Suctioning & Endotracheal Intubation

Objectives - Describe how to perform endotracheal and nasotracheal suctioning safely, evaluate suctioning indications and hazards, and provide airway management including intubation.

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Suctioning

Definition and Purpose

Suctioning is the application of negative pressure, or vacuum, to the airways through a collecting tube such as a flexible catheter or suction tip.

Purposes:

• Maintain airway patency
• Collect sputum specimen
• Stimulate cough

An oral suction device, such as a Yankauer or tonsil suction device, is used to suction the mouth and throat using aseptic technique.

Indications

Suctioning is indicated for:

• Maintaining airway patency and integrity
• Accumulated secretions
• Sawtooth pattern on ventilator graphics
• Increased peak pressures or decreased volume delivery in pressure control ventilation
• Visible secretions in the airway
• Deteriorating ABG values and/or oxygen saturation
• Obstructed airway
• Depressed cough
• Inability to swallow

Contraindication

The source lists epiglottitis or croup as a contraindication.

Hazards

Suctioning hazards include:

• Atelectasis
• Mucosal trauma, which is the most common
• Contamination
• Hypoxemia leading to tachycardia or arrhythmias, which is the most severe
• Bradycardia from vagus nerve stimulation
• Bleeding from overly vigorous suctioning

Use gentle technique, lubricate the catheter for nasal-tracheal suctioning, use aseptic technique, and suction only when indicated.

Apply suction while withdrawing the catheter for no more than 15 seconds, then clear the catheter with sterile water or saline.

Vacuum Pressure

Suction Catheter Sizing

Suction catheter size is listed in French units, which refer to circumference.

The external diameter of the suction catheter should be no greater than one-half the inside diameter of the endotracheal or tracheostomy tube.

Quick sizing method:

• Multiply the tube inner diameter by 2
• Use the next smallest even catheter size

Examples:

Suctioning Techniques

Open suctioning uses a sterile catheter each time the airway is suctioned.

Closed suctioning keeps the catheter enclosed in the ventilator circuit and is commonly used for endotracheal suctioning.

Nasotracheal Suctioning

Nasotracheal suctioning is an open suctioning procedure:

• Lubricate the catheter with sterile water-soluble lubricant
• Insert gently through the nostril toward the septum and floor of the nasal cavity
• As the catheter enters the lower pharynx, place the patient's head in the sniffing position
• Advance until the patient coughs or resistance is felt
• Apply suction while withdrawing the catheter

Endotracheal Suctioning

Endotracheal suctioning is usually closed suctioning.

Key source points:

• 100% oxygen is required before and after suctioning
• Oxygenation should last at least 1 to 2 minutes
• Close cardiac monitoring by ECG is important
• Sterile catheter, solutions, and gloves should be used each time
• Suction the ET tube first, then the mouth
• Change the catheter after suctioning the mouth before suctioning the ET tube again

Mini-Bronchoalveolar Lavage

A mini-BAL is a non-bronchoscopic method of performing a small-volume bronchoalveolar lavage for quantitative culture results. It is used to guide antibiotic therapy for patients with ventilator-associated pneumonia. The catheter design allows sampling of uncontaminated distal lung specimens.

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Endotracheal Intubation

Definition

Endotracheal intubation establishes an artificial airway by placing a tube through the mouth or nose, through the glottis, and into the trachea.

Indications

Intubation is indicated to:

• Provide a patent airway
• Treat respiratory failure
• Provide a means for mechanical ventilation
• Directly instill medications when IV access is unavailable

Medication examples from the source:

• Valium or Versed for sedation
• Atropine for bradycardia
• Narcan for narcotic overdose
• Epinephrine for asystole

When medications are administered through the endotracheal tube, double the normal IV dose, flush with 10 mL saline, and hyperventilate for 30 seconds.

Contraindication

The source lists legal documentation indicating the patient does not want intubation, such as DNI status, as a contraindication.

Complications and Hazards

Hazards include:

• Upper airway trauma
• Aspiration and pneumonia
• Vocal cord paralysis
• Laryngospasm, which is the most serious complication
• Dental accidents and broken teeth
• Right mainstem intubation
• Esophageal intubation

Routes for Intubation

Orotracheal Route

Advantages:

• Larger tube can be placed
• Easier insertion
• Less airway resistance
• Reduced risk of kinking

Disadvantages:

• Gagging, coughing, and salivation may occur when airway reflexes are intact
• Securing the tube can be difficult
• Mucosal irritation and ulceration can occur on the lips and mouth

Nasotracheal Route

Indication:

• Oral route is unavailable, such as maxillofacial injuries or oral surgery

Methods:

• Blind insertion
• Direct visualization with a standard or flexible laryngoscope

Advantages:

• More comfortable
• Less gagging and salivation
• Easier swallowing
• Improved oral care
• More secure airway
• Improved communication

Disadvantages:

• Sinusitis
• Epistaxis
• Otitis
• More difficult procedure
• Requires smaller tube
• Increased airway resistance
• Less effective suctioning

Evidence of Difficult Airway

Signs suggesting a difficult airway include:

• Tracheal shift or deviation
• Enlarged thyroid
• Short receding mandible
• Enlarged tongue, or macroglossia
• Bull neck
• Limited neck or cervical spine range of motion
• Cervical spine immobilization collar
• Small mouth opening
• Mallampati Class III or IV

A thin soft guide, also called a bougie, can be used if the clinician has difficulty passing an ETT through the glottic opening.

Intubation Equipment

Assemble and check:

• PPE
• Laryngoscope handle
• Miller straight blade
• Macintosh curved blade
• Magill forceps for nasal intubation
• Yankauer oral suction
• Various ETT sizes
• Stylet
• 10-mL syringe
• Bite block or OPA
• ETT securing device or cloth tape
• BVM with 100% oxygen
• Carbon dioxide detector
• Sedative and paralytic agents for RSI

All suction equipment should be assembled and vacuum pressure checked. Attach the appropriate laryngoscope blade to its handle and check brightness. If the light does not work, check bulb and batteries.

Tube and Blade Sizes

Select the appropriate-size tube, plus one size larger and one size smaller. ETTs are sized by internal diameter in millimeters.

Depth markings:

• Oral intubation: approximately 21 to 25 cm at the lips
• Nasal intubation: approximately 26 to 29 cm at the naris

Blade notes:

• Handle is always held in the left hand
• Curved Macintosh blade tip is placed in the vallecula
• Straight Miller blade tip lifts the epiglottis
• Adult blade size is 3
• Pediatric blade size is 2
• Term infant blade size is 1
• Preterm infant blade size is 0

Before insertion, inflate the tube cuff and check for leaks, then deflate the cuff. Lubricate with water-soluble gel. Insert a stylet to add rigidity and maintain shape. The stylet tip must never extend beyond the ETT tip.

Magill forceps are used only to aid nasal intubation by lifting the tube into the trachea.

Intubation Procedure

1. Assemble and check equipment.
2. Position the patient in sniffing position when not contraindicated.
3. Preoxygenate and ventilate with 100% oxygen.
4. Insert the laryngoscope with the left hand.
5. Visualize the glottis.
6. Displace the epiglottis according to blade type.
7. Insert the tube through the glottis.
8. Assess tube position.
9. Stabilize the tube.

Sniffing position places the head midline and tilted back to improve visualization of the vocal cords. It is contraindicated in neck injury. Align the ear opening with the sternum and use pillows, folded towels, or blankets under the head, neck, and shoulders as needed.

Preoxygenation with BVM and 100% oxygen helps the patient tolerate intubation. CPAP or high-flow nasal cannula may also be used during preoxygenation. No more than 30 seconds should be devoted to an intubation attempt. If intubation fails, ventilate and oxygenate for 3 to 5 minutes before the next attempt.

The laryngoscope is inserted into the right side of the mouth and moved toward the center, displacing the tongue left. Advance along the curve of the tongue until the epiglottis is visualized. If the arytenoid cartilage and epiglottis are not visible, the blade may be too far advanced and may be in the esophagus. Maintain upward force and slowly withdraw until the larynx is seen.

With a Macintosh blade, displace the epiglottis indirectly by advancing the blade tip into the vallecula and lifting up and forward. With a Miller blade, displace the epiglottis directly by advancing the tip over its posterior surface and lifting up and forward. Do not lever the laryngoscope against the teeth.

Insert the tube with the right hand. Once the tube is seen passing through the glottis, advance the cuff 2 to 3 cm past the cords. Maintain a grasp on the tube, remove the laryngoscope and stylet, inflate the cuff with 5 to 10 mL air, remove the syringe, and ventilate the patient.

Cricoid pressure, or Sellick maneuver, is indicated if the larynx is anterior or the patient is at risk of aspiration. BURP means backward, upward, rightward pressure. It compresses the esophagus and may help prevent gastric inflation.

Confirming and Securing Tube Placement

Assess tube position by:

• Inspecting for bilateral chest expansion
• Suspecting right mainstem intubation if only the right side rises and falls
• Auscultating for bilateral breath sounds
• Using capnography or colorimetry
• Noting ETT depth at the upper incisors

"Gold/yellow is good" for colorimetric CO2 detection.

After stabilization, a chest x-ray should confirm position. Locate the carina and ETT tip. The ETT tip should be 2 to 3 cm above the carina.

Cuff Pressure

Monitor cuff pressure with a cuff manometer.

Target pressures:

• 25 to 35 cm H2O
• 20 to 25 mm Hg

Correct cuff pressure helps prevent tracheal stenosis in both endotracheal and tracheostomy patients.

Minimal seal and minimal leak techniques exist for settings without a cuff manometer, but the source states neither technique is recommended anymore.

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