Reprinted from RESPIRATORY CARE (Respir Care 1992;37:898-901)

AARC Clinical Practice Guideline

Nasotracheal Suctioning

NTS 1.0 PROCEDURE:

Nasotracheal suctioning (NTS) is a component of bronchial hygiene therapy.

NTS 2.0 DESCRIPTION/DEFINITION:

NTS is intended to remove accumulated secretions, blood, vomitus, and other foreign material from the trachea that cannot be removed by the patient's spontaneous cough or other less invasive procedures. NTS has been used to avoid intubation that was solely intended for the removal of secretions.(1-4)

NTS refers to the insertion of a suction catheter through the nasal passage and pharynx into the trachea in order to aspirate accumulated secretions or foreign material.(3)

The clearance of secretions is accomplished by application of subatmospheric pressure.(5)

NTS 3.0 SETTINGS:

NTS is performed in a wide variety of settings, and this guideline applies to patients of all ages.

3.1 Critical care
3.2 Emergency room or department
3.3 Inpatient acute care
3.4 Extended care and skilled nursing facility care
3.5 Home care
3.6 Outpatient or ambulatory care

NTS 4.0 INDICATIONS:

The need to maintain a patent airway and remove secretions or foreign material from the trachea in the presence of

4.1 inability to clear secretions;(6)
4.2 audible evidence of secretions in the large/central airways that persist in spite of patient's best cough effort.(4,7,8-10)

NTS 5.0 CONTRAINDICATIONS:

Listed contraindications are relative unless marked as absolute.

5.1 Occluded nasal passages
5.2 Nasal bleeding
5.3 Epiglottitis or croup (absolute)
5.4 Acute head, facial, or neck injury
5.5 Coagulopathy or bleeding disorder(2)
5.6 Laryngospasm(2)
5.7 Irritable airway
5.8 Upper respiratory tract infection

NTS 6.0 HAZARDS/COMPLICATIONS:

6.1 Mechanical trauma(10-15)
6.1.1 Laceration of nasal turbinates(5,7,16)
6.1.2 Perforation of the pharynx(17)
6.1.3 Nasal irritation/bleeding(16,18)
6.1.4 Tracheitis
6.1.5 Mucosal hemorrhage(13)
6.2 Hypoxia/hypoxemia(1,14,19-21)
6.3 Cardiac dysrhythmias/arrest(3,7,14,15)
6.4 Bradycardia(1,19,22-24)
6.5 Increase in blood pressure(1,19,21)
6.6 Hypotension(1,19)
6.7 Respiratory arrest(7)
6.8 Uncontrolled coughing(1,15,18)
6.9 Gagging/vomiting(18,25)
6.10 Laryngospasm(1,2,7)
6.11 Bronchoconstriction/bronchospasm(1,14,15)
6.12 Pain(18)
6.13 Nosocomial infection(15,16,23)
6.14 Atelectasis(5,14)
6.15 Misdirection of catheter((15,18)
6.16 Increased intracranial pressure (ICP)(21,26,27)
6.16.1 Intraventricular hemorrhage(21)
6.16.2 Exacerbation of cerebral edema

NTS 7.0 LIMITATIONS OF METHOD:

7.1 NTS is a blind, high-risk procedure with uncertain outcome.(18,24)
7.2 NTS should not be used to stimulate a cough.
7.3 Risks are increased in a combative or uncooperative patient.
7.4 Duration of application of subatmospheric pressure, or suction, should be limited to < or = 15 seconds.(20,28)
7.5 Controversy exists concerning possible overuse of this procedure.(5,8,10)

NTS 8.0 ASSESSMENT OF NEED:

8.1 Personnel should auscultate chest for indications for NT suctioning.(1,29)
8.2 Personnel should assess effectiveness of cough.

NTS 9.0 ASSESSMENT OF OUTCOME:

9.1 Effectiveness of NTS should be reflected by improved breath sounds.
9.2 Effectiveness of NTS should be reflected by removal of secretions.

NTS 10.0 RESOURCES:

10.1 Equipment:
10.1.1 Vacuum source(1)
10.1.2 Calibrated, adjustable regulator(30 )
10.1.3 Collection vessel and connecting tubing(1)
10.1.4 Sterile suction catheter of appropriate caliber(1,8,29)
10.1.5 Sterile disposable gloves(1,8)
10.1.6 Sterile water and cup(1,8)
10.1.7 Sterile normal saline--amount adequate for irrigation (5-10 mL for adults)(1,8,31)
10.1.8 Water-based lubricant(1,8)
10.1.9 Local anesthetic is sometimes used to reduce discomfort.(1)
10.1.10 Nasopharyngeal airway when frequent NTS is required(1,18,29)
10.1.11 Resuscitation bag with mask(1,23,29,31)
In the acute care setting, with initiation of NTS, or when working with the unstable patient, the following are recommended.
10.1.12 EKG monitor
10.1.13 Oxygen(1,20,28,32,33)
10.1.14 Personnel protective equipment for Universal Precautions(34,35)
10.2 Personnel:
10.2.1 Level I caregiver may be the provider of service after Level II personnel have established need by patient assessment and the first NTS episode has been completed. Level I personnel must demonstrate
10.2.1.1 knowledge of proper assembly and use of equipment;(7)
10.2.1.2 knowledge of upper airway anatomy and physiology;(7,23)
10.2.1.3 ability to recognize secretion retention on auscultation;(1)
10.2.1.4 ability to monitor vital signs and assess patient's condition and response to procedure;
10.2.1.5 ability to recognize and re-spond to adverse reactions and compli-cations of procedures;
10.2.1.6 ability to employ technique of cardiopulmonary resuscitation when indicated;
10.2.1.7 ability to evaluate and document procedure effectiveness and patient response.
10.2.2 Level II provider initially assesses the patient, determines the need for NTS, and evaluates response to and effectiveness of first episode.Level II personnel have all the skills of Level I providers plus:
10.2.2.1 knowledge and understanding of patient's disease, goals, and limitation of NTS;(23)
10.2.2.2 recognition and understanding of basis of pathophysiology;
10.2.2.3 ability to perform initial treatment and be available to troubleshoot the procedure;
10.2.2.4 ability to modify techniques and equipment and take definitive action in response to adverse reaction;
10.2.2.5 ability to detect adverse reactions and avoid patient harm by em-ploying techniques of cardiopulmonary resuscitation with mechanical airway adjuncts and bag-mask devices;
10.2.2.6 knowledge of basic EKG and dysrhythmia recognition;
10.2.2.7 knowledge of signs and symptoms of decreased cardiac output, oxygenation, and perfusion;
10.2.2.8 ability to teach Level I and lay personnel providing home care.
10.2.3 Home care should be provided by lay personnel trained and knowledgeable in
10.2.3.1 proper assembly and use of equipment;
10.2.3.2 correct positioning of patient;
10.2.3.3 proper suctioning technique;
10.2.3.4 assessment of patient response to procedure;
10.2.3.5 response to adverse reaction;
10.2.3.6 care and cleaning of equipment.

NTS 11.0 MONITORING:

The following should be monitored during and following the procedure.
11.1 Breath sounds
11.2 Skin color(36)
11.3 Breathing pattern and rate
11.4 Pulse rate, dysrhythmia, EKG if available
11.5 Color, consistency, and volume of secretions
11.6 Presence of bleeding or evidence of physical trauma
11.7 Subjective response including pain(25)
11.8 Cough
11.9 Oxygenation (pulse oximeter if available)
11.10 Intracranial pressure (ICP), if equipment is available

NTS 12.0 FREQUENCY:

Nasotracheal suctioning should be performed only when absolutely necessary and other methods to remove secretions from airway have failed.(4,5,8,10,29)

NTS 13.0 INFECTION CONTROL:

13.1 CDC Guidelines for Universal Precautions should be adhered to.(35)
13.2 All equipment and supplies should be appropriately disposed of or disinfected.
Bronchial Hygiene Guidelines Committee:

Lana Hilling RCP CRTT, Chairman, Concord CA
Eric Bakow MA RRT, Pittsburgh PA
James Fink MS RCP RRT, San Francisco CA
Chris Kelly BA RCP RRT, Oakland CA
Dennis Sobush MA PT, Milwaukee WI
Peter A Southorn MD, Rochester MN

REFERENCES
  1. Burton GG, Hodgkin JE, Ward JJ, eds. Respiratory care: a guide to clinical practice, 3rd ed. Philadelphia: JB Lippincott, 1991:498-502.
  2. Fuchs PL. Streamlining your suctioning techniques. Part I. Nasotracheal suctioning. Nursing 1984;14:55-61.
  3. Demers RR. Management of the airway in the perioperative period. Respir Care 1984;29:529-536.
  4. Vender JS, Shapiro BA. Essentials of artificial airway management in critical care. Acute Care 1987;13:97-124.
  5. Demers RR, Saklad M. Minimizing harmful effects of mechanical aspiration. Heart Lung 1973;2:542.
  6. Stiller K, Geake T, Taylor J, Grant R, Hall B. Acute lobar atelectasis: a comparison of two chest physiotherapy regimens. Chest 1990;98:1336-1340.
  7. Demers RR, Saklad M. Mechanical aspiration: a reappraisal of its hazards. Respir Care 1975;20:661-666.
  8. Hoffman LA, Maszkiewicz RC. Airway management for the critically ill patient. Am J Nurs 1987;87:39-53.
  9. Lough MD, Doershuk CF, Stern RC. Pediatric respira-tory therapy, 3rd ed. Chicago: Year Book Medical Publishers, 1985:125.
  10. Carroll P. Safe suctioning. Nursing 1989;19:49-51.
  11. Jung RC, Gottlieb LS. Comparison of tracheobronchial suction catheters in humans. Chest 1976;69:179-181.
  12. Landa J, Kwoka M, Chapman G, Brito M, Sackner M. Effects of suctioning on mucociliary transport. Chest 1980;77:202-207.
  13. Sackner MA, Landa JF, Greeneltch N, Robinson MJ. Pathogenesis and prevention of tracheobronchial damage with suction procedures. Chest 1973;64:284-290.
  14. Riegel B, Forshee T. A review and critique on preoxygenation for endotracheal suctioning. Heart Lung 1985; 14:507-518.
  15. Demers RR. Complications of endotracheal suctioning procedures. Respir Care 1982;27:453-457.
  16. LeFrock JL, Klainer AS, Wu H-W, Turndorf H. Transient bacteremia associated with nasotracheal suction-ing. JAMA 1976;236:1610-1611.
  17. Touloukian RJ, Beardsley GP, Ablow RC, Effman EL. Traumatic perforation of the pharynx in the newborn. Pediatrics 1977;59:1019-1022.
  18. Wanner A, Zighelboim A, Sackner MA. Nasopharyn-geal airway: a facilitated access to the trachea. Ann Intern Med 1971;75:593.
  19. Simbruner G, Coradello H, Fodor M, Havelec L, Lubec G, Pollak A. Effect of tracheal suction on oxygenation, circulation and lung mechanics in newborn infants. Arch Dis Child 1981;56:326-330.
  20. Naigow D, Powaser MM. The effect of different endotracheal suction procedures on arterial blood gases in a controlled experimental model. Heart Lung 1977;6:808-816.
  21. Perlman JM, Volpe JJ. Suctioning in the pre-term: effects on cerebral blood flow velocity, intracranial pressure, and arterial blood pressure. Pediatrics 1983;72:329-334.
  22. Fox WW, Schwartz BS, Shaffer TH. Pulmonary physiotherapy in neonates: physiologic changes and respira-tory management. J Pediatr 1978;92:977-981.
  23. Scanlon CL, Spearman CB, Sheldon RL, Egan DF, eds. Egan's fundamentals of respiratory care, 5th edition. St Louis: CV Mosby, 1990:483-486.
  24. Cordero L, Hon EH. Neonatal bradycardia following nasopharyngeal simulation. J Pediatr 1971;78:441-447.
  25. Larson RP, Ingalls-Severn KJ, Wright JR, Kiviat NC, Maunder RJ. Diagnosis of Pneumocystis carinii pneumonia by respiratory care practitioners: advantages of a nasotracheal suctioning method over sputum induction. Respir Care 1989;34:249-253.
  26. Fisher DM, Frewen T, Swedlow DB. Increase in intracranial pressure during suctioning stimulation vs rise io PaCO2. Anesthesiology 1982;57:416-417.
  27. Parsons LC, Shogan JS. The effects of the endotracheal tube suctioning/manual hyperinflation procedure on patients with severe closed head injuries. Heart Lung 1984;13:372-380.
  28. Peterson GM, Pierson DJ, Hunter PM. Arterial oxygen saturation during nasotracheal suctioning. Chest 1979; 76:283-287.
  29. Petty TL. Intensive and rehabilitative respiratory care, 3rd ed. Philadelphia: Lea & Febiger, 1982:30-33,154.
  30. Curran JF, Stanek KS, Kacmarek RM. Portable airway-suction systems: a comparison of performance. Respir Care 1991;36:259-266.
  31. Bostick J, Wendelgass ST. Normal saline instillation as part of the suctioning procedure: effects on PaO2 and amount of secretions. Heart Lung 1987;16:532-537.
  32. Langrehr EA, Woodburn SC, Guthrie MP. Oxygen insufflation during endotracheal suctioning. Heart Lung 1981;10:1028-1036.
  33. Jacquette G. To reduce hazards of tracheal suction. Am J Nurs 1971;71:2362-2364.
  34. Occupational exposure to bloodborne pathogens. Final Rule. Federal Register 1991;56:64175-64182.
  35. Centers for Disease Control. Update: Universal Precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other blood-borne pathogens in health care
  36. settings. MMWR 1988; 37:377-399.
  37. McFadden R. Decreasing respiratory compromise during infant suctioning. Am J Nurs 1981;81:2158-2161.
Interested persons may copy these Guidelines for noncommercial purposes of scientific or educational advancement. Please credit AARC and Respiratory Care Journal.


Top Back