from oral suctioning be-

fore, during, and after meals.o Oral mucosa in older adulrs is fragile, and a lower suction pres'

sure is needed.. Older adults are prone to aspiration oforal secretions because of

decreased cough and gag reflexes (Meiner and Lueckenotte,

2006).

Long-Term and Flome eare Considerations. In the long-term care or home setting, make sure patient knows

[o clean and disinfect or change the secretion collection con-

tainer every 24 hours according to home care or institutionalprotocol. Many institutions seal and dispose of the entire dis'posabie secretion collection canister as biohazardous material'

o Assess home for the presence of respiratory irritants, includingcigarette smoke, dust, pollen, animal dander, mold, and

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Ihe major differences between oropharyngeal and tracheal airway

,uctioning are the depth suctioned, sterile procedure, and the po'

:ential for complications' Oropharyngeal suctioning only removes

,ecretions from the back of the throat. Tiacheai airway suctioning

:rtends into the lower airway. Suctioning is necessary to remove

::spiratory secretions and maintain optimum ventilation and oxy-

"enation in patients who are unable to independentiy remove

:rese secretions (Demir and Dramali, 2005). Assess the patient to

:etermine frequency and depth of suctioning. Some patients re'

-uire suctioning every hour or two, whereas others need suctioning

nly once or twice a day (Considine, 2005).

If the secretions are only in the nose and mouth, then only the

:harynx requires suctioning, although in most instances you will:ction both the pharynx and the trachea. Suction secretions from

.re pharynx as oflen as necessary. Secretions that are not removed

.re more likely to be aspirated into the lungs, increasing the risk'-.r infection and respiratory failure.

The suctioning procedure has many risks associated with it' The

rost serious relate to hypoxemia, which often results in cardiac

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dysrhythmias; laryngeal spasm; bradycardia, which is associated

with stimulation of the vagus nerve; and nasal trauma and bleed-

ing, which can develop from trauma of the suction catheter (Demir

and Dramali, 2005).

NASOPHAHYNGEAL AND NASOTRACHEALsucTtoNlNG {ffi**-

lrrlermeciiate r'fiesptrufr:ry *a.re a*d Sucti*nir;g IFerfa rrn i n g JVasoliacneai Sucfionrng

t'tso Airway fdart;';gement fv4saule I Lesson 4

Nasopharyngeal and nasotracheal suctioning assist in maintaining

a patent airway by removing secretions from the pharynx or throatand the trachea. This type of suctioning is used when oral suction'ing with a Yankauer devlce is ineffective or inappropriate or when

th. lowet airway requires removal of secretions. It involves

inserting a smal1 rubber or soft plastic tube into the nares to the

pharynx or trachea and then applying negative pressure to

withdraw mucus.