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A couple of the newbies were really having trouble with this one, so we decided to
clear things up. This is one of those procedures that people get vague about: “Did
you deep suction her.” “Yeah, with the Yankauer.” (But Yankauer suction isn’t deep
suctioning.) “Uh… well, did you blind suction her?” “Yeah, like I said, with the
Yankauer!” (Yeah, well, that ain’t right either.) “Well, I mean, did you get into her
airway?” “Yeah, in the back of her throat.” (Nope, nope…)
So let’s clear things up a little. As always, please remember that these articles are
not meant to be official references in any way! This is just what we do, where I work,
elsewhere things may be different. Always check with your local policies, procedures,
and references!
Lots of patients need secretion management. Pneumonia and the like. Seems simple enough
– your patient has some secretions that he can’t clear: he can’t cough them up, maybe he’s a
bit weak, maybe he just has too much down there to clear on his own – what to do?
There’s a lot of confusion about this, and as usual, using terms precisely goes a long way
towards getting un-confused. Deep suctioning means going past the posterior pharynx with a
catheter, through the vocal cords, down into the patient’s airway (trachea!), and applying
suction, to remove thick secretions that are making it hard for your patient to breathe.
This is a pretty serious maneuver – in essence, it’s the same as intubating someone, except
with a skinny catheter, and blindly - wooo…. You need to know exactly how to do this, and
safely!
http://www.ssgfx.com/CP2020/medtech/tools/images/yankauer.jpg
The idea is that you can’t really see where you’re going with the catheter, so you have to work
“blind”.
Here…
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Your assessment skill don’t need to really be too advanced to notice that your patient is
turning kind of blue, can’t cough up the secretions he’s got from his pneumonia, or aspirated
ice cream or whatever. It’s usually pretty clear. Was your patient extubated too soon?
http://www.healthsystem.virginia.edu/internet/periop/images/pacup053.jpg
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- Is he a cardiac patient? What nerve runs through the carina? What is the carina?
What could happen if you stimulate your patient’s vagus nerve if he’s having – say,
an inferior MI? What drug might you want to have at the bedside? Anyway?
- You can injure the patient (or get the lung biopsy the surgeons were going to get
anyhow), by using suction equipment that’s pulling too hard.
- You can provoke a serious bradycardia from vagal stimulation. This is pretty rare,
but it does happen once in a while. Usually with inferior MI’s .
- You can provoke nasopharyngeal bleeding, and the patient could aspirate blood.
Yup, it’s all true. But if your patient’s airway is almost obstructed with secretions, you need to do
something! So learn to do it safely…
http://anesthesia.uihc.uiowa.edu/proceduralsedation3/adult/images/nasalairway.jpg
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g
Good question! The answer is: probably. Usually. Almost always. Ventilated patients should
always get pre-oxygenated: there’s a 100% Fi02 button that you can press to do this.
But a patient on prongs? Or a mask? Well… hm. Are there situations when it wouldn’t be safe to
give a certain patient 100% oxygen? Which patients are those? Why isn’t it safe?
In those situations, you have to watch the patient like a hawk, and have mask oxygen at hand. If
they desaturate
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Ok, the patient is drowning. Saturation is getting low. He’s clearly in distress. Let’s save him!
Gather your equipment: got the trumpet in? Got the catheter? The lube? Sterile gloves? Is the
suction setup working? You had all this stuff ready at the bedside, right, because you knew your
patient might need this…
- Make sure your patient agrees to this procedure. You are NOT allowed to attack a
patient who is competent to refuse things. At the same time, you do need to keep her
safe, so it’s best to have things worked out in advance. Patients who aren’t
competent to refuse need to have proxy issues worked out…
- Apologize ahead of time. This is one of the most unpleasant things you’ll ever do to a
patient…
- Try to have a helper on hand to catch flying extremities. It’s not nice to get punched
out by an angry, confused patient that you’re trying to help…
- Sit the patient up. Pillow behind the head. (Assignment for next time: look up the
“sniffing position”. Does she have an NG tube? I’d hook it up to suction, try to empty
her stomach – if you provoke vomiting while you suction her, you KNOW what’s going
to happen, right?
- Apply the oxygen, in the right amount. If this patient retains carbon dioxide when she
gets oxygen, I’d apply just enough for her to resaturate – it’s hyperoxia that’s going to
make her stop breathing, right? This is rather a judgment call – what you want to do
is assess her oxygenation almost continuously as you do this.
- Insert the lubricated trumpet. Slide in easily? If it doesn’t, try the other side. You’re
watching her sat while you do this, right?
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- Open the end of the catheter packaging, and tuck the catheter under your arm. Hold
it there.
- Sterile gloves. I squeeze some sterile lube onto the glove paper and leave it there.
- Suction tubing handy? Set to the right negative pressure? Not too high!
- Ok – with a sterile gloved hand, reach over to your armpit and pull out the catheter.
Don’t get it contaminated on anything – you’ll have to start over if you do, and your
patient isn’t breathing too well! (Jayne says: “Are you OUT of your mind? NEVER put
anything, even in sterile packaging, under your ARM! Your armpit is DIRTY! Open the
end of the package and leave it on the bedside table..”) (Eeek! Eek! She runs an OR-
based EP lab, among other things…)
- Position the patient’s head at the midline. Start passing the catheter through the
trumpet.
- Now – listen! Literally listen - put your ear to the end of the catheter that you’re
holding. You should be able to hear air moving through the catheter. Advance the
catheter a bit, on the patient’s inspiration (why?), listening… if it goes into the
esophagus, what should you hear? If it goes into the trachea, then what should you
hear? What will the patient probably do?
- In the trachea? Not too hard to tell, is it? Advance the catheter to about ¾ of it’s
length. Now attach the suction. Put your finger over the catheter button, and slowly
withdraw the catheter, suctioning all the while. Don’t just haul the catheter out at full
speed – it needs to stay in long enough for the secretions to get suctioned out.
o Look a the monitor: stable rhythm? Slowing? (That’s bad – her airway may
be occluded, or you may be poking her carina – back out the catheter while
suctioning, to try to open the airway, then get it out of there…) How’s her
saturation doing?
o Look at the catheter: are secretions coming out? That IS the idea, after all –
are they coming up the tubing? No? Do you need to turn the suction up? You
may have to turn it up to max, if the secretions are really thick, and you have
to clear the patient’s airway. Yup, it’s dangerous – turn it back down as soon
as you can. Are the secretions bloody, at all? Hmm…
- Now, apologize again. Wipe the tears out of your patient’s eyes. Wipe your own eyes.
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- Re-assess! Is he going to need it again? Is this the second time in the shift that
you’ve had to do this? Or the twelfth? Does he need to be intubated? Re-intubated?
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Jayne says: “Make sure you tell them that they have to use new, sterile
suction tubing to the canister every time they do this, or the specimen
will just get contaminated by the nasty old tubing that’s just been
hanging off the wall…”
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