Adult and Paediatric Oral/nasal-pharyngeal suctioning

April 08

Validation Grid:
Title Author Associate authors Target Audience Oral/Nasal pharyngeal suctioning Angela Griggs - Lecturer Practitioner ENT Nursing RNTNE Clinical Practice Group Nurses, Doctors RNTNE Directorate, Oncology, Plastics, Paediatrics CPG Clinical practice group Physiotherapy
Directorates: Acute medicine Medical specialities Womens and childrens RNTNE, ENT, audiology and ophthalmology Surgery, anaesthetics and critical care Hepatology, nephrology and transplantation Clinical haematology, oncology and private practice Neurosciences

Commissioning body Stakeholders consulted

Clinical Practice/ Advanced Practice Associated policies / guidelines Guideline replacement Date of submission Review date 10 Key words

Clinical practice Tracheostomy care Oral/Nasal pharyngeal suctioning, 2004 April 2008 April 2010 Oral, nasal, pharyngeal, suction

Contents:
Background/supporting information Staff who may undertake the procedure Potential Problems Guidelines for managing a patient requiring oral pharyngeal suctioning Guidelines for managing a patient requiring nasal pharyngeal suctioning Risk assessment, Patient information, Audit References 3 3 4 6 8 10 10

Oral-pharyngeal suction

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Introduction Background/supporting information

Oral/nasal-pharyngeal suction is the passing of a suction catheter into the upper airway through which a negative pressure is applied as the suction catheter is withdrawn in order to aspirate secretions. Unlike tracheal suctioning they do not completely occlude the patient's airway and as these routes do not enter a sterile area the procedure is clean, rather than aseptic. Indications for Oral-pharyngeal suction The group of patients who will require oral-pharyngeal suction are patients unable to effectively remove secretions independently by coughing due to conditions such as a reduced level of consciousness, fatigue, and muscle weakness The frequency with which suction is required will vary widely between patients. Each must be individually assessed. Factors that should be considered are: patients ability to cough and clear own secretions amount and consistency of secretions oxygen saturation/arterial blood gases presence of infection Routes for suction Suctioning can be performed using a number of routes. The most appropriate route should be chosen that minimises or prevents trauma. Oral - This removes secretions from the mouth using a Yankauer sucker. Oropharyngeal - This can be performed on patients who can breathe spontaneously, but are unable to maintain an open airway. This means an airway adjunct may be required. Most conscious patients cannot tolerate the placement of this type of airway. A size 2, 3 or 4 is used in adults and 0, 1, 2 or 3 in paediatrics Nose - catheters may be inserted directly into the nose or via a nasopharyngeal airway. This method is only used in patients who have a very weak cough, to collect virology specimens or in paediatrics for clearance of retained secretions. Endotracheal and tracheostomy tubes - these will be used for patients requiring artificial ventilation or long term airway protection. Patients with a tracheostomy or endotracheal tubes also have an increased risk of pneumonia as the natural defence mechanisms of the upper airway are bypassed. See the guidelines for caring for a patient with tracheostomy for further details.

Aim/ purpose of the procedure/guideline

To remove excess secretions from the upper respiratory tract in patients who are unable to do so independently.

Staff who may undertake the procedure

Within this Trust oral/nasal pharyngeal suction is regarded as a clinical practice. A clinical practice may be defined as an aspect of care, which may be undertaken by registered nurses, midwives and physiotherapists who accept accountability for their actions and feel competent to undertake the procedure. There is no formal assessment for these practices but they may be aspects of care, which require a period of supervised, guided practice. They should form part of preceptorship or mentorship programmes. Student nurses and midwives may undertake this practice under the supervision of a registered nurse or midwife who feels competent in this aspect of care and in the supervisory role.
Oral-pharyngeal suction

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Patients and carers may undertake this procedure if felt appropriate by nurse or midwife. In line with guidelines laid down by the NMC on standards for records and record keeping, there must be a current and appropriate plan of care for patients. The plan must incorporate on-going evaluation and reassessment of care and evidence that relevant interventions and observations have been communicated to appropriate members of the multidisciplinary team. Potential Problems Patient Distress. Suction may be very uncomfortable for the patient. Nasal or oral suction should only take place if absolutely necessary. Careful explanation and reassurance are essential. Hypoxia. Caused by obstructing the airway with the catheter and by reducing the patients oxygen supply during the procedure. Giving extra oxygen prior to the procedure, using an appropriate sized catheter, and not prolonging the suction procedure may prevent this. NB care is needed when considering preoxygenation of patients with type II respiratory failure (i.e. normal oxygen, high CO2) as they become dependant on low oxygen levels to initiate respiration. If they are given additional oxygen this may reduce their respiratory drive. However patients with both type I and type II respiratory failure (i.e. low oxygen, high CO2 ) may benefit from additional oxygen - they should be monitored closely. For further advice staff should contact medical, PARR or physiotherapy staff. Soft Tissue Damage such as epistaxis, mucosal damage and ulceration. Using appropriate vacuum pressures (20Kpa or 120mmHg) and careful selection of the catheter size may prevent this. Gagging/Vomiting. Touching the posterior pharyngeal wall with a suction catheter causes this. Careful technique will reduce the risks. Vasovagal Stimulation causing Bradycardia and Hypotension. This is most common in unstable patients. Introducing the catheter gently and to the correct depth will prevent this. Infection. Infection may be introduced during oral-pharyngeal suction. A clean technique must be used and catheters are for single use only. Infection may also be spread from the patient unless universal precautions are used to protect the staff and other patients. Hypertension. This is usually due to patient distress and will settle quickly after the procedure is complete. Raised Intracranial Pressure (ICP). If the patients blood pressure is raised this will also increase ICP. ICP will also rise if the patient coughs, vomits or becomes hypoxic. If any of these conditions persist in a neurologically unstable patient it may cause further instability. Contraindications General: tracheo/oesophageal fistulae severe bronchospasm. stridor Nasal suction: basal skull fractures - as the catheter may pass into the brain instead of down the trachea severe epistaxis leakage of cerebral spinal fluid - suggests skull fracture so suction may cause further damage occluded nasal passage
Oral-pharyngeal suction

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 clotting problems Oral suction: jaw fractures Precautions recent oesophageal or tracheal surgery coagulopathy and bleeding disorders upper airway lesions irritable airways pulmonary oedema loose teeth

Signs that suction has been effective reduced work of breathing reduced respiratory rate increased oxygen saturation visible evidence of removal of secretions absence of audible secretions in large airways patients colour improves.

Specific training required

There is no specific training required to carry out these guidelines, but in-service education is provided on this topic and all nurses are accountable for their own professional practice and should ensure that they are familiar with these guidelines. Suction catheter selection Catheter Sizes for Adults Type of suction Nasal Oropharyngeal airway Nasopharyngeal airway Catheter sizes for Paediatrics Nasal only Suction Catheter FG mm 10 or 12 12 10 or 12

6-10

Oral-pharyngeal suction

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Guidelines for managing a patient requiring oral pharyngeal suctioning Aim To ensure the safe management of a patient requiring oral pharyngeal suctioning Equipment Required: Equipment required for suction Functioning suction unit Oral suction catheter e.g. Yankeur sucker Lubricant i.e. KY Jelly-except in paediatrics Gloves Face mask Procedure Intervention Check the equipment Explain the procedure to the patient and any visitors Position the patient in semi-recumbent position with head turned towards you. If the patient is unconscious, position lying on their side facing you Paediatrics-swaddle in a blanket, lying on side facing you-head positioned midline or slightly extended. Place towel under the patient's chin-adults only If the patient is oxygen dependent or cardiovascularly unstable, it may be necessary to give the patient some extra oxygen for a short while before and after suctioning. If patient is producing copious amounts of secretions and requiring frequent suctioning-seek advice from appropriate MDT. NB this procedure must not be carried out for patients who are CO2 retainers. Observe the patient throughout the procedure to ensure their general condition is not affected. Rationale To maintain a safe environment To obtain patients co-operation. This procedure is unpleasant & can be frightening. Prevent aspiration of gastric contents Suction catheters of correct size Oral/nasal pharyngeal airway Protective eyewear Disposable apron Towel

To protect patient's clothes & bed linen. Introducing a suction catheter into the airway may cause hypoxia

Pharyngeal suction may cause vagal stimulation leading to bradycardia, hypoxia and may stimulate bronchospasm. Put on disposable apron, protective eye wear & To reduce the risk of cross infection and protect nurse through universal precautions. Most mask. Wash & dry hands patients cough directly onto the nurses clothes after suction; standing to one side should minimise the risk. Switch suction unit on and check that the suction To ensure the machine is working correctly. Too machine is set appropriately no higher than great a suction pressure can cause injury to the mucosa, teeth and gums. Greater suction 20Kpa or 120mmHg-adults pressure does not equal increased secretion 15Kpa or 115Hg-paediatrics removal.
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Put on gloves Ask patient to open their mouth, assist as necessary If paediatric patient, ask parent to assist in holding child With out applying suction, insert the Yankauer sucker into the mouth along one side and guide it along the inside of the cheek towards the oropharynx. Apply suction and remove secretions from the oropharynx and debris from the mouth. Do not force the sucker between the teeth or touch the posterior pharyngeal wall.

To protect hands from secretions

Suction can cause damage to the mucosa

As this can make the patient gag or vomit.

Note the colour, tenacity and quantity of the Monitor changes and anticipate potential secretions. If secretions look infected infection at an early stage. (yellow/green) consider sending a sample via a sputum trap if this has not recently occurred. Assess the patients respiratory rate, skin colour Suction should be performed only when needed and/or oxygen saturation to ensure they have not and not as part of a routine been compromised by the procedure and if they need further suction. If the patient needs further suction, repeat the above actions using new gloves & a new sucker Turn the suction off. Dispose of the yancker To prevent infection sucker into a yellow bag Remove gloves and wash hands Prevent cross infection Ensure that the patient is comfortable. Ensure that further Yankauer suckers are Ensures that in an emergency equipment is ready available at the bedside for immediate use. Record the colour, quantity & tenacity of To facilitate on-going evaluation. secretions, and any other relevant details, in nursing notes

Oral-pharyngeal suction

April 08

Guidelines for managing a patient requiring nasal pharyngeal suctioning Aim To ensure the safe management of a patient requiring nasal pharyngeal suctioning Equipment Required: Equipment required for suction Functioning suction unit Suction catheters of correct size Sterile water Sterile Bowl Procedure Intervention Check the equipment Explain the procedure to the patient and any visitors Position the patient in semi-recumbent position with head turned towards you. If the patient is unconscious, position lying on their side facing you Paediatrics-swaddle in a blanket, lying on side facing you-head positioned midline or slightly extended. Place towel under the patient's chin-adults only If the patient is oxygen dependent or cardiovascularly unstable, it may be necessary to give the patient some extra oxygen for a short while before and after suctioning. If patient is producing copious amounts of secretions and requiring frequent suctioning-seek advice from appropriate MDT. NB this procedure must not be carried out for patients who are CO2 retainers. Observe the patient throughout the procedure to ensure their general condition is not affected. Rationale To maintain a safe environment To obtain patients co-operation. This procedure is unpleasant & can be frightening. Prevent aspiration of gastric contents Personal protective equipment Oral/nasal pharyngeal airway-adults only Gloves

To protect patient's clothes & bed linen. Introducing a suction catheter into the airway may cause hypoxia

Pharyngeal suction may cause vagal stimulation leading to bradycardia, hypoxia and may stimulate bronchospasm. Put on disposable apron, protective eye wear & To reduce the risk of cross infection and protect nurse through universal precautions. Most mask. Wash & dry hands patients cough directly onto the nurses clothes after suction; standing to one side should minimise the risk. Switch suction unit on and check that the suction To ensure the machine is working correctly. Too great a suction pressure can cause mucosal injury machine is set appropriately at Greater suction pressure does not equal 20Kpa or 120mmHg-adults increased secretion removal. 15Kpa or 115Hg-paediatrics Put on gloves To protect hands from secretions

Oral-pharyngeal suction

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Estimate the distance between the patient's ear lobe and nasal tip and mark this point on the catheter with gloved thumb and forefinger. Moisten catheter tip with sterile water. Without applying suction introduce catheter into one nostril pushing it gently towards the back of the nose with an upward inclination until a slight resistance is felt. If an obstruction is felt remove catheter and try the other nostril Rotate the catheter gently between thumb and index finger until this resistance is overcome Continue to advance the catheter until you reach the marked point. If the patient coughs withdraw the catheter Apply suction & smoothly withdraw the catheter back through the nose. Do not suction for longer than 15 seconds at a time

To ensure catheter length inserted will remain in the pharynx and not enter the trachea To aid smooth passage and limit trauma. Suctioning while introducing the catheter causes mucosal irritation and damage The patient may have a deviated nasal septum or enlarged turbinates that prevents passage of the suction catheter. This will ensure the catheter does not enter the trachea. Coughing indicates that the catheter is in the larynx.

It is not necessary to rotate the catheter whilst applying suction as catheters have circumferential holes. Prolonged suctioning will result trauma and hypoxia

Note the colour, tenacity and quantity of the Monitor changes and anticipate potential secretions. If secretions look infected infection at an early stage. (yellow/green) consider sending a sample if this has not recently occurred. Remove the glove from the dominant hand by To minimise the risk of infection inverting it over the used catheter & dispose in yellow polythene bag Assess the patients respiratory rate, skin colour Suction should be performed only when needed and/or oxygen saturation to ensure they have not and not as part of a routine been compromised by the procedure and if they need further suction. If the patient needs further suction, repeat the above actions using new gloves & a new catheter Remove gloves and wash hands Prevent cross infection NB: If NG tube in situ confirm the tube remains The tube tip can migrate into the oesophagus in position. during suctioning. Ensure that the patient is comfortable. Record the colour, quantity & tenacity of To facilitate on-going evaluation. secretions, and any other relevant details, in nursing notes

Oral-pharyngeal suction

April 08

Risk assessment
All procedures carry risk and as part of the procedure for having oral/nasopharyngeal suctioning the patient will have the procedure fully explained to them by the nurse and the risks and benefits clearly set out. The patient is free to ask questions to clarify the procedure at any time.

Patient information
Verbal explanation will be given to the patient and relatives.

Audit
Audit will be carried out if there is a significant increase in critical incident reports (submitted by any members of the multidisciplinary team) in the six months after the implementation of these guidelines. Audit may also be carried out if a new innovation is identified in the management of these patients and is to be introduced.

References
A A R C (1992). Clinical Practice Guidelines - Nasotracheal Suctioning Respiratory Care 37 (8), 898-901. Bennett C (2003) Nursing the breathless patient Nursing Standard 17 (17) 45-51 Care of the breathless patient (Essential Skills, 11. Includes oral suctioning procedure) Nursing Standard 2001. 15 (29). p (2 unnumbered pages) Harey N (1996) Tracheobronchial Suction. Journal of the Association of Chartered Physiotherapists in Respiratory Care. 28, 22-25. Moore T (2003) Suctioning techniques for the removal of respiratory secretions Nursing Standard 18 (9) 47-53 Nursing and Midwifery Council (2008) Code of Professional Conduct. NMC, London Place B, Fell H (1998) Clearing tracheobroncheal secretions using suction. Nursing Times 94(47): 54-56

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Appendix
Full Equality Impact Assessment Matrix Name of policy/service Name of Manager responsible for completing impact assessment Is this a new policy/service or a review of an existing policy/service? What is the purpose of the policy/service? Who is intended to benefit from the policy and in what way? Date commenced Policy/service review date April 2008 April 2010 Oral / nasal pharyngeal suctioning Barbara Richards Review of existing policy To provide guidance for staff on Oral / nasal pharyngeal suctioning Staff and patients Date completed April 2008

Using the matrix below, review the policy/service under consideration, in relation to the six equality strands, for differential impact upon service users or trust staff and identify what these might be: Group (highlight relevant groups)
1. Is there any evidence that groups have different needs, experiences or priorities in relation to this policy and if so, what? 2. Is the any evidence/ concern that this proposal could result in a qualitative or quantitative differences in impact on any group and if so what?

Age
Procedure is for both adult and paediatric patients. This has been taken into account when completing the procedure. The policy promotes principles of good care and safety for all groups

Race/ethnicity
No evidence seen

Gender
No evidence seen

Disability
No evidence seen

Religion/belief
No evidence seen

Sexual orientation
No evidence seen

The policy promotes principles of good care and safety for all groups

The policy promotes principles of good care and safety for all groups

The policy promotes principles of good care and safety for all groups

The policy promotes principles of good care and safety for all groups

The policy promotes principles of good care and safety for all groups

3. Does the proposal promote equality of opportunity/ access/good relations within the organisation and the wider community and how is this evidenced? 4. Who are the key stakeholders in relation to this policy and how are they being consulted? 5. Are there any concerns that the policy/service development could have a differential impact on any group(s) and how might this be evidenced? 6. Do you anticipate any areas where there may be inconsistencies in application and are there alternative arrangements that could reduce/eliminate impact?

The policy promotes equality of opportunity and access to all groups

The policy promotes equality of opportunity and access to all groups

The policy promotes equality of opportunity and access to all groups

The policy promotes equality of opportunity and access to all groups

The policy promotes equality of opportunity and access to all groups

The policy promotes equality of opportunity and access to all groups

Clinical practice group, clinical risk committee, risk and safety department, and clinical directorates. No evidence of potential differential impact

Clinical practice group, clinical risk committee, risk and safety department, and clinical directorates. No evidence of potential differential impact

Clinical practice group, clinical risk committee, risk and safety department, and clinical directorates. No evidence of potential differential impact

Clinical practice group, clinical risk committee, risk and safety department, and clinical directorates. No evidence of potential differential impact

Clinical practice group, clinical risk committee, risk and safety department, and clinical directorates. No evidence of potential differential impact

Clinical practice group, clinical risk committee, risk and safety department, and clinical directorates. No evidence of potential differential impact

No evidence of inconsistencies found

No evidence of inconsistencies found

No evidence of inconsistencies found

No evidence of inconsistencies found

No evidence of inconsistencies found

No evidence of inconsistencies found

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Using the information from the matrix complete the following action plan: Area of concern Groups likely to experience differential Action planned to minimise discrimination/promote equality of access Monitoring arrangements Review date

1. No areas of concern noted. Practice will be monitored through the audit process. Name/signature of manager completing assessment Date assessment sent to Equality and Diversity Manager Name/signature of Equality and Diversity Manager Date of publication of Impact assessment Barbara Richards May 2008 Jennifer Kenward August 2008

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