Airway Management Tracheostomy care and suctioning

What may jeopardize airway?

✤ Increased volume of mucous
✤ Thick, tenacious mucous
✤ Fatigue and weakness in the client- difficulty coughing strongly and
effective
✤ Decreased LOC
✤ Ineffective cough
✤ Impaired airway
✤ Paralysis

What should you do as the nurse to help maintain patent airway?

✤ Keep pt airway by performing the following:
- Educating the client on CDBE (cough and deep breathing)
- Encouraging ambulation
- Assisting with liquefying secretions through adequate hydration
- Promoting expectoration through encouragement, chest physiotherapy and
postural drainage, mechanical clearance
- Assisting with inhalation therapy

Suctioning?
✤ Use of catheter to suction out and a negative pressure container
✤ Amount of suction depends on the client and the secretions
✤ Wall suction 100-140 (adult) 95-100 (children) 50-95 (infant)
✤ Check order!
✤ Upper suction (mouth suction-honker???) and lower suction (sterile procedure-
mouth, trachea, nose)
✤ Upper and lower airway suctioning: 2 types of pharyngeal airways
(nasopharyngeal and oropharyngeal). The other airway is endotracheal, airways
are used to keep the tongue from falling back into the throat
✤ oropharyngeal
✤ Routes:
- Endotracheal tubes (ETTs):
➡ Maintain an airway in patients who are unconscious or unable to
breathe on their own. Tube is inserted by physician or certified
advanced practice nurse. Tube usually removed after 48-72 hrs but can
be left in place for a week or more. Pt is unable to speak w/ ETT bc
tube sits between vocal cords so therefore find another way to
communicate. If intubation is needed for an extended period pt needs
to have tracheostomy done. ETT can cause a mucosal ulcer after 5-7
days of use depending on cuff pressures or type of cuff.  
- Nasopharyngeal suctioning:
➡ PURPOSE IS TO MAINTAIN A PATENT AIRWAY BY REMOVING ACCUMULATED
SECRETIONS. Pharyngeal suctioning involves the upper air passages of
the nose, mouth, and pharynx. Those who may require suctioning are
infants, gravely debilitated, unconscious pt, or those w/ ineffective
cough. Coughing moves secretions up into the trachea. Oral suctioning
is usually tried b4 nasopharyngeal bc it is more comfortable, a
Yankauer suction tip is used. Suction pressure should be set between
80-120 mm Hg. Suction catheter is selected based on size of pt tube
and thickness of secretions, 8-12 Fr. For thin secretions and 14-16
Fr. For adult with thick and sticky secretions. Virtually impossible
to maintain sterility when suctioning the nose or pharynx but clean
technique and thorough handwashing are essential. Aseptic technique
is MANDATORY for suctioning of the trachea. Never reuse a catheter.  
- Tracheobronchial suctioning:
 ➡ Deep suctioning of the lower respiratory passages stimulates the
cough reflex and removes secretions from the trachea and bronchi.
Used when pt has been intubated or has a tracheostomy. Sterile
technique is MANDATORY.  Bc pt isn’t receiving oxygen when you are
suctioning DO NOT suction for longer than 10 seconds at a time.

Artificial airways
✤ Oral airway: keep the tongue away from the open airway
✤ Tracheostomy: check on them frequently , they cannot speak so need to use
board, writing or sign language, most of the time leave the door open unless
they are on isolation

When suctioning
✤ Client with a trach tube can usually cough, but it is typically not effective
enough to expectorate
✤ Catheter for suctioning are placed into the trach tube
✤ Catheter is usually placed about 4-5 into trachea until you hit the carina or
until resistance is felt
- The resistance is due to contact btwn the carina and the catheter tip
- If you meet resistance: raise the catheter tip about half an inch before
suctioning
- The client’s typically begin to cough when there is resistance
- The clients can become very anxious at this point, so educate prior to
beginning the process and calm the client during suctioning
✤ Provide oxygen before and in between suctioning b/c the clients can become
hyperemic and SOB
✤ Always assess lung sounds before and after suctioning
✤ Be sure to document what was assessed, the amount of secretions removed,
color, and how the client managed the suctioning
✤ Orders are fairly specific for how often suctioning should take place, but
use nursing judgment
✤ If it is not time to suction and the client needs it- just do it
✤ education pt before we do something

Chest tubes
✤ For removal of be blood/fluid and air from the pleural cavity
✤ Helps to restore negative intra-pleural pressure and re-inflates the lungs
via negative pressure
✤ Clients will have 1 or 2 chest tubes connected to the drainage system
✤ 3-chamber system: suction control chamber, water-seal chamber, and drainage
chamber

Chest drainage tubes

✤ Inserted by physician or advanced practice nurse. Connected to a disposable
pleural drainage system. If gravity drainage is inadequate to remove air and
fluids from pt with a large pleural leak suction can be applied using either
wall suction or a portable suction machine. If suction is used in the water-
seal system there should be constant bubbling in the suction chamber. Chest
tubes are removed by the physician after x-ray reveals the lung has re-
inflated and pleural space has decreased. 

Chest tube management

✤ The chest tube must never be separated from the drainage system unless you
clamp it off!!!
- Even then (only for a brief period)
✤ Periodic palpation of the inception site is needed to check for subcutaneous
air leaks- feel for skin “crackling” and listen for the same
✤ Inspect dressings for drainage/bleeding
 ✤ Keep dressing and tape secure
✤ If connections appear loose- tape them
✤ Be sure tubing remains un-kinked and that they hang freely
✤ If there is a suction control chamber- water level should remain at 20 cm
✤ Fluid levels on the water seal should remain at 2 cm
✤ If below 2 cm… add sterile water to bring the seal to 2 cm
✤ Assess for “tidaling”- the water in the water seal chamber should rise and
fall w/inspiration and expiration
✤ Observe for continuous bubbling in the water seal chamber- this will indicate
that there is a leak in the tubing or at the connection
✤ Constant bubbling is expected in the suction control chamber if used
✤ If there is continuous bubbling in the water seal chamber, notify MD
✤ Never clamp the tubing for an extended period!
✤ Clamping can cause a tension pneumothorax (increased air pressure within the
lung with no avenue for air escape)
✤ Only clamp tubing briefly when changing the entire drainage system…
✤ What if a tube becomes separated? Insert it into sterile water until it can
be re-attached (this provides a temporary water seal and prevents the
entrance of atmospheric air)
✤ Cover the tube insertion site with a gloved hand if the tube comes out of the
chest! This reduces the amount of lung collapse
✤ Mark drainage level on the collection chamber at the end of each shift- Do
your I/O…
✤ Removal of tube? Done by the physician after X-ray reveals re-inflation
✤ Medication beforehand would be advisable!
✤ Don’t separate suction from the drainage system (when it’s too full then you
can change it- independent nursing action)

Geriatric clients
✤ Physical changes (occur in lungs): lung less elastic, more rigid, cough and
gas refills diminish, breath by their mouth, snore, cartilage airway get more
calcification too, monitor them a lot more, higher risk for respiratory
infection
✤ Health promotion: encourage fluid, hydration, keep mucus membrane moist
because they dry out more, regular _____ exercise, encourage them to
socialization, teaching safety, tell them to not smoking, encourage the flu
vaccine, pneumonia vaccine

Trach suctioning (the skill)

✤ Auscultate lungs prior to suctioning
✤ Obtain equipment: suction cath kit, sterile water or sterile NS, face shield,
sterile gloves, resuscitation bag or “Ambu” bag, suction container to wall
suction, connection tubing
✤ Follow P&P, but most of the time you will pre-oxygenate the patient (AMBU?)
- WHY? Suctioning the pt can seriously deplete the pt’s oxygen level
✤ Attach suction tubing to connection tubing, check pressure
✤ Wall suction is generally set btwn 80-120 mmHg
✤ Suctioning a trach is a sterile procedure…
✤ Again, follow P&P about the max time for suctioning “PASSES”. Rule of thumb
is no more than 10-15 seconds (hold your own breath)
✤ Do not make any more than 3 passes max
✤ Remember to clear the tubing is btwn each pass
✤ Rotate the catheter when pulling out from the trachea
✤ Remember to re-oxygenate in-btwn passes
✤ Might be a good idea to assess O2 Sats before and while suctioning
✤ Give the pt a cue to let you know if they need more air
✤ Gove them recovery time btwn each pass
✤ Rinse the catheter and suction water into connection tubing
 ✤ Remove tubing from connection tubing, coil in hand and discard
✤ Remember this is a sterile procedure
✤ Hand hygiene, introduce yourself

Trach care
✤ Cleaning the inner cannula (a sterile procedure)
- Gather supplies/equipment
➡ Trach kit
➡ Small brush or pipe cleaners (if no kit)
➡ Half- strength solution of hydrogen peroxide (1/2 water, 1/2 hydrogen
peroxide)
➡ Saline
- Wash your hands
- Place 1/2 strength peroxide solution in one area and the saline in
another
- Remove the inner cannula while holding the neck plate of the trach
- Place inner cannula in peroxide solution or saline and soak until crust
are softened or removed
- Use the brush or pipe cleaner to clean the inside, outside and creases of
the tube
- Look inside the inner cannula to make sure it is clean and clear of mucus
- Rinse tube in saline
- Re-insert the cannula while holding the neck plate of the trach still
- Turn the inner cannula until it locks into position
- Double check the locking by pulling forward gently on the inner cannula