Adapted from Respiratory Care
(Respir Care 1999;44(1):99-104)
Respiratory Home Care Working Group
Susan L McInturff RRT RCP, Chairman, Bremerton WA
Barry J Make MD, Denver CO
Peggi Robart MA RRT,RCP, Boston MA
Allan B Saposnick MS RRT, Sharon Hill PA
A AARC Clinical Practice Guideline
What is the Procedure?
This procedure covers the suctioning of the patient (with or
without an artificial airway) when cared for in the home. This
includes nasal, oropharyngeal, and endotracheal suctioning.
Description of the Procedure
Suctioning is a component of bronchial hygiene that involves
the mechanical aspiration of secretions from the nasopharynx,
oropharynx, and trachea. The airway may be in its natural state
or artificial (as with a tracheostomy) or surgically altered (as
with a laryngectomy). The patient may or may not be receiving
mechanical ventilation. The procedure includes patient
preparation, the actual suctioning event, and follow-up care and
observation of the patient.
Patient Preparation:
Whenever possible, the patient should be encouraged to clear
the airway by directed cough or other airway clearance
techniques. [1-5]
Whenever possible, the patient should be taught to perform
this procedure for himself. [4-7]
Preoxygenation or hyperinflation prior to the suctioning
event may not be routinely indicated for all patients cared for
in the home. Whenever possible the patient's response to
suctioning during his stay in the acute care or long-term care
facility should be made a part of the discharge summary, and the
health care professional establishing the patient in the home
should request this information.
Experience with neuromuscular patients suggests that
hyperinflation when the vital capacity of such patients is <
1.5L makes tracheal suctioning unnecessary. [5,8]
Other patients for whom preoxygenation or hyperinflation may not
be necessary or advisable include those:
requiring only nasal or oropharyngeal suctioning;
[9]
without an endotracheal airway, whose vital capacity and
muscle strength are adequate to produce an effective cough;
whose ventilatory drive has been demonstrated to stem from
hypoxia; [10]
with a demonstrated tolerance for the procedure with no
adverse reactions.
Preoxygenation and/or hyperinflation may be indicated in:
pediatric patients with decreased respiratory reserve;
patients who have been documented to experience oxygen
desaturation during the suctioning event as evidenced by pulse
oximetry;
patients who exhibit cardiac dysrhythmias during the
suctioning event;
patients who are receiving continuous supplemental
oxygen.
When preoxygenation and/or hyperinflation are indicated, it
is recommended that this be done manually using a resuscitation
bag with supplemental oxygen, as appropriate. All caregivers
should receive thorough instruction in the use of resuscitation
bags and manual hyperventilation techniques; improper or
imprecise use of resuscitation bags for hyperinflation can cause
lung injury and respiratory alkalosis. If hyperoxygenation or
hyperventilation are not required, tidal volume may be conserved
by passing the suction catheter through the port cap on the
swivel adapter of the ventilator circuit.
Normal saline solution should not be instilled routinely but
only when specifically medically indicated[11-15] (for
example, to stimulate cough [14,15]).
The suctioning event:
Actual introduction of the suction device (catheter or oral
suction tip) into the naso- or oropharynx, or into the trachea
via the laryngostoma or artificial airway should be in accordance
with existing AARC Clinical Practice Guidelines.
[9,16]
It is common and accepted practice to use 'clean'
rather than sterile technique during suctioning in the home
environment, although scientific evidence to support or discount
either technique in home care is lacking. [17]
Clean (non-sterile) gloves should be used when endotracheal
suctioning is performed. Gloves reduce the risk of introduction
of inoculant to the patient's airway, [15] the
risk of cutaneous infection in the caregiver, and transmission of
organisms to others. [18,19] Gloves may not be
necessary when oropharyngeal suctioning is performed.
At the conclusion of the suctioning event, the catheter or
tonsil tip should be flushed by suctioning recently boiled or
distilled water to rinse away mucus, followed by the suctioning
of air through the device to dry the internal surface and, thus,
discourage microbial growth. The outer surface of the device may
be wiped with alcohol or hydrogen peroxide. The suction catheter
or tonsil tip should be allowed to air dry and then be stored in
a clean, dry area.
Suction catheters treated in the manner described may be
reused. We recommend that the catheters be discarded after 24
hours although no evidence for or against this can be found.
Tonsil tips may be cleaned, boiled, and reused indefinitely. If
it is feasible to clean the suction device and subject it to high
level disinfection, it may be reused until its integrity is lost.
[20] The importance of mechanical cleaning cannot be
overemphasized (ie, removal of mucus and other organic
material).
Follow-up care:
Following the suctioning event
the patient should be monitored for adverse reactions;
[9,16]
the patient in whom pre-procedure hyperoxygenation and/or
hyperinflation was indicated should be treated by the same
method(s) post-procedure. [16,21]
The Setting
This guideline applies only to the home care setting.
Alternate care sites such as subacute, rehabilitation, or skilled
nursing facilities should use Guidelines for suctioning in the
acute care setting. [9,16]
Indications that Suctioning is Needed
The primary indication for suctioning the patient cared for at
home is the patient's inability to adequately clear the
airway by cough. The need for airway clearance is evidenced
by:
More frequent or congested-sounding cough;
Coarse rhonchi and expiratory wheezing audible to the patient
and/or caregiver with or without auscultation;
Visible secretions;
Increased peak pressures during volume-cycled mechanical
ventilation;
Decreased tidal volumes during pressure-cycled
ventilation;
Indication by the patient that suctioning is necessary;
Suspected aspiration of gastric or upper airway
secretions;
Otherwise unexplained increase in shortness of breath,
respiratory rate, or heart rate;
Decreases in vital capacity and/or oxygen saturation (as
indicated by pulse oximetry), thought to be related to mucus
plugging.[22]
Contraindications
When suctioning is indicated, no absolute contraindications
exist and failure to suction can prove to be more detrimental
than potential adverse reactions. Routine or 'scheduled'
suctioning, with no indication of need is not recommended.
Hazards and Complications
Because the suctioning event is inherently the same in the
home as in the critical care setting, the possible hazards and
complications are the same. Dislodgement and introduction into
the lower airway of bacteria colonizing the tracheal tube has
been demonstrated. Further, the bacterial count introduced may be
increased when saline is instilled.[12,13] The home
care patient is not monitored by any except the most basic
methods, and the patient must be closely observed for all of the
following:
oxygen desaturation as indicated by pulse oximetry if such
monitoring has been prescribed;
trauma to the oral, tracheal, or bronchial mucosa;
cardiac arrest;
respiratory arrest;
cardiac dysrhythmias;
pulmonary atelectasis;
bronchospasm or bronchoconstriction;
airway infection;
bleeding or hemorrhage from the airway;
hypertension;
hypotension.
The Limitations of this Procedure
Endotracheal suctioning is not a benign procedure, and the
caregiver should remain sensitive to possible hazards and
complications, taking all necessary precautions to ensure patient
safety. Secretions in the peripheral airways cannot be removed by
suctioning. Optimal humidification of inspired gases and
appropriate systemic hydration is important to the maintenance of
airway integrity.
Assessment of Need
The patient should be periodically assessed by the caregiver
to determine the need for suctioning when the need does not
obviously present itself. For patients on long-term mechanical
ventilation, this assessment should be included in the
patient/ventilator system check.[23]
Assessment of Outcome
Results and observations related to suctioning should be
recorded to inform and alert other caregivers. The suctioning
procedure can be considered successful and the need for
suctioning affirmed by one or more of the following:
removal of secretions;
improvement in breath sounds;
decreased peak inspiratory pressure during volume-cycled
mechanical ventilation;
increased tidal volume delivery during pressure-cycled
mechanical ventilation;
clearing of cough;
improvement in oxyhemoglobin saturation as reflected by pulse
oximetry;
subjective improvement as reported by patient;
a decrease in respiratory and heart rate and decreased
shortness of breath.
Resources
Equipment:
Equipment and supplies to used for suctioning the home care
patient may include:
An electrically powered aspirator with a calibrated,
adjustable regulator and collection bottle with overflow
protection. A battery-powered aspirator may be needed for the
patient who leaves the home or lives in an environment subject to
frequent power failures;
Several suction catheters, sized appropriately. Open suction
systems are used most frequently. (The use of closed systems has
not been demonstrated to be medically indicated in the patient
who is not immunosuppressed[18]);
Tap water that has been boiled, stored in a closed, clean
container, and used within 24 hours of boiling to flush the
catheter. (Water directly from the tap should not be used because
of the possibility of contamination.[18])
Clean or sterile gloves to provide barrier protection when
active infection is present or suspected;
A manual resuscitator when hyperinflation is medically
indicated;
An oxygen source when preoxygenation is medically
indicated;
Sterile normal saline for instillation when medically
indicated;
An oral suction device (eg, tonsil tip);
Sterile distilled and/or recently boiled water and cleaning
solution.
Personnel:
As stated previously, the patient should be trained in
self-care whenever possible. In the event that the patient is
unable to perform the procedure, the bedside caregivers (family
members, personal care attendants, other designated care givers)
should be thoroughly trained and demonstrate their ability to
perform the procedure and clean and care for
equipment.[24]
Only credentialed or licensed professional staff with
documented specialized training and experience in airway
management procedures and patient assessment should be specified
as trainers (eg, licensed and credentialed respiratory care
practitioners and registered nurses). These trainers should also
observe, on a regular basis, performance of the procedure by the
patient and caregivers to determine the need for reinforcement
and remediation.[24]
All caregivers should demonstrate a good understanding of the
procedure and the ability to perform the procedure competently,
including:
knowledge of proper use and assembly of all necessary
equipment and supplies;
ability to recognize that suctioning is indicated;
ability to assess effectiveness of the procedure;
ability to monitor vital signs, assess the patient's
condition, and appropriately respond to complications or adverse
reactions;
ability to perform the procedure with the least amount of
risk of introducing inoculant into the patient's airway;
knowledge of infection control procedures and demonstrated
ability to effectively wash hands and clean, disinfect, and
properly store equipment and supplies.
Monitoring
The patient should be monitored to ascertain effectiveness of
the procedure and to detect any adverse reaction. Variables to be
monitored include:
breath sounds;
skin color--including the presence or absence of
cyanosis;
oxygen saturation by pulse oximetry when medically
indicated.
Frequency
The suctioning procedure should be undertaken only when
indications are clearly present.
Infection Control
All caregivers should practice infection control procedures
appropriate to the home environment.[25] To the extent
feasible, patients should be protected from visitors and
caregivers with active viral and bacterial infections that are
airborne or spread by direct contact.
Immunizations recommended by the Centers for Disease Control
and Prevention should be current in both caregivers and patient.
When HIV and/or hepatitis or other bloodborne infection are known
to be present or when the patient's status is unknown and
when infection with organisms spread by droplet infection is
known or suspected, specific precautions should be
instituted.[25]
With all patients the steps undertaken are:
proper handwashing before and after performing the
procedure;
clean or sterile suctioning technique as indicated;
cleaning and disinfection of all equipment and supplies
beginning with thorough mechanical cleaning with detergent and
water and followed by one of the following:
a 60-minute soak in a solution of vinegar and water with an
acetic acid content > or = 1.25% (The vinegar solution should
not be reused.);[26,27]
quaternary ammonium compound (prepared and reused according
to manufacturer's instructions);[26,27]
glutaraldehyde;[28]
boiling when equipment withstands such procedures;
proper storage of equipment and supplies between use;
proper disposal of spent supplies and infectious
waste.[29]
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Interested persons may copy these Guidelines for noncommercial
purposes of scientific or educational advancement. Please credit
AARC and RESPIRATORY CARE Journal.
