Suctioning, Patent Airway, Tracheostomy Care, Chest Tubes
MIKE L. GILLIAM, R.N., M.S.N., CCRN and GENENE ARVIDSON-PERKINS, M.S.N, R.N.
I. Suctioning: done in order to ensure airway patency.
A. Normally, patency maintained by:
2. Thin mucus blanket
3. Phagocytic cells of alveoli
4. Peristalsis of bronchioles
B. To ensure patency when the client is unable to remove secretions, he will be suctioned as necessary.
1. This means not routinely but as necessary
2. The more frequent the procedure, the more irritation ensues.
C. Use of excessive pressure causes undue trauma and may result in biopsy of lung tissue
1. Pressure of 80 to 100 mm.hg vacuum is used for suctioning the client with endotracheal tube or with tracheostomy.
2. Only on rare occasions will pressure up to 110 to 120 mm. hg. be needed.
D. Suction is applied only when removing catheter from the tracheobronchial tree, and not while inserting the catheter.
E. Suction is always intermittent ‑ not continuous; will traumatize if continuous.
F. Suction as deep as necessary in order to elicit a cough response or to obtain secretions or both.
G. This is a sterile procedure and requires attention to sterile technique.
H. Maximum time is 10 to 15 seconds. Hyperoxygenation of the client is recommended prior to and following each entry into the TB tree.
I. Hyperoxygenation is possible via 100% oxygen for 3 to 5 breaths or by sign mechanism of the ventilator which provides deeper, full respirations. Current recommendation in literature is to do both, but practice is either one.
1. Extra, regular respirations may be given and are probably best, since hyperinflation problem results from sigh mechanism.
2. Two or three of these hyperoxygenation maneuvers may be performed. It is best to hyperoxygenate client on the ventilator if this is permitted in the facility.
3. If 100% oxygen used, is essential that it be turned back to prior FIO2 in order to preclude oxygen toxicity. Some machines do this automatically
4. Bag-valve-apparatus may be best to hyperoxygenate the client with an ET tube or with tracheostomy tube
a. hook up to 100 % oxygen source and bag client slowly with full strokes of the bag to allow adequate time for bag to fill
b. bag between suctioning maneuvers
c. bag following all suctioning and before reconnecting client to ventilator
J. If secretions are thick, a lavage of 3‑5 ml. of saline used prior to suctioning.
K. The lavage solution is placed in the endotracheal or tracheostomy tube, the client is ventilated, then suctioning is performed.
II. Tracheostomy care ‑ performed to maintain patency of airway by removal of secretions and encrustations
A. If cuff present, suction above cuff, through mouth or nose prior to deflating cuff.
B. Tracheostomy care is a sterile procedure.
C. If low pressure cuff present, will not be deflated.
D. Many tracheostomy sets now have an inner cannula that is disposable; it is removed daily and a new one inserted.
E. If reusable inner cannula, it is removed by touching outer flanges only with hand and
1. dropped into soaking basin of sterile H2O2 or bicarbonate solution. This Facilitates removal of mucus.
2. Bristle brush used to clean out bore of cannula.
3. Use H2O2 on 4 x 4 gauze to cleanse around tracheostomy stoma/outer cannula.
4. Desirable to suction outer cannula during time the inner cannula is soaking if secretions are present and client needs suctioning.
5. Rinse inner cannula with sterile saline and then inspect inside to be sure no bristles are left from brushing.
6. Shake off excess solution and replace. Be sure is secure so cannot be coughed out.
III. Chest Tubes: used to facilitate expansion of lung following surgical intervention or trauma by restoration of negative pleural/thoracic pressure.
A. Used following thoracotomy if only one section or lobe is removed to assist in reexpanding lungs and for drainage of serous and serosanguinous fluids ‑
1. Client position should not be on this operative side as this may interfere with expansion and fluid removal - prefer operative side up to "facilitate expansion of remaining lobes adjacent to resected lung tissue"
2. Client with thoracotomy for pneumonectomy will not have tubes and will be positioned onto the operative side or onto the back in order to facilitate oxygenation of unaffected lung, promote consolidation of the cavity as it fills with fluid, and prevent leakage from the operative side to the unaffected, health lung.
B. Used to restore a negative pressure relative to barometric pressure of atmosphere.
C. Water seal prevents air from reentering the lung during respirations.
1. Respiration negativity increases with inhalation and decreases with exhalation.
2. Therefore will see water rise in tube during inhalation and fall during exhalation because pressure more negative on inhalation.
IV. Nursing intervention in chest tubes:
A. Be sure fluid type and amount is noted and bottle is marked at level of fluid.
B. Watch for bubbling or rising of fluid in the tube ‑ indicates leaking or atelectasis is taking place unless pressure is applied by external vacuum line; bubbling is normal then, but rising of fluid is still abnormal. ATELECTASIS
C. Keep tubes patent by milking or squeezing them every 2 hours; some facilities use tube strippers to do this.
D. Keep system patent by checking pressure if is attached to suction/vacuum device. Most are attached at 12‑20 cm/H2O pressure.
E. Watch for loops below bed level and prevent by pin/rubber band, as these may allow fluid to reenter pleural space
F. Fluctuation is normal in tubing and should be assessed, especially in tube not attached to vacuum/suction line and to lesser extent in those attached to suction/vacuum.
G. If observe drainage rising rather than leaving tubing, atelectasis or collapse is usual cause; clamp tube and report at once
H. Be prepared to clamp tube close to chest in event leak occurs in system or breakage of system occurs. Two clamps that are shod used.
V. Types of Systems
A. One bottle system - used for air and fluid drainage from chest cavity; amount of fluid and air removed is gravity dependant, and air escapes via vented opening on top
1. Water seal is maintained by rod to which drainage tube is attached being under water by about 1 inch.
2. Suction attachment is possible but unusual in single bottle system
3. Since fluid drains in with water seal solution, the solution rises and slows the rate or amount of lung expansion.
B. Two Bottle system - allows for collection of drainage in a separate bottle or container, with a separate bottle for maintaining suction control (water seal and drainage are in one bottle; suction control is separate
C. Three bottle system - The third bottle is specifically used to control the amount of suction applied to the system. The first and second bottle allow for separation of water seal and collection
1. The depth of the venting glass rod below the water determines the amount of negative pressure
2. Bubbling is expected and indicates the system is working and has enough negative pressure applied to it to maintain the desired negativity in the bottle system.
3. The Pleur-evac system is a three bottle system housed in one chamber
Updated April 1, 2011 by Mike L. Gilliam with Genene Arvidson-Perkins