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Discussion

suctioning

Does anyone have any tips on suctioning for a 3 y/o patient? I am new to pediatrics (most of my experience is med/surg), and I have a patient who has a history of mucous plugs and uses a vibra-vest and periodic suctioning (due to partial paralysis). I work in home health, so I work with this patient every week. They usually suction only his nares with a BBG nasal aspirator tip (or a "mushroom tip"). He has orders for PRN suctioning. The mother would like me to do this orally, and the nurse I did orientation with agreed with the mother. However, I don't see any benefits to suctioning orally as opposed to nasally (without the BBG adaptor). I think that trying to suction a 3 y/o orally would just be even more traumatizing, and more difficult. The nurse who was in charge of my orientation did not seem to know very much about suctioning, so I could really benefit from some advice from other Peds nurses. I am very comfortable with suctioning in adults, but not with children. Any advice?

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    Actually, nasal suctioning can be far more traumatizing to a 3 year old than oral suctioning. (Think of every person who is visiting a dentist today and I don't think they'd say that the suctioning was their biggest stressor.) I can't quite figure out how a mucus plug could be suctioned out of a patient nasally; if they have any kind of a cough at all, the stuff will go into the back of their throat or into their mouth. Your BBG suctioning attachment isn't going to get the secretions at the back of the throat, just what's in the nasal cavity and nasopharynx. When I do oral suctioning on a conscious child I slide the catheter along the inside of one cheek to the back of the mouth and encourage them to cough. Even a weak or assisted cough will move secretions into the path of the suction catheter eventually. Stimulating a gag is something I try to avoid because it traumatizes me... and the child, of course. Our unit has a number of frequent fliers who have muscular dystrophies of one sort or another and they are usually too weak to cough effectively so we use a variety of techniques to improve their effort, but that kind of intervention isn't something I could teach you here. The vibra-vest should manage that aspect anyway. Don't be reluctant to suction orally. It's really not that bad!

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    Thanks for the encouragement, it did make me feel better. I'm still a little confused, though, about a couple things. As far as the mucous plug, if the patient had one I think it would be in a bronchus. The catheter might be too small to suction out the plug, but it might be able to remove part of it. However, if the goal is to get to the bronchus, then I don't understand the difference between going in nasally and going in orally...because if I went in nasally, the suction catheter would pass through the nasopharynx and then go into the oropharynx. So it would still remove secretions from the back of the throat. As far as the BBG tip, it can be removed so that I can insert the suction catheter. He has a yonker so that I can suction the oral cavity, and that will probably be enough but if he did end up getting a mucous plug I'd like to be able to suction deeper than that. It's home health care and he lives out in the country, so if he coded from a mucous plug, I wouldn't have all the equipment I needed and it would take a long time for the ambulance to get there. So I'm mainly concerned about being in a situation where I need to use deep suctioning. If I needed to go past the oropharynx, would oral suctioning still work better than nasal suctioning? He is mentally handicapped and deaf, so I wouldn't be able to instruct him on coughing, and I'm scared that if I tried deep suctioning through the oral cavity he would fight the catheter and it would be more difficult than oral suctioning.

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    • Experts

    You can accomplish the same thing by either route. The oropharynx is much larger of course and when you pass your catheter you may elicit a cough which will move the plug. The key is to suction... One consideration is how well he manages his oral secretions. If he doesn't do a great job, when you pass the suction catheter nasally first or only, you run the risk of him gasping and aspirating. So you might want to consider suctioning out the oral cavity first to reduce the odds. Just a thought.

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    Please review your P&P on suctioning children. Oral suctioning, when you can see the tip of your suction device is fine, but nasopharyngeal or oropharyngeal suctioning (let alone orotracheal or nasotracheal) is so dangerous. You can traumatize the glotus or cords and do permenant damage without ever realizing it. In young children the tissues of the upper airway can be as fragile as butterfly wings. The hospital in my area only critical care patients may be pharyngeal suctioned by nurses trained in this proceedure. Even on the floors (in-patient) NP or OP suctioning is forbidden. I can't imagine home care patients being suctioned NT/NP or OT/OP.

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    i agreed with their advices, as a psycholoogist, i may describe it as a trauma factor and its will be difficult for that child to regain its confidence to others especially in those in the health field :)

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    I work part time as a home health nurse and full time as a nurse on a respiratory unit. I'm newer so not an expert by any means. My advice in your shoes would be to go to your supervisor and ask them what they recommend, or ask to speak to another nurse in your company who has more experience with this. I did suction my toddler aged home health kid NP three times one night when they were not able to maintain their sats and still needed some O2. They were coming down with a cold. It dramatically increased their condition for a few hours. I totally believe in doing it when needed but not on a routine basis. Just reading your post I would be hesistant to go forward without some guidance.

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    With the mucus plugs, you're not trying to suction them out the lungs/bronchus/trachea. You're helping clear the secretions once the patient coughs them up. (Suctioning will often trigger that cough, thus is why you use suctioning to clear the mucus plug and why sometimes during suctioning, you'll sometimes get a mucus plug from the cough moving the secretions.)

    for a three year old, unless they're congested nasally, I'd go oral. When they cough that stuff up, it's going to be at the back of their throat, not going up their nose. So you'll just go towards the back of the throat. AND PLEASE BE GENTLE. I've seen throats turned into hamburger meat with a Yankauer. I prefer a large suction catheter or some sort of flexible suction device when going near mucus membranes.

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