Clinical review
Suction therapy in the critically ill patient Stephen Ashurst, Maelor General Hospital, Wrexham Caring for patients with inefficient airway function who need suctioning requires a great deal of nursing skill. This article outlines the methods of suction therapy currently available, the role of research in improving clinical practice and the way in which new technology may be used to benefit both patient and nurse.
Mr Ashurst is a Staff Nurse in the Intensive Care Unit, Maelor General Hospital, Wrexham, Clwyd
c
ritically ill patients are highly de pendent on skilled nursing therapy throughout all aspects of their care. One such aspect is the ability to maintain a clear airway which may necessitate suctioning, even in the absence of an endotracheal tube or tracheostomy. A major function of the upper airways is to protect the bronchial tree from infection. The bronchi contain many mucus-producing cells (goblet cells) that trap invading organisms; the activity of these cells is usually increased during ac tive respiratory infections. The bronchial mucosa may also be hyperresponsive to in haled allergens which cause mast cells to release inflammatory mediators, leading to the bronchoconstriction and oedema of the mucosa with excessive production of mucus typically seen in asthma. The lower airways, terminal bronchioles and alveoli have an extensive blood supply and are susceptible to capillary leakage in addition to microbial invasion (pneu monia). Secretions from these regions may therefore be infective (microorganisms and pus), immunological (polymorphonuclear cells and vascular transudate) or cardiac (pulmonary oedema) in origin. Often, how ever, multiple causes are evident and a mix ture of these types is often present in respir atory secretions. In the healthy adult, the action of the ciliated cells, the functions of the local im mune system (secretory immunoglobulin and alveolar macrophages) and the cough reflex are of prime importance in the killing and removal of microorganisms and the clearing of debris from the lung. These functions may be compromised in the criti cally ill patient due to a variety of condi tions (Table /), resulting in inefficient air way function and excessive production of secretions. The inability to expectorate this material, which is often thick and tenacious, is a common problem for these patients and the possible resultant complications (Table 2) may be life-threatening.
British Journal of Nursing, 1992, Vol 1, No 10
An important role of nurses caring for these patients is to maximize ventilation by utilizing good positioning, physiotherapy, reassurance and effective drug therapy, to maintain microbiological surveillance by obtaining adequate and correct specimens, and to promote efficient removal of retain ed secretions, utilizing humidification and suction therapy where necessary. Several Table I. Clinical conditions that may result in retained respiratory secretions Exacerbation of chronic obstructive airways disease Carcinoma of the bronchus Upper abdominal surgery/trauma Thoracic surgery/trauma Neurological muscle weakness Coma states Shock Presence of an endotracheal tube
Table 2. Problems associated with retained respiratory secretions Increased airway pressures: pneumothorax and cardiovascular instability Carbon dioxide retention Lobar consolidation Ventilation/perfusion mismatch Arterial desaturation: tissue acidosis Bacterial colonization Pneumonia Hypoxaemia/atelectasis
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Suction therapy in the critically ill patient
Table 3. Routes for suction therapy Associated problems Type of suction therapy Oropharyngeal
Retching, vomiting, aspiration, bradycardia, oral ulceration
Nasopharyngeal
Nasal trauma/stress, sneezing, bradycardia, ethical conflict
Endotracheal
Needs open access, numerous problems ( Table 4)
___________ _________________________________________ ___________ 1
Fig. 1a. Nasopharyngeal airway.
ume of secretions. This is particularly evi dent with oral endotracheal tubes, where hypersalivation may result in a substantial loss of fluid. These secretions may be re moved by gentle suctioning (5-10 kPa) (conversion: 1 kPa = 7.5 mmHg), with a soft plastic catheter, at regular intervals to prevent ‘dribbling’ over central venous lines, haemodialysis catheters and wounds. The continuous use of hard, plastic cath eters at high vacuum pressures can cause oral trauma resulting in minor haemorrhage and ulceration which may predispose to infection in the critically ill patient, e.g. Candida. The removal of tracheobronchial secretions via oropharyngeal suctioning is at best inefficient. This is primarily due to poor guidance of the catheter and, unless the patient is deeply sedated or comatose, movement of the tongue and the gag reflex. Severe bradycardia may be provoked by va gal and/or carotid body stimulation during this procedure. Contraindications to oropharyngeal suctioning may include orofacial surgery/trauma, upper oesophageal/tracheal surgery and severe coagulation defects. Caution must always be exercised to pre vent gagging and the risk of aspiration.
Nasopharyngeal suction
Fig. 1b. Nasopharyngeal airway in situ.
routes for suctioning are available to the nurse, depending on the type of access to the upper airways (Table 3). The unpleasant nature of these procedures can be reduced if the practitioner is confident, can work quickly and provides the necessary reassur ance (Casey, 1989).
O ropharyngeal suction The presence of a nasogastric tube/ nasopharyngeal airway or nasal/oral endotracheal tube often irritates the rel evant mucosa, leading to an increased vol
486
Most patients will expectorate tracheo bronchial secretions by coughing if posture, humidification, hydration, physiotherapy and analgesia are maximized. However, the presence of acute/chronic confusional states or a degree of coma may lead to sputum retention, due to a refusal or an inability to cough effectively. If the patient can move respiratory secre tions into the pharynx, these may be re moved by nasopharyngeal suction in a rea sonably efficient manner. Stimulation of the cough reflex by this process encourages fur ther expectoration of secretions from the upper airways. However, continued use of this route, even with a soft catheter, lubri cation and low vacuum suction (5-10 kPa), often causes trauma to the nasal mucosa, resulting in sneezing, pain and minor haem-, orrhage. The use of a nasopharyngeal airway (Fig. 1) together with lubrication ensures atraumatic passage and consistent position ing of the suction catheter. Complications such as transient bacteraemia (LeFrock et al, 1976) and cardiac arrest (Fincberg et al, 1960) have been reported following nasotracheal suction; therefore care should be exercised in patients who are
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Suction therapy in the critically ill patient
immunocompromised or have excessive cardiac instability. The patient is often uncooperative with nasopharyngeal suctioning and may require some degree of restraint. This may promote a conflict of moral and ethical values as to the need for such procedures and each case must be assessed individually to ensure that such procedures will benefit the patient and not infringe the UKCC’s (1992) Code of Professional Conduct. Retained tracheo bronchial secretions may lead to pulmonary consolidation, atelectasis and pneumonia (Oh, 1986) (Table 2). Contraindications to nasopharyngeal suctioning may include head injury, faciomaxillary surgery/trauma, upper oesophageal/tracheal surgery and severe co agulation defects.
Endotracheal suction During a period of critical illness many pathological processes may necessitate the use, at least initially, of mechanical ventila tion (Oh, 1986). Primary access to the up per airways is usually achieved by oropharyngeal/nasopharyngeal intubation and later, if necessary, by tracheostomy. Suction may then be applied directly to the bronchial tree to remove secretions. This is routinely achieved by manual hyperinflation or preoxygenation with 100% oxygen, postural drainage, physio therapy, instillation of saline when necess ary, and a clean suction technique using a sterilc/clean gloved hand(s) and a single-use Table 4. Potential problems associated with endotracheal suctioning
Tracheobronchial trauma: mucosal irritation minor haemorrhage major haemorrhage tracheobronchial perforation: surgical emphysema pneumothorax Bronchospasm/paroxysmal coughing Hypoxaemia/atelectasis Cardiovascular instability: stress — tachycardia/arrhythmias/hypertension vagal stimulation — bradycardia/hypotension Raised intracranial pressure Ventilator eye
British Journal of Nursing. 1992, Vol l.N o 10
suction catheter with high vacuum suction (13-16 kPa) (Allen, 1988; Lippincott, 1990).
Adverse effects All suction techniques may produce ad verse effects. Manual hyperinflation is by no means universally beneficial (Enright, 1992) and may reduce venous return to the heart leading to hypotension. The use of excessive force during manual hyperinflation can result in barotrauma, with potential complications such as pneumothorax and/or surgical emphysema (Klick et al, 1978). Postural drainage may provoke an unwanted rise in intracranial pressure in a patient with cerebral oedema or head injuries. Instillation of saline (2-10 ml) via the endotracheal tube is often inefficient as much of it can be forced out immediately during expiration. The frac tion that is delivered only rests in the upper airways, does not mix with or liquefy secre tions and may cause tracheal irritation (Ackerman, 1985). Use of a single gloved hand can result in infection of the ungloved hand when occluding the suction port (Baroni and Lucy, 1984). Endotracheal suctioning can be associat ed with several potential problems (Demers, 1982) (Table 4), many of which can be avoided by research-based practice. If the patient can cough, insertion of the catheter just beyond the end of the endotracheal tube can reduce pain and minimize tracheal irritation (De Carle, 1985; Serra et al, 1986). Further insertion of the suction catheter may be necessary in the paralysed/sedated patient, but invari ably results in passage into the right main bronchus which may reduce the effective ness of secretion removal (Serra et al, 1986). Some units have achieved good results us ing a coude-tip or angled suction catheter which may be carefully guided into the tra chea to preferentially remove secretions from the right or left bronchus (Kubota et al, 1980). This technique appears to be fair ly successful but the time spent guiding the catheter into position reduces the effective time that suction can be applied. The severity of hypoxaemic episodes is reduced by preoxygenation for 2-3 minutes pre- and post-suctioning (Oh, 1986) and the use of a suction catheter not more than half the internal size of the airway for no longer than 10-15 s (Kuzenski, 1978; Casey, 1989). This may also serve to mini mize bronchospasm, paroxysmal coughing and rises in intracranial pressure. Manual hyperinflation, despite its adverse effects,
487
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Suction therapy in the critically ill patient
can help to reduce atelectasis postsuctioning (Novak et al, 1987). If the pa tient is very ventilator dependent, he/she may deteriorate rapidly when the ventilator circuit is opened; in such cases the use ol a bronchoscopic swivel connector enables ventilation to continue during the suction procedure. Although the use of air-flow suction catheters is recommended (Serra et al, 1986), injury to the tracheal mucosa may occur with all catheter types even during a single suctioning procedure. With repeat ed suctioning, trauma may be reduced by minimizing the frequency and duration of suction, using a gentle insertion technique and the lowest effective vacuum level (Jung and Gottlieb, 1976).
Alternative treatm ents Endotracheal intubation or open tracheostomy may not be indicated for all patients, at a critical stage of their illness, who develop sputum retention. In these cases, minitracheostomy (Matthews and Hopkinson, 1984) or percutaneous dilational tracheostomy (Schachner et al, 1989) may be employed within the inten sive care unit to provide an access for tracheobronchial suction and/or sup plemental oxygenation. Neither procedure is without risk (Terry and Cook, 1989; Hutchinson and Mitchell, 1991); in the case of minitracheostomy, the cannula will only admit a size 8 or 10 FG suction catheter which may be ineffective at removing thick, tenacious secretions.
Fig. 2. The closed-system multiple-use suction catheter.
488
Patients requiring ventilation with high concentrations of inspired oxygen and gen erating high airway pressures or those with copious secretions, e.g. after inhalation of smoke/heat, present a particularly hazard ous problem. Opening the ventilation cir cuit to insert a suction catheter allows se cretions to leave the airway under pressure, sometimes as virtual aerosols (Cobley et al, 1991). The resultant implications for cross infection are obvious (Tobin and Grenvik, 1984). Staff may protect themselves by wearing mask and goggles when providing suction care as per local policies; however, frequent opening of the ventilator circuit may allow nosocomial organisms to infect the patient. Closed-system, multiple-use suction catheters In order to address the problems associated with endotracheal suction (Table 4), closedsystem, multiple-use (CSMU) suction cath eters have been developed. In these systems the catheter is contained within a plastic sleeve; when not in use it rests in the with drawn position just outside the airway (Fig. 2). Different length catheters are available for tracheostomy and oropharyngeal/ nasopharyngeal/endotracheal tubes to limit the length of catheter that can be inserted into the trachea and bronchi. This arrangement has several advantages over single-use suction catheters (Birdsall, 1986; Carlon et al, 1987). The CSMU cath eter becomes part of the ventilator circuit so there is no need to discontinue ventila tion during suctioning, thus reducing the severity of hypoxaemia (Craig et al, 1984) and the risk of cardiovascular instability. There is no leakage of aerosolized secre tions and if the patient coughs during suc tion any exhaled material is propelled into the expiratory limb of the ventilator tubing and not dispersed about the bedside. The CSMU catheter has an injection port (Fig. 2) which can be used to clear the suction tubing after withdrawal of the catheter from the airway or, with the catheter insert ed, to instill sterile saline (5-10 ml) into the bronchi or lower trachea. When used in this manner, together with manual hyper inflation, saline appears to be more effective in aiding secretion removal. If left lung pa thology is a problem, a coudé-tip version of this catheter is now available. The CSMU suction catheter is changed with the ventilator tubing every 24 hours. Studies indicate a high level of bacterial contamination of the catheter during this
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Suction therapy in the critically ill patient
c The expanding range of equipment and the bulk of research data available to the nurse caring for a critically ill patient mean that an informed choice is available. 5
period (Ritz et al, 1986); however, if suc tion with the CSMU system is instigated from the outset, it is likely to be endo genous rather than exogenous (nosocomial) colonization that is mainly responsible (Demers, 1989).
The author wishes to express his thanks to Mr Andrew Whitfield, Sister Theda Clarke, Sister Glenys Davies and Dr Leslie Gemmell fo r helpful discussions in the preparation o f this article.
risks associated with endotracheal suctioning and airway management. Respir Care 34: 339-41 Enright S (1992) Cardiorespiratory effects of chest physiotherapy. In: Rennie M, ed. Intensive Care Britain 1992. lsted n . Greycoat Publications, Lon don: 118-23 Fineberg C, Cohn HE, Gibbon JH Jr (1960) Cardiac arrest during nasotracheal aspiration. JAM A 174: 410-12 Hutchinson RC, Mitchell RD (1991) Life-threatening complications from percutaneous dilations! tracheostomy. Crit Care Med 19: 118-20 Jung RC, Gottlieb LS (1976) Comparison of tracheobronchial suction catheters in humans. Chest 69: 179-81 Klick JM, Bushneil LS, Bancroft ML (1978) Barotrauma, a potential hazard of manual resuscitators. Anaesthesiology 49: 363-5 Kubota Y, Margaribuchi T, Ohara M et al (1980) Evaluation of selective bronchial suctioning in the adult. Crit Care Med 8: 748-9 Kuzenski BM (1978) Effect of negative pressure on tracheobronchial trauma. Nurs Res 27: 250-4 LeFrock JL, Klainer AS, Wu HW, Turndorf H (1976) Transient bacteraemia associated with nasotracheal suctioning. JAMA 236: 1510-611 Lipincott JB (1990) In: Brunner LS, Suddarth DS, eds. Manual o f Medical-Surgical Nursing. 2nd edn. Harper and Row, London: 153-8 Matthews HR, Hopkinson RB (1984) Treatment of sputum retention by minitracneotomy. Br J Surg
Ackerman MH (1985) The use of bolus normal saline instillations in artificial airways. Is it useful or necessary? Heart Lung 14: 505-6 Allen D (1988) Making sense of suction. Nurs Times 84(10): 46-47 Barom M, Lucy J (1984) Herpetic whitlow. Am / Nurs 84(1): 60-1 Birdsall C (1986) How do you use a closed suction adaptor? Am J Nurs 86(11): 1222-3 Carlon GC, Fox SI, Ackerman RN (1987) Evaluation of a closed tracheal suction system. Crit Care Med 15: 522-5 Casey DC (1989) Tracheostomy — open airways. Nurs Standard 3: 19-20 Cobley M, Atkins M, Jones PL (1991) Environmental contamination during trachea) suction. Anaesthesia 46: 957-61 Craig KC, Benson MS, Pierson DJ (1984) Prevention of arterial oxygen desaturation during closed air way endotracheal suction. Effect of ventilator mode. Resptr Care 29: 1013-18 De Carle B (1985) Occasional paper — Tracheostomy care. Nurs Times 81: 50-4 Demers RR (1982) Complications of endotracheal suctioning procedures. Respir Care 27: 453-7 Demers B (1989) The impact of technology on the
Novak RA, Shumaker L, Snyder V, Pinsky MR (1987) Do periodic hyperinflations improve gas exchange in patients with hypoxaemic respiratory failure. Crit Care Med 15: 1081-5 O h TE, ed (1986) Intensive Care Manual. 2nd edn. Butterworths, London: 67, 87 Ritz R, Scott LR, Coyle MB, Pierson DJ (1986) Con tamination of a multiple-use suction catheter in a closed circuit system compared to contamination of a disposable single-use suction catheter. Respir Care 31: 1086-91 Schachner A, Ovil Y, Sidi J, Roger M, Heilbron Y, Levy MJ (1989) Percutaneous tracheostomy — a new method. Crit Care Med 17: 1053-6 Selsby D (1989) Chest physiotherapy — may be harm ful in some patients. Rr Med J 298: 541-2 Serra AM, Baily CM, Jackson P (1986) Ear, Nose and Throat Nursing. Blackwell Scientific Publications, Oxford: 232-3 Terry RM, Cook P (1989) Haemorrhage during mini tracheotomy: a reduction of risk bv altered inci sion. / Laryngol Otol Suppl 103: 207-8 Tobin MJ, Grenvik A (1984) Nosocomial lung infec tion and its diagnosis. Crit Care Med 12: 191-9 UKCC (1992) Code o f Professional Conduct fo r the Nurse, Midwife and Health Visitor. UKCC, London
Conclusion The expanding range of equipment and the bulk of research data available to the nurse caring for a critically ill patient mean that an informed choice is available. Even the traditional premise that all patients with chest problems should have physiotherapy is being questioned (Selsby, 1989; Enright, 1992). The ultimate goal has to be the right therapy for the right patient.
KEY POINTS • Retention of respiratory secretions may be extremely detrimental to the critically ill patient. • Effective treatment of patients requiring suction demands a multidisciplinary approach from nurses, physiotherapists and medical staff. • Nurses should be able to maximize the efforts of the patient in achieving expectoration and know when to intervene with appropriate and effective suction therapy. • Suctioning may be a hazardous procedure, particularly in the unstable, critically ill patient. Adequate numbers of skilled staff are necessary to ensure that preoxygenation, physiotherapy, analgesia, sedation and haemodynamic monitoring are optimized and that any adverse reactions may be dealt with confidently. • New techniques and equipment available to the nurse can help to reduce the Incidence of adverse effects and promote the effectiveness of suctioning procedures. procedures.
British Journal of Nursing, 1992,Vol l.N o 10
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Suction therapy in the critically ill patient Stephen Ashurst, Maelor General Hospital, Wrexham Caring for patients with inefficient airway function who need suctioning requires a great deal of nursing skill. This article outlines the methods of suction therapy currently available, the role of research in improving clinical practice and the way in which new technology may be used to benefit both patient and nurse.
Mr Ashurst is a Staff Nurse in the Intensive Care Unit, Maelor General Hospital, Wrexham, Clwyd
c
ritically ill patients are highly de pendent on skilled nursing therapy throughout all aspects of their care. One such aspect is the ability to maintain a clear airway which may necessitate suctioning, even in the absence of an endotracheal tube or tracheostomy. A major function of the upper airways is to protect the bronchial tree from infection. The bronchi contain many mucus-producing cells (goblet cells) that trap invading organisms; the activity of these cells is usually increased during ac tive respiratory infections. The bronchial mucosa may also be hyperresponsive to in haled allergens which cause mast cells to release inflammatory mediators, leading to the bronchoconstriction and oedema of the mucosa with excessive production of mucus typically seen in asthma. The lower airways, terminal bronchioles and alveoli have an extensive blood supply and are susceptible to capillary leakage in addition to microbial invasion (pneu monia). Secretions from these regions may therefore be infective (microorganisms and pus), immunological (polymorphonuclear cells and vascular transudate) or cardiac (pulmonary oedema) in origin. Often, how ever, multiple causes are evident and a mix ture of these types is often present in respir atory secretions. In the healthy adult, the action of the ciliated cells, the functions of the local im mune system (secretory immunoglobulin and alveolar macrophages) and the cough reflex are of prime importance in the killing and removal of microorganisms and the clearing of debris from the lung. These functions may be compromised in the criti cally ill patient due to a variety of condi tions (Table /), resulting in inefficient air way function and excessive production of secretions. The inability to expectorate this material, which is often thick and tenacious, is a common problem for these patients and the possible resultant complications (Table 2) may be life-threatening.
British Journal of Nursing, 1992, Vol 1, No 10
An important role of nurses caring for these patients is to maximize ventilation by utilizing good positioning, physiotherapy, reassurance and effective drug therapy, to maintain microbiological surveillance by obtaining adequate and correct specimens, and to promote efficient removal of retain ed secretions, utilizing humidification and suction therapy where necessary. Several Table I. Clinical conditions that may result in retained respiratory secretions Exacerbation of chronic obstructive airways disease Carcinoma of the bronchus Upper abdominal surgery/trauma Thoracic surgery/trauma Neurological muscle weakness Coma states Shock Presence of an endotracheal tube
Table 2. Problems associated with retained respiratory secretions Increased airway pressures: pneumothorax and cardiovascular instability Carbon dioxide retention Lobar consolidation Ventilation/perfusion mismatch Arterial desaturation: tissue acidosis Bacterial colonization Pneumonia Hypoxaemia/atelectasis
485
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Suction therapy in the critically ill patient
Table 3. Routes for suction therapy Associated problems Type of suction therapy Oropharyngeal
Retching, vomiting, aspiration, bradycardia, oral ulceration
Nasopharyngeal
Nasal trauma/stress, sneezing, bradycardia, ethical conflict
Endotracheal
Needs open access, numerous problems ( Table 4)
___________ _________________________________________ ___________ 1
Fig. 1a. Nasopharyngeal airway.
ume of secretions. This is particularly evi dent with oral endotracheal tubes, where hypersalivation may result in a substantial loss of fluid. These secretions may be re moved by gentle suctioning (5-10 kPa) (conversion: 1 kPa = 7.5 mmHg), with a soft plastic catheter, at regular intervals to prevent ‘dribbling’ over central venous lines, haemodialysis catheters and wounds. The continuous use of hard, plastic cath eters at high vacuum pressures can cause oral trauma resulting in minor haemorrhage and ulceration which may predispose to infection in the critically ill patient, e.g. Candida. The removal of tracheobronchial secretions via oropharyngeal suctioning is at best inefficient. This is primarily due to poor guidance of the catheter and, unless the patient is deeply sedated or comatose, movement of the tongue and the gag reflex. Severe bradycardia may be provoked by va gal and/or carotid body stimulation during this procedure. Contraindications to oropharyngeal suctioning may include orofacial surgery/trauma, upper oesophageal/tracheal surgery and severe coagulation defects. Caution must always be exercised to pre vent gagging and the risk of aspiration.
Nasopharyngeal suction
Fig. 1b. Nasopharyngeal airway in situ.
routes for suctioning are available to the nurse, depending on the type of access to the upper airways (Table 3). The unpleasant nature of these procedures can be reduced if the practitioner is confident, can work quickly and provides the necessary reassur ance (Casey, 1989).
O ropharyngeal suction The presence of a nasogastric tube/ nasopharyngeal airway or nasal/oral endotracheal tube often irritates the rel evant mucosa, leading to an increased vol
486
Most patients will expectorate tracheo bronchial secretions by coughing if posture, humidification, hydration, physiotherapy and analgesia are maximized. However, the presence of acute/chronic confusional states or a degree of coma may lead to sputum retention, due to a refusal or an inability to cough effectively. If the patient can move respiratory secre tions into the pharynx, these may be re moved by nasopharyngeal suction in a rea sonably efficient manner. Stimulation of the cough reflex by this process encourages fur ther expectoration of secretions from the upper airways. However, continued use of this route, even with a soft catheter, lubri cation and low vacuum suction (5-10 kPa), often causes trauma to the nasal mucosa, resulting in sneezing, pain and minor haem-, orrhage. The use of a nasopharyngeal airway (Fig. 1) together with lubrication ensures atraumatic passage and consistent position ing of the suction catheter. Complications such as transient bacteraemia (LeFrock et al, 1976) and cardiac arrest (Fincberg et al, 1960) have been reported following nasotracheal suction; therefore care should be exercised in patients who are
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Suction therapy in the critically ill patient
immunocompromised or have excessive cardiac instability. The patient is often uncooperative with nasopharyngeal suctioning and may require some degree of restraint. This may promote a conflict of moral and ethical values as to the need for such procedures and each case must be assessed individually to ensure that such procedures will benefit the patient and not infringe the UKCC’s (1992) Code of Professional Conduct. Retained tracheo bronchial secretions may lead to pulmonary consolidation, atelectasis and pneumonia (Oh, 1986) (Table 2). Contraindications to nasopharyngeal suctioning may include head injury, faciomaxillary surgery/trauma, upper oesophageal/tracheal surgery and severe co agulation defects.
Endotracheal suction During a period of critical illness many pathological processes may necessitate the use, at least initially, of mechanical ventila tion (Oh, 1986). Primary access to the up per airways is usually achieved by oropharyngeal/nasopharyngeal intubation and later, if necessary, by tracheostomy. Suction may then be applied directly to the bronchial tree to remove secretions. This is routinely achieved by manual hyperinflation or preoxygenation with 100% oxygen, postural drainage, physio therapy, instillation of saline when necess ary, and a clean suction technique using a sterilc/clean gloved hand(s) and a single-use Table 4. Potential problems associated with endotracheal suctioning
Tracheobronchial trauma: mucosal irritation minor haemorrhage major haemorrhage tracheobronchial perforation: surgical emphysema pneumothorax Bronchospasm/paroxysmal coughing Hypoxaemia/atelectasis Cardiovascular instability: stress — tachycardia/arrhythmias/hypertension vagal stimulation — bradycardia/hypotension Raised intracranial pressure Ventilator eye
British Journal of Nursing. 1992, Vol l.N o 10
suction catheter with high vacuum suction (13-16 kPa) (Allen, 1988; Lippincott, 1990).
Adverse effects All suction techniques may produce ad verse effects. Manual hyperinflation is by no means universally beneficial (Enright, 1992) and may reduce venous return to the heart leading to hypotension. The use of excessive force during manual hyperinflation can result in barotrauma, with potential complications such as pneumothorax and/or surgical emphysema (Klick et al, 1978). Postural drainage may provoke an unwanted rise in intracranial pressure in a patient with cerebral oedema or head injuries. Instillation of saline (2-10 ml) via the endotracheal tube is often inefficient as much of it can be forced out immediately during expiration. The frac tion that is delivered only rests in the upper airways, does not mix with or liquefy secre tions and may cause tracheal irritation (Ackerman, 1985). Use of a single gloved hand can result in infection of the ungloved hand when occluding the suction port (Baroni and Lucy, 1984). Endotracheal suctioning can be associat ed with several potential problems (Demers, 1982) (Table 4), many of which can be avoided by research-based practice. If the patient can cough, insertion of the catheter just beyond the end of the endotracheal tube can reduce pain and minimize tracheal irritation (De Carle, 1985; Serra et al, 1986). Further insertion of the suction catheter may be necessary in the paralysed/sedated patient, but invari ably results in passage into the right main bronchus which may reduce the effective ness of secretion removal (Serra et al, 1986). Some units have achieved good results us ing a coude-tip or angled suction catheter which may be carefully guided into the tra chea to preferentially remove secretions from the right or left bronchus (Kubota et al, 1980). This technique appears to be fair ly successful but the time spent guiding the catheter into position reduces the effective time that suction can be applied. The severity of hypoxaemic episodes is reduced by preoxygenation for 2-3 minutes pre- and post-suctioning (Oh, 1986) and the use of a suction catheter not more than half the internal size of the airway for no longer than 10-15 s (Kuzenski, 1978; Casey, 1989). This may also serve to mini mize bronchospasm, paroxysmal coughing and rises in intracranial pressure. Manual hyperinflation, despite its adverse effects,
487
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Suction therapy in the critically ill patient
can help to reduce atelectasis postsuctioning (Novak et al, 1987). If the pa tient is very ventilator dependent, he/she may deteriorate rapidly when the ventilator circuit is opened; in such cases the use ol a bronchoscopic swivel connector enables ventilation to continue during the suction procedure. Although the use of air-flow suction catheters is recommended (Serra et al, 1986), injury to the tracheal mucosa may occur with all catheter types even during a single suctioning procedure. With repeat ed suctioning, trauma may be reduced by minimizing the frequency and duration of suction, using a gentle insertion technique and the lowest effective vacuum level (Jung and Gottlieb, 1976).
Alternative treatm ents Endotracheal intubation or open tracheostomy may not be indicated for all patients, at a critical stage of their illness, who develop sputum retention. In these cases, minitracheostomy (Matthews and Hopkinson, 1984) or percutaneous dilational tracheostomy (Schachner et al, 1989) may be employed within the inten sive care unit to provide an access for tracheobronchial suction and/or sup plemental oxygenation. Neither procedure is without risk (Terry and Cook, 1989; Hutchinson and Mitchell, 1991); in the case of minitracheostomy, the cannula will only admit a size 8 or 10 FG suction catheter which may be ineffective at removing thick, tenacious secretions.
Fig. 2. The closed-system multiple-use suction catheter.
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Patients requiring ventilation with high concentrations of inspired oxygen and gen erating high airway pressures or those with copious secretions, e.g. after inhalation of smoke/heat, present a particularly hazard ous problem. Opening the ventilation cir cuit to insert a suction catheter allows se cretions to leave the airway under pressure, sometimes as virtual aerosols (Cobley et al, 1991). The resultant implications for cross infection are obvious (Tobin and Grenvik, 1984). Staff may protect themselves by wearing mask and goggles when providing suction care as per local policies; however, frequent opening of the ventilator circuit may allow nosocomial organisms to infect the patient. Closed-system, multiple-use suction catheters In order to address the problems associated with endotracheal suction (Table 4), closedsystem, multiple-use (CSMU) suction cath eters have been developed. In these systems the catheter is contained within a plastic sleeve; when not in use it rests in the with drawn position just outside the airway (Fig. 2). Different length catheters are available for tracheostomy and oropharyngeal/ nasopharyngeal/endotracheal tubes to limit the length of catheter that can be inserted into the trachea and bronchi. This arrangement has several advantages over single-use suction catheters (Birdsall, 1986; Carlon et al, 1987). The CSMU cath eter becomes part of the ventilator circuit so there is no need to discontinue ventila tion during suctioning, thus reducing the severity of hypoxaemia (Craig et al, 1984) and the risk of cardiovascular instability. There is no leakage of aerosolized secre tions and if the patient coughs during suc tion any exhaled material is propelled into the expiratory limb of the ventilator tubing and not dispersed about the bedside. The CSMU catheter has an injection port (Fig. 2) which can be used to clear the suction tubing after withdrawal of the catheter from the airway or, with the catheter insert ed, to instill sterile saline (5-10 ml) into the bronchi or lower trachea. When used in this manner, together with manual hyper inflation, saline appears to be more effective in aiding secretion removal. If left lung pa thology is a problem, a coudé-tip version of this catheter is now available. The CSMU suction catheter is changed with the ventilator tubing every 24 hours. Studies indicate a high level of bacterial contamination of the catheter during this
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Suction therapy in the critically ill patient
c The expanding range of equipment and the bulk of research data available to the nurse caring for a critically ill patient mean that an informed choice is available. 5
period (Ritz et al, 1986); however, if suc tion with the CSMU system is instigated from the outset, it is likely to be endo genous rather than exogenous (nosocomial) colonization that is mainly responsible (Demers, 1989).
The author wishes to express his thanks to Mr Andrew Whitfield, Sister Theda Clarke, Sister Glenys Davies and Dr Leslie Gemmell fo r helpful discussions in the preparation o f this article.
risks associated with endotracheal suctioning and airway management. Respir Care 34: 339-41 Enright S (1992) Cardiorespiratory effects of chest physiotherapy. In: Rennie M, ed. Intensive Care Britain 1992. lsted n . Greycoat Publications, Lon don: 118-23 Fineberg C, Cohn HE, Gibbon JH Jr (1960) Cardiac arrest during nasotracheal aspiration. JAM A 174: 410-12 Hutchinson RC, Mitchell RD (1991) Life-threatening complications from percutaneous dilations! tracheostomy. Crit Care Med 19: 118-20 Jung RC, Gottlieb LS (1976) Comparison of tracheobronchial suction catheters in humans. Chest 69: 179-81 Klick JM, Bushneil LS, Bancroft ML (1978) Barotrauma, a potential hazard of manual resuscitators. Anaesthesiology 49: 363-5 Kubota Y, Margaribuchi T, Ohara M et al (1980) Evaluation of selective bronchial suctioning in the adult. Crit Care Med 8: 748-9 Kuzenski BM (1978) Effect of negative pressure on tracheobronchial trauma. Nurs Res 27: 250-4 LeFrock JL, Klainer AS, Wu HW, Turndorf H (1976) Transient bacteraemia associated with nasotracheal suctioning. JAMA 236: 1510-611 Lipincott JB (1990) In: Brunner LS, Suddarth DS, eds. Manual o f Medical-Surgical Nursing. 2nd edn. Harper and Row, London: 153-8 Matthews HR, Hopkinson RB (1984) Treatment of sputum retention by minitracneotomy. Br J Surg
Ackerman MH (1985) The use of bolus normal saline instillations in artificial airways. Is it useful or necessary? Heart Lung 14: 505-6 Allen D (1988) Making sense of suction. Nurs Times 84(10): 46-47 Barom M, Lucy J (1984) Herpetic whitlow. Am / Nurs 84(1): 60-1 Birdsall C (1986) How do you use a closed suction adaptor? Am J Nurs 86(11): 1222-3 Carlon GC, Fox SI, Ackerman RN (1987) Evaluation of a closed tracheal suction system. Crit Care Med 15: 522-5 Casey DC (1989) Tracheostomy — open airways. Nurs Standard 3: 19-20 Cobley M, Atkins M, Jones PL (1991) Environmental contamination during trachea) suction. Anaesthesia 46: 957-61 Craig KC, Benson MS, Pierson DJ (1984) Prevention of arterial oxygen desaturation during closed air way endotracheal suction. Effect of ventilator mode. Resptr Care 29: 1013-18 De Carle B (1985) Occasional paper — Tracheostomy care. Nurs Times 81: 50-4 Demers RR (1982) Complications of endotracheal suctioning procedures. Respir Care 27: 453-7 Demers B (1989) The impact of technology on the
Novak RA, Shumaker L, Snyder V, Pinsky MR (1987) Do periodic hyperinflations improve gas exchange in patients with hypoxaemic respiratory failure. Crit Care Med 15: 1081-5 O h TE, ed (1986) Intensive Care Manual. 2nd edn. Butterworths, London: 67, 87 Ritz R, Scott LR, Coyle MB, Pierson DJ (1986) Con tamination of a multiple-use suction catheter in a closed circuit system compared to contamination of a disposable single-use suction catheter. Respir Care 31: 1086-91 Schachner A, Ovil Y, Sidi J, Roger M, Heilbron Y, Levy MJ (1989) Percutaneous tracheostomy — a new method. Crit Care Med 17: 1053-6 Selsby D (1989) Chest physiotherapy — may be harm ful in some patients. Rr Med J 298: 541-2 Serra AM, Baily CM, Jackson P (1986) Ear, Nose and Throat Nursing. Blackwell Scientific Publications, Oxford: 232-3 Terry RM, Cook P (1989) Haemorrhage during mini tracheotomy: a reduction of risk bv altered inci sion. / Laryngol Otol Suppl 103: 207-8 Tobin MJ, Grenvik A (1984) Nosocomial lung infec tion and its diagnosis. Crit Care Med 12: 191-9 UKCC (1992) Code o f Professional Conduct fo r the Nurse, Midwife and Health Visitor. UKCC, London
Conclusion The expanding range of equipment and the bulk of research data available to the nurse caring for a critically ill patient mean that an informed choice is available. Even the traditional premise that all patients with chest problems should have physiotherapy is being questioned (Selsby, 1989; Enright, 1992). The ultimate goal has to be the right therapy for the right patient.
KEY POINTS • Retention of respiratory secretions may be extremely detrimental to the critically ill patient. • Effective treatment of patients requiring suction demands a multidisciplinary approach from nurses, physiotherapists and medical staff. • Nurses should be able to maximize the efforts of the patient in achieving expectoration and know when to intervene with appropriate and effective suction therapy. • Suctioning may be a hazardous procedure, particularly in the unstable, critically ill patient. Adequate numbers of skilled staff are necessary to ensure that preoxygenation, physiotherapy, analgesia, sedation and haemodynamic monitoring are optimized and that any adverse reactions may be dealt with confidently. • New techniques and equipment available to the nurse can help to reduce the Incidence of adverse effects and promote the effectiveness of suctioning procedures. procedures.
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