6.

14

PROCEDURE

SUBJECT: Suctioning of the non-intubated paediatric patient

DOCUMENT NUMBER: 6.14

DATE DEVELOPED: July 2012
DATES REVISED: NEW
DATE APPROVED: August 2012
REVIEW DATE: August 2016

DISTRIBUTION:
All Clinical Wards JHCH Excluding NICU
PERSON RESPONSIBLE FOR MONITORING AND REVIEW:
Head of Paediatric Physiotherapy, JHCH and Respiratory CNC
COMMITTEE RESPONSIBLE FOR RATIFICATION AND REVIEW:
JHCH Clinical Practice Guidelines Advisory Group (CPGAG)
Kaleidoscope GNS Quality Committee

Keywords: children, paediatric, secretions, suction

Disclaimer:
It should be noted that this document reflects what is currently regarded as a safe and appropriate approach
to care. However, as in any clinical situation there may be factors that cannot be covered by a single set of
guidelines, this document should be used as a guide, rather than as a complete authorative statement of
procedures to be followed in respect of each individual presentation. It does not replace the need for the
application of clinical judgment to each individual presentation.

SAFE WORK PRACTICE

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Suctioning of the non-intubated paediatric patient

Aims
To remove/clear excess bronchial secretions when a cough is either absent or
ineffective.
to obtain a sputum specimen

Indications
Absent or ineffective cough with secretions present
Airway obstruction
Respiratory distress
Desaturation not improved with oxygen
Blocked nasal passage in babies/infants

Hazards and complications of suctioning

trauma to the trachea / carina / bronchial mucosa
hypoxia / hypoxemia
atelectasis
cardiac arrhythmias; especially bradycardia in the neonatal and infant population
pneumothorax
introduction of infection
increase in intra-cranial pressure
Bronchoconstriction / bronchospasm
Hypertension
Hypotension

Precautions
evidence of stridor
recent feed

A Paedi-Y-Catheter may be used in the following instances if suction is authorised by the

surgeon. The surgeon will specify the depth of suctioning allowed.

cleft palate repair

after tonsillectomy
if suction is absolutely necessary following a tracheo-oesophageal fistula (TOF) repair.

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 following oesophageal atresia repair be very careful with naso-pharyngeal and oro-
pharyngeal suction as there is a danger of perforating the repair

Contraindications
no naso-pharyngeal suction on patient with skull or facial fractures, or CHARGE
syndrome.

Personnel
Suctioning of paediatric patients may require two people, one of whom should be a
clinician experienced in suction techniques and emergency care in the event of patient
deterioration. The parent/carer may also assist as able. If suction is accompanying
physiotherapy treatment it can be carried by the physiotherapist alone. If nursing staff are
suctioning a patient in the event of acute deterioration a second nurse is required to be in
attendance.

Suction Pressure
The negative pressures on wall suction should be no greater than:
Red figures on suction gauge Black figures on suction gauge
-60-80mmHg for neonates -8-10kPa
-80-100mmHg for infants -10-13kPa
-100-120mmHg for children -13-16kPa
-120-150mmHg for adults -16-20kPa
The pressure is always measured with the thumb held over the end of the suction tubing
and without the catheter in situ.
It should be as low as possible to effectively clear secretions.

Frequency
Suction should be performed as often as it is clinically indicated.

PROCEDURE FOR SUCTION OF NON-INTUBATED CHILDREN based on AARC

Clinical Practice Guideline (2004)

Suction is carried out through the nasopharynx (N/P) and the oropharynx (O/P).

Only Paedi-Y-catheters are used as they have a rounded soft end and no hole in the end.
This will help to decrease mucosal trauma.

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This is not a pleasant experience for the therapist or the child but it is vital to stimulate a
cough and clear secretions.

It is also sometimes necessary to clear the nasal passages as young babies are
predominantly nose breathers and will desaturate if their nose is blocked, even if their
chest is clear. This can occur if having oxygen (O2) administered via nasal prongs.

It is also used for obtaining sputum specimens (N/P for viral and O/P for all others).

Suction should only be done on an empty stomach or at least an hour after eating. If the
patient is on nasogastric feeds or PEG feeds they should be turned off an hour before
treatment.

Suction of N/P & O/P requires clean/aseptic technique, not sterile.

Equipment

Suction pack
Disposable glove (sterile not necessary)
Eye protection goggles
Paedi-Y-catheter of the appropriate size (size 8 & 10)
Sterile water or tap water
Lubricating jelly for suctioning of naso-pharyngeal if required
Emergency oxygen equipment available

Procedure to be attended following respiratory assessment and documented baseline

observations.

Explain the procedure to the child/parents/carer and obtain verbal consent to proceed.
Staff to apply protective eyewear.
Follow the 5 Moments of Hand Hygiene throughout the procedure.
Prepare suction equipment, including turning wall suction on, before commencing chest
physiotherapy as you may need to suction urgently. Be sure you only turn on the high
suction; do not adjust the low suction used for drains.

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 If a meter that measures the negative pressure is attached to the wall suction, the
negative pressures should be:
Red figures on suction gauge Black figures on suction gauge
-60-80mmHg for neonates -8-10kPa
-80-100mmHg for infants -10-13kPa
-100-120mmHg for children -13-16kPa
-120-150mmHg for adults -16-20kPa

Before suctioning, always ensure that the tubing is attached correctly to the suction
container and that oxygen is readily available.
Open equipment keeping it covered and clean.
When ready to suction you may need to swaddle the baby or child (Refer to the JHCH
Procedural Care Clinical Practice Guideline)
Place the patient on their side, if possible, in case he/she vomits.
During suction a glove must be worn on the hand holding the suction catheter to
protect the proceduralist from contact with secretions.

During naso-pharyngeal suction the suction catheter should be passed no deeper than
the pharynx. The aim is to stimulate a cough and then suctioning of the secretions
produced. This distance is approximately equal to the distance between the tip of the
patients ear (tragus) and the tip of the nose.

The maximum duration of each suction attempt should be determined by the individuals
response, but should be limited to no longer than 10-15 seconds.

There is no literature to support the order of, or the amount of o/p or n/p suction. Some
staff start with O/P suction then N/P suction then return to the O/P. Be aware N/P tends
to traumatise and bleed more easily than O/P. Suction of the O/P should cause no
trauma.

When suctioning through the O/P, the cough reflex and the gag reflex are close, so the
child may gag. Withdraw the catheter and try again.

Apply suction pressure after a cough and only on withdrawal of catheter.

The patient should have an opportunity to rest between suction passes. The patients
SaO2 and respiratory rate should return to baseline (or near baseline) before next
suction pass if being used as part of physiotherapy treatment.
SaO2 and respiratory rate should be monitored throughout the procedure.

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 Suction passes should be kept to a minimum, but the number of suction passes
depends on the amount of secretions and the tolerance of the patient.

If the suction catheter needs to be flushed during the procedure, then the water in the
suction pack can be used. After suctioning, dispose of the suction catheter and flush the
suction tubing completely with water leaving it upright in wall bracket or on canister
caddy.

Check the patient is comfortable and stable following the procedure.

Reassess the patients respiratory status.

Wash hands.

Document the assessment, verbal consent, treatment, and reassessment in the notes, and
all observations on an age-appropriate Standard Paediatric Observation Chart.
REFERENCES

American Association of Respiratory Care Clinical Practice Guideline. Nasotracheal

Suctioning-2004 Revision and Update. Respiratory Care 2004; 49 (9): 1080-1084.

Bagley CE, Gray PH, Tudehope DI, Flenady V, Shearman AD & Lamont A. J Paediatr
Health 2005; 41: 592-97.

Brooks D. Anderson M, Carter MA, Downes LA, Keenan SP, Kelsey CJ & Lacy JB. Clinical
practice guidelines for suctioning the airway of the intubated and nonintubated patient.
Can Respir J. 2001; 8 (2): 163-181.

Dat T, Farnell S, & Wilson-Barnett J. Suctioning: a review of current research

recommendations. Intensive and Critical Care Nursing 2002; 18: 79-89

Young C. Recommended Guidelines for Suction. Physiotherapy 1984; 70 (3): 106-108.

AUTHOR
Elke Werner & Rosie Day, Senior Physiotherapists JHCH

CONSULTATION
Elizabeth Kepreotes, Clinical Improvement Coordinator KGN
Linda Cheese, Paediatric Respiratory CNC
Bernadette Goddard, Paediatric Respiratory CNC
Leanne Lehrle, Acting NUM Ward H1
Sandy Stone, NUM Ward J1
Paul Widseth, NUM Ward J2
Blair McLellan, Trache CNC
Jenny Hall, ICU Liaison Nurse

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