Intensive Care and Ward Nurses Knowlegde Level and Scope of Practice on Oral and Airway Suctioning in Korle- Bu Teaching Hospital
Dorothy Honny Bendah*1, Dr. Esther Brobbey2, Mr. Rodger Okpara3, Dr. Christian Okey Owoo4, Joseph Boateng Makae5
*Correspondence to: Dorothy Honny.
© 2023 Dorothy Honny. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 30 August 2023
Published: 15 September 2023
Background: Suctioning of respiratory secretions in intubated or tracheostomized patients is a common procedure within Intensive Care Units (ICUs) and Wards. Effective suctioning is an essential aspect of airway management in the critically ill. However, there are many associated risks and complications. These patients may be unable to clear their own airway due to several different problems, including neuromuscular disease, sedation or neurological deficits. Studies aiming to determine the knowledge and practices of nurses regarding endotracheal suctioning methods indicate that their training and experience of suctioning is far from sufficient. Moreover, most nurses are inclined to rely on personal experience and ward routine to inform practice over any other source.
Aim: The study aimed to assess the knowledge and practices of oral and airway suctioning among nurses in Korle -Bu Teaching Hospital (KBTH).
Method: This is a quantitative cross-sectional study looking at the Knowledge level and Scope Practices of oral and airway suctioning among nurses in Korle-Bu Teaching Hospital using self-administered questionnaire in the data collection.
Results: Majority of Nurses, (55%) knew the action to take in case of abrupt changes in Electrocardiogram (ECG) monitor but not doing the procedure as per guidelines. However, (45%) of Nurses did not know what actions to take. About 33% of Nurses chose the appropriate catheter size for a child and an adult (46%) of Nurses did not know the appropriate way of suctioning the children. There was no significant difference in knowledge among the Nurses with different levels of nursing ranks and ICU experiences (p-value 0.73). However, nurses who had received ICU training demonstrated significantly higher knowledge than ward Nurses. Also, in scope of practice, ICU nurses recorded a greater scope of practice as compared to the ward nurses with an average 57% for ICU nurses and 37% for ward nurses with a p-value of 0.542 .This implied that though ICU nurses have some knowledge in suctioning, the routine practices give them better understanding of the procedure. Few Nurses (13%) were able to identify indications for suctioning, 42 % of nurses identified complications of oral and airway suctioning and 43% of nurses knew how often to suction a patient. (33%) of Nurses had knowledge in catheter selection for adult s and children (47%) knew the normal negative pressures for adult and children. 55% knew the action to take in case of abrupt change in the ECG monitor; however, 80.6% demonstrated undesirable knowledge on Endotracheal suctioning evidence-based recommendations. Nurses with ICU training (57%) significantly demonstrated higher knowledge of ETS than Ward nurses. This concludes that though ward nurses have some knowledge in oral and airway suctioning they do not practice suctioning often as ICU nurses who practice suctioning as their routine work.
Conclusion: Most Intensive Care Units and Ward nurses did not have knowledge and skills (Practice) on Oral and Endotracheal Suctioning (ETS) and are currently not following current ETS recommendations. This study has shown that training on Suctioning skills have positive influence to recommended Endotracheal Suctioning knowledge.
Keywords: Knowledge level, Practices, , Endotracheal Suctioning, Intensive Care Unit, Nurses
ENT - Ear nose and throat
ECG - Electrocardiogram
FiO2 - Fractional Inspired Oxygen
ICU - Intensive Care Unit
MRB - Manual Rebreather Bag
PIP - Peak Inspiratory Pressure
PEEP - Peak End Expiratory Pressure
PaO2 - Partial Pressure of Oxygen
SpO2 - Saturation of oxygen pressure
SaO2 - Oxygen Saturation
Airway management is a unique aspect of care for patients admitted in the Intensive Care Units and Wards. (Murgo, 2016). It includes maintenance of suctioning procedures of oral and nasal care, the artificial airway, management of equipment and endotracheal suctioning (Murgo, 2016). Airway Suctioning is a procedure for removing substances from the trachea, pharynx, nose or mouth either through a natural orifice (nose or mouth) or artificial tubing (endotracheal tube, tracheostomy tube, nasal or oral airway). Physiotherapists, Respiratory Therapists, Nurses and Physicians use suctioning to promote secretion clearance (pulmonary hygiene) and /or maintain a patent airway (Patak et al., 2004).
History of Suctioning
Invented circa 1907, the Yankauer suction tip remains the most commonly used piece of suctioning equipment in the world. Sidney Yankauer began work in the outpatient surgery department at Mount Sinai Hospital in New York in the late 1800s, specializing in ENT. He invented many medical devices that greatly affected the profession during that time, but he is best known for his rigid suctioning catheter, the Yankauer tip. It was originally designed to help clear the surgical field during a tonsillectomy. However, its use has expanded to include many surgical procedures, as well as in-hospital and prehospital oropharyngeal suctioning. Often made of plastic or stainless steel, the Yankauer catheter is characterized by small holes in a bulbous tip designed to remove fluid while minimizing damage to the surrounding tissues. The catheter is curved, making it maneuverable and easy to grasp.
The purpose of oral and airway suctioning is to maintain a patent airway and improve oxygenation by removing mucous secretions and foreign material (vomit or gastric secretions) from the mouth and throat (oropharynx) (Perry et al., 2014). Oral suction is the use of a rigid plastic suction catheter, known as a Yankauer to remove pharyngeal secretions through the mouth (Perry et al., 2014). The suction catheter has a large hole for the thumb to cover to initiate suctioning, with smaller holes along the end, which mucous enters when suctioning is applied. The oral suctioning catheter is not used for tracheotomies due to its large size. Oral suctioning clears secretions from the mouth when a patient is unable to remove secretions or foreign matter by effective coughing. Patients who benefit the most include those with Cerebrovascular Accidents, drooling, impaired cough reflex related to age or condition, or impaired swallowing (Perry et al., 2014).
Role of Suctioning in Airway Management
A patent airway is crucial to patient survival. Removal of accumulated secretions, blood and vomit increases respiratory efficiency, decreases the risk of complete airway obstruction and improves visualization of the trachea for intubation (Doran et al., 1995). Awareness of the risks involved is the first step toward developing a plan for prehospital suctioning of the critically ill patient (Vandenberg et al., 1999). Together with appropriate use of equipment, this enables provision of the best possible patient care during suctioning (Vandenberg et al., 1999.). Working under local policies and procedures, the Emergency Medical Service (EMS) provider must determine the most appropriate method for suction, taking into consideration issues of patient safety, time requirements, the suctioning source and patient comfort (Van de Leur et al., 2003).
Suction Equipment Checks
Most suction units offer easy-to-use testing to confirm that all functions are in working order: occlusion check, vacuum buildup efficiency, maximum achievable vacuum level and air leakage status. Large dials and single-control units are easier to operate with gloves and in the often-constrained environments of Emergency Medical Service operations (Vandenberg et al., 1999). All suctioning equipment must be checked at the beginning of each shift and after each use, following the manufacturer's recommendations (Vandenberg et al., 1999). Portable and wall-mounted suctioning devices within the ambulance commonly have variable vacuum settings of zero mmHg- 500 mmHg. Suctioning pressure in mechanical, battery-operated units and Venturi systems are regulated with adjustment of a control knob or valve. Suctioning systems incorporate some form of check valve to prevent liquid or particulate matter entering the suctioning line to the pump. Never connect the suction tubing directly to the suctioning source. Bypassing the trap could result in contamination of the pump and associated tubing, degradation of pump performance or complete pump failure Vandenberg et al., 1999).
Clinical indications for suctioning include respiratory distress due to increased copious, retained secretions (Sole et al., 2015) Signs of respiratory distress may include increased respiratory rate, tachycardia, gasping and difficulty talking. In the intubated patient, increased resistance, decreased Saturation Oxygen Pressure (SPO2), increased Peak End Expiration Pressure (PEEP) and an increasing Fractional Inspired Oxygen (FiO2) are indications that suctioning may be required. Non- intubated patients with coarse breath sounds should be encouraged to cough before suctioning is performed (Sole et al., 2015).The following are recommendations for endotracheal suctioning from the American Association of Respiratory Care (Sole et al., 2015)
• - Saw tooth pattern on flow-volume loop on ventilator monitor
• - Coarse crackles auscultated over trachea
• - Increased peak inspiratory pressure during volume control ventilation
• - Decreased tidal volume during pressure-controlled ventilation
• - Deterioration in oxygen saturation and/or arterial blood gas values
• - Visible secretions in airway
• - Patient’s inability to generate an effective cough
• - Acute respiratory distress
• - Suspected aspiration of gastric or upper airway secretions
• - . Patient has an ineffective cough and unable to clear the secretion spontaneously (audible secretion sound in patients under mechanical ventilation)
•- Retained secretion causing patient distress or physiological derangement (e.g. increased work of breathing, respiratory rate, impaired oximetry or blood gases)
•- When all other less invasive secretion clearance interventions has failed (e.g. cough assist (manual or mechanical), positioning, and other breathing/coughing techniques)
• - To obtain sputum sample for microbiology or cytological analysis
(NHS document Mar 2015, Andrews et al 2004, Vandenberg et al 1999)
Severe bleeding disorder, unexplained hemoptysis
• Severe bronchospasm or laryngeal spasm, irritable airway
• Epiglottitis or croup
• Basal skull fractures / facial injury
• Cerebral spinal fluid leak
• Recent nasal, oral or esophageal surgery
• Occluded nasal passage, nasal bleeding
• Loose teeth, denture or crown
• Increased intra-cranial pressure
• Severe gag reflex
• Hemodynamic instability and Tracheo/esophageal fistulae
Possible Hazards of Suctioning:
• Mechanical trauma to the airway
• Cardiac arrhythmias
• Vasovagal stimulation (↓HR/BP)
• Laryngospasm or bronchospasm
• Respiratory arrest
• Changes in Intracranial pressure (ICP)
• Lesions in tracheal mucosa
PROCESS OF SUCTIONING (S.S Celik et al, 2000)
1. Thorough chart review, patient & need assessment
a. IPPA (Inspection, Palpation, Percussion, Auscultation)
b. Monitor vitals
c. Monitor oxygen saturation
d. Check effectiveness of huff/cough if possible
e. Be aware of patient’s code status (or Goals of Care) and any high risk airways
f. Provide pertinent physiotherapy intervention for airway clearance and secretion mobilization as indicated
g. Check the last time patient was suctioned and frequency & outcome of suction
2. Provide appropriate explanation to patient (and family) and obtain consent
3. Provide adequate sedation or pain relief (and or other medications) if indicated
4. Hand Hygiene
5. Set up & Equipment:
a. Set up a clean bedside table for necessary equipment
b. Turn on suction regulator, check & set negative pressure (-100 to -150 mmHg for adult, set pressure as low as possible and yet effectively clear secretions)
c. Ensure proper working order of collection bottle/device (i.e. not over-filling)
6. Obtain & prepare suction catheters with appropriate caliber (for artificial airway, the outside diameter of the suction catheter should be less than 50% of the inner diameter of the artificial airway)
7. Personal Protective Equipment (mask, eye or face shield, gown, etc) as per infection prevention & control
a. Gloves (clean / sterile as per needs)
b. Water based lubricants for nasopharyngeal suction
8. Cups and clean water for oral suctioning, normal saline for nasopharyngeal suction/ open tracheostomy suction
9. Nasal trumpet/airway, oropharyngeal airway for frequent suctioning, or bite block as indicated
10. Use Pulse oximeter if available
11. Provide pre-oxygenation or supplementary oxygen source, resuscitation bag with mask
12. Other monitors Intracranial Pressure, ECG, etc.as indicated
13. Arrange for help if a second staff if necessary (e.g. for hyperinflation, cough assist, safety, etc.)
14. Ensure adequate lighting
•15Good understanding of emergency protocol & procedure
16. Position patient on side, half-side lying or in half lying and tilt the head slight back if possible.
17. Place a clean towel on patient’s chest just in case
18. Prepare sputum trapper if a sputum sample if needed
19. Pause ventilator alarm just before suctioning if patient is on mechanical ventilator
Hyperinflation involves inflating a patient’s lung with tidal volumes greater than those delivered by the ventilator (Wood 1998). This can be achieved by means of a Manual Rebreather Bag or an increased ventilator tidal volume (Mancinelli-Van Atta & Beck 1992; Robson 1998; Wood 1998). Hyperinflation is known to increase residual capacity and reduce the incidence of atelectasis and shunting (Fiorentini 1992; Carroll 1994). Moreover, large tidal volumes have been associated with barotrauma (Lookinland & Appel 1991), changes in mean arterial pressure and intrathoracic pressure (Ashurst 1992; Carroll1994), and reduced venous return, resulting in hypotension (Odell et al., 1993; Glass & Grap 1995; Wainwright & Gould 1996).
Instillation of normal saline
The instillation of normal saline prior to suctioning has become common practice in some areas (Ackerman 1993; Ackerman et al., 1996). However, as Blackwood (1999) argued, this is an example of a widely practiced intervention not supported by research. In fact, there is considerable research evidence against its use (Blackwood 1999). Respiratory secretions and saline apparently do not mix in vitro, and there is no evidence to indicate that they might mix in vivo (Hanley et al., 1978), Hanley instilled isotope-tagged 0.9% saline prior to suctioning and found that only 18.7% of the saline was removed. The remaining saline was shown by X-ray to remain in the trachea and bronchi, with none reaching the lung peripheries. In light of the empirical findings, questions raised about the effectiveness of normal saline instillation. One theory is that it elicits a cough reflex (Gibbs et al., 1997). However, (Gray et al., 1990) observed that a comparable cough could be stimulated by the suctioning procedure alone. Although some authors have continued to support the use of saline (Burton & Hodgkin 1984), this is not based on controlled research studies.
Maintenance of Asepsis
Suctioning is an invasive procedure and, therefore, is associated with an increased risk of infection(Pierce1995).Tracheal or endotracheal intubation prevents an effective cough as the glottis remains open, which limits the clearance of secretions and promotes pooling at or near the end of the tube (Judson & Sahn 1994; Chatila et al., 1995). The tube itself acts as an irritant, leading to inflammation and impaired mucociliary function. All of these factors may lead to an increased risk of infection in a debilitated and immunocompromised patient (Judson & Sahn 1994; Wood 1998). There is little argument that aseptic suctioning should be mandatory in all patients (Luce et al. 1993; Odell et al., 1993; Dean 1997). However, there is considerable variation in how this has implemented in practice, ranging from the use of non-sterile gloves (using a non-touch suctioning technique) to sterile gloves (Parker 1999a). The closed method of suctioning has shown to reduce the incidence of nosocomial pneumonia by avoiding opening the airway to contamination (Ashurst 1992). Closed systems also limit exposure of the surrounding area to contamination and protect nearby personnel from exhaled secretions. Parker (1999b) argued that the importance of hand hygiene and the use of protective gloves could not be overemphasized. Universal precautions such as use of gloves, aprons and goggles during open suctioning in order to minimize the infection risks to the practitioner (Wood 1998; Pratt et al., 2001). Brooks et al., 1999, investigated the suctioning practices of practitioners during suctioning and discovered that glove practices varied from not using gloves, to using two sterile gloves. Surprisingly, 2.8% (n =7) of subjects reported not wearing gloves. (May 2000) argued that infection control is an issue that affects everybody and it should emphasize on clinical practice across the entire spectrum of healthcare management. However, it requires role models for good practice and appropriate training of all professional and ancillary staff.
During suctioning Catheter selection, it is widely accepted that the external diameter of the suction catheter should not exceed one-half of the internal diameter of the endotracheal tube (Odell et al., 1993; Glass & Grap 1995; Wood 1998). This allows air to enter the lungs whilst oxygen is removed during suctioning, which guards against excessive negative pressures and potential atelectasis. Larger size catheters has shown to increase the risk of trauma due to greater mucosal contact (Young 1984). In fact, one study identified that all nurses (n =16) used a larger than recommended size suction catheter (Day et al. 2001). Adult size endotracheal or tracheostomy tubes range from 30 to 38 French Gauge (FG), or 7 to 9mm, whereas suction catheters range from 8 to 16 FG, or 2 to 2.5mm (Odell et al. 1993). In order to calculate the maximum size suction catheter to use, Odell et al., 1993) recommended the following formula: size of endotracheal/ tracheal tube minus 2 times two.
Depth of insertion
Stimulation of the valgus nerve may result in alterations in heart rate (such as bradycardias) and blood pressure. Prolonged paroxysmal coughing will result in increased intrathoracic pressure, decreased venous return and transient hypotension (Wood 1998). Griggs (1998) suggested that, a few days after tracheostomy formation, most patients are able to cough secretions to the end of the tracheostomy tube and the suction catheter need only be inserted to just beyond the end of the tube (approximately 15cm), thus reducing pain and trauma (Ashurst 1992). This method, although rather subjective, can also be applied to those patients with endotracheal tubes as long as they are able to cough. However, Pierce (1995), Dean (1997),and Wood (1998) all recommended inserting the catheter fully to the carina, which is either felt by resistance or on stimulation of a cough, then withdrawing the catheter1cmpriortotheapplicationofsuction .
Significant tracheal damage, ulceration and necrosis were found in an animal study where the effects of continuous and intermittent suctioning in two experimental groups were compared with a control group (Czarnik et al., 1991). However, the excessive suction pressures of 200mmHg may have contributed to these findings. Using high negative pressures does not mean that more secretions will be aspirated; therefore limiting pressures to between 80 and 150mmHg is accepted (Boggs 1993; Luce et al., 1993). To prevent the suction catheter from adhering to the tracheal mucosa, negative pressure is only be applied during withdrawal (Glass & Grap 1995). Glass and Grap (1995) also advocated the use of continuous suctioning on catheter removal as there is no evidence to suggest that intermittent suctioning reduces trauma and at least one study that has identified it as ineffective (Luce et al. 1993; Thelan et al., 1994). Similarly, rotation of the catheter during withdrawal has not been associated with significant increases in sputum removal, and may in fact contribute to further trauma (Glass & Grap 1995). Despite this evidence, practitioners continue to use excessively high suctioning pressures. Celik and Elbas (2000) reported that the patients in their study were being suctioned using a suction machine that delivered a ‘minimum’ negative pressure of 300mmHg. This is twice the recommended negative pressure. This study also found that 82.6% of suction passes (n =90) performed by nurses involved suction being applied during insertion of the suction catheter, which is also not recommended practice. Suction catheters should have a built-in valve to prevent suction is applied on insertion (Odell et al., 1993).
Duration of Procedure
The majority of researchers recommend that suctioning should take between 10 and 15s to perform, as longer durations are associated with an increased risk of mucosal damage and hypoxemia (Boggs 1993; Odell et al., 1993; Smith 1993). In Day et al., 2001) study all nurses (n =16) failed to suction within this recommended duration.
Number of Passes
(Wood 1998) argued that the number of suction passes in one suctioning event, perhaps due to copious amounts of secretions, might lead to complications. Some authors recommend allowing the SpO2 to return to pre-suctioning parameters before another suction pass is attempted (Smith 1993), which Pierce (1995) argued should be no less than 30s. However, the majority of researchers advocate that no more than three suction passes should be made per episode and that the number of passes should be kept to a minimum (Fiorentini 1992; Glass & Grap 1995). Monitoring the patient’s heart rate and rhythm, arterial blood pressure and SpO2 during the suctioning procedure is recommended. Suctioning should cease when hyper oxygenation is initiated if any untoward complications are observed (Glass & Grap 1995; Wood 1998)
1.2.5 DURING SUCTION
1. Without applying suction pressure, gently insert catheter into patient’s airway
2. Clear any visible secretion before inserting the suction catheter deep into patient’s nares, mouth or artificial airway
3. Do not force catheter in when experiencing resistance, reinsert catheter if needed
4. Stimulate cough if it does not occur naturally
5. Withdraw catheter slightly (1-2 mm) prior to applying suction
6. Apply suction only when withdrawing catheter in a rotating manner
7. No need to rotate catheter if using an in-line/closed suction system
8. Total suction duration should not exceed 15 seconds
9. Rest between suction passes; closely monitoring patient vitals, discomfort and condition; calm patient if necessary
10. Observe secretion aspirated (e.g. amount, color, tenacity, any blood in secretion, etc.)
11. Rinse suction catheter if necessary
12. Saline instillation is not recommended as a routine for patients with artificial airway
1. Ensure patient is safe and stable by auscultating the lungs
2. Monitor oxygen saturations
3. Rinse suction catheter & tubing
4. Discard used catheter and gloves
5. Hand hygiene
6. Reassess patient’s cardiorespiratory status; repeat suctioning if indicated
7. Turn off suction source if no further suctioning is needed.
8. Set supplementary oxygen back to normal level if patient is stable
9. Check ventilator setting & alarm if patient is on ventilator support
10. Hand Hygiene
11. Documentation – details of patient response and outcome, time, secretion suctioned (quantities in measurable units such as in mills or teaspoonful, color, tenacity, smell, presence of blood, etc.), number of passes of catheter, preoxygenation needed, etc. Follow site or program specific documentation guideline
12. Liaise with other disciplines (e.g. Nursing, Respiratory Therapists, and Physicians) regarding any pertinent information about suctioning and patient’s response
13. Coordinate suctioning with other disciplines if indicated (e.g. medication pre or post suctioning, with Cough Assist and suctioning with Respiratory Therapists, etc
Complications from airway suctioning are relatively uncommon if performed with care and adequate pre-oxygenation. Suctioning can stimulate the vagal nerve, predisposing the patient to bradycardia and hypoxia. Hypoxia can be profound from occlusion, interruption of oxygen supply, and prolonged suctioning. Mucosal trauma, physical injuries, and bleeding can result from blunt or penetrating trauma. Pain and discomfort can result from suctioning. Anxiety can be associated with suctioning
Poor practices in airway/oral suctioning leads to infection, bleeding, hypoxemia, arrhythmias, increased intracranial pressures etc., which can lead to life threatening conditions.
There seem to be currently many wards in Korle- Bu Teaching Hospital with hesitance in admitting patients requiring airway and tracheostomy care including suctioning. Lack of competence and fear of complications has been suggested as reasons for this hesitance. There is, however, no documentation of the knowledge and competence level of nurses regarding this very important and often life-saving procedure
The study aims to assess the knowledge and practices of oral and airway suctioning among nurses in KBTH
-To assess knowledge level of oral and airway suctioning among nurses in Korle- Bu Teaching Hospital (KBTH).
- To evaluate the scope of practice of oral and airway suctioning among nurses in KBTH.
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