Desating and Suctioning

MLB55 · Oct 18, 2012

Give them more sedation/analgesia before suctioning

Esme12, ASN, BSN, RN · Oct 19, 2012

I'm a new grad on an ICU floor and most of our pts are on vents. I feel like many of my patients cannot seem to tolerate suctioning. As soon as I start using the inline suction they start gagging, desating into the mid to upper 80s, start getting frequent PVCs, RR goes into the 30s etc. After I am done suctioning, they stay like that for a while too which is even more unnerving. The ventilator will keep alarming afterwards with high tidal volume alarms as well as other alarms. I know this is normal since suctioning is very uncomfortable, but every time it still freaks me out. I pre-oxygenate with 100% and I always explain what I am going to do and what they might feel beforehand to minimize their anxiety. Is there anything else I can do to help them tolerate it better or help them return to baseline afterwards?

What does your preceptor say? Have you talked this over with them or your charge nurse? How are you suctioning them? Do you apply suction on the way in? How long are you applying suction? How many times are you suctioning in a row? Do you use a bronchial toilet/instilling saline? Are these patients "awake"? How long is "a while" before the patient recovers?

"I know this is normal since suctioning is very uncomfortable"

Have you ever choked on food or water? I mean really choked? Or very nearly drowned in a pol/ocean/lake because you accidentally inhaled water? Have you Choked and coughed and sputtered because you couldn't catch your breath and thought you were going to pass out? That anxiety is because that patient, for those few brief moments, is choking in that suction tubing and saline that was instilled.

That is what that patient feels. That "someone is sucking the air out of my lungs, I'm going to die" feeling....every time you suction them.....with or without saline. Some patients will experience bronchospasm even with minimal suctioning. Some MD's will order bronchial toilet with one cc of lidocaine to help prevent spasm. How much of the saline bullet/container are you using to instill to suction? It should only be about a cc or one squirt instilled for each suction attempt.

The "high volume" alarms are because the patient is still coughing. Make yourself cough......put your hand in front of your mouth....fell that air rush? That forceful exhale is the high vent alarm. Even a sedated patient has a cough gag reflex unless they deeply sedated/paralyzed or neurologically impaired. The negative pressure alarm will also alarm when the patient takes that sucking breath to cough.

I am curious as to how many patients of your develop cardiac arrhythmia, PVC's, with suctioning for that does not always happen and should rarely happen.

Could those PVC's that you are seeing and the computer are reading actually be artifact on the monitor because of the up and down movement of the patients chest when they are coughing? Are you reading the monitor respirations that is at that point also counting the up and down motion of the chest when the patients coughs? Where is the pulse ox placed when you are suctioning....on the finger? Is the pulse ox also giving inaccurate readings due to artifact when the patients taps their hands during suctioning? Are those 30 resps present because when you suction you break the system "seal" and cause it to repetitively cycle like it does when the vet is disconnected?

Sometimes it helps to give the patient some resps with 100% O2 to help them "catch their breath. But you should try to synchronize those resps to the patients. I do not know your vents but some vents actually have a 100% O2 button made just for suctioning that shuts itself off. Some vents allow you to silence the alarms so that during procedures like this that alarms don't alarm, which can alarm the patient, and quickly reset themselves.

These alarms, monitoring tools are to help us in monitoring the patient but they are not always accurate under every circumstance. Who is the once that is anxious? You or the patient? Is the patient's anxiety amplified becasue they can see your anxiety? Patients are just like any living thing......they can sense/smell fear and anxiety a mile away. They figure if you are freaked out they should be as well.

Have you asked your preceptor about this? What do they say?

Anoetos, BSN, RN · Oct 19, 2012

I have had several vented patients ask for suction. I wouldn't say they like it, but they understand it to be necessary and they deal with it. Some even want it a lot, like every time I or the RT come into the room. We have to tell them it's not such a great idea to suction so much, the trachea can get injured from frequent contact with the cannula.

I was taught that gagging and bradying and desatting are common temporary results which usually resolve.

But I know very little. Esme12's comments are excellent.

hodgieRN · Oct 23, 2012

When that happens to me, I alternate between suctioning just the ET tube and suctioning with induced coughing. When you hit the carina, that's what causes the coughing. If you go just deep enough to reach the end of ET tube, they won't cough and sometimes, that's enough to get the mucous during routine suctioning. Like Anoetos said, going deep every time can cause trauma or irritation. And you will see people go all the way down to the hub which bothers me. If the sedation is just right and you get a good turn after lowering the HOB real quick, that can cause some good coughing and and you don't have to hit the carina.

If they are following some commands and moderately sedated you can say, "I'm not going all the way down. I'm only getting what's in the tube. Actually, you give me a good cough on the count of three, and I'll just catch what comes up. Deal?" They will LOVE you! If the pt is hypoxic (while being comatose), do what you gotta do, but I believe there's no reason hit the carina all the time.

Altra, BSN, RN · Oct 29, 2012

The presence of cough/gag reflexes is encouraging from a neurological standpoint. Keep that in mind. If you're so inclined and you have an empty ICU room and a few minutes, connect yourself to a pulse ox, see what your baseline reading is, and then stick your finger as far back as you can in your oropharynx. Watch your SpO2 as you gag & cough briefly. Now think about the proportionate response you should expect to see in someone whose baseline respiratory status prior to suctioning is that they are trached and/or vented.

Make sense?

P.S. -- A "high tidal volume alarm" is a good problem to have.

turnforthenurse, MSN, NP · Oct 29, 2012

What does your preceptor say? Have you talked this over with them or your charge nurse? How are you suctioning them? Do you apply suction on the way in? How long are you applying suction? How many times are you suctioning in a row? Do you use a bronchial toilet/instilling saline? Are these patients "awake"? How long is "a while" before the patient recovers?

Saline lavage has been used for suctioning to help thin mucous and prevent mucous plugs, but currently there is no research that supports the use of saline lavage. In the ask the experts section of the October 2012 Critical Care Nurse magazine, this issue was discussed.

Normal (0.9%) saline has not been shown to thin mucus or to remove or prevent formation of mucous plugs, and it may cause a decrease in arterial and venous oxygenation along with other potential harmful complications including increased risk of infection.

Seckel, M. (2012, 10). Normal saline and mucous plugging. Critical Care Nurse, 32(5), 66-67

Altra, BSN, RN · Oct 30, 2012

Saline lavage has been used for suctioning to help thin mucous and prevent mucous plugs, but currently there is no research that supports the use of saline lavage. In the ask the experts section of the October 2012 Critical Care Nurse magazine, this issue was discussed.

True. We were strongly encouraged to discontinue this practice about 2 years ago.

Esme12, ASN, BSN, RN · Oct 31, 2012

Saline lavage has been used for suctioning to help thin mucous and prevent mucous plugs, but currently there is no research that supports the use of saline lavage. In the ask the experts section of the October 2012 Critical Care Nurse magazine, this issue was discussed.
Seckel, M. (2012, 10). Normal saline and mucous plugging. Critical Care Nurse, 32(5), 66-67

Which is exactly why I asked if this was a practice where this student was precepting.

Sun0408, ASN, RN · Oct 31, 2012

How often and how long are you suctioning them?? It may be you are doing it for too long and too often, not allowing them to recover before attempting another pass.. I try to minimize my sxn to 10 sec and no more than 2 passes at each time unless the pt has excessive secretions, audible rattle etc.. Sedated or not, I rarely have an issue unless the pt is already on 80% or higher FI02, with severally compromised lungs.

bittybritty · Oct 31, 2012

When you're suctioning your patients what is their O2 Sat prior to suctioning? Are they alarming the vent? Tachnepic? Whats their peak pressure? Are you getting minimal secretions or copius amts? Basically what I'm getting at is that you should never do something as invasive as tracheal suctioning with out just cause.

Also when you're suctioning make sure you're not suctioning while advancing the catheter down the trachea.

Britt