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Critical Care Nurse. 2002;22: 130-131
Copyright © 2002 by the American Association of Critical-Care Nurses.
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Ask the Experts
Do you have a clinical, practical, or legal question you’d like to have answered? Send it to us and we’ll pass it on to our "Ask the Experts" panel. Call (800) 394-5995, ext 8839, to leave your message. Questions may also be faxed to (949) 362-2049, mailed to Ask the Experts, CRITICAL CARE NURSE, 101 Columbia, Aliso Viejo, CA 92656, or sent by e-mail to ccn{at}aacn.org. Questions of greatest general interest will be answered in this department each issue.

Mary Frances D. Pate is a clinical nurse specialist and Terry Zapata is a staff nurse in the pediatric intensive care unit at Doernbecher Children’s Hospital in Portland, Ore.

Q How deeply should I go when I suction an endotracheal tube (ETT) or tracheostomy tube (TT)?

A Mary Frances Pate, RN, DSN, and Terry Zapata, RN, RRT, reply: ______

ETT and TT suctioning is frequently performed by critical care nurses. Regardless of the frequency and seemingly routine nature of this activity, suctioning is not a benign procedure. The purpose of suctioning is to remove secretions that are not accessible to bypassed cilia. Therefore, insertion of suction catheters only as far as the end of the placed ETT and TT has been recommended.1,2

Research describing the potential negative effects of deep suctioning has been reported dating back to the 1960s.3 However, it is still a common practice for nurses to insert suction catheters until they meet resistance and then apply suction. Although this practice is not supported in the research, a survey of pediatric nurses revealed that 75% of the respondents inserted suction catheters to resistance.4 The resistance felt is when the catheter impacts the carina or bronchial mucosa. Inserting a suction catheter to this point can cause negative consequences for the patient. Alternately, some nurses insert suction catheters until resistance is met, and then pull the catheter back before applying suction. Unfortunately, meeting resistance and then "pulling back" before suctioning is not a solution. Research suggests that catheter contact rather than suction is responsible for mucosal damage.1

Studies in kittens have shown that inserting a catheter to resistance caused as much damage as insertion to resistance with the subsequent addition of suction.5 The effect of deep suctioning is tracheal mucosal damage, including epithelial denudement, hyperemia, loss of cilia, edema, fibrosis, and granuloma formation. This damage occurs when tissue is pulled into the catheter tip holes, and increases the risk of infection and bleeding for the patient. Use of special, tipped catheters, low levels of suction pressure, or intermittent suction pressure has not been shown to decrease tracheal mucosal damage.6

Shallow suctioning can has been shown to decrease the effects of tracheal mucosal damage, as shown in a study of rabbits.1 Rabbits that were suctioned using deep suctioning had significantly more necrosis and inflammation than rabbits receiving shallow suctioning. Rabbits in the deep-suctioned group had necrosis of 40% to 100% of the circumferences of their tracheas and bronchi, whereas the shallow-suctioned group experienced 0% to 10%. Tracheal bronchial tissues from deeply suctioned subjects all showed major disruption of mucosa, near total loss of cilia, inflammatory reaction in mucosa and submucosa, and markedly increased mucus production.

Nurses may argue that though shallow suctioning appears to be less injurious to mucosa, it may also be a less effective method of removing secretions. However, there is no reason to suspect that mucocilliary transport below the tip of the ETT or TT should function abnormally. Therefore, larger volumes of aspirates would be collected in shallow-suctioned animals. Once deep-suction is initiated, the resulting damage to cilia may necessitate the need for continued deep suctioning.1

When an adult patient is endotracheally intubated, the distal portion of the tube sits between 3 to 7 cm above the carina.7 In neonates, the end of the ETT is frequently placed just 1 to 2 cm above the carina. Therefore, suction catheters should be inserted to a predetermined length. Passing suction catheters no further than 1 cm past the length of the ETT or TT can avoid contact with the trachea and carina.4 Resistance should not be met. If resistance is met, the suction catheter should be withdrawn at least 0.5 cm before applying suction.6 Methods of predetermining suction catheter depth are outlined below.

TRADITIONAL SUCTIONING OF ETTs

  1. Obtain a suction catheter with centimeter increments on it.
  2. Insert the suction catheter until the centimeter markings on the ETT and the centimeter markings on the suction catheter are aligned.
  3. Insert the suction catheter no more than 1 cm further. This places the end of the suction catheter 0.5 cm past the end of the ETT.

Measuring can be difficult if tape or the tube holder obstructs the numbers on the ETT, or if the suction catheters available do not have markings. Suction catheter vendors will provide products that have centimeter markings upon request.

TRADITIONAL SUCTIONING OF ETTs

  1. Add the length of the ETT, the length of the ETT adapter, and 1 cm to determine the length of the catheter.
  2. Document in writing the depth of suction in centimeters either at the bedside, on the kardex, or on the plan of care.

ETTs are sometimes cut and the adapter is replaced. Therefore, it is important to make sure that the actual length of the ETT is known.

TRADITIONAL SUCTIONING OF ETTs OR TTs

  1. Place an appropriately sized suction catheter into an ETT or TT of the same size that the patient requires.
  2. After inserting the suction catheter to the appropriate depth for suctioning, post the information at the bedside. The information can be posted in written form or by placing a catheter without centimeter markings at the bedside with a permanent ink mark, or a piece of tape at the appropriate depth.

These methods are less accurate and should only be used until catheters with centimeter markings can be obtained.

IN-LINE ETT OR TT SUCTIONING

  1. Add the length of the ETT, the length of the ETT or TT adapter, and 1 cm to determine the length of the suction catheter.
  2. Advance the catheter until the appropriate length can be viewed through the in-line suction catheter’s window.
  3. Document in writing the depth of suction in centimeters either at the bedside, on the kardex, or on the plan of care.

Request the manufacturer’s recommendations for how to pre-measure the length of the suction catheter. Perform a trial of recommendations with a "wasted" artificial airway and suction catheter before implementing the procedure globally in the unit to test the validity of the recommendations; that is, that the suction catheter extends no more than 1 cm past the end of the artificial airway.

IN-LINE OR TRADITIONAL SUCTIONING OF ETT OR TT

Place poster boards with each type of ETT or TT used in the unit in a prominent location, with the proper size of suction catheter and depth of suctioning noted on the board. This method decreases the need for repeated measurements. This recommendation only works for ETTs or TTs that have not changed length due to cutting. Posting a TT and a suction catheter at the bedside for families who are learning to suction at the appropriate depth, assists in understanding of process.

References

  1. Bailey C, Buckley T, Kattwinkel J, Teja K. Shallow versus deep endotracheal suctioning in young rabbits: pathologic effects on the tracheobronchial wall. Pediatrics. 1988;82:746–751.[Abstract/Free Full Text]
  2. Turner BS, Loan LA. Tracheobronchial trauma associated with airway management in neonates. AACN Clin Issues. 2000;11:283–299.[Medline]
  3. Thambrian AK, Ripley SH. Observations on tracheal trauma following suction: an experimental study. Br J Anesthesiol. 1966;38:459–462.
  4. Swartz K, Noonan DM, Edwards-Beckett J. A national survey of endotracheal suctioning techniques in the pediatric population. Heart Lung. 1996;25(10):52–60.[Medline]
  5. Kleiber C, Krutzfield N, Rose EF. Acute histologic changes in the tracheo-bronchial tree associated with different suction catheter insertion techniques. Heart Lung. 1988;17(1):10–14.[Medline]
  6. Lynn-McHale DJ, Carlson KK, eds. AACN Procedure Manual for Critical Care. 4th ed. Philadelphia, Pa: WB Saunders Company; 2001:41–48.
  7. Chang VM. Protocol for prevention of complications of endotracheal intubation. Crit Care Nurse. October 1995; 15:19–20, 23–27.[Medline]
  8. Wrightson DD. Suctioning smarter: answers to eight common questions about endotracheal suctioning in neonates. Neonat Network. 1999;8(10):51–55.



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M. F. D. Pate and R. E. St. John
Placement of endotracheal and tracheostomy tubes
Crit. Care Nurse, June 1, 2004; 24(3): 13 - 14.
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