Trach suctioning. Bullet vs. no bullet

Specialties Pulmonary

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I know in the past NS bullets have been used to help clear thick secretions in trached/ vented pts. I know that EBP says we should NOT do this. I personally will not do it as an RN. If RT wants to do it then fine but I will not. What are some other ways to effectively remove thick secretions without a bullet? I have had a few trach pts that are unable to clear secretions and will end up with a plug or just be very junky and it can be very difficult to suction the secretions because they are sooo thick. *yuck* Any tips?

I am applying for a job in Home Health with Maxim Healthcare. I need to pass an exam on trached or vented patients. Does anyone have any suggestions on how to prepare for this exam?

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Specializes in Vents, Telemetry, Home Care, Home infusion.

moved to our pulmonary nursing forum --see posts a the top re vent info.

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Thank you. I found most of the answers I was looking for, although not all. The information was most helpful.

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Thank you for distilling all the known research in such a brief form. This practice is a HUGE NONO, and has been since at least 2002.

Unless cleaning out a closed ETT suction line, saline bullets have NO business near a ventilator or trach set up.

That is a broad statement and does not apply to every situation. Education for the appropriateness of the use of saline should be emphasized instead.

Not everyone will have a bottle of Mucomyst or NaHCO3/saline mix sitting around for direct instillation when an ETT or trach plugs nor is it always safe to pull every tube because of a plug nor will the plug always be so serious it requires meds but still needs some help getting out of the airway.

There are also recent studies that have shown saline reduces colonization by making the secretions more readily coughed and suctioned out. However, some of the concerns from older studies siting not using saline are with patients who do not have a cough from either paralysis or sedation to where there is a possiblity of more contamination in the lower airways.

Each patient should have their specific needs evaluated and anticipated. I do agree a mucolytic and hydration should be first considered when secretions are becoming thicker but those may not work instantly. Education should provide when suctioning with saline is appropriate.

Of course the neonatal unit is a very different area with other considerations.

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We teach all our long term trach pts to use these, or sterile saline through a syringe, when they need to clear their secretions. Its NBD

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Its NBD

That depends. If you are doing it because you've been taught you always do it that way or if you actually know when to use saline and when it should not be used. Some RTs and RNs flood the trach or ETT just because that is what they were taught to do with each suctioning regardless of secretions. They then teach this to the LTC trachs which if they are not able to adequately cough, will return again and again with pulmonary infections.

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Specializes in behavioral health.

I have had a few trachs due to sub-glottic stenosis. The last one that I had was in 1994, and I used NS bullet for plugs. It really helped to cough up the thick secretion. I used the bullet when needed then followed with the suctioning.

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I recently took a class run by the PA dept of health Trach and Vent home program. They have had over a thousand cases across the state over time. So based on their research which is pretty much the latest and greatest..based on the American Thoracic Society recommendations...BEST PRACTICE is not to use the saline any more...not even the drops to clear a plug. They admitted that many in the medical community are still widly using saline to try to breakup a plug or for thick secretions even though the evidence has been around for 10 years. (I for instance work for places where that is the policy.) The instructors felt that part of the reason is our culture IE: "well that was how I was shown to do it so its the right way...we are so resistant to change! Anyway...saline in itself is an irritant to the lungs and the lining of the alveoli. They know that no matter how much you suction after putting saline down the trach that you can never get it all out of those small passages in the lower lobes. And...for those wondering about the drops for the "emergency plug" ...they dont want you to waste your time messing around with that...SO..try to suction once, try to reposition once, then just change the whole trach.

I can provide better references then verbatum i am sure if anyone was interested...i dont have those materials with me ATM.

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