Rationale for taking apical pulse prior to trach suctioning

ArmaniX, MSN, APRN · Jul 9, 2015

It's been years but my check offs for suctioning did not include checking an apical pulse.

If a patient is drowning in their own secretions and desatting. .. I don't care what their pulse is, I need to clear that airway.

I don't see any reason that a nurse would suction a calm patient with a HR less then 60. Suction only when necessary.

As far as the idea of a vagal, I've known two patients who's HR ranged in the low 100s.. would get suctioned and go asystole.

RNNPICU, BSN, RN · Jul 9, 2015

I haven't heard of taking an apical pulse prior to tracheal suctioning. All trachs have a specific length and you are only suctioning to the end of the trach, not going all the way in. The reason for a vagal response could be that you hit the carina. if you hit the carina, you have gone way to far. Trachs only need suctioned past the tip of the trach since you are trying to clear the airway.

Even if a pt is bradying, I would suction, to help clear the airway, then bag pt.

JustBeachyNurse, LPN · Jul 9, 2015

The low heart rate could be due to hypoxia/hypoxemia related to excessive secretions or a mucus plug. I work pediatrics trach/vent. It is not part of our competency to assess apical heart rate prior to trach suction. Lung sounds yes but not if acute distress where you can see/hear tracheal secretions.

You can restart a heart that stops due to hypoxia or vasovagal reaction. You cannot reverse hypoxic brain damage due to blocked airway.

Mattskiematt · Jul 9, 2015

I have worked in the Intensive Care Unit and Critical Care Unit for years, never once that I have checked nor have heard that nurses should check the apical pulse before suctioning the patient's tracheostomy. Above post is right, if ever we hit the carina of the patient, then that's the time that the vagus nerve would tick and show response. What I do is I always assess the patient's airway, trach position, check for sounds, check oxygen saturation, but never has taken account the pulse.

la_chica_suerte85, BSN, RN · Jul 9, 2015

I googled this because we were never taught this as part of our skills check off for trach sxn. I did find a .pdf of a skills check off that included the apical pulse check in the steps but still no rationale. Maybe it's just some old-school way someone decided would be best practice d/t the effects of oxygenation on the HR but, like ArmaniX said, it's airway and breathing first, circulation last.

jena5111, ASN, RN · Jul 9, 2015

I appreciate all of the responses--thank you so much for taking the time!

Since it doesn't sound like this is standard or current practice, I can see why textbook, Google and AllNurses searching didn't yield any pertinent results. I would ask an instructor but it's summer and we're between classes right now.

Assessing apical pulse prior to trach suctioning is listed as a "critical element" in our skills checklist without any sort of rationale. I guess my critical thinking skills have gotten a little sharper since learning trach suctioning in second semester, haha--I want to know the WHY and not just the WHAT.

I also see why the vasovagal reason doesn't make much sense; the patient needs to be breathing well no matter what else may be happening (ABCs--a real thing!)

Thank you again!

nurseprnRN, BSN, RN · Jul 10, 2015

I'd always eyeball the HR doing anything that might be stressful to see if there was any untoward effect. I think most everybody would do the same, given the opportunity.

But you know what? I think this sounds like a great evidence-based practice study. Save all those things you find online, and when you have to do research (real research, not a Survey Monkey opinion poll) for your MN (from a real school), you're all set to start.

CarpeDiem'15 · Jul 10, 2015

Hi Jena,

I actually covered tracheal suctioning in my ABSN program a couple weeks ago, and we were taught that taking the apical pulse prior to the suctioning is a way to confirm the patient does not have any cardiac dysrythmias that could be exacerbated by the suctioning, since cardiac dysrhythmia is an unwanted side-effect. If you feel that your patient may be at risk for cardiac dysrythmia, then you can check for apical pulse again after the suctioning. The cardiac dysrhythmia occurs mainly as a result of hypoxemia, but can occur from 1) mechanical stimulation of the airways (esp. around the larynx) triggering arrythmias, vagal stimulation when the catheter touches the larynx / carina resulting in bradycardia, or the hypoxemia combined with patient agitation inducing tachycardia. Hyperoxygenating the patient greatly decreases the risks for developing cardiac dysrhythmias during the suctioning process.

And this is just one of those things where critical thinking and ability to prioritize is important... if the patient is severely hypoxic and O2 sats are plummeting, by all means get into that trach and suction! In other cases, if a patient does present with potentially dangerous cardiac arrythmias, in most cases hyperoxygenating them with 100% O2 (assuming that it's not contraindicated for them) prior to suctioning and engaging in safe suctioning (appropriate depth of the suctioning tube, less than 15 secs duration, no more than 3 passes, hyperoxygenating between passes) should be able to help them avoid further complications.

Hope this helps! :)

RNNPICU, BSN, RN · Jul 10, 2015

Hi Jena,
I actually covered tracheal suctioning in my ABSN program a couple weeks ago, and we were taught that taking the apical pulse prior to the suctioning is a way to confirm the patient does not have any cardiac dysrythmias that could be exacerbated by the suctioning, since cardiac dysrhythmia is an unwanted side-effect. If you feel that your patient may be at risk for cardiac dysrythmia, then you can check for apical pulse again after the suctioning. The cardiac dysrhythmia occurs mainly as a result of hypoxemia, but can occur from 1) mechanical stimulation of the airways (esp. around the larynx) triggering arrythmias, vagal stimulation when the catheter touches the larynx / carina resulting in bradycardia, or the hypoxemia combined with patient agitation inducing tachycardia. Hyperoxygenating the patient greatly decreases the risks for developing cardiac dysrhythmias during the suctioning process.
And this is just one of those things where critical thinking and ability to prioritize is important... if the patient is severely hypoxic and O2 sats are plummeting, by all means get into that trach and suction! In other cases, if a patient does present with potentially dangerous cardiac arrythmias, in most cases hyperoxygenating them with 100% O2 (assuming that it's not contraindicated for them) prior to suctioning and engaging in safe suctioning (appropriate depth of the suctioning tube, less than 15 secs duration, no more than 3 passes, hyperoxygenating between passes) should be able to help them avoid further complications.
Hope this helps! :)[/
Interesting. Although, when suctioning trach pts, you are suctioning the trach, you should not be going past the tip of the trach or touching the carina. Many pts are on CR monitors and you could observe for arrhythmia. As for always per/post oxygenation for a pt, truly depends on the pt. Remember oxygen is also a drug, if your pt does not need it, even ventilator dependent pts, don't give it. Have manual resuscitation bag within reach in case needed.
I won't giive O2 to a pt, just because, some pts do not like the extra breaths. As for suctioning it really should be no more than 5 seconds, not 15 seconds a pass. True, do 2-3 passes, then give your pt a break.

CarpeDiem'15 · Jul 10, 2015

Just to clarify, the 15 seconds was for the entire suctioning, not per pass.... That would be way too long for one pass! So 3 passes while keeping the trach suctioning within 15 seconds.

Also, my professors were pretty adamant that evidence based research has shown that hyperoxygenating a patient prior to suctioning and between suctioning drastically reduces the risk for cardiac dysrhythmias and hypoxia. But again, I think that if the patient adamantly refuses hyperoxygenation (even after you've explained to them the benefits of doing so), then don't give it to them... as long as you've done your best to educate them on why it's being done, because as nurses patient education is our public health service. :) As for apical pulse, I think it's more of a best practice protocol that's we are taught as students so we can be prepared to use it if we are ever in a situation where we are caring for patient populations that don't have access to CR monitors (e.g. rural or from a global standpoint, 3rd world developing countries). But if you have access to CR monitors, than by all means use that! :)

JustBeachyNurse, LPN · Jul 10, 2015

Not everyone requires hyperoxygenation prior to endo tracheal suctioning. Most COPD patients do not. Neither do many pediatric patients. Not all patients with a tracheostomy are at risk for cardiac arrhythmia or dysrhythmia either.

Apical pulse can be helpful if you are in a LTC or home care environment where you only have pulse oximetry and no telemetry. Not just rural or third world areas.

You reduce the risk of vasovagal dysrhythmia by only going to the predetermined depth and not to the carina

In pediatrics hyperoxygenation prior to suctioning requires a specific order and is not standard protocol. Even with my kiddo that requires continuous FiO2 of 30%, we are not to hyperoxygenate pre or post suctioning even in this case