Judging when to suction trach

  1. Hey everybody,

    Does anyone have wisdom they can share with me regarding how they decide when to suction? I suctioned my first tracheostomy this past 2 days after watching my buddy nurse (I'm on orientation) do it. She explained that it's a good idea to suction when the patients breathing/secretions start to sound pretty wet (I mean what you hear from the tracheotomy opening), but you shouldn't do it too often or the patient will just produce a an excess of fluid again - then it will have to be done more often.

    Do you guys suction as soon as the patient sounds a bit wet, or do you wait until they sound a bit coarser? How do you judge if they have a good cough?
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  2. 7 Comments

  3. by   anon456
    Of course if you can visibly see secretions, or if they are coughing they most likely are bringing up secretions and need to be suctioned. You learn to get an ear for when they need suctioning. You can also watch the patient and see if they are working harder to breathe or look uncomfortable with their facial expression or body language. Plugs can be serious and they should a lot like a vibrating sound or you can hear air moving more through the trach. Of course if the patient's O2 sats are going down this is also a good time to suction.

    If you only go as far as the guidelines for that trach size (on our unit it's posted at bedside how far to go down with what french catheter) it causes no harm to suction if you think you need to try. It's only if you go too far that you can hurt tissue, and should only save the deeper suctioning for more urgent situations.

    I don't know what your nurse buddy meant by suctioning too much and it causing excess secretions. Perhaps he or she was referring to tissue damage caused by going too far down too often. If you stay at the safe length of the trach you won't touch the patient's tracheal tissue and cause any irritation or affect their secretions in any way.

    How to judge a good cough-- deep breath in that you can hear through the trach, usually produces mucous in the trach that can be removed with suctioning.
  4. by   Maddy_Rose
    Quote from anon456
    Of course if you can visibly see secretions, or if they are coughing they most likely are bringing up secretions and need to be suctioned. You learn to get an ear for when they need suctioning. You can also watch the patient and see if they are working harder to breathe or look uncomfortable with their facial expression or body language. Plugs can be serious and they should a lot like a vibrating sound or you can hear air moving more through the trach. Of course if the patient's O2 sats are going down this is also a good time to suction.

    If you only go as far as the guidelines for that trach size (on our unit it's posted at bedside how far to go down with what french catheter) it causes no harm to suction if you think you need to try. It's only if you go too far that you can hurt tissue, and should only save the deeper suctioning for more urgent situations.

    I don't know what your nurse buddy meant by suctioning too much and it causing excess secretions. Perhaps he or she was referring to tissue damage caused by going too far down too often. If you stay at the safe length of the trach you won't touch the patient's tracheal tissue and cause any irritation or affect their secretions in any way.

    How to judge a good cough-- deep breath in that you can hear through the trach, usually produces mucous in the trach that can be removed with suctioning.
    Thanks very much for the reply! From what you said here I think we probably should have been suctioning him more often, I could definitely hear what you described that vibrating or audible air moving in and out.
  5. by   smurfynursey
    Hi,
    I have quite a lot of experiance with trachs.

    Most of my T/V patients were kids who were severely neurologically devestated, and therefore could not cough on their own. If this is the kind of patient you had, by all means, suctioning them often could be the right thing.

    However...
    If this person had the capability to couggh or swallow, I would not jump on the suction machine as fast - someday (hopefully) they are going to go home, and they will need to learn to manage their secretions. A more conservative approach would be to see if they can cough/clear it on their own. Also, decreases the chance of tracheal irritation/infection/vomiting/aspiration (which in turn, makes your job easier haha)

    Good luck!
  6. by   flyfarfaraway
    I always make sure to ask first though too, because if a person has had a trach for awhile, they know what they need as well and it gives them a bigger hand in their care to make some decisions.
  7. by   RRT_charlie
    It takes time to learn when a patient *really* needs to be suctioned and it helps to get to know the patient. If the trach is <24 hours old, suction only when absolutely necessary ( but I would pass a suction catheter down a time or two per shift to ensure the airway is patent). Once the trach isn't as fresh, *gentle* suctioning is advised when the patient sounds coarse. If the patient has a very strong cough, I try to suction as little as possible, and like someone else mentioned, if the trach is old and the patient is used to it I always ask if they'd like to be suctioned as they tend to know their bodies better than us.

    Keeping an eye on their vitals is also a good indicator of when suctioning might need to be performed. If their sats drop to the low 90's or their HR become a bit higher than normal I might suction to ensure they're not developing plugs. Don't be afraid to lavage if needed. If the patient is on a vent, always pre-oxygenate them (even COPDers!) with 100% FIO2 for a minute or two before suctioning. I personally feel that this cuts down on the number of vagal responses, but some RT's will disagree with me. To each their own. I personally pre-oxygenate ANY patient regardless of what type of O2 device their on. If they're on RA, I'll slap them on some O2 for a few, even.

    Also, keep in mind that on the change that the trached pt is an end-stage COPDer, their sats will usually drop to the low 90's during the overnight hours. This is usually normal for them and doesn't always indicate a need for suctioning. Watching other vital signs and assessing the patient comes in handy here. Sometimes suctioning a dry patient can do more harm than good.
  8. by   llewol007
    There are several indicators that will let you know to suction. One way is to listen or auscultate the patient and if you hear rhonchus breath sounds, that is a tell tale sign that it is secretions causing the sound you are hearing. Another thing is visibly seeing the patient cough up secretions that maybe too thick for the patient to clear on their own. What your Nurse buddy said is very true. Over suctioning can lead to more secretions. Sometimes when dealing with trach patients, you will have some that will produce an over abundance of saliva as a way to protect itself from the foreign object i.e. the trach and also if they tend to over produce orally, this may also drain into the back of the throat and make its way down into the trach area. One thing to keep in mind is suctioning is meant to clear what the patient cannot. If the patient has a strong cough, there should be no need for you to suction and the main reason for this is, every time you introduce a foreign object into the airway i.e. the suction catheter, the airways once again produce more secretions as a defense mechanism to protect itself to in theory carry that foreign object up the mucocilliary elscalator. This over suctioning of secretions the patient can cough up on their own is doing a disservice because of the added secretions the patient must now clear. No all this must be taken into consideration when suction. Most people will freak out because it is not a natural thing to see secretions coming out of the trach. Yes very true but keep in mind, the secretions are coming out easily and not occluding the airway(trach). The Nurse must be deligent in ruling out if the patient has a strong enough cough to clear the secretions and also whether or no the secretions are too thick to clear effectively. Those two things are big assessment tools in regards to deciding to ultimately suction a patient. Hope that helps.
  9. by   pmath_RRT
    Suction PRN. You can cause mucosal damage thus causing the pt to bleed in their airway. If the pt isn't able to cough it up through the trach or is desatting then suction. If they can cough it out of the trach and their SpO2 is fine then don't suction, no indication. Also don't forget your vagus nerve is right in that area and suctioning can cause a vasovagal response and your pt can code. I've seen it happen more than once from suctioing...

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