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Suction of a Tracheal Tube When to Suction

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Recommendations for Suctioning a Tracheal Tube 

Part 1: When to Suction

Recommendation Statement
Grade of Recommendation

Due to the potential for adverse effects, suctioning a tracheal tube should not be carried out on a routine basis. The decision to suction a tracheal tube must be made on the basis of the clinical need to maintain the patency of the tracheobronchial tree. This implies that different diagnostic groups and individual patients will have different requirements and a tracheal tube should only be
suctioned when clinically indicated by signs which could include:

  • Visible or audible secretions (such as sputum or blood);
  • Respiratory: desaturation, rising peak inspiratory pressure, decreasing tidal volume, increased respiratory rate, increased work of breathing or coarse breathe sounds on auscultation;
  • Cardiovascular: increased heart rate and blood pressure;
  • Other: restless patient or diaphoresis.
Assessment of the patient to identify the need to suction a tracheal tube should be continuous with chest auscultation performed every two hours or more frequently as indicated by clinical signs.
Patient assessment post suction should include an evaluation of the effects on the patient’s pre suction signs and symptoms as well as the development of hypertension or increased intracranial pressure.
To ensure patency of the tracheal tube the maximum time between individual suction procedures should be four hours.

Suctioning is an uncomfortable and distressing procedure for patients. Nonetheless, suctioning of a tracheal tube is an essential component of keeping the tracheobronchial tree and the artificial airway free of secretions thus ensuring delivery of gases to alveoli.

There are a number of potential adverse effects, however, on several body systems including:

  • respiratory (e.g. reduction in lung volumes, hypoxia, alveoli collapse, introduction of infection and trauma to the
  • cardiovascular (e.g. bradycardia and hypertension);
  • neurological (e.g. increase in intracranial pressure and reduction in cerebral blood flow). Despite the relative frequency of this
    procedure the body of evidence is limited.

A systematic review recommended to only suction when clinically indicated because of the potential complications associated with the procedure (Thompson 2000). A randomised controlled trial (RCT) compared a routinised procedure (RES)
and a minimally invasive procedure (MIAS) and found no differences on length of intubation, ICU mortality and incidence of infection, but found significantly more adverse events in RES group (Leur, Zwaveling et al. 2003). The application of these findings is limited due to the differences in RES protocol and usual NSW ICU practice, the level of protocol violation and that the patients who did not receive their assigned protocol had an increased length of intubation and increased risk of infection.

The recommendation to only suction when clinically indicated is based on the Thompson (2000) review and the clinical experience of GDN members. In a prospective observational study Guglielminotti and colleagues (2000) examined the value of a number of clinical signs (including patient agitation, SpO2 fall, respiratory sounds, changes in respiratory pattern and a ‘saw-tooth’ pattern on the flow-volume loop) as indicators of retained secretions in a cohort of 66 consecutive ventilated patients. In this group of patients, only a sawtooth pattern (sensitivity 0.82, specificity 0.70 and positive predictive value 0.80, likelihood of a positive test 2.70) and respiratory sounds (sensitivity 0.66, specificity 0.74 and positive predictive value 0.78, likelihood of a positive test 2.50) appeared to be of value. However, for two-thirds of patients there was only one observer who was not blinded to outcomes, limiting the value of these findings.

Clinical indications for suctioning have not been systematically evaluated within the literature; therefore, the clinical signs listed within the recommendation are based on the clinical experience of the GDN members. These clinical indicators are inline with those listed by the Australian College of Critical Care Nurses (ACCCN) (Cuthbertson and Kelly 2007), American Association of Critical Care Nurses (ACCN) (Chulay 2005) and the American Association of Respiratory Therapists (AARC) (Branson, Campbell
et al.). Identification of these clinical signs will require the nurse to constantly review the patient (visual inspection with regular chest auscultation to identify coarse breath sounds and/or changes in air entry) and ventilator (that is indications of disruption to gas flow such as alteration of flowvolume loop for sawtooth pattern or changes indicating reduction in tidal volume).

The effects of the suction procedure on the patient must be evaluated and this should include reversal of pre-suction clinical signs, examination of suction yield and possible adverse effects of the suction procedure such as patient distress, hypertension, hypoxia and intracranial hypertension. This recommendation is based on the clinical experience of GDN members, is
supported by other expert groups (Branson, Campbell et al.; Chulay 2005) and achieved consensus.

Maintenance of a patent tracheal tube is of vital importance and whilst there is evidence to indicate that suctioning should only be done when clinically indicated there was little quality evidence to identify what the maximum time between suction procedures should be. Difficulty passing the suction catheter through the tracheal tube may be an indication of the build up of secretions in the lumen of the tube (Cuthbertson and Kelly 2007). Therefore, it is the consensus opinion of GDN members that this time interval should not exceed four hours so that clinicians know with a high degree of certainty that the tracheal tube is patent.