NHS Lothian Induction: Closed Suction via ETT

So now that you have checked that you have all the emergency kits available, you have secured the tube, and you have documented that in the nursing notes or on the device charts, you need to think about the patency of the ET tube and how important it is to keep that tube patent at all times. Things that are likely to block an ET tube are things like blood clots, copious secretions, or if the patient bites down on the tube. It’s very important to remember that most intubated ventilated patients will be deeply sedated while the ET tube is in situ.

Very common for patients who are intubated and ventilated to get what’s known as a ventilator-induced or ventilator-associated pneumonia, and it’s likely if that occurs, that you will need to suction the patient frequently. So we would like to demonstrate for you how you do that safely and effectively. First of all, you need to think about what size of suction catheter should you use, and that all depends on the size of the endotracheal tube that you have in situ. So for the size 7 to 7.5 ET tube, you should be using a suction catheter that has a diameter of no greater than 10.

For size 8 to 8.5, a suction catheter that is no greater than size 12, and for an ET tube that’s 9 to 9.5, you should be using a suction catheter of 14 gauge. One thing to just mention is that in intensive care in NHS Lothian, we use close suction, and that protects the staff from aerosol generated particles. There are two forms of suction tubing. One is short and has an alert sign to alert you to the fact that that should only be used for patients with tracheotomy. So when you’re suctioning down an endotracheal tube, that alert sign will be missing. So I have got a size 12 gauge suction catheter here.

For this patient who has a size 8 tube, he would indeed need a size 12 suction catheter. So now we’re going to demonstrate the technique of suction. I have assessed my patient. He has started to cough. I can feel secretions on his chest, and the alarm coming from the ventilator is a high pressure alarm. If I have time to do so, I will use a stethoscope to listen in to the patient’s lungs to see if I can hear wheeze or secretions. If it confirms the patient has upper airway secretions, I will proceed to suction. In order to suction, we have a closed unit here.

So I don’t need to have as many concerns about it as I would for an open suction unit because this has a layer of plastic over the top. One thing to know about this suction catheter is that there is a black mark at the top, which ensures that you can see that the suction catheter is going in the correct direction before you suction, and that it is all returning because it’s at the top of your catheter when you return. In order to begin suctioning, I would have a look at my patient’s oxygenation status first. And I may consider turning up the oxygen to 100% for a bit of time before I undertake the suctioning procedure.

Once I am happy my patient is oxygenating well, I am going to pass the suction catheter without applying suction at this time. So I am just going to slowly insert my suction catheter, watching that my black mark is passing the teeth and that there’s no obstruction there. And I’m going to pass that most of the way down to ensure I’m at the back of the tube. If at any point I meet resistance, it may be because there is a blockage if it’s higher up, but it may be if I’m quite far down that I have now hit the carina. If I was to start pressing the suction now, that would then suction on the carina and potentially cause damage.

So I would pull back one to two centimetres before I start suctioning. And the way I do this with this machine is I am going to press these parts together, which will start the suctioning, and slowly withdraw the suction catheter for a maximum of about 15 seconds. A slow count of 10 will work for most people. Colloquially, we’ve always taught people that if you can hold your breath for that amount of time, your patient should be able to do so as well. However, you have to remember these patients are critically ill and probably don’t have the respiratory reserve that we do. So that might be too long for them. I would strongly recommend sticking to a slow count of 10.

You may find that when you depress this part of the suction catheter, it does not move because it has a locking mechanism. So if that is applied, I won’t be able to press it down. The way I deactivate that is just completely turn it 180 degrees. I will now be able to suction through it. The pressure when you’re suctioning must be set between 120 and 150 millimetres of mercury. Every time you pass a suction catheter into the patient’s airway, it can cause damage to the actual airway and overtime, even ulcerate the trachea. So it’s very important to think, one, does the patient really need suction, and two, is my suction pressure set at the correct range?

Also until a patient gets used to an endotracheal tube, suctioning is very uncomfortable. And patients don’t like it. So it is always worth considering whether they might need a small bolus of analgesia or sedation before you proceed with the suction. Once you have suctioned, this line will usually have the secretions that you have managed to remove from your patient’s chest within this line here. The first thing that I would want to do with that is make sure that I have documented what I have got back from my patient’s chest, and we have a system for doing that in critical care on the 24 hour chart. You will see that there is a section labelled suction.

The findings are usually either a combination of one of three or two of three letters and a number. So we’ve got MPB and then one, two, three. M is mucoidal secretions, and that’s the secretions that you or I would spit if we were to spit now, and we were healthy. They’re nice and clear. They’re quite thin. P is for [purulent So that secretions that you might have. If you have a chest infection like our patient here has. So they’re usually thicker, yellow, green, or brown, and can be quite difficult to remove from the chest at times. And B can be used to indicate bloodstain secretions of any type. Sometimes, we will have any combination of these.

For instance, in heart failure where you have pink, frothy sputum, we would probably term that MB for mucoidal and bloodstained. And we can have a combination of all three, MPB, where you’ve got a bit of mucus, but it’s thick, purulent and it’s bloodstained. The numbers are just to do with size, one being small, two being medium, and three being large. And it just takes some experience with secretion management for you to make that decision, and until you’re comfortable with that, you could ask for some advice from someone else beside you on the unit.

The other thing that we will now want to do is to clear the secretions from this tube because it is quite fine and prone to blockage if we don’t do that. So part of your care is to ensure that this is clear, and you will see that there is a port here to which I can attach a vial of saline, which do come in the suctioning packages in nice pink vials. These are used for clearing the suction tubing only and are not for a substitute for IV therapy, for instance.

Each vial has a twisty cap which can come off like so. All I’m going to do is flip open my cap, attach the vial, which should stay there itself if it’s done correctly. I do not want to squeeze this vial. The risk if I squeeze the vial is that gravity will pull the saline into my patient’s respiratory system, which is not where we want it to go. But with that attached, if I apply some suction to the same line, it will draw the saline through that tubing and into my suction canister, thereby clearing any secretions that are still in that line.

You mean I’ll get rid of all of them but as long as you’re getting rid of the majority to ensure patency, that would be sufficient. Afterwards, I’m going to take this off. These are single use only, and this will be now disposed of in clinical waste. So another consideration you may have is you may have to suction more than once to remove an adequate amount of secretions from your patient, but you will always be guided by your patient’s condition. So after each suction pass, I’m going to wait for a minimum of 30 seconds and watch the monitor to ensure that my patient’s saturations are reaching a more normal level before I would pass that suction catheter again.

It may be that I want to remain on 100% O2 during this procedure and through the recovery phase in order to achieve that. Another consideration is although this is a closed suction unit and therefore, is not an aerosol generating procedure, if there is a risk or any reason where I may have to disconnect any part of this circuit, that has now become an aerosol generating procedure, and particularly, if you are already using transmission-based precautions on a patient for whatever reason, you may have to consider enhanced PPE if you are worried the circuit may become disconnected or you are intending to do so. So the other consideration for closed line suction is that they have to be changed every 72 hours.

So when you open a new pack, there is, in fact, colour-coded date stickers. So we are currently on Friday, and it is going to be three days, so Saturday, Sunday, Monday. So it’s the Monday sticker I want to apply to the unit. So we take off Monday. And where I apply this doesn’t matter too much with the exception of please do not put it in this in line suction unit. A– you can’t see the entirety of your [AUDIO OUT],, B– it will get crunched up and fall off.

So one option is to put it at the top end here around part of the tube, or the other option is to put it around the bottom end of your tube where the port is. Whatever your unit’s preference or your own preferences, just make sure the day is still visible there. So despite having an endotracheal tube in, some people will manage to cough pass that cup that we demonstrated earlier, and the secretions will reach their upper respiratory cap and their mouth potentially. Now obviously, this method is only good for suctioning passed the end of the endotracheal tube or down the lumen. So we would use a Yankauer suction to suction any secretions that make it as far as the mouth.

And we will usually use the same suction that we do for in line suction by just removing it from that suction and applying it to a fresh Yankauer there. I can then assess my patient’s mouth for any secretions, and any heavy secretions, I can just get out from the back of the mouth there. It may be that they collect more to the side your patient’s head is facing at that time. So that would be the area to focus upon.