Nasal and Oral Suction Nov 2011

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CLINICAL GUIDELINES/NURSING

Guideline for Adult Nasal and Oropharyngeal Suction
Reference
Date approved Nov 2011
Approving Body Matrons Forum
Supporting Policy/ Working in
New Ways (WINW) Package

Implementation date
Supersedes Version 1
Consultation undertaken Nursing Practice Guidelines Group, Ward
Sisters/Charge Nurses, Practice
Development Matrons (PDMs), Clinical
Leads, Matrons. Respiratory
Physiotherapists,
Add any other groups that have been consulted in
the writing/review of the guidelines
Target audience Clinical staff

Document derivation /
evidence base:

Review Date Nov 2014

Lead Executive Director of Nursing

Author/Lead Manager Fiona Moffatt
Nursing practice Guidelines group member
link Holly Scothern

Further Guidance/Information

Distribution:

Ward Sisters/Charge Nurses, PDMs, Clinical
Leads, Matrons, Nursing Practice Guidelines
Group (includes University of Nottingham
representative), Clinical Quality, Risk and
Safety Manager, Trust Intranet.
Add any extra groups/organisations to whom guideline
has been circulated



Nasal and Oral Suction Nov 2011
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NOTTINGHAM UNIVERSITY HOSPITALS

NURSING PRACTICE GUIDELINES





" 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."

INTRODUCTION

Description

Oropharangeal and nasopharangeal suction is a technique intended to
stimulate a cough to remove excess secretions and / or aspirate secretions
from the airways which cannot be removed by the patients spontaneous
effort. A cough can be stimulated by the catheter in the pharynx or it may be
necessary to pass the catheter between the vocal cords and into the trachea
to stimulate a cough. The trachea is accessed by insertion of a suction
catheter either via nasal passage and pharynx (nasotracheal suction) or via
the oral cavity and pharynx (orotracheal suction) using an airway adjunct.
Nasotracheal suction may be undertaken directly via the nostril without an
airway adjunct. However, in some situations, repeated suction is anticipated
and therefore a nasopharyngeal airway should be utilised. Secretions are
removed by the application of sub-atmospheric pressure via wall mounted
suction apparatus or portable suction unit.

N.B. These guidelines are only intended to cover the use of orotracheal and
nasotracheal suction in the patient without an endotracheal or tracheostomy
tube.
At all times, staff must adhere to their codes of professional conduct
(Nursing Midwifery Council 2008, Chartered Society of Physiotherapy
2002).






NASAL AND OROPHARYNGEAL SUCTION

Nasal and Oral Suction Nov 2011
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Abbreviations

mmHg millimetres of mercury
kPa Kilopascals
Sp0
2
Oxygen saturation
TB Tuberculosis
ICP Intracranial pressure

INDICATIONS

Airway suction is indicated to maintain a patent airway and remove excess
secretions or aspirate from the trachea, when:
1. The patient is unable to clear the airway spontaneously
2. The secretions / aspirate are of detriment to the patient
3. All other methods to remove secretions / aspirate have failed (such as
cough assist methods).











Best Practice

Nasotracheal and orotracheal suction should only be undertaken when
other less invasive techniques have proved unsuccessful, and where the
secretions are causing physiological deterioration and / or distress
(Pedersen et al., 2008) Indications that the patients may need suctioning
include audible secretions in upper airway or noisy crackles, on
auscultation, palpable secretions, in effective or weak coughing,
desaturation despite increased oxygen requirements or raised respiratory
rate.
Nasotracheal and orotracheal suction should only be performed by staff
who, have been trained and deemed competent as per local policy with
relevant training and education being included in an in-service training
programme. In addition, opportunities should be offered locally to
competent practitioners at all levels wishing to maintain their skills in
tracheal suction.
Best Practice

Tracheal suction is an invasive, blind, high-risk procedure with uncertain
outcome, and therefore should only be undertaken when a clear indication
has been identified via assessment. Nurses should work closely with the
physiotherapy team when considering any of these procedures.
Secretions/aspirate may be deemed as detrimental when they cause the
patient distress, or physiological derangement e.g. impaired ABGs,
reduced SpO
2
and/or increased respiratory rate.
Nasal and Oral Suction Nov 2011
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CONTRAINDICATIONS

Nasotracheal suction
Severe coagulopathy and / or unexplained haemoptysis
Laryngospasm (stridor)
Basal skull fractures, or cerebrospinal fluid leakage via the ear
Severe bronchospasm
Recent oesophageal or tracheal anastamoses, or tracheo-oesophageal
fistula
Occluded nasal passages
Nasal bleeding
Recent oral / nasal surgery


Orotracheal suction
Severe coagulopathy and / or unexplained haemoptysis
Laryngospasm (stridor)
Acute neck, facial or head injury (particularly basal skull fractures, or
cerebrospinal fluid leakage via the ear)
Severe bronchospasm
Recent oesophageal or tracheal anastamoses, or tracheo-oesophageal
fistula
Loose teeth or crowns
Intact gag reflex (relative contraindication)


RELATIVE CONTRAINDICATIONS (seek medical advice prior to insertion)
Acute neck, facial or head injury
Haemodynamic instability
Nasal/oral burns, due to infection risk
Signs suggestive of raised intracranial pressure
Coagulopathy

HAZARDS
Mechanical trauma that is trauma to airway mucosa particularly
associated with poor technique and excessive suction pressures
Hypoxia / hypoxaemia
Cardiac arrhythmias
Fluctuations in blood pressure
Vasovagal stimulation eliciting bradycardia and hypotension
Respiratory arrest / apnoea
Nasal and Oral Suction Nov 2011
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Gagging / vomiting (particularly orotracheal suction)
Aspiration
Laryngospasm
Bronchospasm
Pain
Infection
Atelectasis area of lung collapse particularly associated with excessive
suction pressures or prolonged coughing
Increase in intracranial pressure
Misdirection into the oesophagus
Patient distress and discomfort


EQUIPMENT LIST

Suction source with adjustable pressure regulator
Collection vessel and connector tubing
Sterile, multi-eyed suction catheters of appropriate size use the smallest
size catheter to be effective, ideally 10-12 FG
Sterile water (dated, named and timed) plus container
Clean disposable examination gloves
Apron
Sterile disposable co-polymer examination gloves
Eye protection and/or mask if indicated
Orotracheal suction: Guedel airway of appropriate size (Appendix 1,diagram
A)
Nasotracheal suction: Lubricating gel, nasopharyngeal airway (optional) of
appropriate size (Appendix 2, Diagram B).
Oxygen supply and delivery device
Sputum trap if specimen required
Monitoring equipment (pulse oximeter)
Ensure emergency equipment available if required
Refer to General Principles for All Procedures.


PRINCIPLE

RATIONALE

1.







Assess the patients
requirements for suctioning:
Abnormal breathing,
physiological deterioration and
/ or distress, audible secretions
in upper airway or noisy
crackles on auscultation,
coughing, desaturation or
To determine whether suctioning is
necessary Endotracheal suctioning
should be performed only when
necessary (Pedersen et al., 2008)




Nasal and Oral Suction Nov 2011
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2
raised respiratory rate (Wood,
1998b)
Ensure informed consent is
given where able as per trust
policy.
Prepare patient by giving
analgesia if required and
reassurance and information

Close Curtains


Patient must have information to
consent to procedure and feel
reassured. NB there will be patients
who lack capacity to consent
See NUH consent to Examination or
Treatment policy (Ref CL/CGP/020)

To maintain privacy & dignity and to
avoid distress for other patients
3 Wash & dry hands & put on
non-sterile examination gloves
and apron, and eye
protection/mask if indicated.

Minimises risk of cross infection to
patient or operator (Saving lives DoH,
2007, Day et al., 2002)
4 Check correct functioning of
vacuum source and set
negative pressure to up to a
maximum of 20kilo Pascals
(kPa)/ 150 mmHg.

Minimises the risk of mechanical
trauma. Note that increased pressures
do not facilitate better removal of
secretions. (Glas, 1995, Wood, 1998,
Day et al., 2002, Branson, 1993)










PRINCIPLE

RATIONALE

5. Where possible, position the
patient to ensure their airway is
open, either in high side lying
or sitting upright

Minimises the risk of misdirection of the
catheter into the oesophagus.
Care to keep position safe where spinal
injury is involved
6. Pre -oxygenate for at least 30
seconds. Oxygen must be
prescribed, and should be
given at maximum rate safely
tolerated by the patient (see
NUH oxygen policy ) Caution in
Minimises the risk of hypoxia /
hypoxaemia and cardiac dysrhythmias
(Thompson et al., 2000, Branson et al.,
1993)
Best Practice

The use of eye protection and a mask is recommended if the patient has
such infections as TB, meningococcal meningitis or any blood or air borne
virus. For further advice, contact the Infection Control team.
Nasal and Oral Suction Nov 2011
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patients requiring controlled
oxygen therapy

7a. Orotracheal suction:
wash & dry hands & put on
gloves
Insert a Guedel Airway if the
patient has a GCS of 8 or less.
(see appendix for sizing guide)

Prevent cross infection
Provides a patent route for passage of
the suction catheter and prevents the
patient biting down on the catheter.
Patient with a GCS of 8 or less will
have an incompetent airway and there
is a risk of aspiration should the patient
vomit during suction.
7b. Nasotracheal suction:
wash & dry & wear gloves

Insert nasopharyngeal
airway, if repeated
nasotracheal suction is
anticipated. (Appendix 2,
diagram C)




Provides a more comfortable route for
repeated passage of the suction
catheter and less damage to the
mucosa with repeated suction.
8. Open suction catheter
packaging. Connect suction
catheter tubing, ensuring that
catheter remains within the
sterile pack. Put sterile co-
polymer glove on dominant
hand and use that hand to
withdraw catheter from pack.

Minimises risk of cross infection to
patient or operator.
9. Insert suction catheter via
guedel airway, or nostril. Aim to
time this with patients
inspiratory phase. If using a
nasopharyngeal airway or
nostril, dipping the suction
catheter in a small amount of
sterile water will facilitate
passage. If performing suction
directly via the nostril, introduce
the catheter and progress it
gently towards the back of the
nose with an upward
inclination. Once resistance is
felt, gently rotate the catheter
until the resistance is
Minimises mechanical trauma to airway
passages and patient discomfort.
(Wood, 1998b, Celik, 2000, Day et al.,
2002)












Nasal and Oral Suction Nov 2011
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overcome.


9 Do not apply suction during
insertion. The catheter should
be inserted no further than the
carina (or when resistance is
felt) and retracted a maximum
of 1 2 cms.

Reduces risk of damage to the carina
and subsequent vagal stimulation.

10. Continue to insert catheter until
a resistance is felt or a cough
elicited. Withdraw by a
maximum1- 2 cms before
applying suction to ensure tip
of catheter is not abutting the
carina.

Minimises the risk of mechanical
trauma to carina and subsequent vagal
stimulation. Withdrawing the catheter
too far from the point of resistance or
from the point of cough stimulation may
result in some secretions remaining in
the airway.
11. Remove catheter if misdirection
into the oesophagus is
suspected (e.g. gagging,
absence of cough, aspiration of
gastric contents).

Maximises effectiveness of procedure
and minimises risk of aspiration.

12. Apply suction continuously (not
intermittently) throughout
catheter removal. Withdraw
catheter smoothly (without
rotation). Ensure that this
period of suction application
does not exceed 15 seconds
(Pedersen et al., 2008). The
catheter must be withdrawn
cleanly and not reinserted
during withdrawal.

Continuous suction minimises adverse
effects / hazards associated with
suction, e.g. hypoxia / hypoxaemia,
cardiac dysrhythmias, blood pressure
fluctuations, pain, apnoea, atelectasis,
raised intra-cerebral pressure etc
(Czarnik et al., 1991, Stenqvist et al.,
2001, Day et al., 2002, Celik & Elbas,
2000, Wood, 1998b)
13. Monitor patients condition
during and following treatment,
e.g. colour, breathing pattern,
respiratory rate, heart rate,
secretions (colour, tenacity,
quantity), evidence of trauma,
distress, cough, SpO
2
. Seek
urgent help in the event of
patient deterioration.
Ensures patient safety and assesses
improvement in patient condition.
Detects deterioration quickly.
Nasal and Oral Suction Nov 2011
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14. Remove sterile glove inverting
it over the used catheter and
dispose in clinical waste bin.

Maximises effectiveness of procedure
and minimises risk of cross infection.


15. After the final episode of
suction, remove airway adjunct,
provided the patient is able to
maintain a safe airway.

Ensures patient safety and comfort.




16. Where possible encourage
deep breathing.

Minimise atelectasis.
17. Once treatment is completed,
rinse suction connector tubing
using a small amount of sterile
water decanted from the bottle
into a container. Ensure
opening date and time has
been marked on bottled water
in order that it may be
discarded after 24 hours. Turn
suction off. Ensure suction
tubing is supported well clear of
the floor.

Maintain safe, clean environment.
Minimise risk of cross infection.
18. Wash hands.
Discard any disposable items
in appropriate clinical waste
bins and change suction bottle
if necessary.

Maintain safe, clean environment.
Guedel airways are single use products
and therefore must be discarded after
use. Nasal airways can remain in situ
but should be changed every 48 hours
or sooner if indicated to prevent
occlusion by dried secretions.
19. Reassess patient and report
any adverse effects or changes
in patients overall condition to
senior nursing and/or medical
personnel. Return oxygen to
pre suction levels if the
patients saturations are within
their target range.

To ensure patient safety.


20. Document procedure, effects
and response as per
documentation policies.
Allows ongoing multidisciplinary team
assessment and evaluation of patients
condition.
Nasal and Oral Suction Nov 2011
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FURTHER READING & REFERENCES

American Association of Respiratory Care (1992) Clinical Practice Guideline
Nasotracheal Suctioning Respiratory Care Vol. 37, pp. 898-901

American Association of Respiratory Care (1993) Clinical Practice Guideline
Endotracheal suctioning of mechanically ventilated adults and children with
artificial airways Respiratory Care Vol. 38, pp. 500-504.

Branson RD, Cambell RS, Chatburn RL, Covington J (1993) AARC clinical
practice guideline: Endotracheal suctioning of mechanically ventilated adults
and children with artificial airways. Respiratory care; 38 (5): 500-4


Celik SS, Elbas NO (2000) The standard of suction for patients undergoing
endotracheal intubation. Intensive critical care Nursing; 16 (3) 191-8

Chartered Society of Physiotherapy (2002) Rules of Professional Conduct.

Czarnic RE, Stone KS, Everhart CC J r, Preusser BA. (1991) Differential
effects of continuous versus intermittent suction on tracheal tissue. Heart Lung
; 20 (2) :144-51

Day T, Farnell S, Wilson-Barnett J . (2002) Suctioning: a review of current
research recommendations. Intensive Critical Care Nursing 18 (2): 79-89

Department of Health (2007) Saving Lives: a delivery programme to reduce
healthcare associated infection including MRSA London

Frankell HL, Mathias CJ , Spalding J M (1975) Mechanisms of reflex cardiac
arrest in tetraplegic patients The Lancet Vol. 2, pp.1183-1185

Glass C, Grap MJ . Ten tips for safer suctioning American J ournal of Nursing ;
95 (5): 51-53
Higgens,D; (2005) Tracheal suction. 22 February, Nursing TimesVOL: 101, ISSUE: 08, P
36 -38
http://www.nursingtimes.net/nursing-practice-clinical-research/tracheal-
suction/203988.article

J ones M and Moffatt F (2002) Cardiopulmonary Physiotherapy Oxford: Bios
Scientific Publishers

J ung RC, Gottlieb LS (1976) Comparison of tracheo-bronchial suction
catheters in humans. Chest Vol. 69, pp. 170-181
Nasal and Oral Suction Nov 2011
11

Kleiber C, Krutzfield N, Rose EF (1988) Acute histologic changes in the
tracheo-bronchial tree associated with different suction catheter insertion
techniques. Heart & Lung Vol. 17, pp. 10-14

Leith DE (1985) The development of cough. American Review of Respiratory
Disease Vol. 131, pp. S39-42

Mansell A, Bryan C, Levison H (1972) Airway closure in children. J ournal of
Applied Physiology Vol. 33, pp. 711-714

NUH Consent to Examination or Treatment policy 2010 (Ref CL/CGP/020)
http://nuhnet/nuh_documents/Documents/Consent%20to%20Examination%20
or%20Treatment.doc

NUH Oxygen Policy (2010)

Nursing and Midwifery Council (2008) The Code: standards for conduct,
performance and ethics for nurses and midwives (May 2008).

Pedersen C, Rosendahl-Nielsen M, Hjermind J and Egerod I (2008)
Endotracheal suctioning of the adult intubated patient What is the Evidence
? Intensive and critical care Nursing (2009) 25, 21-30


Rosen M, Hillard EK (1962) The effects of negative pressure during tracheal
suction Anaesthesia and Analgesia Vol. 41, pp. 50-57

Stenqvist O, Lindgren S, Karason S, Sondergaard S, Lundin S (2001)
Warning ! Suctioning. A lung model evaluation of closed suctioning systems.
Acta Anaesthesiol Scand ; 45 (2): 167 72

Thomson L, Morton R, Cuthebertson S. (2000) Tracheal suctioning of adults
with an artificial airway. Best Practice; 4 (4): 1-6

Quirke S (1997) Closed circuit suction systems. Care of the Critically ill.
Vol.13, No. 6 Supplement.

Widdicombe J G (1980) Mechanism of cough and its regulation. European
J ournal of Respiratory Disease Vol. 61: (Suppl 110) pp. 11-15

Wood C J (1998b) Endotracheal suctioning: a literature review. Intensive
Critical care nursing 14 (3): 124-136

Nasal and Oral Suction Nov 2011
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Young CS (1984) A review of the adverse effects of airway suction.
Physiotherapy Vol. 70, pp. 104-106




Author: Fiona Moffatt, Critical Care Outreach Team Physiotherapist, NUH
Queens Campus and Cheryl Crocker, Consultant Nurse Critical Care


NPGRG Link: Holly Scothern.

For Review: 2011





AUDIT POINTS


1. Have other less invasive techniques been attempted and proved
unsuccessful prior to naso or oral tracheal suction being attempted?

2. Has the patient been prepared with explanation, reassurance, privacy &
dignity and analgesia (if necessary)?

3. Has informed consent been obtained?

4. Has the vacuum been set to a negative pressure no greater than 20kPa
/ 150mmHg?

5. Has asepsis been maintained throughout the procedure?

6. Has the patients condition during and following treatment been
monitored?

7. Have any adverse effects or changes in patients overall condition been
reported to the relevant nursing or medical staff?





Nasal and Oral Suction Nov 2011
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APPENDIX 1
Selection and Insertion of an Oropharyngeal Airway
Resuscitation Council UK (20011) Advanced Life Support Course Provider
Manual 6th Edition London: Resuscitation Council UK(reference is incorrect)
http://www.resus.org.uk/pages/pub_ALS.htm



Selection:
Most commonly used sizes are 2, 3 and 4.
For small, medium and large adults respectively.
The length of the airway should correspond to the vertical distance
between the patients incisors and angle of the jaw (see diagram).
Diagram A
Insertion:
Only used in patients with a reduced level of consciousness, as vomiting
and laryngospasm may occur if glossopharyngeal and laryngeal reflexes
are present.
Open patients mouth and ensure that there is no foreign material that
could be pushed into the larynx.
Introduce airway into the oral cavity in an upside-down position (as far
as the junction between the hard and soft palate), then rotate through
180. This rotation minimises the chances of pushing the tongue down
and back
Insert further until the airway lies in the oropharynx.

Diagram B










Remove airway immediately if any reflex responses are seen.
Nasal and Oral Suction Nov 2011
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APPENDIX 2

Selection and Insertion of a Nasopharyngeal Airway
Resuscitation Council UK (2011) Advanced Life Support Course Provider
Manual 6th Edition London: Resuscitation Council UK
http://www.resus.org.uk/pages/pub_ALS.htm
Selection:
Most commonly used sizes are 6 for females and size 7 for males


Insertion:
Generally better tolerated than an oropharyngeal airway in patients
who have a higher level of consciousness.
Not suitable for patients with actual or suspected basal skull fracture.
Can cause damage to the mucosal lining, leading to bleeding. It is
essential to ensure that clotting is normal.
If the tube is too long, it may stimulate laryngeal and glosso-
phayngeal reflexes eliciting laryngospasm and vomiting.
Prepare the nasal airway by lubricating the airway with water-based
gel.
Some nasal airways have a wide flange to prevent inhalation via the
nostril. Others have smaller flanges and these require the insertion of
the supplied safety pin through the flange to prevent inhalation.
Slowly and gently insert the bevel end first along the floor of the nose,
with a slight twisting action. The curve of the airway should direct it
towards the patients feet.
Once in place, establish the patency of the tube and adequacy of
ventilation (look, listen, feel).
In patients with coagulopathies this will need to be performed under
platelet cover where there is significant risk of bleeding, and
consultation should be made with the medical team prior to insertion.

Diagram C