ICID > Clinical Management > Physiotherapy > Nasopharyngeal Airway Management and Nasphoryngeal Suctioning in Adults  
 

Nasopharyngeal Airway Management and Nasphoryngeal Suctioning in Adults 

  •  
  • 1. Indications
  • 2. Clinical Management
  • 3. Patient Information
  • 4. Audit
  • 5. Evidence Base
  • 6. Appendices
  • 1. Indications

    1.1 Background

    Nasopharyngeal suction is the passing of a suction catheter into the upper airway through which a negative pressure is applied as the suction catheter is withdrawn in order to aspirate secretions. Within Salisbury Foundation Trust it is deemed as best practice to use a sterile technique.

    1.2 Aim/purpose

    To remove excess secretions from the upper respiratory tract in patients who are unable to do so independently.

    1.3 Patient/client group

    Self ventilating adult inpatients who require assistance with secretion removal. This policy is for adult patients only and does NOT cover secretion management in children under the age of 18.

    1.4 Exceptions/ contraindications

    Contraindications

    General:

    • tracheo/oesophageal fistulae

    • severe bronchospasm or stridor (due to risk of total airway obstruction with the introduction of the catheter).

    • acute head, facial or neck injury (as the catheter may pass into the brain instead of down the trachea in basal skull fractures)

    • severe epistaxis

    • leakage of cerebral spinal fluid  (suggests skull fracture so suction may cause further damage)

    • occluded nasal passage

    • clotting problems (normal limits INR 1-1.3 and platelets 120-500)

    • inhalation injury

    • CVS instability

    Precautions

    • recent oesophageal or tracheal surgery

    • coagulopathy and bleeding disorders (patients on warfarin or heparin)

    • upper airway lesions

    • irritable airways (eg: uncontrolled cough, chest tightness, wheeze, bronchospasm)

    • pulmonary oedema

    • Latex allergy (consider latex free NP airway from theatres)


    2. Clinical Management

    2.1 Staff & equipment

    Within this Trust nasopharyngeal suction and NP airway management are regarded as clinical practice. A clinical practice may be defined as an aspect of care, which may be undertaken by registered nurses and physiotherapists who accept accountability for their actions and feel competent to undertake the procedure. In some professions such as Physiotherapy there is formal training and assessment of competencies, but in other professions is no formal assessment for these practices but there may be aspects of care, which require a period of supervised, guided practice.

    Student nurses and student physiotherapists may undertake this practice under the supervision of a registered nurse or physiotherapist who feels competent in this aspect of care and in the supervisory role.  In certain clinical areas assistants that have been trained specifically to carry out this role may also do so (for example bands 3 or 4 on the Spinal Unit).

    In line with guidelines laid down by the NMC / CSP / HPC on standards for records and record keeping, there must be a current and appropriate plan of care for patients. The plan must incorporate on-going evaluation and reassessment of care and evidence that relevant interventions and observations have been communicated to appropriate members of the multidisciplinary team.

    2.1a Specific training required

    As well as the formal training provided through resuscitation courses and profession specific competencies, in-service bedside teaching is also provided and supervision offered.  It is emphasised that all nurses and physiotherapists are accountable for their own professional practice and should ensure that they are familiar with these guidelines

    2.2 Method/procedure

    Guidelines for managing a patient requiring nasopharyngeal suctioning

    Aim

    To ensure the safe management of a patient requiring nasopharyngeal suctioning

    2.2a Equipment required for nasopharyngeal suction:

    Functioning suction unit

    Personal protective equipment

    Suction catheters of correct size

    Nasopharyngeal airway (appropriate size for patient)

    Sterile water

    Sterile gloves

    Sterile Jug

    Sputum trap if indicated

    Aqua-gel or water based lubricant

    Saturations monitor

    Procedure

    Intervention

    Rationale

    Check patient’s resuscitation status

    To ensure correct management in the case of a cardiac arrest during the procedure

    Check the equipment

    To maintain a safe environment

    Put on disposable apron, protective eye wear & mask if indicated. Wash & dry hands

    To reduce the risk of cross infection and protect health professional through universal precautions.  Most patients cough directly onto the member of staff’s clothing after suction; standing to one side should minimise this risk.

    Explain the procedure to the patient and any visitors (regardless of conscious level)

    Provide suction leaflet (available on ICID)

    To obtain patients’ verbal consent if able.  This procedure can be unpleasant & frightening. 

    Either position the patient in a high sitting position or side lying with their head turned towards you with a head tilt into slight extension.

     

    Attach saturations monitor

    Prevent aspiration of gastric contents

     

    To enable monitoring of oxygenation levels throughout the procedure and assess effectiveness

    Ideally optimise oxygen saturations  >95% prior to and between suctioning.  The oxygen mask should then be kept close to the face throughout.

     

    NB optimal oxygen saturations for known COPD patients should be between 88-92% unless otherwise documented

    Hypoxia may be caused by introducing negative pressure into the airway.

    Monitor oxygen saturations and observe the patient throughout the procedure to ensure their general condition is not affected.

    Nasopharyngeal suction may cause vagal stimulation leading to bradycardia, hypoxia and may stimulate bronchospasm.

    Switch suction unit on and check that the suction machine is set appropriately at

    20Kpa or 120mmHg-adults  

    To ensure the machine is working correctly.  Too great a suction pressure can cause mucosal injury Greater suction pressure does not equal increased secretion removal.

    Connect appropriate sized suction catheter to suction tubing, whilst keeping catheter in the pack.

    (A size 12FG catheter is preferable but this should be assessed depending on the size of airway and amount/viscosity of secs)

    Minimises risk of infection.

     

    It is necessary to utilise a catheter which is large enough for secretions to pass through whilst causing minimal trauma to the mucosa.

    Put gloves on both hands and then a sterile glove on top on the dominant hand.

    To reduce risk of introduction of bacteria to respiratory tract.

    Remove the catheter from the pack handling only with the dominant hand and lubricate catheter tip with aqua-gel. You do not need to use aqua-gel if you have an airway in place, but if you find the catheter is not gliding easily, you may find the aqua-gel helps.  

    To aid smooth passage and limit trauma.

     

    Without applying suction gently introduce catheter into one nostril directing it parallel to the floor of the nose towards the opposite eye.

     

    If an obstruction is felt remove catheter and try the other nostril.

     

    If slight resistance is felt at the back of the pharynx, rotate the catheter slowly between the fingers and ease gently forwards.  

    Suctioning whilst introducing the catheter  causes mucosal irritation and damage

      

    The patient may have a deviated nasal septum or enlarged turbinates that prevents passage of the suction catheter.  

     

    To minimise the risk of introducing the catheter into the oesophageus, ask the patient to tilt their head back, stick out their tongue and cough. If coughing is not possible slide the catheter down during inspiration when the glottis is more open. 

    Coughing usually indicates that the catheter is in the trachea.

    Once the patient coughs apply suction and withdraw the catheter slowly and smoothly.

      

    If resistance is felt before the patient coughs it is likely you have hit the carina.  In this instance the catheter should be withdrawn slightly prior to applying suction to limit trauma.  

     

    Do not suction for longer than 15 seconds at a time

    Slow withdrawal should reduce the need for further attempts. It is not necessary to rotate the catheter whilst applying suction as catheters have circumferential holes. 

    Occasionally a cough may be stimulated when the catheter reaches the pharynx and suction can be applied and catheter withdrawn.  However, often it is necessary to pass the catheter between the vocal cords in to the trachea to stimulate coughing. 

    Prolonged suctioning will result in trauma and hypoxia.  

    Document the colour, tenacity and quantity of the secretions on NP suctioning chart (see appendix B). If secretions look infected (ie different to what the patient normally expectorates) consider sending a sample if this has not recently occurred. Monitor changes and anticipate potential infection at an early stage.

    Remove the glove from the dominant hand by inverting it over the used catheter & dispose in yellow polythene bag

    Suction tubing should be rinsed out and oxygen therapy given as indicated.

    To minimise the risk of infection
    Assess the patient’s respiratory rate and oxygen saturation to ensure they have not been compromised by the procedure and whether they need further suction. Suction should be performed only when needed and not as part of a routine
    If the patient needs further suction, repeat the above actions using new gloves & a new catheter
    Remove gloves and wash hands Prevent cross infection
    NB: If NG tube in situ confirm the tube remains in position. The tube tip can migrate into the oesophagus during suctioning.
    Ensure that the patient is comfortable  
    Record the colour, quantity & tenacity of secretions, and any other relevant details,  in nursing notes. To facilitate on-going evaluation.

    A nasopharyngeal (NP) airway is indicated when a patient requires regular suctioning for secretion clearance.  This is to limit the amount of trauma to the mucosa through repeatedly passing suction catheters.

    2.2b Suctioning with a nasopharyngeal airway

    Note that the most commonly available NP airways in the trust are made from Latex.  If it is suspected that the patient may have a Latex allergy, Latex free NP airways can be obtained from theatres.

    Sizing:

    Measure both length and width. Average size female (163cm tall) will normally require a size 6 and an average size male (178cm tall) will normally need a size 7.

    Length:

    Choose an airway that best matches the distance from nasal opening to the tragus of the ipsilateral ear.

    Width:

    Choose the airway with a width equal to that of the patients nasal opening (approximately the same width as their little finger). The airway diameter should not be too wide and should not blanche the nasal tissue.

    Procedure

     

    Intervention

    Rationale

    Explain the procedure to the patient

    Gain patients consent. Procedure can be unpleasant and potentially frightening.

    Monitor respiratory rate, pulse and oxygen saturations throughout procedure.

    Nasopharyngeal suction may cause vagal stimulation leading to bradycardia, hypoxia and may stimulate bronchospasm.

    Optimise patients saturations (be aware of CO2 retainers as with suction procedure)

    To prevent desaturation during insertion of the airway and the suction procedure.

    Lubricate the NP airway well with aqua gel or other water-based lubricant.

    To prevent damage to the mucosa

    Using a sterile glove, insert the airway into the right nostril if able (if unable to pass into right nostril, remove and try left). The NP airway should follow the curve of the patients airway

    Minimise infection risk with sterile technique.

     

    If an NG tube is in place, placement of NP airway should be in the opposite nostril if possible to avoid pressure damage.

    Reproduced from Resuscitation Council UK (1998) Advanced life support manual.

    Abort the procedure if:

    • resistance cannot be gently pushed through

    • the patient is in too much distress

    • trauma is caused

    Suction as per procedure outlined previously.  If using lubrication the airway may require changing more frequently due to potential for occlusion.

    Duration of insertion:

    Insertion of the NP airway can cause a degree of trauma to the mucosa and fibrosis could develop around it. Further trauma could also be caused during removal of the airway. If the NP airway is to be used for more than 24 hours a clear management plan needs to be agreed with the medical team.  Daily review of continued need and condition of the skin must be assessed on a daily basis and documented in the patient’s medical notes.  If the patient has an NP airway for suctioning of secretions, the ward physiotherapist should be aware of the patient and whether they need to review for chest clearance techniques.

    There is limited research stating maximum duration of NP airways but the trust advises that only in exceptional circumstances (which must be clearly documented),  can NP airways be left in situ for more than 48hrs before removing and/or replacing in the other nostril.  

    Removal:

    Remove the airway as soon as access for suctioning is no longer required. It must be removed and replaced if it becomes occluded.  Explain the procedure to the patient, gain consent if able. Pull the airway firmly down and out.  Dispose of the airway in a clinical waste bin. Document in medical notes and on NP suctioning chart (appendix B) .

    2.3 Potential complications / Risk Management

    Patient Distress. Suction may be very uncomfortable for the patient. Nasopharyngeal suction should only take place if absolutely necessary. Careful explanation and reassurance are essential.

    Hypoxia. Caused by reducing the airway with the catheter and by decreasing the patients’ oxygen supply during the procedure. Giving extra oxygen prior to the procedure, using an appropriate sized catheter, and not prolonging the suction procedure may prevent this.

    NB care is needed when considering preoxygenation of patients with type II respiratory failure (i.e. normal oxygen, high CO2) as they become dependant on low oxygen levels to initiate respiration. If they are given additional oxygen this may reduce their respiratory drive. However patients with both type I and type II respiratory failure (i.e. low oxygen, high CO2 ) may benefit from additional oxygen - they should be monitored closely. For further advice staff should contact medical, CCOT or physiotherapy staff.

    Soft Tissue Damage such as epistaxis, mucosal damage and ulceration. This can be caused by both passing of the catheter and the pressure from the suction which can lead to up to 50% reduction in mucocilliary transport.  Using appropriate suction pressures (20Kpa or 120mmHg) and careful selection of the catheter size may prevent this. If patient continues to bleed, stop suction and contact medical team for advice.

    Gagging/Vomiting. Touching the posterior pharyngeal wall with a suction catheter causes this. Careful technique will reduce the risks and correct positioning of the patient beforehand should limit the risks of aspiration should vomiting occur.

    Vasovagal Stimulation causing Bradycardia and Hypotension. This is most common in unstable patients and can be caused by hypoxaemia or irritation of the vagus nerve.  Introducing the catheter gently and to the correct depth will prevent this.

    Infection. Infection may be introduced during nasopharyngeal suction. A clean technique must be used and it is recommended best practice to use a sterile technique.  Catheters are for single use only and once suction applied should only be withdrawn, never re-inserted.

    Atelectasis. This can be caused by the vacuum, therefore ensure the correct suction pressure is used (see above).

    Hypertension. This is usually due to patient distress and should settle quickly after the procedure is complete.

    Laryngospasm. Whilst rare, this is an emergency.  If the patient stops breathing during suctioning and the catheter fills stuck and can’t be withdrawn, the cardiac arrest team should be called. Laryngospasm may be relieved by gentle positive pressure ventilation using an ambi-bag from the crash trolley, however intubation may be necessary.

    Raised Intracranial Pressure (ICP). If the patient’s blood pressure is raised this will also increase ICP. ICP will also rise if the patient coughs, vomits or becomes hypoxic. If any of these conditions persist in a neurologically unstable patient it may cause further instability.

    Blocked airway. An occluded NP airway can cause hypoxia from retained secretions as well as reducing the patients airway.  Daily review of the NP airway and removal at the earliest opportunity should reduce this risk.

    2.4 After care

    Following suctioning or insertion of an NP airway, assessment of the patient should be undertaken to see whether the procedure has been effective:

    • patient’s opinion

    • reduced work of breathing

    • reduced respiratory rate

    • increased oxygen saturation

    • visible evidence of removal of secretions

    • reduced crackles on auscultation

    • patient’s colour improves.

    Any patient requiring nasopharyngeal suctioning more than once in 24hrs must be alerted to the ward physiotherapist (or on-call physiotherapist at weekends


    3. Patient Information

    All procedures carry risk and as part of the procedure for having nasopharyngeal suctioning the patient will have the procedure fully explained to them by the health care professional and the risks and benefits clearly set out. The patient is free to ask questions to clarify the procedure at any time. The patient / relative will also be provided with an information leaflet on suctioning available on ICID at the start of any suctioning.


    4. Audit

    4.1 Audit Indicators

    An audit will be carried out after one year following implementation of these guidelines. The audit will be carried out using staff surveys of clinical knowledge and skills involved in the use of these techniques. A review of this policy and current practice will also be carried out if a new innovation is identified in the management of these patients and is to be introduced.

    5. Evidence Base

    5.1 Sources of information

    1. A A R C (1992). Clinical Practice Guidelines - Nasotracheal Suctioning Respiratory Care 37 (8), 898-901.

    2. Bennett C (2003) Nursing the breathless patient Nursing Standard 17 (17) 45-51

    3. Care of the breathless patient (Essential Skills, 11. Includes oral suctioning procedure) Nursing Standard 2001. 15 (29). p (2 unnumbered pages)

    4. Harey N (1996) Tracheobronchial Suction. Journal of the Association of Chartered Physiotherapists in Respiratory Care. 28, 22-25.

    5. Hough A (2001) Physiotherapy in Respiratory Care – An evidenced based approach to respiratory and cardiac management. (3rd ed.) Nelson Thornes: London

    6. Moore T (2003) Suctioning techniques for the removal of respiratory secretions Nursing Standard 18 (9) 47-53

    7. Nursing and Midwifery Council (2008) Code of Professional Conduct. NMC, London

    8. Place B, Fell H (1998) Clearing tracheobroncheal secretions using suction. Nursing Times 94(47): 54-56

    9. Pryor J & Prasas A (2008) Physiotherapy for Respiratory and Cardiac Problems, (4th ed.) Churchill Livingstone. Oxford

    10. Resuscitation Council UK (1998) Advanced Life Support Manual. London

    5.2 Summary of evidence, review and recommendations


    6. Appendices

     Appendix A    
     Appendix B Suctioning Chart   


    Document Owner Jenna Wippell, Hannah Colton 
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