To Suction, or Not to Suction

[IKnowYouRider]

I just started working at an LTAC facility and have a lot of patients on vents, so I'll probably have a lot of posts in this section for a while.

Yesterday I had a patient on a trach collar, SaO2 95% on 4-6L of O2 (I don't remember exactly). He had recent bacterial pneumonia infection. LOC probably x1, restless, agitated.

So, he was expelling a lot of secretions through his trach by coughing all throughout the day. I would clean around his trach frequently. Still, he sounded pretty coorifice and I asked my orientating nurse if I should maybe deep suction him a few times to help him out. She told me not to because he was expelling a lot on his own and his SaO2 was normal. Is this what your recommendation would have been, or would you have deep suctioned?

I regret going against my best judgement and not suctioning because I now feel maybe his agitation/restlessness was somewhat low Pa02. He was also getting a lot of opiates/benzos, but still....

[eatmysoxRN, ASN, RN]

Unless he had trouble coughing it up, I'd think you should just let him cough it up himself. Deep suctioning may be necessary but I wouldn't think so if he is expelling it on his own.

[TraumaSurfer]

LTAC? Was the aerosol a venturi humidifier? If so, you need to track the FiO2 rather than the liter flow to give you a better indication of his oxygenation status. SpO2 refers to oxygenation and often with secretions you will have a ventilation problem. You should also be checking the patency of the inner cannula or trach periodically. This doesn't mean you have to bury the suction catheter to the carina but you should make sure there are no secretions adhering to the walls of the inner cannula or trach. It also does not mean you need to suction every time the patient coughs. But, periodic patency checks should be documented. Also, with long term patients, most are on tube feedings and have chronic illness which skews the SpO2 readings due to a low H&H or anemia. Hence, the low PaO2. Breath sounds should be your guide especially if the person is always in bed at just a 30 degree angle and has any altered mental status or level of consciousness. At 30 or even 45 degrees they are still fighting gravity. Once you clear whatever secretions you can with a suction catheter you should again listen to breath sounds. That will give you a better baseline guide.

[tewdles, RN]

How about some comfort meds...an expectorant and a suppressant?

Suction for comfort, otherwise let him control that part.

Is he a DNR?

If he is old he may have paradoxical response to benzos.

[chare]

I agree with TraumaSurfer. While patients with artificial airways should be suctioned at regular intervals, these intervals should be determined based upon the patient and their presentation, rather than a fixed interval (i.e., every two hours). For a patient with an established tracheostomy, this might be as infrequently as once a shift with their routine tracheostomy care. Patients with new tracheostomies, or with an acute process, might require suctioning hourly, or more frequently. However, if the patient is able to cough and expel secretions through his tracheostomy tube, then they likely do not need to be suctioned. While patient's with tracheostomy tubes, particularly those that are capable of expelling their secretions, sound horrible, all that might be necessary is cleaning the exterior portion of the tracheostomy.

When you do suction the tracheostomy, you should never perform "deep suction;" rather you should only pass the suction catheter to where the tip of the suction catheter is even with, or slightly beyond, the tip of the tracheostomy tube. When you suction any artificial airway, all you are doing is clearing secretions from the inner lumen of the tracheostomy tube. Performing deep suctioning can damage the tracheal or bronchial lumen.

There are several resources available on line. While I haven't reviewed the entire site, the Tracheostomy Training Resources; created by the National Tracheostomy Safety Project seems to be a fairly extensive. There is an updated version available on their resources, but it is a large file, and I haven't downloaded it yet. In addition to the resources available, they also maintain a YouTube channel, NTSP 2010 Channel.

[TraumaSurfer]

Another thing to consider is aspiration and this should be assessed thoroughly. Treated for GERD? Is the patient on cuff deflation trials? It may take awhile for the patient to get tolerate air movement through his vocal cords. Does he aspirate? Cuff inflation does very little to prevent aspiration which has been a misconception for a long time. Is the patient on G-tube feeds or PO? Is a PMV used with PO feeds? We now know inflated cuffs and PO feeds can be a recipe for disaster. Does the patient have a new infection? Is the patient getting adequate hydration which might include in his G-Tube? Is the trach appropriately secured? Is the trach a good fit for the patient? Trachs too short or too long can create problems and a custom should be considered. These are all things which make LTACs special since trachs are their thing and acute hospitals just want these patients out as quickly as possible. Some hospitals put whatever trach they have in the closet into the patient and dump to the LTAC or SubAcute. You might be the first to notice (or care) that it is not the appropriate trach.