suction in self ventilating and ventilated children

Version 2.0 From: Nov 2020 – To: Nov 2023 Authors: Sophie Coles (Physio) and Eve Hallam (LP PICU) of 23

SETTING Women’s and Children’s Division FOR STAFF Healthcare professionals trained in undertaking Nasopharyngeal (NP) and/or

Oropharyngeal (OP) suctioning in self-ventilating children, and suctioning of ventilated children on PICU.

PATIENTS Neonate to 18 years. _____________________________________________________________________________ This guideline promotes a safe and evidence-based approach to suctioning airways

Contents

1. Nasopharyngeal/Oropharyngeal Suction in Self-Ventilating Children ........................... 2

1.1 Introduction and Rationale: ............................................................................................. 2

1.2 Indications for NP/OP suctioning:.................................................................................... 2

1.3 Complications of NP/OP Suctioning: ............................................................................... 2

1.4 Equipment: ...................................................................................................................... 3

1.5 Pressure Guide: .............................................................................................................. 3

1.6 Procedure: ...................................................................................................................... 4

1.7 Considerations for technique: ......................................................................................... 6

2. Endotracheal Suctioning in Ventilated Children in PICU ................................................ 7

2.1 Introduction and Rationale ............................................................................................. 7

2.2 Preparation Prior to Performing Endotracheal Tube (ETT) Suctioning .......................... 8

2.3. Selecting the Correct Closed Suction Catheter .......................................................... 12

2.4. Performing Open Suction ............................................................................................ 11

2.5. Cleaning and Disposal of Equipment .......................................................................... 19

2.6. Suctioning Techniques for Specific Patient Groups .................................................... 19

Clinical Guideline

SUCTION IN SELF-VENTILATING AND VENTILATED CHILDREN


1. Nasopharyngeal/Oropharyngeal Suction in Self-Ventilating Children

1.1 Introduction and Rationale:

The aim of naso-pharyngeal (NP) and, or oropharyngeal (OP) suction is to clear secretions from a child’s respiratory tract. This will help maintain a patent airway, reduce work of breathing and improve ventilation and oxygenation. Suctioning should be performed when there are clear indications of retained secretions and/or an inability to effectively cough. These secretions may be affecting the patency of a child’s airway or the ability to effectively ventilate. Common conditions where suctioning may be required include:

• Respiratory disease/dysfunction where there may be an alteration of secretion type or quantity, or a disruption to the normal mucociliary process

• Neurological disorders that may suppress or inhibit the normal cough reflex and disrupt oromotor function

• Presence of an artificial airway (Tracheostomy, Endotracheal Tube or Nasopharyngeal Airway) - Refer to UHBristol Paediatric and Newborn Tracheostomy Care Nursing Guideline

1.2 Indications for NP/OP suctioning: Suctioning should only be performed when there are clear indications. These indications include an ineffective cough and retained or excessive secretions. Evidence of this could include:

• Visible, audible or palpable secretions • Increased work of breathing (including increased respiratory rate and cardiovascular

changes or other signs of respiratory distress) • Decreased oxygen saturation levels • Increased oxygen requirements • Reduced breath sounds or coarse crackles on auscultation

1.3 Complications of NP/OP Suctioning:

• Hypoxia • Cardiovascular instability – including bradycardia, tachycardia, hypotension or

hypertension • Apnoeas • Bronchospasm or Laryngospasm • Pneumothorax • Trauma • Atelectasis – collapse or closure of alveoli resulting in reduced or absent gas exchange • Changes in intracranial pressure (ICP) • Risk of vomiting +/- aspiration

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NB Before nasal suction on a child with head trauma – discussion should be had with the medical team to ensure basal skull fractures have been ruled out. To reduce the risk of potential complications, the indication for suctioning should be assessed on an individual basis.

1.4 Equipment:

• Suction unit with container and connection tubing – ensure all parts of the equipment are clean and intact. Check the pressure prior to suctioning.

• Suction catheters – size dependent on the patient. • As a guide the catheter should have a diameter less than half the size of the patient’s

airway diameter. • It should be a graduated catheter with 2 lateral holes and 1 distal hole. • Suction Catheter Guide for NP suction:

Approximate Age Recommended Catheter Size in French Guage (Fr)

Neonates (Birth – 1 month) 6-7

1-12 months 7-8

2-12 years 8-10

13 years + 10

• Non-sterile gloves and apron – to enable a clean technique • Oxygen available – for pre/post-oxygenation as appropriate • Tap water – in a container to rinse the suction tubing • Clinical Waste Disposal – for suction catheter, gloves, apron etc.

1.5 Pressure Guide:

Age

Suction Pressure

kPa mmHg

Neonates 8-10 60-75

0-24 months 10-12 75-90

3-12 years 12-15 90-112

13 years + 15-20 112-150 If secretions are not clearing with the above pressures, higher pressures can be used with


caution up to a maximum of 20kPa/150mmHg. 1.6 Procedure: In a non-emergency situation check the patient has not just been fed (approx. 30 minutes). If they are on continuous feeds ensure the feed is turned off immediately prior to suction.

Action

Rationale

1. Assess the indication for suction (where possible the child should be encouraged to clear their airway by coughing)

Suction is an invasive procedure with associated risks and it should be implemented with care and thorough assessment.

2. Collect the appropriate equipment As identified above in Section 1.4.

Suction equipment needs to be prepared and ready for use.

3. Explain the procedure to parents and the child

To ensure understanding and gain consent. It may also encourage cooperation and reduce anxiety.

4. Prepare the child for the procedure. Pre-oxygenate where appropriate.

Consider the positioning of the child, including sitting/supine or side lying.

Pre-oxygenation will reduce the risk of hypoxia.

Appropriate positioning will prevent obstruction of the airways and reduce the risk of potential aspiration.

5. Wash hands, dry thoroughly and don gloves and apron.

NP/OP suctioning is a CLEAN (not sterile) procedure; therefore wear non-sterile gloves on both hands. The glove in contact with the suction catheter must touch nothing other than the catheter itself.

Ensures a clean technique and minimises the risk of infection.

6. Attach the sleeved catheter to the suction tubing, turn the suction unit on and check the set pressure.

Withdraw the catheter. Only touch the un-sleeved catheter with your clean glove.

Ensures the catheter remains sterile.

See above for guide on appropriate pressure.

7. Gently insert the catheter into the nasal passage or mouth without the suction applied.

N.B. If resistance is felt when inserting the

Reduces risk of trauma.


catheter into the nostril, do not force catheter, remove and try the other nostril. Lubrication may be needed using lubricating gel.

8. Pass the catheter down until an effective cough is stimulated. If the child has a good effective cough and suction is being used to clear the upper airways only:

• As a guide measure from the corner of the mouth to the angle of the jaw (for oral suction) or tip of the nose to tragus (for nasal suction) to clear the upper airways.

For children without an effective cough, the catheter may have to be advanced further to ensure effective secretion clearance:

• As a guide, measure from the child’s nostril to the mid part of the ear lobe and down to the base of the neck. This should be sufficient to pass through the nasopharynx and stimulate a cough. (See below as a guide to suctioning beyond the upper airways).

Allows effective and optimal secretion clearance, reducing the need for multiple attempts. Measured suction depth causes less trauma and arrhythmias.

9. Apply the suction continuously. Withdraw the catheter slowly and do not rotate. Each suction procedure should take no longer than 10 – 15 seconds.

If the technique is too quick there is risk not all the secretions will be cleared. However caution needs to be taken that prolonged suction does not stimulate a vagal response, cause undo distress to the child or hypoxia.

10. If the procedure needs repeating, withdraw the suction catheter and allow the child a recovery period before repeating.

Allows for re-oxygenation.

11. One catheter can be used per episode unless the catheter becomes blocked with secretions or contamination occurs.

Minimises the risk of infection.

12. Once the episode of suction is completed, gather the suction catheter into a gloved hand

Safe disposal of equipment prevents cross contamination/spread of infection.


and remove the glove, enclosing the catheter. Dispose of gloves and catheter into clinical waste bin and rinse the suction tubing.

13. Wash hands and dry thoroughly.

Reduces transmission or micro-organisms.

14. Report and document the procedure on the observation chart, including the colour/consistency of secretions.

It is important to record the frequency of suction required and monitor secretions. Any changes in colour noted, collect a sample to be sent for analysis

If suctioning via a Nasopharyngeal Airway (NPA) – See Paediatric Nasopharyngeal Airway Guideline for catheter guide selection and suction procedure. The frequency of suctioning should be assessed for each child on an individual basis. Liaise with the medical team as to whether a sputum sample should be sent if secretions have changed.

1.7 Considerations for technique: If retained secretions are not effectively cleared, consider:

• Increasing the suction pressure • Increasing the size of the catheter • Adequate humidification and possible addition of nebulisers.

If it is difficult passing the catheter, consider:

• Changing the position of the child • Changing nostril • Use of lubricant to ease passage • Using a smaller size suction catheter

If the child is requiring repeated suction or shows evidence of trauma, consider:

• Use of lubricant • Decreasing the size of the catheter • Changing nostril • The need for nasopharyngeal airway – discuss with the medical team

In the unstable patient, oxygen saturations may drop dramatically with suction and an increase in inspired oxygen may be required – in this situation oxygen should be given pre and post procedure. Oxygen must always be available during any suction procedure. Suction should never be used routinely but must be used when necessary.

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2. Endotracheal Suctioning in Ventilated Children in PICU

2.1 Introduction and Rationale

2.1.1 Definition of Terms Used

Children/Population: considered to be all patients in PICU from birth to 18 years except in exceptional circumstances. Suctioning episode: Endotracheal suctioning is the term used to describe the procedure of carrying out suctioning on a child at a point in time. For example one episode may last several minutes and require multiple suction catheter passes or may last for a few seconds and take only one catheter pass. Pre-oxygenation (or hyper-oxygenation): the procedure of increasing the FiO2 for a short period prior to suctioning to minimise hypoxaemia. Ventilator Associated Pneumonia (VAP): pneumonia acquired as a result of being in hospital, and in this context, with an artificial airway and/or on a ventilator.

2.1.2 Complications of Endotracheal Suctioning

Endotracheal suctioning is one of the most frequently performed procedures in Intensive Care; however this procedure is not risk free. There are numerous complications/adverse events that can result from endotracheal suctioning including:

• Infection and bacteraemia • Hypoxaemia • Airway mucosal trauma including pulmonary haemorrhage • Pneumothorax • Micro-atelectasis • Lobar Collapse

• Vagal stimulation / dysrhythmias including risk of cardiac arrest • Raised intracranial pressure • Alterations in blood pressure • Bronchospasm / laryngospasm

• Incomplete endotracheal tube clearance • Intraventricular haemorrhage in preterm infants • Apnoea • Anxiety and discomfort • Risk of unplanned extubation

Therefore the risks of endotracheal suctioning must be balanced against the risks of endotracheal tube blockage.


2.2 Preparation Prior to Performing Endotracheal Tube (ETT) Suctioning 2.2.1 Registered nurses, associate practitioners, the band 2-4 workforce (who have appropriate

competencies completed), physiotherapists and medical staff will safely perform endotracheal suctioning on invasively ventilated children, using a consistent and safe procedure. In the case of tracheostomy tube suctioning parents/carers and patients may also be taught to perform the procedure.

2.2.2 As endotracheal suctioning is a potentially hazardous procedure it should not be

performed routinely, but a minimum of one suction episode must be performed per 12 hours shift to ensure tube patency is maintained.

It is often of benefit to coordinate suction with cares, particularly if the child is a high risk or unstable patient, or has a poor tolerance to suction. Consideration must also be given to making sure appropriate staff are present when this procedure is performed, if there is potential of instability.

2.2.3 A child with an artificial airway will have suctioning performed only when there are clear

indications that excessive pulmonary secretions are affecting the patency of the airway or the effective ventilation of the patient. An assessment of the need for suctioning will be made by the nurse, physiotherapist or doctor prior to suctioning and then following the procedure to evaluate effectiveness.

Indications for suction:

• Alteration on observations likely to be secondary to retained secretions: o ↓SaO2 o ↑ETCO2 o Arterial blood gas showing ↑pCO2 or ↓pO2

• Chest X-ray changes • Secretions audible on auscultation • Secretions palpable on examination • Change in ventilator requirements

o ↑FiO2 o ↑PIP o ↑Rate o ↑PEEP

• Change in ventilator observations o ↓Tidal volume o ↑Measured PIP

• Increased work of breathing • Patient coughing • Visible secretions within ETT or ventilator tubing • Suspected aspiration of gastric secretions • Evidence of secretions on ventilator waveforms:


Before suction: 2.2.4 Considerations should be taken before suctioning patients with the following presentations:

• Active bleeding • Platelets <50 • Pulmonary haemorrhage • Pulmonary oedema • Cardiovascular instability • Neurological instability • Unsafe ETT (not secure) • High PEEP • Significant wheeze / bronchospasm (not secretion related) and reactive airways • Airway surgery • Consider the need for a sedation bolus prior to suctioning in high risk patients e.g.

children with raised ICP and cardiac infants with pulmonary hypertension. 2.2.5 Prior to performing suction, consider verbal reports and review the patient’s charts for

information on specific precautions and the patient’s previous response to suctioning. 2.2.6 Explain the procedure fully to the patient using age-appropriate language, and to the

parents / carers. Discuss with parents / carers who choose to remain present, the potential need to hold and reassure the child during suctioning.

2.2.7 Set suction pressure appropriately for the size of child. This may vary slightly depending on

the size/weight of the child and the tenacity of secretions, a guide is provided below.

Suction Pressure Guide

Age of Child Suction Pressure Recommended

Neonate 60 – 80 mmHg (8 – 10.6 kPa)

Child 80 – 100 mmHg (10.6 – 13.3 kPa)

Large Child/Adolescent/Adult Should not exceed 150mmHg (20kPa)

There is little evidence to specify the optimal negative pressure. The lowest pressure that will effectively clear secretions should be used.

After suction:


2.3 Selecting the correct closed suction catheter 2.3.1 It is essential that the correct size, length and type of closed suction catheter is selected

for each patient. This ensures effective suctioning of secretions and maintains patient safety.

2.3.2 Considerations: • Correct diameter

o ETT size x2 o If the correct size catheter is not available, use one size smaller o Do not use a larger size catheter as this increases the risk of pneumothorax by

creating a seal during suction when coughing is expected • Correct connection:

o Y-Connector – reduces dead space but requires end of ETT to be changed (by airway-competent doctor / ATNP) – not suitable for unstable patients

o T-Piece Connector – has more dead space, but easier to place in circuit (by nursing staff)

• Correct length o Some patients with size 4.0 or 4.5 ETT need longer catheter in order to clear

the end of the ETT and stimulate an effective cough. Check length of patient’s ETT and select the correct length catheter

ETT size 3.0mm

ETT size 3.5mm

Size 6 Fr Y-Connector

Unless unstable, then use T-Piece Connector (kept at far end of Respiratory Cupboard on left hand side)

Size 7 Fr Y-Connector or T-Connector dependent on patient


ETT Size 4mm and 4.5mm

ETT Size 5mm and above

2.4. Performing Closed Suction

Closed suction technique involves the attachment of a sterile, closed, in-line suction catheter to the ventilator circuit. This allows passage of the catheter through the artificial airway without disconnecting the patient from the ventilator. 2.4.1 Closed suction is used as standard in all invasively ventilated patients on PICU. However

in some patients, the use of closed suction alone may not achieve adequate clearance of secretions and open suctioning (together with instillation of normal saline / gentle hand ventilation) is therefore sometimes required. Closed suction should always be used first, and if secretion clearance has not been achieved, the troubleshooting guidance in section 2.5 below should be followed before undertaking open suction.

Size 10, 12 or 14 Fr T-Piece Connector – Adult size

Size 8 Fr T-Piece Connector

Ensure you choose the correct length for your patient:

• Halyard (pictured) are 30cm long

• GBUK are 25cm long

Size 8 Y-Connector available for patients with CO2 clearance problems (Kept at far end of Respiratory cupboard on left hand side)


2.4.2 Patients at risk of secretion retention in whom open suction may be required to effectively clear secretions include:

• Increased secretion load secondary to: o Viral / bacterial illness o Respiratory illness / disease i.e cystic fibrosis, asthma, exacerbation of

chronic respiratory condition o Aspiration

• Increased secretions viscosity • Sedated and muscle relaxed patients who are not coughing • Patients with an impaired cough i.e neuromuscular conditions, global weakness • Head injuries and multi-trauma patients • Tracheal / airway reconstructions • Burns involving smoke inhalation • Post pulmonary haemorrhage, once active bleeding has stopped

2.4.3 An appropriate sized closed suctioning circuit (see section 2.3 above) should be fitted to

the patient’s ventilator circuit. This must currently be changed on day 3 and day 7 (with the ventilator tubing) of admission. The rationale for this is to reduce ventilation disconnections during the Covid-19 pandemic. Manufacture recommendation is to change the closed suction circuit every 24hrs, and we will return to this practice as soon as it is deemed safe to do so. An exception to this practice would be with unstable patients in whom disconnection from the ventilator causes clinical instability

2.4.4 Due to the Covid-19 pandemic additional bacterial / viral filters are being used (see SOP

Nursing Care of Children on PICU during Covid-19 Pandemic). There is an increased risk of these filters becoming waterlogged and adversely affecting the patient’s ventilation. Filters are changed every 24hrs, but may need more frequent changes especially in patients receiving nebulised medications. See Nursing Care of Children Requiring Paediatric Intensive Care During the Covid-19 Pandemic (Clinical SOP)

Action

Rationale

Assemble equipment: • Appropriate PPE • Appropriately sized hand ventilation

circuit set up with the correct FiO2 (in case needed)

• Oxygen saturation and heart rate monitoring (this is the minimum level of monitoring required during a suctioning episode)

• Sterile 0.9% sodium chloride drawn up into appropriate sized syringe using ANTT

• Stethoscope • Bowl of clean tap water (changed

every 24 hours) to irrigate tubing at the end of procedure

To maintain patient safety and avoid unnecessary complications


Perform the following safety check:

• Is the patient cardiovascularly stable? • Is the hand ventilation circuit set up

appropriately with correct FiO2? • Is open suction available and set up

correctly, in case required? • Is the bedspace checked and safe to

proceed: o Appropriate lighting o ETT secure o Awareness of lines and

attachments o Monitors visible?

• Is assistance available should the need for open suction arise? (See section 2.6)

Consider the need for a sedation bolus prior to suctioning in high risk patients e.g. children with severe head trauma with raised ICP and cardiac infants with pulmonary hypertension.

Reduces risk of complications

Ensure the correct size, length and connection type closed suction circuit has been selected (See section 2.3 above)

Prevents complications from incorrect size or length catheter being used: risk of pneumothorax or trauma (if catheter diameter too large), inability to clear secretions (if catheter not long enough)

Check the total length of the ETT and identify the correct length to pass the closed suction catheter to. For the initial suction, this depth is 1cm beyond the end of the ETT, or to a depth determined by the PICU Consultant

To ensure catheter is passed to the required depth in order to clear secretions effectively

Wash hands and don appropriate PPE


Pre-oxygenate patient using the suction support function, if required. Assess the child’s physiological parameters (HR / rhythm, SaO2, BP, skin colour) prior to suctioning to gauge a baseline.

Pre-oxygenation will reduce the risk of hypoxia. This risk is lower with closed suction, but may still be required with some patients.

Cardiac patients with balanced circulation should not be pre-oxygenated. If in doubt, check with a senior nurse or doctor.

Test the suction pressure by occluding the end of the suction tubing before attaching it to

To ensure the suction is functioning correctly and to ensure the correct pressure is set


the closed suction catheter. See recommended pressures above. Maximum pressure 20kPa

With one hand holding the ETT securely, pass the closed suction catheter (without applying suction) down the ETT to either 1cm past the end of the ETT, or to the depth determined by the PICU Consultant. This depth may be less in neonates, 0.5cm past the end of the ETT may be enough to stimulate an effective cough. Monitor the child’s observations and terminate suctioning immediately if the child becomes bradycardic, hypotensive, cyanotic, mottled or develops cardiac arrhythmias.

Deeper suctioning may be required for patients who are muscle relaxed, have an absent cough reflex or difficult to clear secretions. See troubleshooting guide in section 2.5 below

Measured suction depth causes less trauma and arrhythmias. Allows effective and optimal secretion clearance, reducing the need for multiple attempts.

Once the desired depth is reached, apply suction continuously and pull catheter back. Limit the duration of suctioning to a maximum of 10 seconds for an infant or 15 seconds for a child.


Ensure closed suction catheter is fully retracted and is not still partially sitting within the ETT or closed suction connector

If the closed suction catheter is not fully retracted it can cause significant issues with CO2 clearance

Check patient is ventilating properly. Check the patient’s tidal volumes and ensure equal bilateral chest rise. Check the patient’s observations are stable

To ensure the patient continues to ventilate properly and to ensure prompt recognition of any problems

Assess patient for retained secretions. If suctioning has not been effective, follow the troubleshooting guide in section 2.5 below

To ensure secretions are effectively removed

Clean the closed suction catheter after every use. Draw up 1ml of NaCl 0.9% using ANTT. Instil this into the closed suction catheter via the port, with the catheter in the retracted position, while applying suction.

Essential to ensure the closed suction catheter does not become blocked with secretions. ANTT is used to reduce the risk of infection


Rinse wide-bore suction tubing with tap water and then turn off suction at the wall and either leave suction tubing disconnected, or reconnect and turn the suction cap into the locked position.

To avoid unnecessary use of the suction system, and to ensure the suction is not applied inadvertently to the patient

Remove PPE and wash hands To maintain infection control

2.5 Closed Suction Troubleshooting

If, on reassessing the patient after the initial closed suction, they have retained secretions follow the steps below:

1. Check closed suction catheter is not blocked. Draw up 1ml of NaCl 0.9% using ANTT. Clean the suction catheter by instilling this into the closed suction catheter via the port while applying suction. If the closed suction catheter is blocked, change it (this may require full PPE).

2. Check the suction pressure and increase to a maximum of 16-20 kPa (120-150 mmHg)

3. Check to make sure the closed suction catheter is long enough to reach 1cm beyond the end of the ETT (size 8 closed suction comes in two lengths, use the longer one if needed). If the catheter is not long enough, consult a senior nurse and the child’s doctor to determine if the ETT can be cut shorter.

4. If suctioning to a predetermined length, increase the depth of suction either until a cough

is stimulated or resistance met (where resistance is met, withdraw the suction catheter by 0.5cm prior to applying suction to avoid causing trauma to the trachea)

5. Using a syringe, instill 0.1ml/kg NaCl 0.9% (max. 0.5ml in infants, 1ml for young children

and 2ml for older children and adolescents (per individual instillation) down ETT, via instillation port on the closed suction set prior to suctioning.

The need for saline instillation should be assessed on an individual basis, and must not be instilled as a routine practice. A syringe must be used to measure the saline.

6. Don appropriate PPE and perform open suction (see section 2.6 below)

7. If secretions are still retained after performing open suction, refer to the physio

8. Further steps may involve increasing humidification (if able) and use of nebulisers


2.6 Performing Open Suction Open suction requires disconnecting the patient from mechanical ventilation to be able to pass the catheter through the artificial airway. This should not be performed routinely, but only after closed suction, and the closed suction troubleshooting list have been performed. This is a two person technique and may require full PPE.

Action

Rationale

Assemble equipment: • Appropriate PPE • Appropriately sized hand ventilation

circuit set up with the correct FiO2 • Oxygen saturation and heart rate

monitoring (this is the minimum level of monitoring required during a suctioning episode)

• Sterile 0.9% sodium chloride drawn up into appropriate sized syringe using ANTT

• Stethoscope • Bowl of clean tap water (changed

every 24 hours) to irrigate tubing at the end of procedure

Perform the following safety check:

• Is the patient cardiovascularly stable? • Is the hand ventilation circuit set up

appropriately with correct FiO2? • Is open suction set up correctly? • Is the bedspace checked and safe to

proceed: o Appropriate lighting o ETT secure o Awareness of lines and

attachments o Monitors visible?

Open suction is a two-person technique at all times

To maintain patient safety and avoid unnecessary complications Undertaking hand ventilation and suction as a single person will likely result in ineffective hand ventilation, distress to the child, potential hypoxia and / or compromise of aseptic technique of suction. Full, level 3 PPE may be required for this procedure.

Consider the need for a sedation bolus prior to suctioning in high risk patients e.g. children with severe head trauma with raised ICP and cardiac infants with pulmonary hypertension.

Reduces risk of complications


Connect suction catheter to wide bore tubing and then remove from packaging. Make sure you avoid contact with anything other than gloved hand.


Activate suction support mode on the ventilator ensuring the correct FiO2 is set. Disconnect patient from ventilator and commence hand ventilation. Staff members who are inexperienced at hand ventilation should use a manometer to ensure correct pressures are delivered.

Pre-oxygenation will reduce the risk of hypoxia.

In suction support mode the ventilator will automatically give 20% more oxygen than the patient is set on. It will also delay the ventilator alarm for 2 minutes. It will also prevent the ventilator from continuing to deliver a flow of gases/infection into the room. Some patients should not have increased FiO2 during this procedure, and care should be taken to ensure the FiO2 is set correctly.

Gently insert the suction catheter into the endotracheal tube to a maximum depth of 1 cm beyond the end of the tube to prevent causing trauma to the trachea (Do not apply suction during insertion). This depth may be less in neonates, 0.5cm past the end of the ETT may be enough to stimulate an effective cough. Deeper suctioning may be required for patients who are muscle relaxed, have an absent cough reflex or difficult to clear secretions. See troubleshooting guide in section 2.5 above

Measured suction depth causes less trauma and arrhythmias. Allows effective and optimal secretion clearance, reducing the need for multiple attempts.

Apply suction whilst catheter is withdrawn, this should be continuous. Do not rotate catheter or use a stirring motion. Limit the duration of suctioning to a maximum of 10 seconds for an infant or 15 seconds for a child.


Recommence hand ventilation and ensure satisfactory chest wall movement and satisfactory clearance of secretions.

The child’s response should be noted and suctioning terminated immediately if the child becomes bradycardic, hypotensive, cyanotic, mottled, and pale or develops cardiac


arrhythmias.

The same suction catheter should be reused for the entire suctioning episode unless the catheter becomes blocked with secretions or contamination occurs. The catheter must not be used to clean the child’s nose and/or mouth between passes in the tube, however it may be used to clear secretions from these areas only at the end of the procedure.

Reduces transmission or micro-organisms. Open endotracheal suctioning is a clean (not sterile) procedure; therefore wear non-sterile gloves on both hands. The glove in contact with the suction catheter must touch nothing other than the catheter itself. Clinicians assisting with manual ventilation should also wear non-sterile gloves to protect their hands from contamination. Suction is a clean technique and preservation of this is important to reduce the risk of VAP

Assess patient and if evidence of retained secretions, follow troubleshooting guide in section 2.5 above (as per closed suction) Once the clinician is satisfied that secretions have been removed, reconnect child to the ventilator, ensure the ventilator is functioning correctly, adequate tidal volumes are being delivered and there is satisfactory chest wall movement. Hyper-oxygenation (if appropriate) should be continued for approximately one minute after the last catheter pass (this is done automatically on suction support), and then the FiO2 may be returned to pre-suctioning levels (or reduced as patient condition allows).

Allows for re-oxygenation.

Gather the catheter into gloved hand and remove gloves enclosing catheter, dispose of gloves and catheter into orange clinical waste bin to prevent nosocomial infection spread.

Safe disposal of equipment prevents cross contamination / spread of infection.

Rinse suction tubing with clean water from bowl and switch suction unit off.

Remove full PPE appropriately or dispose of plastic apron into orange clinical waste bin, wash and dry hands thoroughly.


2.7 Cleaning and Disposal of Equipment 2.7.1 The disposable suction canister should be changed between patients and weekly or when

canister is ¾ full to prevent contamination of vacuum equipment. Gloves and aprons must be worn during disposal. Seal canister with the caps provided on lid and place in the labelled bin in the sluice

2.7.2 The wide bore suction tubing should be changed every 24 hours or if blocked, and must

be labelled with a day sticker when changed. 2.7.3 Check the filter in the suction unit every time suction is set up and replace the filter when

discoloured, wet or contaminated. 2.7.4 Clean the vacuum unit between patients as per UHBW Infection Control Guidelines.

2.8 Suctioning Techniques for Specific Patient Groups 2.8.1 Pulmonary Hypertensive Patients

In patients with known severe pulmonary hypertension, consideration should be given to administering an intravenous bolus of sedation or analgesia (Fentanyl is often preferred) prior to suctioning and physiotherapy to reduce the physiological response to this procedure. The patient’s physiological parameters must be closely monitored during and after suctioning procedures for signs of increased pulmonary vascular resistance including:

• Falling oxygen saturations • Rising CVP or right atrial pressure • Falling left atrial pressure • Falling arterial blood pressure

2.8.2 Patients with an acute head injury and labile Intracranial pressure (ICP)

In patients with acute head injuries and fluctuating ICPs, consideration should be given to the use of muscle relaxants and sedation boluses of fentanyl prior to suctioning and physiotherapy, to reduce the physiological response to this procedure. Care should be taken to carefully observe patient monitoring.

2.8.3 High Frequency Oscillation Ventilation (HFOV) Patients:

Patients who are being ventilated with HFOV must avoid being disconnected from the oscillator circuit as much as possible, as disconnection will result in a loss of mean airway pressure (MAP) and hence a reduction in the efficiency of treatment. Endotracheal suctioning results not only in a loss of MAP but also functional residual capacity (FRC) and lung recruitment. This means that suctioning must be kept to a


minimum and ONLY occur when necessary. Closed suction should be used with these patients. Exceptions to this should be agreed with the PICU Consultant. If open suction is used, lung recruitment strategies should be considered to optimise re- recruitment and stability post suction. Increasing the MAP for short periods, clamping of the endotracheal tube and manual hyperinflation techniques may be beneficial but these should be discussed with the PICU consultant.

2.6.4 Post Op Stage 1 Norwood Procedure and Right Modified Blalock-Taussig Shunt

These patient groups have a balanced circulation and are sensitive to alterations in pH, pCO2 and pO2. Care needs to be taken if the patients are being bagged alongside suction, primarily bagging in air to prevent pulmonary over-circulation.


Appendix One

Required suction catheter sizes

Approximate Age Tracheal Tube size in mm

Recommended Catheter Size in French Guage (Fr)

Premature (<1kg) 2.0 - 2.5 5

Premature (<2.5kg) 3.0 6

0 - 6 months 3.5 7

6 months – 3 years 4.0 - 4.5 8

3 - 6 years 5.0 - 5.5 10

6 - 10 years 6.0 - 6.5 12

10 - 16 years 7.0 - 7.5 14


REFERENCES Curley, M.A.Q., Thompson, J.E. (2001) Oxygenation and Ventilation. In Curley, M.A.Q., Moloney-Harmon, P.A. (eds) Critical Care Nursing of Infants and Children. 2nd ed. Philadelphia, Pennsylvania: W. B. Saunders Pollard, C. (2001) Endotracheal suction in the infant with an artificial airway. Nursing in Critical Care, 6(2), 76-82. Pryor, J.A., Prasad, S.A. (2008) Physiotherapy for Respiratory and Cardiac Problems: Adults and Paediatrics (4th Edition). London: Churchill Livingstone.

Ridling, D.A., Martin, L.D., Bratton, S.L. (2003) Endotracheal suctioning with or without instillation of isotonic sodium chloride solution in critically ill children. American Journal of Critical Care, 12(3), 212-219 Maggiore, S.M., Iacobone, E., Zito, G., Conti, G., Antonelli, M., Proietti, R. (2002) Closed versus open suction techniques. Minerva Anestesiol, 68(5), 360-364.

Hough A. Physiotherapy in Respiratory Care: An Evidence Based Approach to Respiratory and Cardiac Management. 3rd Edition. Nelson Thornes; 2001.205-209,441-443.

Moore T. Suctioning Techniques for the removal of respiratory secretions. Nursing Standard. 2003; 18(9): 47-55. Thompson L. Suctioning adults with an artificial airway. Systemic review. No 9. The Joanna Briggs Institute for Evidence-Based Nursing and Midwifery 2000; cited in: Moore T. Suctioning techniques for the removal of respiratory secretions. Nursing Standard. 2003; 18(9): 47-55.

Trigg E & Mohammed T. Practices in Children’s Nursing. Guidelines for Hospital and Community. 3rd ed. London: Churchill Livingstone; 2010. Association of Paediatric Charted Physiotherapists (APCP). Guidelines for Nasopharyngeal Suction of a Child or Young Adult; 2015: 1-11.

Tume LN, Baines PB, Guerrero R, Johnson R, Kalantre A, Ramaraj R, Ritson P, Scott E, Arnold P, Walsh L Patterns of instability associated with endotracheal suctioning in infants with single ventricle physiology. Am J Crit Care 2017; 26(5).

Tume LN, Copnell B (2015) Endotracheal Suctioning in Critically Ill Children. J Pediatric Intensive Care 2015 4(2):1–9.

American Association for Respiratory Care (2010) Clinical Practice Guidelines: Endotracheal Suctioning of Mechanically Ventilated Patients with Artificial Airways. Respir Care 55 (6): 758-764

Morrow B, Argent AC (2008) A comprehensive review of paediatric endotracheal suctioning: Effects, indications, and clinical practice. Paediatric Critical Care Med 9 (5): 465-477

Walsh BK, Hood K, Merritt G (2011) Paediatric airway maintenance and


clearance in the acute care setting: How to stay out of trouble. Respiratory Care 56 (9): 1424-1444

Wang C.H. et. al. (2017) Normal saline instillation before suctioning: A meta-analysis of randomized controlled trails. Australian Critical Care 2017: 260-265

Scoble, M.K., Copnell, B., Taylor, A, Kinney, S., Shann, F. (2001) Effects of reusing suction catheters on the occurrence of pneumonia in children. Heart and Lung, 30(3), 225-233.

RELATED DOCUMENTS AND PAGES

Paediatric and Newborn Tracheostomy Care Nursing Guideline Paediatric Nasopharyngeal Airway Guideline Nursing Care of Children Requiring Paediatric Intensive Care During the Covid-19 Pandemic (Clinical SOP)

AUTHORISING BODY

PICU Quality and Safety Improvement Programme BRHC Nurse Practice Group

SAFETY Oxygen must always be available during any suction procedure. Suction should never be used routinely but must be used when necessary.

QUERIES AND CONTACT

Nurse in Charge PICU Contact Physiotherapy Department on ext 28525 / bleep 3157 or bleep 2720 to answer a query.



suction in self ventilating and ventilated children

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