When suctioning a patient with a tracheostomy How long should the nurse limit each suction attempt to prevent hypoxemia?

Suction-Tipped Catheters

This technique works well with objects that are round and difficult to grasp. Suction is readily available in the ED but should provide 100 to 140 mm Hg of negative pressure to be useful. To avoid iatrogenic injury, inform the patient of the impending noise to prevent sudden movements caused by a startle reflex. Place either the blunt or the soft plastic tip against the object and withdraw it slowly. If using a suction instrument with a thumb-controlled release valve (as with the Frazier suction tip), remember to cover the port to activate the suction.

The Hognose (IQDr, Inc., Manitou Springs CO), a commercially available device designed by an emergency clinician, aids in the removal of FBs in the auditory canal. It is used in combination with an otoscope and suction setup. It is essentially an otoscope speculum with suction attachment and a soft self-molding tip that can attach to objects. The flange comes in three color-coded sizes: 4, 5, and 6 mm. To use, first attach the Hognose to the otoscope and set the standard wall suction at a low to medium vacuum setting (Fig. 63.21). Next, under direct visualization, approach the FB with the otoscope. Finally, engage suction by applying finger pressure on the open insufflation port and withdraw.

2 Equipment

Numerous commercial suction catheters exist.5,7,29 The ideal catheter is one that optimizes secretion removal and minimizes tissue trauma. Specific features of the catheters include the material of construction, frictional resistance, size (length and diameter), shape, and position of the aspirating holes. An opening at the proximal end of the catheter to allow the entrance of room air, neutralizing the vacuum without disconnecting the vacuum apparatus, is ideal. The proximal hole should be larger than the catheter lumen. Tracheal suctioning can occur only with occlusion of this proximal opening. The conventional suction catheter has side holes and end holes (Fig. 14-6).

The length of the typical catheter should pass beyond the distal tip of the artificial airway. The diameter of the suction catheter is very important. The optimal catheter diameter should not exceed one half of the internal diameter of the artificial airway. A catheter that is too large can produce an excessive vacuum and evacuation of gases distal to the tip of the airway, promoting atelectasis because of inadequate space for entrainment of air around the suction catheter. If the catheter is too small, removal of secretions can be compromised.

Guidewire Technique for Catheter Aspiration

Catheters designed specifically for aspirating a pneumothorax are made of flexible, thrombosis-resistant radiopaque material with multiple distal side ports to reduce the risk of occlusion. Commercially available small-bore catheter systems are ideal for this procedure.

The catheters are placed via a standard “over-the-wire” (Seldinger) technique. The most common insertion site is the second intercostal space in the midclavicular line, but either of the standard locations (the midaxillary to anterior axillary line, usually in the fourth or fifth intercostal space, or the midclavicular line, second intercostal space) can be used. Place the patient in a semi-upright position. Clean the skin with an antiseptic solution and drape the area. Infiltrate locally with lidocaine for anesthesia. Advance the guide needle in a straight line at a 60-degree angle cephalad over the top of the rib (Figs. 10.27 and10.28). Unless a straight tract is created, it will be difficult to advance the floppy catheter, so a tunneling approach cannot be used. When the pleural space is identified by intermittent aspiration, halt advancement of the needle. Stabilize the needle and feed a guidewire through the needle and into the pleural space. Remove the needle while stabilizing the guidewire to keep it in the pleural space. Make a small incision in the skin with a No. 11 blade at the base of the wire to allow passage of the catheter through the skin. Some systems use a dilator over the wire to open the path through the soft tissue. Thread the mini-catheter over the guidewire and into the pleural space. Remove the wire and dilator while leaving the catheter in the pleural space. Advance the catheter through the subcutaneous tissue with a twisting motion. Secure the catheter to the skin with a suture and dress the incision site. The catheter may be removed after a period of observation, or suction may be maintained for a few days. If the catheter becomes clogged with mucus or blood, inject sterile saline through the device to clear it.

To aspirate the pneumothorax, attach a three-way stopcock to the catheter and slowly aspirate air with a 60-mL syringe until resistance is felt. Gentle wall suction can also be used because a number of aspirations may be required until all the air exits. Take a chest radiograph to determine whether the lung is fully expanded. If a residual pneumothorax is present, attempt further aspirations. If the residual pneumothorax persists and air cannot be aspirated, the catheter may be kinked or blocked with soft tissue. To relieve the blockage, place the patient in the full upright position and have the patient cough or take a deep breath. Alternatively, the catheter can be twisted or rotated gently.

Airway Secretion Removal

Postural drainage, percussion and vibration, and the assisted cough techniques described previously can be used to centralize secretions to the tracheostomy tube where they can be expelled by suctioning or insufflation-exsufflation. Suctioning is the removal of excessive secretions by inserting a catheter through a tube and applying negative pressure. The clinician should be aware of the major complications of airway suctioning: hypoxemia, cardiac arrhythmia, lung collapse, and infections.

To avoid these complications, the clinician can take precautions such as preoxygenation before suctioning, limiting suctioning to 10 seconds each time, and using the correct size of catheter. For an adult patient, a catheter is used with an outer diameter no greater than half the inner diameter of the tracheostomy tube. Suction pressure (checked by occluding the tube) should not exceed 7 to 15 mm Hg by portable suction machine or 100 to 120 mm Hg by wall suction. The clinician must be careful to keep the gloved hand on the catheter sterile; the other gloved hand that handles the tubing and adjusts dials must be kept clean (Clinical Note: Steps for Using Suction Catheter with Tracheostomy).

The suction catheter is inserted until gentle resistance is met at the carina (Figure 4-30, A) and is then withdrawn a few centimeters before suction is applied (Figure 4-30, B). Suction is applied intermittently while the catheter is rotated between the thumb and forefinger. The catheter should not be in the airway longer than 10 seconds and the total time between suctioning and re-establishing ventilation and oxygenation should not exceed 20 seconds. It may be necessary to replace the ventilator or use the Ambu bag for 5 breaths before repeating the suctioning process. The catheter may be rinsed with saline solution between each suction attempt to clear out the secretions. It is more difficult to suction the left mainstem bronchus because of the anatomical arrangement of the bronchus,2 which may cause increased risk of pneumonias in the left lung. Use of a directed catheter2 or MI-E may address this problem.8

Clinical Note

Steps for Using Suction Catheter with Tracheostomy

Check equipment and make sure it is present and sterile; maintain a sterile field

Check monitors

Wash hands

Hyperoxygenate with 100% oxygen for three to five breaths with manual resuscitation bag

Place the patient's neck in extension

Put on sterile gloves and goggles

Lubricate the catheter with sterile saline solution or water-soluble gel

Place the catheter (without suction) upward and backward in short increments; continue until an obstruction (the carina) is reached

When the carina is stimulated, the patient will generally cough unless his reflexes are obtruded

Pull the catheter back slightly from the carina and then apply suction with no more than 120 mm Hg pressure (wall suction)as the catheter is withdrawn in a rotating motion

Suctioning Aspiration time should be within 10 to 15 seconds total (a good guideline is for the therapist to hold her breath during suctioning because the patient is not breathing; this helps develop sensitivity for what the patient is experiencing)

Allow the patient to rest for several seconds and preoxygenate him again

Check the patient's breath sounds and repeat the procedure if necessary

Suction the pharynx

Observe the patient and monitor for any arrhythmias

Use pulse oximetry to monitor desaturation

Discard used equipment; remove gloves and goggles

Wash hands

Adapted from Frownfelter D, Dean E: Cardiovascular and pulmonary physical therapy: evidence and practice, ed 4, St. Louis, 2006, Elsevier Mosby, p. 781.

An alternate method of airway secretion removal is MI-E, using the CoughAssist (Figure 4-31). This mechanical device delivers a maximal insufflation, usually at pressures of 35 to 60 cm H2O, immediately followed by a decrease in pressure to create a forced exsufflation at pressures usually between −35 and −60 cm H2O. The clinician applies insufflation for a count of three or less and then exsufflation for a count of three to four. The procedure can be applied four to five times with pauses to prevent hyperventilation.

Clinical Note

Precautions and Contraindications for Mechanical Insufflation-Exsufflation (MI-E)

CoughAssist applied by endotracheal or tracheostomy tube can be more effective than tracheal suctioning and can eliminate the need for emergency bronchoscopy by clearing mucus plugs from distal airways where routine suctioning cannot. The efficacy of CoughAssist has been demonstrated clinically and in animal models, and because it is noninvasive, there is less chance of lower airway contamination compared with traditional suctioning, and it is more comfortable for patients.23-26 CoughAssist is not without risk, however, and therefore certain precautions and contraindications must be considered (Clinical Note: Precautions and Contraindications for Mechanical Insufflation-Exsufflation [MI-E]).

Catheter-Directed Therapies

Catheter-directed therapies aim to establish reperfusion in the setting of life-threatening PE while avoiding the major bleeding complications of systemic thrombolysis. Patients with hypotension from PE and absolute contraindications to thrombolysis may be treated with pigtail or balloon-tipped catheters to fragment PEs or aspiration catheters to suction PEs.

Catheter embolectomy provides an alternative treatment when thrombolysis is contraindicated, unavailable, or has already failed in patients with hypotension, shock, or cardiac arrest from acute PE. This approach also avoids the risks of surgery for patients unlikely to tolerate surgical embolectomy. Investigators have reported several catheter embolectomy techniques.98,142-149 No randomized controlled trial has compared systemic thrombolysis with catheter-directed thrombolysis, and we do not have comparative data about the choice of catheters, adjunctive thrombolysis, and anticoagulation management in these patients. Thus, this therapy relies on available expertise andresources. However, experts recommend (1) discontinuation of catheter embolectomy once hypotension is reversed and (2) removal of clot only in the main or lobar pulmonary arteries to minimize the risk of perforation or dissection of pulmonary arteries.98

In the absence of absolute contraindications to thrombolysis, investigators have attempted direct infusions of thrombolytic drugs into the pulmonary artery or the combination of mechanical fragmentation of PE with local infusion of thrombolytic drugs to improve the benefit of thrombolysis and reduce the risk of major bleeding. In 1988, a randomized clinical trial demonstrated no difference in PE outcomes between a direct infusion of recombinant tissue plasminogen activator into the pulmonary artery and intravenous recombinant tissue plasminogen activator.150 More recently, investigators have reported experiences with ultrasound-assisted catheter-directed thrombolysis, but all main results are physiologic or anatomic rather than patient-centered outcomes (Table 82.6).

For now, the relative safety and efficacy of all catheter-directed therapies remain to be demonstrated in well-designed clinical trials. However, these approaches deserve consideration for patients with life-threating acute PE who are not candidates for systemic thrombolysis or surgical embolectomy.

Intensive Care Unit

The role of the physiotherapist in the intensive care unit is to treat intubated patients by clearing chest secretions and using mechanical aids to stimulate lung function.

Hemorrhage

Although not specifically designed to detect bleeding, the use of closed-suction catheter drainage allows early recognition of hemorrhage, an uncommon complication of mastectomy. Hemorrhage is reported as a postoperative complication in 1% to 4% of patients and is manifested by undue swelling of flaps of the operative site and increased bloody drainage.19 Early recognition of this complication is imperative. Hemorrhage may be treated by aspirating the liquefied hematoma and establishing patency of the suction catheters. The application of a light compression dressing reinforced with Elastoplast tape should diminish the recurrence of this adverse event. Moderate to severe hemorrhage in the immediate postoperative course is rare and is best managed with wound reexploration. Early, severe hemorrhage is most often related to arterial perforators of the thoracoacromial vessels or internal mammary arteries. Direct suture ligation is advisable. Thereafter closed drainage systems are replaced, and tubing patency is ensured before wound closure.

Surgeons hold varying opinions as to the best technique to elevate skin flaps for performance of total mastectomy. Electrocautery, cold scalpel, Shaw hot knife, and, more recently, laser have been used to create skin flaps for modified radical and radical mastectomies. The cold scalpel has the advantage of minimal tissue injury but may present formidable bleeding problems unless used concomitantly with direct suture ligation or electrocoagulation. Excessive bleeding may obscure the operative field with blood, and the extensive dissection may leave the hematologically compromised patient anemic at termination of the procedure. In contrast, electrocoagulation minimizes blood loss.37,52 However, the experimental studies by Keenan and colleagues53 suggest that the tissue damage initiated with cautery injury may diminish the host response to infection.

In a prospective nonrandomized study of 60 patients undergoing total mastectomy,54 no statistical differences for infection rate, operating time, wound discharge, or hospital stay were noted with use of the cold scalpel compared with the electrocautery. These authors determined that use of the electrocautery allowed significantly greater blood loss, estimating that blood loss was 440 mL versus 651 mL for the scalpel and electrocautery, respectively. Kakos and James52 completed a similar prospective analysis for comparison of blood loss with the electrocautery versus the scalpel in 50 mastectomy patients. Average blood loss in this series was 960 mL in the scalpel group versus 160 mL in the electrocautery group. Of 25 scalpel-group patients, 24 (96%) received transfusions, compared with only 6 of 25 (24%) in the electrocautery group. Wound necrosis was not different in the two groups.

Miller and associates55 conducted a randomized prospective study to investigate differences in blood loss and postoperative complications in patients undergoing modified radical mastectomy with use of the electrocautery and scalpel. Skin flaps were created with the cold scalpel in 24 patients and with electrocautery in 25 patients. The two groups were similar with respect to age, stage of disease, size of tumor, and body weight. Use of the electrocautery allowed patients to have significantly reduced operative blood loss compared with patients whose skin flaps were created with the cold scalpel (352 vs. 507 mL, respectively; p < .05). None of the patients who underwent electrocautery required transfusion. The primary advantage of the electrocautery was the reduction in blood loss; surprisingly, operating time was not significantly shortened with use of the electrocautery technique. These authors acknowledge that the axillary dissection is the time-limiting factor of the procedure, and because of neurologic injury induced with use of electrocoagulation, axillary dissection techniques used by the surgeons were identical in both subgroups. Total postoperative Hemovac drainage and hospital stay were not significantly different between the two groups. Although the number of fever days and wound complications were slightly higher in the electrocoagulation group, this difference was not statistically significant. Miller and associates55 concluded that use of the electrocautery for the development of skin flaps in the performance of a mastectomy reduces blood loss without incurring a greater incidence of wound complications.

Cautery appears to be the most suitable surgical instrument for tissue plane dissection in the procedure. However, it has the expectant limitation of neurostimulation and heat injury with dissection around motor nerves, such as the brachial plexus, and of motor innervation to muscles of the axillary space, including the medial/lateral pectoral, long thoracic, and thoracodorsal nerves to the pectoralis major, serratus anterior, and latissimus dorsi muscles, respectively. For these reasons, most surgeons use a combination of both techniques.

As indicated by Miller and associates,56 the known risks of blood transfusions include hepatitis (0.26%–1%), transfusion allergic reactions (1%–19%), and acquisition of human immunodeficiency virus. Each of these transfusion-related complications necessitates constant reexamination of the indications for transfusion, with deliberate attempts to reduce transfusion requirements at mastectomy in the nonanemic patient.

Treatment

Preoperative care of the infant with EA includes the insertion of a sump suction catheter into the proximal esophageal pouch for the continuous evacuation of secretions. The preoperative pulmonary complications associated with EA/TEF occur because of aspiration of oral contents or reflux of gastric contents into the airway. Placing a tube with continuous suction into the proximal esophageal pouch can minimize the aspiration of saliva. The infant also should be maintained in an upright position to decrease reflux of gastric secretions through the fistula and into lungs. In addition, minimizing positive-pressure ventilation can minimize gastric distention and reflux of gastric contents. Treatment with systemic antacids can also reduce reflux of acidic gastric contents into lung or distal esophageal pouch. Hydration is maintained by intravenous fluids, and surgical repair is undertaken as soon as the infant’s general condition permits.

If progressive gastric distention occurs, a decompressive gastrostomy can be performed. An associated duodenal atresia should also be considered in severe cases of gastric distention necessitating emergent placement of a gastrostomy tube (Holder, 1993). If the fistula is large, there may be significant loss of tidal volume if the infant requires positive pressure ventilation. This volume loss can usually be controlled by connecting the gastrostomy to a chest tube system under water seal (Fann et al, 1988). In extreme cases in which the infant may not tolerate a thoracotomy and definitive procedure, a Fogarty catheter can be passed with a bronchoscope to occlude the fistula (Filston et al, 1982).

Preoperative evaluation in infants with EA/TEF should include an evaluation for other major anomalies, as they occur in 50% to 70% of these patients (Harmon and Coran, 1999; Holder, 1993; Rejjal, 1999). The VACTERL association consists of vertebral anomalies, anal agenesis (imperforate anus) (Figure 69-4), cardiac defects (most commonly patent ductus arteriosus, atrial septal defect, and ventricular septal defect), tracheo esophageal fistula, renal anomalies, and limb anomalies (most often radial anomalies) and is present in 25% to 30% of children with EA/TEF (Corsello et al, 1993; Harmon and Coran, 1999; Manning et al, 1986; Quan and Smith, 1973). Infants with EA/TEF within the VACTERL association tend to have higher proximal pouches, more complications, and a higher mortality than those in infants with isolated EA/TEF (Greenwood and Rosenthal, 1976; Holder, 1993; Touloukian and Keller, 1988; Weber et al, 1980). In particular, the presence of cardiac defects has a significant impact on mortality rates in EA/TEF (Spitz, 1993). Gastrointestinal anomalies occur in 15% of patients, with anal atresia being the most common, although duodenal atresia may also occur (Harmon and Coran, 1999; Holder, 1993).

Operative strategy in EA/TEF is based on the anatomy and whether other anomalies are present. In general, the infant who lacks other anomalies and has a reasonably stable pulmonary status should undergo primary repair of the atresia and ligation of the fistula soon after birth. To accomplish this, an extrapleural or transpleural approach is used, the fistula is divided, and an anastomosis between the proximal and distal esophageal segments is achieved using an end-to-end anastomosis. In infants with extreme pulmonary compromise or significant associated anomalies, an initial gastrostomy for decompression with later repair of the EA/TEF may be indicated. Infants with the lowest probability of survival are likely to benefit from a staged approach (Alexander et al, 1993; Spitz et al, 1987).

Postoperative care consists of respiratory support, antibiotics, and intravenous nutritional support. Enteral feedings via a gastrostomy or a transpyloric tube may be started on the 3rd or 4th postoperative day. These feedings initially are given by continuous infusion because the stomach is often small. Bolus feedings are usually introduced once full enteral feeds are established, with oral feedings 7 to 10 days postoperatively after confirmation by a radiographic contrast study that there are no esophageal anastomotic leaks. Some investigators have questioned whether contrast studies are necessary for infants who remain free of clinical symptoms related to postoperative complications (Yancher et al, 2001).

Complications after repair of EA/TEF include esophageal anastomotic leak, esophageal stricture, gastroesophageal reflux, recurrent fistula, and tracheal obstruction. The incidence of anastomotic leak is 10% to 15% (Harmon and Coran, 1999). The diagnosis may be made by noting the presence of saliva in the chest tube, but it is confirmed by a contrast swallow study. Management is expectant because most of these leaks close spontaneously. A minor esophageal stricture is almost universal after repair of an EA/TEF. Significant strictures occur in 5% to 10% of infants (Harmon and Coran, 1999). The diagnosis is confirmed by barium swallow examination. Treatment of esophageal strictures is with serial esophageal dilatation, either with Jackson dilators or by balloon dilatation (Benjamin et al, 1993; Shah and Berman, 1993). Esophageal strictures are also one of the most common late complications of EA repair and manifest with abnormal esophageal motility and dysphagia. Esophageal strictures at the anastomotic site should be suspected if feeding difficulty develops, particularly after the 3rd week. Repeated balloon dilation may be necessary to relieve the stricture, although residual esophageal dysmotility may persist for a lifetime. Gastroesophageal reflux occurs in 40% to 70% of these children because of an abnormal angle and incompetence of the lower esophageal sphincter in addition to abnormal motility in the body of the esophagus across the anastomosis (Holder, 1993; Jolley et al, 1980; Pieretii et al, 1974; Whitington et al, 1977). Medical therapy with antacids and intestinal motility agents may be successful initially, but many patients require antireflux surgery. Clinically significant tracheal obstruction may occur in as many as 25% of children with EA/TEF as a consequence of tracheomalacia (Corbally et al, 1993; Harmon and Coran, 1999). The onset of respiratory symptoms with or immediately after feeding usually occurs in the months after repair of EA/TEF but may be in the immediate postoperative period (Holder, 1993). The diagnosis of tracheal obstruction due to tracheomalacia is made by bronchoscopy (Holder, 1993). In the child without significant distress, most symptoms subside over the first year or two of life (Holder, 1993). The surgical treatment of severe tracheomalacia is aortopexy, or suspension of the aorta (and therefore the anterior trachea) to the posterior surface of the sternum (Corbally et al, 1993; Holder, 1993). The incidence of recurrent fistula is probably less than 10% (Harmon and Coran, 1999). Recurrence of TEF usually occurs in the immediate postoperative period, but the diagnosis may not be made for months or years. The manifestations of a recurrent fistula are similar to aspiration with gastroesophageal reflux: coughing with feeds and recurrent pulmonary infections. Small fistulas may close spontaneously, but if a fistula persists for longer than 4 weeks, surgical closure is indicated (Harmon and Coran, 1999). Most surgeons prefer to wait 3 to 6 months after the initial EA/TEF repair, if possible, allowing inflammation and edema to decrease (Holder, 1993).

Device, Procedure-Related, and Environmental Factors.

Endotracheal intubation is frequently considered a risk factor of nosocomial respiratory tract infections. Suction catheters cause mucosal denudation and suppress mucociliary transport.152 Almost all intubated patients aspirate some oropharyngeal secretions.126 A dense bacterial polysaccharide biofilm has been shown to coat endotracheal tubes.249 Detachment and aspiration of aggregates during tracheal suctioning could constitute a large pulmonary inoculum, which may be poorly handled by an impaired lower respiratory defense. Nasogastric tubes allow a direct route from the upper gastrointestinal tract to the nasopharynx. Tracheostomies likewise have been associated with increased risk of nosocomial pneumonia.30 Not surprisingly, the length of respiratory assistance and endotracheal intubation and therefore the device-related risk are frequently reported as significant risk factors of nosocomial pneumonia.154 However, a large prospective epidemiologic study reported that neuromuscular blocking agents (relative risk 17.5, 95% CI 5.4-57.1) were far more predictive of nosocomial pneumonia than mechanical ventilation (relative risk 6.6, 95% CI 1.4-28.5) or endotracheal intubation (relative risk 7.5, 95% CI 2.0-27.5).87

Nasotracheal tubes, nasogastric tubes, and facial trauma can obstruct drainage of the eustachian tubes and paranasal sinuses, and they are risk factors of middle ear infection and sinusitis.65, 67

Colonized hands of medical personnel, especially staff with concurrent dermatitis, are obvious avenues of contamination of the respiratory tract.68 Viral respiratory infections are transmitted via the hands of hospital staff or visitors.