Documentation for suctioning an infant with a trach and vent

Pediatric Critical Care Columnist · Aug 5, 2008

Kids with trachs will always have more secretions when they're awake. If they have the ability to cough their secretions up into the tube and those secretions are really loose, they might not need suctioning immedicately. But your guy is on a vent, and the risk here is that the secretions will coat the inside of the tube and eventually cause it to block. That would be an emergent situation that probably will end with the trach needing to be changed. So suctioning should be done whenever it appears it's needed. When the kid sounds gurgly with each breath, when they're coughing, then their sats drop, when they look distressed... you know it should be done. One trick I can suggest if you're afraid you're taking too long is to hold your breath from the second you disconnect until you withdraw the catheter and put back on the vent. No way you'll take longer than you need to! With practice and experience you onw't need to hold your breath any more, but it does help until then. As for your documentation, the only things I'd add would be patient tolerance and response. ie - Jimmy's sats dropped to 88% with coughing, no visible color change. Sats recovered to 100% within 90 seconds once suctioned and returned to vent. No supplementary oxygen or other interventions required.

liveyourlife747 · Aug 5, 2008

thank you so much! i normally write stats down, sometimes his sp02 hasn't dropped, but he is gurgly, so I go ahead and sx. And I have noticed if he gags alot (which we have a problem with keeping his feedings down sometimes) I sx him and he settles- does that sound like something normal or should I not be sx after he gags?

Pediatric Critical Care Columnist · Aug 5, 2008

Definitely suction when he gags. If he aspirates, you'll be in a bit of a pickle. In theory the trach and its cuff are supposed to reduce the potential for aspiration, but I know darned well that when my patient is gagging, coughing or retching, he's enlarging his airway and anything could happen.

What, if anything, precipitates all the gagging? Is he bolus fed? Could his feeds be going too quickly? Could the volume be too much? Maybe he needs a smaller volume of feed with a higher calorie content? Is he semirecumbent when he's being fed? Maybe sitting him up more might help.

liveyourlife747 · Aug 5, 2008

Usually he is in his swings. Sometimes he gags from changing a position (like semi-fowlers to sitting striaght up) or if he puts something in his mouth too far (he has an easy gag reflex) sometime I wonder if the trach is causing him to gag, but I am not sure if this is possible.

Most of the time he vomits his feedings when he is active, we normally try to get him to sleep during and after the feed, or we hold him quietly after if he is awake.

Thanks for the quick replies

Pediatric Critical Care Columnist · Aug 5, 2008

Of course the trach can cause him to gag. It's a foreign body in his throat! Moving it even a little in a kid with an educated gag reflex is almost guaranteed to cause gagging and its obvious consequence!. And I've never met a neurologically injured patient who didn't have a hyperactive gag. (My son gags when I brush his teeth.) I can see the changing positions in the swing could contibute to his gagging especially if the motion causes the ventilator circuit to move the trach. I think you've got enough ammunition now to go in there and give that boy some great care!

liveyourlife747 · Aug 5, 2008

Thank you so so much! I'm glad that I decided to ask the question because you have given me so much more education and advice. Thanks again!

Pediatric Critical Care Columnist · Aug 5, 2008

I'm glad I was able to help you. I used to work in a PICU that was the parent unit for a peds extended care floor. The kids on that floor were generally those who were dependent on technology or required close obs and/or critical care interventions at times. A lot of those kids had trachs, GTs, seizure disorders, reflux, and so on. Kids with spinal cord injuries would go there when they were no longer critical. The PICU often provided staff to the ECU and for the first year and a half that I worked in the PICU it seemed I spent at least half my time in ECU. Sometimes I'd be the only nurse on the floor. I learned a lot about a lot of things in that place! One little guy seemed to plug his trach whenever I worked, whether in ICU or ECU, and I was one of the few who could change his trach (custom-made and VERY flexible!!). How many times did I hear, "Jan you've gotta come right now! Bobby plugged his trach again!" I'm always glad when my experiences can help someone else... because I'm always learning from others'.