Oral + Nasopharyngeal Suctioning

Upper Respiratory System Anatomy

• Paranasal Sinuses: Air-filled spaces surrounded by bone that open into the nasal cavity.

• Nasal Cavity: The space behind the nose, involved in filtering and humidifying air.

• Nasopharynx: The upper part of the pharynx located behind the nose.

• Nares: External openings of the nasal cavity.

• Hard Palate: The bony front portion of the roof of the mouth.

• Soft Palate: The muscular back part of the roof of the mouth.

• Oropharynx: The part of the pharynx located at the back of the mouth.

• Tonsils: Lymphoid tissues located at the back of the throat.

• Tongue: A muscular organ in the mouth which aids in the digestion and articulation of speech.

• Mandible: The lower jaw bone.

• Hyoid Bone: A U-shaped bone in the neck that supports the tongue.

• Thyroid Cartilage: The largest cartilage of the larynx, commonly referred to as the Adam's apple.

• Cricoid Cartilage: A ring-shaped cartilage located below the thyroid cartilage.

• Thyroid Gland: An endocrine gland that produces hormones regulating metabolism.

• Laryngopharynx: The lower portion of the pharynx that leads to the esophagus and larynx.

• Epiglottis: A flap of cartilage that covers the windpipe while eating.

• Vocal Cords: Folds of tissue that vibrate to produce sound.

• Esophagus: A muscular tube that carries food from the mouth to the stomach.

• Trachea: The windpipe that connects the larynx to the bronchi of the lungs.

Types of Airway Obstructions

• Classification of Airway Obstructions:
    - Upper Airway Obstructions: Occur from the nose and lips to the larynx (voice box).
    - Lower Airway Obstructions: Occur between the larynx and the narrow passageways of the lungs.
    - Partial Airway Obstructions: Allow some air to pass; breathing is difficult but possible.
    - Complete Airway Obstructions: No air can pass; breathing is impossible.
    - Acute Airway Obstructions: Blockages occurring rapidly, e.g., choking on a foreign object.
    - Chronic Airway Obstructions: Long-term blockages may develop slowly or persist for extended periods.

Suctioning

• A method of removing mucus from the airway.

• Suctioning can be performed in the oropharynx and/or trachea to maintain a patent airway.

• Suctioning is conducted through the nose or mouth into the trachea or via an endotracheal/tracheostomy tube.

• While procedures differ slightly, the indications, supplies, procedures, and risks are generally similar.

Types of Suctioning Routes

• Oropharyngeal Suctioning: Involves the mouth using a clean technique.

• Orotracheal Suctioning: Suctioning that occurs by entering the trachea via the mouth.

• Nasopharyngeal Suctioning: A sterile technique where the catheter is inserted through the nose to the pharynx.

• Nasotracheal Suctioning: More invasive procedure where a flexible catheter is inserted through the nose, pharynx, to the trachea, requiring sterile technique.

Frequency of Suctioning

• The frequency of suctioning depends on patient assessment and need.

• Sputum production is not continuous and reflects pathological conditions; thus, no set frequency exists.

• Excessive suctioning can lead to:
    - Hypoxemia: Reduction in oxygen levels in the blood.
    - Potential trauma to the mucosa of the lungs.
    - Hypotension: Low blood pressure.
    - Arrhythmias: May occur, especially bradycardia, due to vagus nerve stimulation.

Procedures for Suctioning

Oropharyngeal and Nasopharyngeal Suctioning

• Oropharyngeal Suctioning: Cleans sputum, emesis, or gastric secretions from the mouth; employs a clean technique.

• Nasopharyngeal Suctioning: Requires sterile technique for inserting a catheter through the nose.

• Nasotracheal Suctioning: Highly invasive suctioning requires insertion of a flexible catheter through the nasal passages to the trachea.

Contraindications to Nasotracheal Suctioning

• Occluded nasal passages.

• Nasal bleeding.

• Coagulation concerns: Risk of excessive bleeding.

• Acute injuries: Such as head, facial, neck injuries or surgeries.

• Epiglottitis and Croup: Conditions that could exacerbate airway obstruction.

• Laryngospasm and Bronchospasm: Muscle contractions that can impede breathing.

• Gastric Surgery with High Anastomosis: Post-operative risks.

• Myocardial Infarct: Heart attack posing additional risks during suctioning procedures.

Equipment Preparation for Suctioning

• Standard Supplies Needed:
    - Towel
    - Portable/wall suction device
    - Sterile disposable container for fluids
    - Sterile normal saline or water (approx. 100 mL)
    - Goggles/face shield
    - Sputum trap (if needed)
    - Y-connector (if port not available on catheter)
    - Clean gloves (or sterile)
    - Pulse Oximeter
    - Stethoscope
    - Oral airway (if needed)

• Additional Supplies for Oral and Nasal Suctioning:
    - Oral Suctioning: Yankauer suction.
    - Nasal Suctioning: Sterile suction catheters, water-soluble lubricant, sterile gloves.

Types of Suction Catheters

• Whistle-tipped Catheter: Less irritating to respiratory tissues.

• Open-tipped Catheter: More effective for thick mucous plugs.

• Yankauer Suction: Specifically used for suctioning in the oral cavity.

Wall Suction Pressures

• Typical suction pressures can vary based on age:
    - Adults: 100-150 mmHg
    - Children/Infants: 60-100 mmHg
    - Pre-Term Infants: 40-60 mmHg

• Values are measured during suction pressure application.

Nursing Assessment for Suctioning

• Assessment Indicators for Suctioning:
    - Signs of respiratory distress.
    - Inability to cough up or clear secretions.
    - Observations of dyspnea.
    - Presence of bubbling or rattling breath sounds.
    - Poor skin color or cyanosis (bluish color indicating low oxygen saturation).
    - Decreased oxygen levels.

Importance of Nursing Assessment

• Accurate nursing assessment and judgment are paramount for determining a client's need for suctioning, ensuring patient safety and effective airway management.

Considerations for Patient’s Level of Consciousness (LOC)

• Unconscious Patients:
    - Position sideways (lateral) in a way that faces the nurse.
    - An oral airway may be required for support.
    - Measure catheter insertion distance: corner of the mouth to the angle of the jaw just beneath the ear.
    - Assess oxygen needs pre-suctioning.

• Conscious Patients (with functional gag reflex):
    - Oral Suctioning: Position in Semi-Fowlers with head turned to the side.
    - Nasal Suctioning: Position should involve neck hyperextension.
    - Assess oxygen needs prior to suctioning.

Procedural Steps for Suctioning

1. Configure wall suction to the appropriate pressure.

2. Connect catheter to suction tubing; coat the distal end with water-soluble lubricant.

3. Dip the catheter into sterile saline and check the wall suction pressure.

4. Hyperextend the neck for facilitating catheter insertion; do not apply suction during insertion.

5. Perform intermittent suctioning while withdrawing the catheter using a rotating motion (no longer than 15 seconds).

6. Wait one minute between suctioning passes.

7. Rinse the catheter to clear secretions between uses.

8. Conduct a respiratory assessment and monitor vital signs post-suctioning.

Catheter Insertion Depth for Suctioning

• Nasopharyngeal Depth Measurements:
    - Adults: 15-20 cm
    - Older Children: 16-20 cm
    - Younger Children and Infants: 8-14 cm

• Nasotracheal Depth Measurements:
    - Adults: 20 cm
    - Older Children: 16-20 cm
    - Younger Children and Infants: 4-14 cm

• Note: If resistance is felt during insertion for max recommended distance, catheter likely contacts the carina—remove 1-2 cm before applying suction.

Post-Suction Assessment

• Encourage the patient to deep breathe and cough post-suctioning.

• Assess the need for repeat suctioning, allowing one minute between each attempt.

• Replace oxygen if necessary.

• Bilaterally auscultate breath sounds from both anterior and posterior lung fields.

• Compare pre- and post-suctioning vital signs and oxygen saturation levels using a pulse oximeter.

Potential Complications of Suctioning

• Hypoxemia: Insufficient oxygen in the blood.

• Trauma to Airway: Potential injuries from suctioning.

• Health Care-Associated Infections: Increased risk due to invasive nature of procedure.

• Cardiac Dysrhythmias: Related to hypoxemia; abnormalities in heart rhythm as a response.

Nasal and Nasopharyngeal Specifics

Do's:

• Don sterile gloves or have a clean glove on the non-dominant hand and sterile on the dominant hand.

• Lubricate the tip of the suction catheter.

• Gently insert and advance along the floor of the nasal cavity.

• Apply intermittent suction and rotate while withdrawing for no more than 15 seconds.

• Encourage the patient to deep breathe and cough.

• Allow at least 60 seconds breaks between attempts.

Don'ts:

• Do not insert the catheter without first checking suction settings.

• Do not apply suction while inserting the catheter.

• Do not force the catheter if it meets resistance.

• Do not perform more than two suction attempts at any one session.

Documentation Requirements

• Document sputum characteristics: Amount, Colour, Consistency, Odour (ACCO).

• Number of suctioning attempts made.

• Patient’s respiratory status: before, during, and after suctioning.

• Patient’s tolerance of the suctioning procedure.

• Note any improvements or changes in the patient’s status post-suctioning.