What prompts you to suction a trach....?

[bella14k]

Ok a question on one of my exams asks something like this, "The nurse decides suctioning is appropriate based on which one of the findings?"

Answer A: Crackles heard on auscultation

Answer B: Audible inspiratory wheezes.

The correct answer is A, but I chose B, although I feel like both are good answers. Here is my rationale. (this was sent in a separate email to my prof in attempt to defend my answer).

I know inspiratory wheezes are associated more with bronchoconstriction, but I associated it with mucus. Wheezes are a result of an obstructed airway, which is from mucus (inflammation). Also, audible inspiratory wheezes are more of a red flag for airway compromise, b/c it could (not is) be a sign of impending ARDS. Crackles can lead to ARDS as well, but that wouldn't happen right away. If I heard inspiratory wheezes in real life would I suction right away? Probably not, maybe I would collect other data first, and if anything, give a bronchodilator. But I thought this was a better answer than choosing crackles.

The answer regarding the crackles turned out to be correct, and I had a hard time between the two, but chose the wheezing. I understand that if the nurse hears crackles, there's clearly congestion in the lungs, but the stem didn't specify where s/he heard the crackles. Crackles are usually heard in the bases, so I went with that. With that said, I know you cannot suction past the carina, and usually crackles are at the bases, so even if I decided to suction just because I auscultated crackles, what would suctioning do to decrease the crackles? It wouldn't do a whole lot, and that's something to think about when choosing the right nursing intervention-Is it even going to be effective?.

Also, page 649 in our MS text at the top right corner states,

"Trachael suctioning is performed when adventitious breath sounds are ​detected or whenever secretions are obviously present" (p.649).

That's all I found about trach's in that volume text. Adventitious breath sounds include crackles and WHEEZES.

I know you said in lecture (and it was in the notes) that if the patient was wheezing that the RN should give a bronchodilator. But between the 2 answer choices, I had to defend the "wheezes" answer choice for the sake of correctly answering, what I thought was, a tricky question. You might think I read too far into the question, but I thought I was critically thinking.

...now that i reflect on all this stuff i wrote, I'm starting to realize why the "crackles"-answer was correct after all. But at the same time, I'm not going back! If i'm wrong, tell me why, and if i'm not, tell me why!-if your reason is different than mine. :)

Thank you everyone!!

[NICU Guy, BSN, RN]

This is where critical thinking comes into place. Adventitious breath sounds are abnormal breath sounds. Not all abnormal breath sounds are due to secretions. If a patient is having an anaphylactic reaction and their airway is closing, they are going to have wheezes. Do they need suctioning? No. A patient with pneumonia has crackles. Are you more likely to suction this patient? Yes.

[JustBeachyNurse, LPN]

Crackles are more commonly due to fluid or increased secretion. Wheezes are due to bronchial constriction and generally expiratory as the patient tries to empty their lungs. It's often associated with bronchospasm (constriction of the airway muscles) and observed in asthma, anaphylaxis and occasionally COPD. Suctioning due to wheezes would often be futile as there is nothing to suction with bronchospasm and you may in fact exacerbate the situation. Usually the intervention is to administer the PRN bronchodilator (albuterol etc). Crackles or rhonchi may require suctioning especially if the patient has an ineffective cough.

But based upon what you wrote out above it seems you figured that out already. not all adventitious breath sounds would necessitate suction stridor and wheezes could be two examples.

[Esme12, ASN, BSN, RN]

Think it through...you already did. Wheezes are from bronchospasm. Suctioning can cause further bronchospasm making it harder for the patient to breathe and worsening the wheeze. You want to bronchodilate with wheezes not cause further spasm.

Suctioning is to remove secretions...wheezing isn't secretions

[bella14k]

Yeah I guess I was trying to argue my way out of that question. Thanks guys! case closed.

[KelRN215, BSN, RN]

I decide to suction a trach when a snot rocket is coming out of it.

[Here.I.Stand, BSN, RN]

And when you HEAR your first trach that needs suctioning in real life, you'll hear why the answer is crackles

Think of when you gargle water or mouthwash--there's moisture "blocking" your airway, and you're forcing air through it. What you hear with the air bubbling through the moisture is more like crackles on a larger scale; you won't hear wheezing.

[JustBeachyNurse, LPN]

And when you HEAR your first trach that needs suctioning in real life, you'll hear why the answer is crackles

Think of when you gargle water or mouthwash--there's moisture "blocking" your airway, and you're forcing air through it. What you hear with the air bubbling through the moisture is more like crackles on a larger scale; you won't hear wheezing.

Good example that someone without ever experiencing severe pulmonary congestion can comprehend. Just like to understand the breathlessness of asthma pinch your nose and try breathing through a tiny coffee stirrer straws.

[EternalFeather]

crackles = fluid in lungs => sunction/drain, diuretics

wheezes = tightening airways => bronchodilators

thats like my reasoning i dont know how to explain it very well so thats like a drawing of words

[bella14k]

Yes, I know crackles occurs from fluid in the lungs ,often associated with left sided HF , and all that other stuff you said. Thanks.

Thanks everyone. I agree with all of you. It seems that my reasoning (for the most part) is correct , except for the fact that I had to choose "wheezes". I will never second guess a question like this on an exam again! I hope that one will be on the final

[Episteme]

This is a good example of the way NCLEX questions are written. Sometimes you'll find more than one "right" answer. But you must chose the BEST answer.

Think about it this way:

Suctioning is simply in intervention to replace or augment airway clearance... which person needs to clear their airway, someone with constricted airways or someone with gunky airways? Who more needs to give a good cough? For that matter, who *does* cough more (yeah, some asthmatics do cough a lot but it's not so typical a feature as it is with URI)

Now that being said, I think most people who hear the word "crackles" think "fluid in the lungs" or, perhaps atelectasis... that is, lower airway stuff, and not "this person needs suctioning" which is basically an upper airway intervention.

Still, in choosing between the two choices... which you must do on tests... the "wheezing" is a much worse choice.

As is often the case, it's sort of a silly discussion without a *real* patient in front of you to assess.