Tracheostomy Suctioning-Clean Technique

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  • When caring for a student who has a tracheostomy, the nurse should always know the reason for the tracheostomy, the child’s underlying health conditions and whether the child needs the tracheostomy to breathe
  • “Deep suctioning” up to or beyond the tracheal carina (point of bronchial bifurcation and tissue resistance) should not be indicated in a school setting, as it may cause epithelial damage
  • Each student will have an absolute length of catheter insertion, “measured length”
    • When suctioning, the catheter should not be inserted deeper than the absolute length of catheter insertion
  • When suctioning, determine what the family has been taught related to applying suction on insertion and when withdrawing catheter or just when withdrawing
  • The child can be suctioned with clean technique or sterile technique per child’s care plan

Considerations:

  • When caring for a student who has a tracheostomy, the nurse should always know the reason for the tracheostomy, the child’s underlying health conditions and whether the child needs the tracheostomy to breathe
  • Attempt to provide the student with as much privacy as possible, given the urgency of the situation
  • Is suctioning necessary or can the student “cough out the secretions?”
    • Encourage the student to cough to expel the secretions
    • If secretions clear and there are no signs of respiratory distress, do not suction
  • Should always have Emergency Travel Bag accessible when completing any tracheostomy procedure
  • “Deep suctioning” up to or beyond the tracheal carina (point of bronchial bifurcation and tissue resistance) should not be indicated in a school setting, as it may cause epithelial damage
  • Each student will have an absolute length of catheter insertion, “measured length”
    • When suctioning, the catheter should not be inserted deeper than the absolute length of catheter insertion
  • When suctioning, determine what the family has been taught related to applying suction on insertion and when withdrawing catheter or just when withdrawing
  • The child can be suctioned with clean technique or sterile technique per child’s care plan

Supplies:
Emergency Travel Bag Equipment:
The essential equipment to be kept with the student at all times is as follows:

  • gloves
  • portable oxygen with appropriate sized Ambu-bag
  • appropriate size Ambu-bag facemask (for emergencies when unable to reinsert a new tracheostomy tube
  • portable suction machine that can operate with battery or electricity
  • clean suction catheters
  • sterile saline vials
  • water-based lubricant
  • two spare tracheostomy tubes
    • one the size the student currently uses
    • one that is a size smaller in the event that the tube needs to be changed and there is difficulty passing it through the stoma
  • obturator, if applicable
  • spare tracheostomy ties
  • blunt scissors
  • emergency phone numbers
  • pulse oximeter — may be optional if student is not on oxygen or mechanical ventilation

Additional Needed Supplies:

  • Student’s individual health plan/healthcare provider’s order
  • Stethoscope
  • Cup of tap water
  • Personal protective equipment
    • goggles
    • mask
    • gloves

procedure download skill competency

trach
Click on the photo to access the video.

  1. Assemble supplies
  2. Review healthcare provider’s order/ Student’s individual health plan
  3. Wash hands
  4. Perform respiratory assessment
    • The respiratory assessment should be an ongoing process to determine:
      • How well the student is tolerating the procedure
      • The amount of time and suction attempts that are clinically indicated
  5. Given the urgency and needs of the student; position the student to provide for the most privacy
    • students in wheelchairs or other supportive seating devices can remain sitting upright or reclined up to, but not exceeding, semi-fowlers or 45 degrees
    • students who are lying should be turned on their side (this position may be commonly associated with a student experiencing a seizure who may require supplemental oxygen and/or suctioning)
  6. Explain the procedure to the student at a level the student understands
  7. If ordered, place pulse oximeter on student’s finger, toe or ear lobe during and after the procedure
  8. Turn on suction machine and check for function
  9. For suction machines that have suction measurements in mm Hg
    • Ensure the suction machine has the appropriate level of subatmospheric pressure:
      • standard maximal pressure for children ranges from 80–100 mm Hg; and
      • standard maximal pressure adolescents ranges 80-120 mm Hg
      • maximal pressure may be determined by turning on suction and occluding extension tubing by folding it in half
      • Pressure reading on the gauge when the tubing is completely occluded is the maximal suction pressure
  10. For suction machines that have a dial with numbered suction settings (i.e. 1, 2, 3), use the lowest level of suctioning that will remove the secretions
    • Start at the lowest suction level and increase as needed
  11. Put on clean gloves
  12. Attach top of catheter to suction tubing
  13. Hold the suction catheter at the absolute length of catheter insertion, “measured length”
  14. Lubricate the catheter with normal saline
  15. The use of normal saline to lavage the tracheostomy tube is based on the Individualized Health Plan and, if indicated, to assist with the removal of thick secretions, needs to be used judiciously
  16. Remove tracheostomy mask, artificial nose or ventilator connection and promptly insert catheter while gently rotating within the cannula
  17. Advance catheter into tracheostomy tube to the “measured length” with or without suction (based on how the procedure is completed in the home setting and healthcare provider’s order)
  18. Twirl catheter between fingers as it is pulled out of tracheostomy tube, staying in no more than 5 seconds
    • When suction catheter is inserted into tracheostomy tube, the student’s airway is occluded, total suction time should not exceed 5 seconds
  19. Suction a small amount of sterile saline with the suction catheter to clear any residual debris/secretions
  20. Allow student to rest and return to normal breathing
    • If student was receiving oxygen and humidification by mask before the suctioning, reapplication of the mask between suctioning passes or 3-5 breaths with manual resuscitator bag with oxygen attached, may be warranted
    • If student is not on oxygen, give 3 to 5 extra breaths with the resuscitator bag, if needed
  21. Repeat suctioning in above order (10-14) until secretions are removed
    • Note the color, presence of odor quantity, and consistency of secretions
  22. Suction nose and mouth with same catheter the same way
    • If re-using catheter for tracheotomy suctioning, use a separate catheter to suction the mouth and nose
  23. Complete suctioning,
  24. For students on oxygen
    • Replace mask, artificial nose or ventilator connection on student
  25.  For students without oxygen:
    • Give 3 to 5 extra breaths with the resuscitator bag, if needed
  26. Assess respiratory status
  27. Rinse suction catheter with ½ strength hydrogen peroxide or vinegar water; then rinse catheter with sterile water  (or procedure used by family)
  28. Place suction catheter in a clean container
    • The suction catheter can be used up to 8 hours
  29. Rinse suction machine tubing with tap water
  30. Wash hands
  31. Document assessment, procedure, and outcomes in student’s healthcare record
  32. Report any concerns to parents/guardian and healthcare provider
    • Such as green/yellow or foul smelling secretions
  33. Replenish supplies as needed

Procedure for cleaning suction catheter:   See above #27


Resources:

Ballard TRACH CARE: Solutions For The Home Care Patient
http://www.kchealthcare.com/media/67088/product%20information%20and%20tool_trach%20care_home%20care%20guide.pdf

UW Pediatric Pulmonary Center, American Family Children’s Hospital, and Children’s Hospital of Wisconsin
Pediatric Tracheostomy and Ventilator Care
http://www.uwppc.org/educational-resources/pediatric-tracheostomy-ventilator-care.html


References:

American Association for Respiratory Care. (2010).  AARC Clinical Practice Guidelines. Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respiratory Care, 55(6),758-64.

American Thoracic Society. (2000). Care of the child with a chronic tracheostomy. American Journal of Respiratory & Critical Care Medicine, 1, 297-308.

Bassham, B.S., Kane I., MacKeil-White, K., Fischer, J., Arnold, D., Whatley, V., Walsh, M. (2012).  Difficult Airways, Difficult Physiology and Difficult Technology: Respiratory Treatment of the Special  Needs Child.  Clinical Pediatric Emergency Medicine, 13(2), 81-90.

Bowden, V. R., & Greenberg, C. S. (2012). Pediatric nursing procedures (Third Edition). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Children’s Hospital of Wisconsin. Caring for Kids with Tracheostomies: Suctioning Secretions.

Cincinnati Children’s Hospital. (2011). Basic Pediatric Tracheostomy Care.  Accessible at: http://www.cincinnatichildrens.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=88057&libID=87745

Connecticut State Department of Education. (2012). Clinical Procedure Guidelines for Connecticut School Nurses. Available at:
http://www.sde.ct.gov/sde/lib/sde/pdf/publications/clinical_guidelines/clinical_guidelines.pdf

Hootman, J.  (1996).  National Association of School Nurses.  Quality Nursing Interventions in the School Setting.

Porter, S., Haynie M.D., Bierle, T., Caldwell, T. & Palfrey, J. (1997). Children and Youth Assisted by Medical Technology in Educational Settings. Guidelines for Care. Second Edition. Paul H. Brookes Publishing Co., P.O. Box 10624, Baltimore, MD 21285-0624


Acknowledgment of Reviewers:

Marcia Creasy, BSN, RN
Retired School Nurse

Cynthia C. Griffith, RN, BSN
Nurse Clinician
Tracheostomy/Home Ventilator Program
Children’s Hospital of Wisconsin

Mary Kay Kempken, RN, BSN, NCSN
School Nurse
Randall Consolidated School

Cecilia Lang, MSN, CCRN, PNP-BC
Tracheostomy/Home Ventilator APN
Children’s Hospital of Wisconsin

Carole Wegner, MSN, RN
Clinical Nurse Specialist
Tracheostomy/Home Ventilator Program
Children’s Hospital of Wisconsin


Page last updated: April 6, 2015
Page last reviewed: November 10, 2015