ENDOTRACHEAL INTUBATION & SUCTIONING

SUBMITTED TO-
Dr. Umarani Adhikari
Lectueer

SUBMITTED BY-
Debipriya Mistry
M. Sc. Nursing, Part- I

College of Nursing, Medical College & Hospital, Kolkata

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 ENDOTRACHEAL INTUBATION
INTRODUCTION :Endotracheal Tracheal intubation, usually simply referred to as intubation, is
the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway . It is
frequently performed in critically injured, ill, or anesthetized patients to facilitate ventilation of the
lungs, including mechanical ventilation, and to prevent the possibility of asphyxiation or airway
obstruction.
The endotracheal tube is passed through the mouth and vocal apparatus into the trachea. Because it is
an invasive and uncomfortable medical procedure, intubation is usually performed after
administration of general anaesthesia and a neuromuscular-blocking drug. It can however be
performed in the awake patient with local or topical anaesthesia or in an emergency without any
anaesthesia at all. Intubation is normally facilitated by using a conventional laryngoscope, flexible
fibreoptic bronchoscope, or video laryngoscope to identify the vocal cords and pass the tube between
them into the trachea instead of into the oesophagus. Other devices and techniques may be used
alternatively.

DEFINITION : Endotracheal intubation is a procedure by which a tube is inserted through the

mouth down into the trachea (the large airway from the mouth to the lungs). Before surgery, this is
often done under deep sedation. In emergency situations, the patient is often unconscious at the time
of this procedure.

What kind of tube is used?

The tube that is used today is usually a flexible plastic tube. It is called an endotracheal tube because
it is slipped within the trachea.

Parts of ET Tube
PURPOSE

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The procedure is needed for any of the following reasons:

1. to open the airways so that one can receive anesthesia, medication, or oxygen
2. to protect lungs
3. the person who have stopped breathing or having difficulty breathing
4. when needed a machine to help in breathing
5. in case of head injury and when a person cannot breathe on his/her own
6. when a person needed to be sedated for a period of time in order to recover from a serious
injury or illness
7. EI keeps airway open. This allows oxygen to pass freely to and from lungs as the person breathe.

RISKS OF ENDOTRACHEAL INTUBATION

Anesthesia risks

Typically, the patient will be under general anaesthesia during the procedure. This means that the
person will not feel anything as the tube is inserted. Healthy people usually don’t have any problems
with general anaesthesia, but there’s a small risk of long-term complications.

These risks largely depend on the general health and the type of procedure undergoing.
Factors that may increase your risk of complications with anaesthesia include:
chronic problems with your lungs, kidneys, or heart
 diabetes
 history of seizures
 a family history of adverse reactions to anaesthesia
 sleep apnoea
 obesity
 allergies to food or medications
 alcohol use
 smoking

More serious complications may occur in older adults who have significant medical problems. These
complications are rare but may include:
 heart attack
 lung infection
 stroke
 temporary mental confusion
 Death

Approximately one or two people in every 1,000 may become partially awake while under general
anaesthesia. If this happens, people are usually aware of their surroundings but won’t feel any pain.
On rare occasions, they can feel severe pain. This may lead to long-term psychological

pg. 3
complications, such as post-traumatic stress disorder (PTSD). Certain factors can make this situation
more likely:
 emergency surgery
 heart or lung problems
 long-term use of opiates, tranquilizers, or cocaine
 daily alcohol use

Intubation risks
There are some risks related to intubation, such as:
 injury to teeth or dental work
 injury to the throat or trachea
 a build-up of too much fluid in organs or tissues
 bleeding
 lung complications or injury
 aspiration (stomach contents and acids that end up in the lungs)

An anaesthesiologist should evaluate the patient before the procedure to help decrease the risk of
these complications from occurring.

INDICATIONS:

Endotracheal intubation is indicated in a variety of situations when illness or a medical procedure

prevents a person from maintaining a clear airway, breathing, and oxygenating the blood. In these
circumstances, oxygen supplementation using a simple face mask is inadequate.
Depressed level of consciousness
Perhaps the most common indication for endotracheal intubation is for the placement of a conduit
through which nitrous oxide or volatile anaesthetics may be administered. General anaesthetic
agents, opioids, and neuromuscular-blocking drugs may diminish or even abolish the respiratory
drive. Although it is not the only means to maintain a patent airway during general anaesthesia,
intubation of the trachea provides the most reliable means of oxygenation and ventilation and the
greatest degree of protection against regurgitation and pulmonary aspiration.
Damage to the brain (such as from a massive stroke, non-penetrating head injury, intoxication or
poisoning) may result in a depressed level of consciousness. When this becomes severe to the point
of stupor or coma (defined as a score on the Glasgow Coma Scale of less than 8),[3] dynamic collapse
of the extrinsic muscles of the airway can obstruct the airway, impeding the free flow of air into the
lungs. Furthermore, protective airway reflexes such as coughing and swallowing may be diminished
or absent. Tracheal intubation is often required to restore patency (the relative absence of blockage)
of the airway and protect the tracheobronchial tree from pulmonary aspiration of gastric contents.

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Hypoxemia
Intubation may be necessary for a patient with decreased oxygen content and oxygen saturation of
the blood caused when their breathing is inadequate (hypoventilation), suspended (apnoea), or when
the lungs are unable to sufficiently transfer gasses to the blood. Such patients, who may be awake
and alert, are typically critically ill with a multisystem disease or multiple severe injuries.[1]
Examples of such conditions include cervical spine injury, multiple rib fractures, severe pneumonia,
acute respiratory distress syndrome (ARDS), or near-drowning. Specifically, intubation is considered
if the arterial partial pressure of oxygen (PaO2) is less than 60 millimetres of mercury (mm Hg) while
breathing an inspired O2 concentration (FIO2) of 50% or greater. In patients with elevated arterial
carbon dioxide, an arterial partial pressure of CO2 (PaCO2) greater than 45 mm Hg in the setting of
acidaemia would prompt intubation, especially if a series of measurements demonstrate a worsening
respiratory acidosis. Regardless of the laboratory values, these guidelines are always interpreted in
the clinical context.
Emergency endotracheal intubation is needed in trauma patients with the following traits:
a) airway obstruction
b) hypoventilation
c) severe hypoxemia (hypoxemia despite supplemental oxygen)
d) severe cognitive impairment (GCS <8)
e) cardiac arrest
f) severe haemorrhagic shock

Emergency endotracheal intubation is needed in smoke inhalation patients with the following
conditions:
a) airway obstruction
b) severe cognitive impairment (GCS < 8)
c) major cutaneous burn (> 40%)
d) prolonged transport time
e) impending airway obstruction:
i. moderate-to-severe facial burn
ii. moderate-to-severe oropharyngeal burn
iii. moderate-to-severe airway injury seen on endoscopy

EQUIPMENTS
NOTE: check beforehand to make sure everything works

 Patient positioning equipment

o Bed or procedure table that can be raised and lowered
o Pillows or blankets that can be rolled and placed under patient for optimal positioning
 Monitoring equipment
o Pulse oximeter
o Blood pressure gauge
o Cardiac monitor

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  Oxygenation equipment
o Oxygen source and tubing
o Face mask
o Anaesthesia bag or self-inflating ambu-bag
o Suction catheter
o Suction source

 Premedication and induction equipment

o Intravenous access
o Premedication agents
o Induction agents
o Paralytic agents

 Intubation equipment

Laryngoscope with function battery, Laryngoscope handle and blades of different sizes and
shapes (remember to check light bulb on each blade):

 Curved blades (e.g. Macintosh blades)

 Straight blades (e.g. Miller or Wisconsin blades)
 metallic stylet
 Oropharyngeal airways
 Sterile syringe 10 ml.
 Sterile gloves
 Normal saline
o Endotracheal tubes
 Have several different sizes available with cuff- appropriate size and adaptors
( For adults No. 6 – 9, for children No. 3 – 5 )
 Remember to check cuff for leaks
o Means of securing tube in place
 Commercial products specifically designed for this purpose are recommended
 Alternatives include tape or ties

 Equipment for verifying tube position after placement

o Stethoscope
o Carbon dioxide detector or end-tidal CO2 monitor
o Chest x-ray to verify position is also required

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Laryngoscope handles with an assortment of Miller blades (large adult, small adult, child,
infant and new born)

Laryngoscope handle with an assortment of Macintosh blades (large adult, small adult, child,
infant and new born)

An endotracheal tube stylet, useful in facilitating orotracheal intubation

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 A cuffed endotracheal tube, constructed of polyvinyl chloride

Preparation and Anaesthesia

 Assemble equipment
 Calculate doses and draw medications into syringes
 Check IV access and flush fluid
 Do you predict a difficult airway?
 Is the patient unresponsive or near death?
 Position patient
o Bed at comfortable height for laryngoscopist
o Align the patient
o Shoulders and/or neck supported with rolls or pillows to allow positioning of head
o Neck flexed approx. 15 degrees on chest
o Head hyperextended on neck to maximum comfortable degree (may be best done after
induction)
 Preoxygenate patient 5 minutes on 100% oxygen via mask (straps or person holding in place)
 Consider premeditations, optional for most patients-usually given 2-3 minutes prior to
induction
o Defasciculating drug (for patients who will get succinylcholine, but may not tolerate
fasciculation, e.g. elevated intracranial or intraocular pressure)
 Succinylcholine 0.15 mg/kg (10% of paralyzing dose)
 Vecuronium 0.01 mg/kg (10% of paralyzing dose)
o Prevention of vagal response (especially children younger than age 5 often have
bradycardic response to laryngoscopy)
 Atropine 0.02 mg/kg
o Prevention of worsening intracranial pressure or bronchospasm
 Lidocaine 1.5 mg/kg
o Prevention of hypertensive response in patients with elevated intracranial pressure,
heart disease or aneurysm
 Fentanyl 3 mcg/kg
 Administer a precalculated dose of an induction agent:

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  Dose Advantages Cautions

Etomidate 0.3 Good for low blood pressure; Nausea and vomiting on
mg/kg okay in hypovolemia emergence

Ketamine 1.5 Good for low blood pressure, Caution in elevated intracranial
mg/kg hypovolemia; good in asthma pressure or heart disease

Propofol 2 - 2.5 Rapid onset and recovery Caution if hypovolemic or risk of

mg/kg hypotension

Thiopental 3-5 Multiple drug interactions; caution

mg/kg if hypovolemic or risk of
hypotension

 Administer a precalculated dose of a paralytic agent


Dose Characteristics Cautions

Contraindicated in hyperkalaemia, crush

Succinylcholin 1 - 1.5 Rapid onset, rapid
injury, renal failure, extensive burns,
e mg/kg recovery; fasciculation
elevated intracranial or intraocular pressure

0.6 - 1.2
Rocuronium
mg/kg
Longer acting-may be problematic if
No fasciculation
0.08 - intubation attempt fails
Vecuronium 0.1
mg/kg

Atracurium 0.4 - 0.5 mg/kg

Procedure
A. Pre-treatment evaluation: Assess clinical necessity for intubation. If informed consent is
indicated this must be granted before sedation begins. A directed history and physical should be
performed that includes:
 Relevant history of acute and chronic diseases
 Clarification of code status
 History of prior intubation
 Physical exam with attention to anatomical defects of the airway and evidence of respiratory
compromise
 Current medications and allergies

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  Time of last oral intake
 Assess airway , extent of mouth opening, thyromental distance, palate width, and neck
mobility

B. Set up: Gather all necessary materials and notify Respiratory Therapist to set up ventilator.

C. Patient preparation
 Explain procedure to patient and acquire consent unless emergency
 Explain procedure to family members if they are present
 Assess for sufficient IV access and attachment appropriate cardiovascular and respiratory
monitoring equipment.
 Position patient in sniffing position. Use blankets as ramps if patient requires additional
aligning of oral, pharyngeal, and laryngeal axes.

PERFORMING THE PROCEDURE

 Wash hands and don personal protective equipment

 Check equipment and check endotracheal cuff for leaks
 Insert stylet into endotracheal tube.
 Attach blade to battery base and assess light function. Have backup blades of different type
and sizes available.
 Preoxygenate with 100% O2 using ambu-bag for 3- 5 minutes to wash out residual
nitrogen gas.
 If necessary administer appropriate sedatives or opioids.
 Have an assistant apply cricoid pressure.

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  Assess for ability to mask ventilate.
 If appropriate administer appropriate neuromuscular blockade and assess for clinical effect.
 Grasp the laryngoscope in the left hand
 Open the patients’ mouth with the cross finger technique
 Slowly insert the blade into the right side of the patient’s mouth using it to push the tongue
to the left. Advance the blade inward and midline toward the base of the tongue.
 The tip of the curved blade should be placed in front of the epiglottis.
 The tip of the straight blade should be placed under the epiglottis. Apply pressure caudally
and upward with the handle at a 45 degree angle to the bed.

 Lift the handle until the vocal cords are visualized ensuring that the blade or handle is not
levered against the incisors.
 Grasp the ETT tube with stylet inserted in the right hand.

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  Gently insert the ETT along the right side of the mouth under direct visualization of the
vocal cords until the cuff is no longer visible.
 Firmly hold the ETT in place, withdraw the blade, remove the stylet, and inflate the ETT
cuff with 5-10ml of air.
 Attach end tidal CO2 monitor to the ETT and give positive pressure breaths.
 Assess for proper placement of ETT by end tidal CO2 waveform, fogging in ETT, bilateral
breath sounds, symmetric chest movement, and absence of breath sounds over the
epigastrium, as well as return to baseline vital signs.
 If assessment indicates that the ETT is not placed in the trachea, deflate the cuff and remove
the ETT. Resume mask ventilation with 100% O2. Consult with ICU fellow or anaesthesia
staff on strategy to reattempt intubation
 If breath sounds are absent on the left, deflate the cuff and withdraw the ETT 1-2cm and
evaluate for correct placement.
 Palpate the suprasternal notch feeling for the ETT cuff.
 Attach the secure the ETT with tape or appropriate device.
 Attach the ETT to the mechanical ventilator.

Follow-up treatment
 Review STAT portable CXR to evaluate the location of the tip of the ETT.
 Review arterial blood gas 30 minutes post intubation.

Documentation

 Documentation of the pre-treatment evaluation and any abnormal physical findings.

 Record the time out, indication for the procedure, procedure, type and size of tube used,
method used, evaluate base line label, the outcome, how the patient tolerated the procedure,
medications (drug, dose, route, & time) given, complications, and the plan in the note.
Clinical events may also require an event or progress note. The patients’ primary service
should be notified of the intubation if they are not already aware.
 All abnormal or unexpected findings are reviewed with the supervising physician.

COMPLICATIONS

 If the tube is inadvertently placed in the oesophagus (right behind the trachea), adequate
respirations will not occur. Brain damage, cardiac arrest, and death can occur.
 Aspiration of stomach contents can result in pneumonia and ARDS.
 Placement of the tube too deep can result in only one lung being ventilated and can result in a
pneumothorax as well as inadequate ventilation.
 During endotracheal tube placement, damage can also occur to the teeth, the soft tissues in
the back of the throat, as well as the vocal cords.
This procedure should be performed by a physician with experience in intubation. In the vast
majority of cases of intubation, no significant complications occur.

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CONTRAINDICATIONS

 Neck immobility or increased risk of neck trauma (e.g. rheumatoid arthritis, cervical spine
injury, etc.)-consider fibreoptic intubation.
 Inability to open mouth (e.g. trismus, scleroderma, surgical wiring, etc.)-consider nasal
intubation, fibreoptic, or surgical airway.

NURSES RESPONSIBILTY

Nurses Responsibility before procedure

 Articles preparation
 Medications and kit to prepare

Nursing roles during insertion of endotracheal tube

It is the physician’s responsibility to insert an endotracheal tube but it doesn’t mean that nurses do
not have a big role during this emergency procedure.

So what are your nurse’s roles, in the event, that this emergency happens?

1. If the patient is in respiratory distress, oxygenate patient using bag valve mask. Attach
patient to a pulse oximeter for monitoring. Make sure to ask for reinforcement of nurses to
help you in this procedure. Delegate tasks immediately (E.g. medication nurse, nurse who
will assist the physician and prepare the laryngoscope, nurse who will assess the condition
of the patient and checks vital signs, and etc.). One nurse cannot perform all the tasks
simultaneously written below.
2. Ensure that the emergency cart is accessible to the room or the area of the patient.
3. If the patient has no intravenous access, immediately insert a line (or ask other nurse or
intravenous therapist) for premedication purposes.
4. Position the patient and the height of bed comfortable to the physician who will insert the
tube. Align patient’s head on a neutral position. Hyperextended the head to a comfortable
degree.
5. Consider premedication, optional for most patients-usually given 2-3 minutes prior to
induction. Prepare and administer the sedative medication as ordered by the physician.
6. Prepare the laryngoscope and blades. Ensure that the batteries and bulbs are working. Ask
the physician what size or type of blade he/she preferred to use.

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 7. Assist the physician during insertion. When the tube is already in place, inflate the cuff to
the desired cuff pressure using a syringe. Check the tube position and the level in the lip
line (e.g. 20 cm, 21 cm, 22 cm, and 23 cm)
8. Fix the tube in place partially using a tape, to ensure that the tube is steady. Assessment
should be done first if the tube is in the correct place.
9. Continue to oxygenate patient using bag valve or the manual resuscitator.
10. Verify tube position immediately. Auscultate both lung fields. Assess if both chest are
rising equally.
11. Check also the pulse oximeter to assess patient’s oxygenation.
12. If the endotracheal tube is correctly place, secure tube in position using either a leucoplast,
an ET holder, or ET ties. Suction patient’s secretions as needed.
13. Attach patient to mechanical ventilator. Check the physician’s orders for the mechanical
ventilator settings.
14. The physician would request a standard chest x-ray to confirm ET placement.
Correspondingly, the physician would order an ABG test one hour after attaching the
patient to the mechanical ventilator.
15. When ABG results are out, the physician would typically adjust the mechanical ventilator
settings according to the patient’s response.
After the patient is intubated, what’s next? Getting the tube isn’t the end of the story, as a nurse,
keeping and taking care of the patient with endotracheal tube is another discussion. Let’s take a look
of the things you can do as nurse.

Nursing Management for patients with endotracheal tube

1. Assess the client’s respiratory status at least every 2 hours or frequently as indicated.
2. Assess nasal and oral mucosa for redness and irritation.
3. Secure the endotracheal tube with tape or ET holder to prevent movement or deviation of
the tube in the trachea.
4. Place the patient in a side lying position or semi fowler’s if not contraindicated to avoid
aspiration. Reposition patient every 2 hours.
5. Ensure the ET for placement. Note lip line marking and compare with desired placement
(18cm, 20cm, and 22cm).
6. Closely monitor cuff pressure, maintaining a pressure of 20 to 25 mmHg to minimize the
risk of tracheal necrosis.
7. Move oral endotracheal tube to the opposite of the mouth every 8 hours or depending on
the protocol of the hospital. This is to prevent irritation to the oral mucosa.
8. Provide oral care at least every 4 hours using antibacterial or antiseptic solution. Use bite
block to avoid patient from biting down.
9. Communicate frequently with the client. Give patient means to communicate using white
board or communication board.
10. Apply an oropharyngeal airway.
Patient with endotracheal tube do not have the ability to cough-out their secretions or clear their
airway. So it is our responsibility as nurses, to maintain a patent airway to the patient. One basic
things that we should learn is suctioning.

pg. 14
TERMINATION

Discard articles as per the bio-medical waste guideline

Laryngoscope Blades and Handles Cleaning –

 Immediately after use, the laryngoscope system should be rinsed under cool running
tap water until all visible soil is removed. Ensure that all hard to reach areas are
flushed with the running tap water.

 Immerse the sealed laryngoscope system in a pre-soak enzymatic cleaner solution,

prepared in accordance to the manufacturer’s recommendations for a minimum of two (2)
minutes.

 Remove device from enzymatic cleaner solution and rinse with lukewarm running tap
water for a minimum of one (1) minute to remove all residues and visible soils.

 Immerse the device in enzymatic detergent. Remove bottom cap and brush items thoroughly
using a soft bristle brush, ensuring all visible soils are removed.

 Rinse under running reverse osmosis/deionized (RO/DI) water to remove detergent

residuals.

 Dry with a lint free cloth or filtered pressurized air.

 The bulb may be cleaned with a cotton ball dampened in alcohol.

pg. 15
Ambu Bag-
 Ideally heat disinfectant or
 Immerse it in 2% glutaraldehyde solution the wash it under sterile distilled water to reduce
infection related to chemical.

CONCLUSION

As a nurse, it comes in handy if we are well aware of the basic interventions or management during
emergency, most especially when it concerns airway management. Time is always of the essence.

However, though this article may provide basic background, it is always a nurse’s duty to be
acquainted with the hospital’s protocols or guidelines for standard procedures.

ENDOTRACHEAL SUCTIONING
Introduction:-
Endotracheal suctioning can be accomplished through an endotracheal tube that the physician
inserts through the patient’s mouth and into the trachea. It can remain in place for several days and,
when its cuff is inflated to provide a tight connection, it can be attached to a respirator for controlled
ventilation.

The inflated cuff also aids in preventing aspiration of blood, vomitus or foreign material into the
bronchus. Although endotracheal suctioning is a common procedure, it is one that interferes with
arterial oxygenation. The decrease in oxygen in the alveoli is directly proportional to the amount of
suction and the length of time the procedure takes. The amount of oxygen in the blood drops
suddenly and produces serious hypoxia. It is essential to oxygenate the patient pre and post
suctioning.

pg. 16
Definition:-It is the process of applying a negative pressure to the distal endotracheal tube or trachea
by introducing a catheter to clear excess or abnormal secretions.

Purposes:-
 To maintain a patent airway by removing secretions.
 To prevent lower respiratory tract infection from retained secretions.

Indications for endotracheal suction:-

 Desaturations
 Bradycardia
 Trachycardia
 Absent or decresed chest movement
 Visible secretions in ETT
 Irritability
 Course or decreased breath sound
 Increased work of breathing
 Blood pressure fluctuations
 Recent history of large amounts of thick/tenacious secretions


Effectiveness of ETT suction should be assessed after the procedure by observing:

 Improvement of breath sounds

 Removal of secretions
 Improved oxygen saturation, heart rate, blood pressure, respiratory rate
 Decreased work of breathing, improved chest movement

Patient preparation:-In preparation for the suctioning event, the patient should receive hyper
oxygenation by the delivery of100%oxygen for more than 30 seconds prior to the suctioning event.

pg. 17
Assessment:-ETT suction should be based on a clinical assessment of the patient. Auscultate with
stethoscope before and after ETT suction to evaluate necessity and effectiveness of the procedure.
Monitor the patient closely before , during and after the procedure to assess the baseline ,acute
physiological changes and recovery.

Parameters to observe:
1. Oxygen saturation
2. Heart rate
3. Respiratory rate
4. Blood pressure
5. Respiratory function monitoring (during conventional modes of ventilation) including flow,
pressure, tidal volume and minute volume.

Articles:-Assemble the following articles or obtain a pre-packaged suctioning kit:

A clean tray containing:

Articles Purpose
1.Sterile suction catheter with cover  For suctioning
2.Sterile water /normal saline in a container  For lubricating and washing the
catheter
3.Sterile gloves and mask  To prevent infection and universal
precaution
4.Kidney tray  To discard used material
5.Alcohol swabs  To clean stethoscope, ambu bag and
6.Stethoscope mask
 To assess the patient

A sterile tray containing:

Articles Purpose
1.Sterile towel  To make sterile field
2.Sterile bowl  To collect sterile water

Additional articles:

Articles Purpose
1.Resuscitation bag with a reservoir connected  To hyper oxygenate the patient
to 100% oxygen source
2.Suction source-portable suction machine or  For suctioning
wall suction unit

pg. 18
PROCEDURE
Nursing Action Rationale
1. Assess the- 1. To determine the need for suctioning.
 Depth and rate of respiration
 Monitor HR if patient is on
continuous cardiac monitoring
 If arterial blood gases are done
routinely check baseline value.

2. Explain the procedure and what the 2. Thorough explanation lessens anxiety
patient should be expecting during the and facilitates patient co-operation.
procedure (if conscious)/ relatives.

pg. 19
 Nursing Action Rationale
3. Assist the patient to a semi-fowlers 3. Sitting position help the patient
position/ fowlers position if conscious,  To cough or breath.
and unconscious patient should be place  The position also uses gravity to
in lateral position facing you. aid in the insertion of the tube.
 Lateral position prevents the
airway becoming obstructed and
promotes drainage of secretion.

Semi-fowlers position

Left lateral position for unconscious patient

4. Assemble equipment, check function of 4. Make sure that all equipment are functioning
suction apparatus and manual before procedure to prevent interruption
resuscitation bag connected with 100%  Use of O2 will help to prevent hypoxia.
O2 source.
5. wear mask and wash hand thoroughly. 5.To prevent infection.

Wearing a mask Hand washing

pg. 20
 Nursing Action Rationale
6. Open sterile tray , take the towel and
place it in a bib like fashion on patient’s
chest.
 Open alcohol swab and place on corner
of towel.

Draping the patient

7. Open sterile catheter and place it into

Sterile tray.
 Fill the bowl with sterile water.

Fill sterile container with about 100 ml sterile

normal saline solution or water

8. If the patient is on mechanical ventilator,

make sure that disconnection of
ventilator attachment may be made with
one hand.
9. Wear sterile gloves. 9.The hand designated as sterile must remain
 Designate one hand as clean hand for untouched, so that organism are not introduced
disconnecting, bagging and working the into the lung.
suction control.
 Usually the dominant hand is kept sterile
and will be used to thread the suction
catheter.

Apply sterile gloves in each hand

pg. 21
 Nursing Action Rationale
10. Connect suction catheter to the Suction
source.

11. Using clean hand disconnect the 11.To prevent contamination of the Connector.
Ventilator, CPAP device and other
oxygen source (place the ventilator
connector on the sterile towel and flip a
corner of the towel over the connection
to prevent fluid from spraying to the
area.
12. Ventilate and oxygenate the patient with 12.Ventilation before suctioning helps
resuscitation bag compressing firmly and maintaining oxygen saturation.
completely as possible, approximately 4-
5 times with clean hand.
 In a spontaneously breathing patient ,
co-ordinate manual ventilation with the
patient’s own effort (when possible get
another nurse or respiratory therapist to
do the bagging)

13. Lubricate the catheter by dipping it 13. Lubrication promotes easy insertion.
into the container of sterile saline/
water.

Lubrication of suction catheter

14. Turn on the suction source with

Clean hand.
15. Pinch the catheter if there is no ‘Y’ 15. Using pinching while inserting
Port and insert it into the endo- catheter to prevent injury to mucosa.
tracheal tube.

Pinching the catheter while inserting

pg. 22
 Nursing Action Rationale
 Insert catheter about 12.5 cm. or 5
inches for adults.
 Less for children or feel resistance.

Resistance is felt at the level of the patient’s

carina.
Insert suction catheter into tracheostomy until
resistance is felt, then pull back about 1/2 inch

16. Apply suction by releasing thumb ‘Y’ 16.Turning the catheter while withdrawing help
port or by releasing the pinch of the cleaning respiratory tract and prevent injury to
catheter. tracheal ring.
 Gently rotate the catheter with thumb
and index finger of sterile gloved hand
as the catheter is being withdrawn.

17. Apply suction for only maximum 10 17. Suctioning for longer than 10 seconds
seconds. Hyperventilate 3-5 times may cause Vagal Stimulation.
between suctioning or encourage the  Hyperventilation reoxygenate the lung.
patient to cough and deep breath
between suctioning.

18. Rinse catheter between suction passes 18. Flushing cleans and clears the catheter and
by inserting tip in cup of sterile lubricate for insertion.
water/ saline and apply suction.

Clear secretions from suction catheter by

suctioning sterile normal saline or water from
sterile container

pg. 23
 Nursing Action Rationale
19. Repeat suctioning as needed and 19. Allowing time interval and replacing
according to the tolerance of the oxygen helps compensate for hypoxia
procedure. induced by suctioning. Irritation from
 Allow patient to take rest at least 01 multiple suctioning increased amount
minute between suctioning and replace of secretions.
oxygen delivery set up if necessary.
20. When airway becomes clear return the
patient to the ventilator or apply CPAP
or another oxygen delivery device.
21. Suction oral secretion from 21. Remove accumulated oral secretions.
oropharynx.

Oropharyngeal suction
22. When suction procedure is completed 22. Prevents transmission of micro- organism.
turn off suction and disconnect
catheter from suction tubing.
 Remove gloves inside out and dispose
off gloves and catheter in proper
receptable.

Technique of removal of gloves

pg. 24
 Nursing Action Rationale
23. Replace the articles, clean ambu bag and
mask with alcohol.

24. Position patient comfortably and auscultate 24. Auscultation helps to determine whether
over lung area. respiratory passages cleared of secretion.

Chest auscultation

Lung auscultation points

25. Recording/ Documentation- 25. Provide accurate documentation and
 Time of suctioning provide opportunity of comprehensive
 Airway secretion amount Care.
 Airway secretion color
 Suction tolerance
 Significant events
 Character and patterns of respiration
before and after suctioning.
26. Perform oral hygiene procedure if 26. Respiratory secretion that accumulate
Required. are irritant to oral mucous
membrane and unpleasant for the
patient.
27. Perform hand hygiene.

pg. 25
Special precautions:
1. The outer diameter of the suction catheter should be no greater than one half the inner
diameter of the artificial airway.
2. Suctioning should be discontinued and oxygen applied or manual ventilation reinstituted if
during the suction procedure the heart rate decreases by 20 beats per minute or increases by
40 beats per minute or blood pressure drops, or cardiac dysrhythmia is noted. Suctioning may
cause hypoxemia or vagal stimulation.

Amount of negative pressure necessary for suctioning

Portable suction machine Wall suction machine

Adult 8-15 mm Hg 100-120 mm Hg
Children 5-8 mm Hg 50-100 mm Hg
Infants 3-5 mm Hg 40-60 mm Hg

Complications :-
1. Hypoxaemia
2. Atelectasis
3. Bradycardia
4. Tachycardia
5. Increased ETT CO2 and transcutaneous CO2
6. Blood pressure fluctuations
7. Decreased tidal volume
8. Airway mucosal trauma
9. ETT dislodging
10. Pneumothorax
11. Pneumomediastinum
12. Bacteraemia
13. Pneumonia
14. Fluctuations in intracranial and cerebral blood flow velocity
15. Hypoxia
16. Bradycardia

Conclusion :-

Endotracheal suctioning which accomplished through an endotracheal tube inserted through mouth
and nose can remain in place for several days when the cough is inflated and provides a tight
connection. Careful, systematic monitoring and accurate documentation helps the nurse to
understand the need for ETT suctioning.

pg. 26
REFERENCES
1. George S, et intubation [internet] https://www.medicinenet.com
2. Wikipedia
3. https://www.health.ucsd.edu.com
4. M Rina. https://www.rnspeak.com
5. Das Gupta S. Nursing Interventions for the Critically Ill. New Delhi: Jaypee Brothers
Medical publishers (P) Ltd. 2005. P 111- 113
6. Jacob Annamma, R Rekha, Jadhav ST.Clinical Nursing Procedures: The Art of Nursing
Practice, 3rd Edition, JAYPEE Brothers Medical Publishers(P) Ltd. Chapter- 11, Page No.
405-408
7. Prof. Clement N. Principles and Practices of Nursing- II Nursing Arts and Procedures
Second edition. EMMESS Medical Publishers; Page No. 232-236
8. AARC Clinical Practice Guideline

pg. 27