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 AIRWAY CLEARANCE
INVASIVE METHOD OF AIRWAY
MANAGEMENT
CARDIOPULMONARY PHYSICAL THERAPY

DR MUHAMMAD ARIF
PHD PT* (HEC SCHOLAR)
MS- RIU MPHIL DPT (KEMU) MPPTA
PGD(CPPT) PGC(NEUROLOGY)
DIRECTOR EDUCATION
INSTITUTE OF PHYSIOTHERAPY
GULAB DEVI EDUCATIONAL COMPLEX

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 AIRWAY CLEARANCE - COUGH

Steps in a normal cough

Deep inspiration
Glottis closes
Abdominal muscles contract to
compress lungs
Glottis is opened
Lung contents are expelled

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 AIRWAY CLEARANCE
Airway obstruction
 Caused by:
 Retained secretions
 Cause increased airway resistance and work of
breathing, hypoxemia, hypercapnia, atelectasis,
infection
 Foreign bodies
 Airway edema
 Tumors
 Trauma

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 AIRWAY CLEARANCE - SUCTIONING
Airway obstruction
 Retained secretions
 Can be removed from the airways using mechanical aspiration –
Suctioning

Nasotracheal

Endotracheal
Oral

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 SECRETION EVACUATION DEVICES

Suction Regulator
 Provide a means of
reducing the high negative
pressures from the supply
line to safe physiological
levels

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 SECRETION EVACUATION DEVICES
Suction Tubing
 Connects regulator to canister,
and canister to suction device
(yankauer, suction catheter,
etc.)

Suction Canisters
 Collection device
 Protects vacuum lines from
infiltration of fluids

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 SECRETION EVACUATION DEVICES

Yankauer Suction Tip

 Used to remove secretions from the
oropharynx (upper airway)

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 SECRETION EVACUATION DEVICES

Suction Catheter
Nelaton Catheter
 Used to remove secretions
from the lower airway

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 SECRETION EVACUATION DEVICES

Closed Suction System

 Maintains PEEP and high FiO2 when
suctioning a mechanically ventilated
patient
 May reduce caregiver and patient risk of
infectious disease exposure
 Permits the suction catheter to be used
multiple times, reducing cost

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 SECRETION EVACUATION DEVICES
Lukens Trap
 Commonly referred to as
“sputum trap”
 Used to obtain sputum
specimens
 Placed in-line between the
vacuum circuit and the suction
catheter

Lukens trap
closed after
obtaining
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 NASOTRACHEAL SUCTIONING

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 NASOTRACHEAL SUCTIONING
Indications – Assessment of Need
 The need to maintain a patent airway and remove retained
secretions or foreign material from the trachea in the presence of:
 Inability to clear secretions – ineffective cough

 Audible evidence (auscultation) of secretions in the large airways (course

crackles) that persist in spite of patient best cough effort

 Signs of respiratory distress

 To obtain sputum samples in patient who are unable to expectorate

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 NASOTRACHEAL SUCTIONING
Contraindications
 The only absolute contraindications are epiglottitis and croup
Relative Contraindications
 Occluded nasal passages
 Nasal bleeding
 Acute head, facial, or neck injury
 Coagulopathy or bleeding disorder
 Laryngospasm
 Irritiable airway
 Upper respiratory tract infection including croup and epiglottitis

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 NASOTRACHEAL SUCTIONING
Procedure
 Step 1: Assess patient for indications
 Auscultate
 Course crackles
 Ineffective cough
 Step 2: Assemble and Check Equipment
 Suction regulator (set pressure)
 Adults:100 to -120; children: 80 to -100; infants: 60 to -80
 Suction canister with tubing
 Suction catheter

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 NASOTRACHEAL SUCTIONING

Procedure
 Step 2: Assemble and Check Equipment (cont.)
 Water-soluble lubricating jelly
 Sterile gloves
 Goggles, mask, gown (standard precautions)
 Sterile water or saline
 Oxygen delivery system (resuscitator bag/mask) and oxygen source
 Nasopharyngeal airway
 Minimizes nasal trauma when repeated access is needed

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 NASOTRACHEAL SUCTIONING
Procedure
 Step 3: Preoxygenate and Hyperinflate the Patient
 Using a manual resuscitator bag/mask connected to an 100% oxygen,
preoxygenate and hyperinflate the patient for at least 30 seconds
prior to suctioning

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 NASOTRACHEAL SUCTIONING

Procedure
 Step 3: Preoxygenate and Hyperinflate the Patient
 Hyperinflation fills underaerated or nonaerated segments via
collateral ventilation, which helps move secretions into larger airways

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 NASOTRACHEAL SUCTIONING

Procedure
 Step 4: Insert the Catheter
 Lubricate the catheter and gently insert it
through the nostril, directing it toward
the septum and floor of the nasal cavity
(do apply negative pressure yet)
 If you encounter resistance, gently twist
the catheter. If this does not help,
remove the catheter and try inserting it
through the other nostril

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 NASOTRACHEAL SUCTIONING
Procedure
 Step 5: Move Catheter in Lower
Pharynx
 Have the patient assume a “sniffing”
position and advance the catheter through
the larynx until the patient’s coughs, or a
resistance is felt much lower in the airway
 Apply suction, while withdrawing the
catheter using a rotating motion

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 NASOTRACHEAL SUCTIONING
Procedure
 Step 5: Move Catheter in Lower Pharynx (cont.)
 Keep total suction time to less than 10 – 15 seconds

 After removing the catheter, clear it using the sterile water/saline

 If any untoward response occurs during suctioning, e.g.,

hypoxemia, an abrupt change in the electrocardiogram wave
form, major change in heart rate or rhythm, hypotension,
increased intracranial pressure, etc., immediately remove the
catheter and oxygenate the patient

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 NASOTRACHEAL SUCTIONING

Equipment and Procedure

 Step 6: Reoxygenate and Hyperinflate the Patient
 Using a manual resuscitator bag/mask connected to an 100%
oxygen, reoxygenate and hyperinflate the patient for at least 60
seconds

 Step 7: Monitor the Patient and Assess

 Repeat steps 3 – 7 as needed until your see improvement or
observe an adverse response

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 NASOTRACHEAL SUCTIONING
Hazards and Complications
 Hypoxia/hypoxemia
 Nasal, pharyngeal, and tracheal mucosal trauma/pain
 To avoid this rotate catheter while withdrawing and limit the amount of
negative pressure used
 Cardiac arrhythmias/bradycardia
 Pulmonary atelectasis
 Avoid this by limiting amount of negative pressure , keeping duration of
suctioning as short as possible, providing hyperinflation before and after
the procedure
 Bronchoconstriction/bronchospasm

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 NASOTRACHEAL SUCTIONING
Hazards and Complications (cont.)
 Infection (patient and/or caregiver)
 Mucosal hemorrhage
 Elevated intracranial pressure
 Uncontrolled coughing/laryngospasm
 Hyper/hypotension
 Gagging/vomiting

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 NASOTRACHEAL SUCTIONING
Assessment of Outcome

 Effectiveness should be reflected by removal of secretions

 Effectiveness should be reflected by improved breath

sounds

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 NASOTRACHEAL SUCTIONING
Monitoring
 The following should be monitored before, during, and
after the procedure:
 Breath sounds
 SpO2
 Respiratory rate and pattern
 Pulse rate, BP, ECG (if available)
 Sputum (color, volume, consistency, odor)
 Presence of bleeding (evidence of trauma)
 ICP (if indicated and available)

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 ENDOTRACHEAL
SUCTIONING

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 ENDOTRACHEAL SUCTIONING
Equipment

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 ENDOTRACHEAL SUCTIONING
Indications – Assessment of Need

The need to maintain a patent airway and remove

retained secretions
 Audible evidence (auscultation) of secretions in the
large airways (course crackles)
 Clinically apparent work of breathing
 To obtain sputum samples for microbiological or
cytologic examination
 Should be a routine part of a patient on ventilator.

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 ENDOTRACHEAL SUCTIONING

Contraindications

 When indicated, there is no absolute contrindication to

endotracheal suctioning because abstaining from suctioning in

order to avoid possible adverse reaction may, in fact be lethal

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 ENDOTRACHEAL SUCTIONING

Procedure
 Step 1: Assess patient for indications
 Auscultate
 Course crackles

 Ineffective cough

 Step 2: Assemble and Check Equipment

 Suction regulator (set pressure)
 Adults:100 to -120
 Children: 80 to -100
 Infants: 60 to -80

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 ENDOTRACHEAL SUCTIONING

Procedure
 Step 2: Assemble and Check Equipment (cont.)
 Suction canister with tubing
 Suction catheter
Nelton Catheter

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 ENDOTRACHEAL SUCTIONING

Procedure
 Step 2: Assemble and Check Equipment (cont.)
 Sterile gloves
 Goggles, mask, gown (standard precautions)
 Sterile water or saline
 Oxygen delivery system (resuscitator bag/mask, ventilator) and oxygen
source

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 ENDOTRACHEAL SUCTIONING
Procedure
 Step 3: Preoxygenate and Hyperinflate the Patient
 Using a manual resuscitator bag/mask connected to an 100% oxygen,
preoxygenate and hyperinflate the patient for at least 30 seconds
 If the patient is on a ventilator, adjust the FiO2 to 100% .

 Step 4: Insert the Catheter

 Insert the catheter carefully until it can go no farther

 Do not contaminate the catheter by touching it to the outside of the ET tube or any other
surface
 Withdraw the catheter a few centimeters before applying suction

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 ENDOTRACHEAL SUCTIONING
Procedure
 Step 5: Apply Suction / Clear Catheter
 Apply suction, while withdrawing the catheter using a rotating motion
 Keep total suction time to less than 10 – 15 seconds
 After removing the catheter, clear it using the sterile water/saline
 Closed suction catheter systems have an adapter for saline vials to be placed inline with
device (the catheter is cleared by squeezing the saline vial and applying suction at the same
time)

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 ENDOTRACHEAL SUCTIONING

Procedure
 If any untoward response occurs during suctioning, e.g.,
hypoxemia, an abrupt change in the electrocardiogram wave
form, major change in heart rate or rhythm, hypotension,
increased intracranial pressure, etc., immediately remove the
catheter and oxygenate the patient

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 ENDOTRACHEAL SUCTIONING
Equipment and Procedure
 Step 6: Reoxygenate and Hyperinflate the Patient
 Using a manual resuscitator bag/mask connected to an 100% oxygen,
reoxygenate and hyperinflate the patient for at least 60 seconds

 If the patient is on a ventilator, adjust the FiO2 to 100%.

 Step 7: Monitor the Patient and Assess Outcomes

 Repeat steps 3 – 7 as needed until your see improvement or observe an
adverse response

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 ENDOTRACHEAL SUCTIONING
Hazards and Complications
 Hypoxia/hypoxemia
 Tracheal or bronchial mucosal trauma
 To avoid this rotate catheter while withdrawing and limit the amount of
negative pressure used
 Cardiac arrhythmias
 Pulmonary atelectasis
 Avoid this by limiting amount of negative pressure , keeping duration of
suctioning as short as possible, providing hyperinflation before and after
the procedure

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 ENDOTRACHEAL SUCTIONING

Hazards and Complications (cont.)

 Bronchoconstriction/bronchospasm
 Infection (patient and/or caregiver)
 Mucosal hemorrhage
 Elevated intracranial pressure
 Hyper/hypotension

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 ENDOTRACHEAL SUCTIONING

Assessment of Outcome

Removal of pulmonary secretions

Improvement in breath sounds
Decreased airway resistance
Improvement in ABG values or SpO2

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 ENDOTRACHEAL SUCTIONING
Monitoring
 The following should be monitored before, during, and
after the procedure:
 Breath sounds
 SpO2
 Respiratory rate and pattern
 Pulse rate, BP, ECG
 Sputum (color, volume, consistency, odor)
 Ventilation parameters
 ICP (if indicated and available)

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 THANK
YOU

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