AIRWAY MANAGEMENT SUCTIONING - TRACHEOSTOMY TUBE AND STOMA

DEFINITIONS:
Inner cannula - a sleeve which fits inside the tracheostomy tube and may be removed for cleaning Hyper-oxygenation - increasing oxygen liter flow for a brief period of time or ventilating the patient 3-4 times with a bag-valve device to increase the blood oxygen level Tracheotomy - a surgical incision into the trachea to establish an airway that may be temporary or permanent Tracheostomy (trach) - a tracheal stoma (opening) that results from a tracheotomy Tracheostomy (trach) tube - a plastic or metal tube inserted below the 2nd or 3rd tracheal ring bypassing the epiglottis

INDICATIONS: To maintain a patent airway in patients with a tracheostomy tube or stoma.

Rattling mucus sound from tracheostomy (noisy respirations) Bubbles of mucus in trach Coughing up secretions Patient requests to be suctioned Respiratory distress due to airway obstruction.

COMPLICATIONS:
Hypoxia Bronchospasm Cardiac dysrhythmias Hypotension Tracheal trauma Infection/sepsis Cardiac arrest

NOTES:
Aseptic technique must be maintained throughout suctioning procedure to prevent infection. Excessive suctioning should be avoided to decrease potential for tracheal damage and increase in mucus production. Catheter size should not exceed the inner diameter of the airway. Larger catheters may cause suction-induced hypoxia, lung collapse and damage to tracheal tissues. Establish and maintain a sterile field. Use the inside of the wrapper to establish field for equipment. Hand-operated vacuum suction devices may be used as long as they have an adaptor for a flexible catheter. Keep suction setting between 80-120 mmHg and adjust setting lower for pediatric and elderly patients (50-100 mmHg). Excessive negative pressures may cause significant hypoxia, damage to tracheal mucosa or lung collapse. Too little suction is ineffective. Pre-oxygenation may be required depending on patients condition. This offsets volume and oxygen loss during suctioning. Patient may or may not be on oxygen and have either a T-bar or tracheal mask for humidification. Oxygen should be maintained until ready to suction. Flow rate may need to be adjusted to prepare patient for suctioning. Rotating the catheter prevents the direct suctioning of the tracheal mucosa. Roll the catheter between thumb and forefinger for rotating motion. Suctioning longer than recommended time will result in hypoxia. Maximum suction time depends on patients age and tolerance and is timed from the insertion to withdrawal of the catheter: - adults maximum 10-15 seconds - children maximum of 5-10 seconds - infants - no longer than 5 seconds

Inner Cannulas:
Not all tracheostomy tubes have inner cannulas. The inner cannula does not need to be removed for routine suctioning. However, if the patient is in respiratory distress the inner cannula must be removed in order not to push the thick secretions back down the trachea and to immediately open the airway. Sometimes just removing the inner cannula corrects the problem. The cannula may only need to be cleaned and replaced. Procedure for cleaning the inner cannula: - Rinse the inner cannula with saline/tap water by dipping the cannula into solution and tipping cannula upside-down to allow solution to run through it. - Suction or use a pipe cleaner (if available) to remove secretions. - Gently tap the cannula to remove excess solution before reinsertion.

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Normal Saline Irrigations:

Instilling normal saline into the tracheostomy tube does NOT liquify or loosen tenacious secretions by breaking the mucus bond. The only effect instillation of saline has is to make the patient cough strongly and thus loosen secretions. EMTs & paramedics may instill normal saline into the tracheostomy tube if needed to loosen secretions. However, this procedure poses a great risk for pneumonia and should only be done if absolutely necessary. Each patient must be evaluated early to determine the need for irrigation to thin or loosen secretions. EMTs & paramedics may use the prepared saline irrigation vial/ampule. Caution - the rescuer must ensure that the vial /ampule contains normal saline and not a medication such as albuterol. Paramedics may use a syringe to draw up saline and instill into the tracheostomy tube after removing the needle. Instill 1-5ml of sterile saline down tracheostomy tube. Amount of saline instilled depends on patients age and tolerance: 3-5ml for adults and 1-2 ml for pediatric patients - Pediatric patients falling into a color zone on the Broselow tape should have only 1-2 ml of solution instilled. Those longer than the Broselow tape may tolerate 3-5 ml of solution.

Developed 10/02 Finalized 1/03

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LOS ANGELES COUNTY EMS AGENCY BASIC AND ADVANCED LIFE SUPPORT SKILL

AIRWAY MANAGEMENT SUCTIONING - TRACHEOSTOMY TUBE AND STOMA

PERFORMANCE OBJECTIVES
The examinee will demonstrate proficiency in suctioning a patient with a tracheostomy tube (consistent with scope of practice) while maintaining aseptic technique.

CONDITION
The examinee will be requested to suction a simulated patient that is having copious secretions and difficulty breathing. The patient has a tracheostomy tube (with or without an inner cannula) and is receiving supplemental oxygen (through a T-bar device or tracheal mask). The adult or child manikin is supine on a simulated bed. Necessary equipment will be adjacent to the manikin.

EQUIPMENT
Simulated adult and pediatric tracheostomy manikin, tracheostomy tube (metal/plastic) with an inner cannula, oxygen tank with connecting tubing, T-bar or tracheal mask, suction device with connecting tubing or hand-powered suction device with adaptor, sterile flexible suction catheter, sterile normal saline irrigation solution, sterile container, plastic saline irrigation vial /ampule, vial of normal saline, 5cc syringe, removable needle, sterile and unsterile gloves, goggles, masks, gown, waste receptacle, timing device.

PERFORMANCE CRITERIA

100% accuracy required on all items designated by a diamond () for skills testing and must manage successfully all items indicated by double asterisks (**). Items identified by the symbol () must be practiced but is not a required test item. Appropriate body substance isolation precautions must be instituted. Must maintain aseptic technique.

PREPARATION Skill Component

Take body substance isolation precautions Assess patient for the need to suction tracheal secretions Open suction kit or individual supplies

Teaching Points
Mandatory personal protective equipment - gloves, goggles Situational - masks, gown Indications for suctioning: noisy respirations, coughing up secretions, respiratory distress or patient request. Establish and maintain a sterile field. Use the inside of the wrapper to establish field. Catheter size should not exceed the inner diameter of the airway.

Open/unfold sterile container and fill with irrigation solution

Sterile saline is used to flush suction catheter as needed. Depending on kit, container may be under gloves and catheter, this should be removed without contaminating gloves and catheter. Not a problem to put on sterile gloves if an assistant is present. Hand-powered suction devices may be used as long as they have an adaptor for a flexible catheter. Excessive negative pressures may cause significant hypoxia, damage to tracheal mucosa or lung collapse.

Ensure suction device is working ** Set appropriate suction setting: Adult - between 80-120 mmHg Pediatric and the elderly - between 50-100mmHg

PROCEDURE Skill Component

Hyper-oxygenate patient - if indicated: Increase Oxygen liter flow OR Ventilate with Bag-valve device 4-5 times

Teaching Points
Hyper-oxygenation may be required in patients dependent on O2 source or if ventilator dependant to offset volume or oxygen loss during suctioning.

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Skill Component
Remove oxygen source - if indicated

Teaching Points
Patient may or may not be on oxygen and have either a T-bar or tracheal mask for humidification. Oxygen should be maintained until ready to suction. Flow rate may need to be adjusted to prepare patient for suctioning.

Unlock and remove inner cannula - if indicated

Not all trach tubes have inner cannulas. The inner cannula does not need to be removed for routine suctioning. However, if the patient is in respiratory distress the inner cannula must be removed in order to avoid pushing thick secretions back down the trachea. Sometimes just removing the inner cannula corrects the problem. The cannula may only need to be cleaned and replaced.

Apply sterile gloves Connect sterile catheter to suction tubing/device ** Keep one (dominant) hand sterile

Sterile gloves are pulled over existing clean gloves. The suction catheter should only be handled using sterile glove. Keep catheter in sterile package until ready to use. Catheter size should be the inner diameter of the trach tube to allow for ease of insertion and air to enter during suctioning.

Suction small amount of irrigation solution to: Ensure suction device is working Lubricate tip of catheter Insert catheter into tracheostomy tube/stoma without applying suction

Lubricating the tip of the catheter with irrigation solution prevents the catheter from adhering to the sides of the trach tube or tracheal mucosa. The patient is not being oxygenated at this time and applying suction would deplete any oxygen reserve. If patient has a stoma, suctioning during insertion may damage the lining of the tracheal mucosa.

Advance catheter gently to appropriate level: Shallow suctioning - opening of trach tube/stoma OR Measured suctioning - length of trach tube OR Deep suctioning - past trach tube to carina

Shallow/measured suctioning may be all that is needed. Deep suctioning is usually not necessary unless cough is ineffective and airway is not cleared. Deep suctioning is at the level of the carina which is determined by the catheter meeting resistance during insertion. The patient may cough when the tip of catheter touches the carina or develop bronchospasms. Catheter insertion should be accomplished as rapidly as possible since the patient is not oxygenated during this step.

Withdraw catheter slightly before applying suction if beyond trach tube Suction while withdrawing catheter using a rotating motion and observe patients response: ** Maximum suction time of 5-15 seconds from insertion to withdrawal of catheter: Adults maximum 10-15 seconds Children maximum of 5-10 seconds Infants - no longer than 5 seconds Place patient on oxygen or replace oxygen source if indicated

Withdrawing the catheter slightly before applying suction prevents damage to the mucosa of the carina. Rotating the catheter prevents the direct suctioning of the tracheal mucosa and suctions secretions from side of the tube. Roll the catheter between thumb and forefinger for rotating motion. Suctioning longer than recommended time will result in hypoxia. Maximum suction time depends on patients age and tolerance: Patients response by coughing or grimacing may indicate the catheter is too deep and irritating the tracheal mucosa or carina. Patients may need supplemental oxygen after suctioning. If the patient is ventilator dependent, ventilate the patient with a bagvalve device in between suctioning

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Skill Component
Evaluate airway patency and heart rate - repeat procedure if needed ** If secretions are thick and unable to clear tracheostomy tube, instill sterile saline and repeat previous steps

Teaching Points
Observe patient for hypoxemia, dysrhythmias, cyanosis, anxiety, bronchospasms and changes in mental status. If vagal stimulation occurs, the patient may experience bradycardia, especially pediatric patients. EMTs & paramedics may instill normal saline into the trach tube if needed to loosen secretions. However, this procedure poses a great risk for pneumonia and should only be done if absolutely necessary. Allow patient to rest and regain adequate oxygen levels between suctioning attempts.

Suction remaining irrigation solution into collection canister and discard appropriately Discard contaminated catheter: Coil contaminated catheter around sterile (dominant) hand and pull glove over catheter Pull glove from other hand over packaged catheter and discard in approved waste receptacle

Irrigation solution is contaminated and should be treated the same as secretions.

REPLACE INNER CANNULA Skill Component

Check for spare or clean the inner cannula - if needed

Teaching Points
Some patients have a spare inner cannula at the bedside. If the inner cannula needs to be cleaned, this can be done by the rescuer, caregiver or partner. Procedure for cleaning the inner cannula: - rinse the inner cannula with saline/tap water - suction or use a pipe cleaner to remove secretions - gently tap the cannula to remove excess solution before reinsertion

Remove oxygen source Replace clean inner cannula and lock Replace oxygen source The inner cannula must be replaced in order to connect to a T-bar, ventilator or bag-valve device.

ONGOING ASSESSMENT Skill Component

Assess airway, breathing and heart rate: Continuously or at least every 5 minutes Changes in airway sounds Changes in respiratory status

Teaching Points
If vagal stimulation occurs, the patient may experience bradycardia, especially pediatric patients.

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INSTILLATION OF NORMAL SALINE Skill Component

Prepare saline irrigation solution - if indicated Check saline for: - drug name - integrity of container/medication - concentration/dose - clarity - expiration date Twist off top of saline irrigation vial /ampule OR Prepare a syringe with 5cc normal saline and remove needle - if within scope of practice Instill 1-5ml of sterile saline down tracheostomy tube 3-5ml for adults 1-2 ml for pediatric patients

Teaching Points
EMTs & paramedics may instill normal saline into the trach tube if needed to loosen secretions. However, this procedure poses a great risk for pneumonia and should only be done if absolutely necessary. Each patient must be evaluated early to determine the need for irrigation to loosen secretions. EMTs & paramedics may use prepared saline irrigation vial /ampule. Caution - the rescuer must ensure that the vial /ampule contains normal saline and not a medication such as albuterol. Paramedics may use a syringe to draw up saline and after removing needle instill into the trach tube. Amount of saline instilled depends on patients age and tolerance. Pediatric patients falling into any color zone on the Broselow tape should have only 1-2 ml of solution instilled and those bigger than the Broselow tape may tolerate 3-5 ml of solution.

Repeat suction procedure

DOCUMENTATION Skill Component

Verbalize/Document Indication for suctioning Oxygen liter flow Patients tolerance of procedure Problems encountered

Teaching Points
Documentation must be on either the Los Angeles County EMS Report form or departmental Patient Care Record form.

Type of secretions: - color - consistency - quantity - odor Respiratory assessment and heart rate: - respiratory rate - effort/quality - tidal volume - lung sounds
Developed 10/02 Finalized 1/03

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