Introduction:
A healthy person breathes in clean, oxygen-rich air through his nose that passes through his trachea (windpipe) to his lungs. In critically ill or injured patients who need breathing assistance, artificial airways (tubes) are used to facilitate breathing. The tubes used in artificial airways can get blocked with secretions and need clearing to ensure that air can pass through easily and reach the lungs. Artificial airway suctioning is the procedure done to clear the tubes, and it plays a vital role in artificial airway management.
What Are Artificial Airways?
Procedures to manage airways are life-saving and facilitate complex patient care. Emergency intubations (artificial insertion of tubes) are done for various medical emergencies, including critical illness and trauma. Artificial airways are devices used to secure breathing and respiration when the patient is not able to breathe or maintain a clear passage of air. These devices are inserted to create a clear path for the oxygen-rich air to reach the lungs. The commonly used devices for artificial airways include:
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Laryngeal Mask Airway: These devices are used to open and maintain the airway temporarily. They facilitate ventilation without a secure airway. These are used when we administer general anesthesia or as an emergency measure to save the lives of patients with a failed airway.
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Endotracheal Tube: These are the most preferred devices (tubes) to secure airways in medical emergencies, critical illness, trauma, and complex patient care, including out-of-hospital cardiac arrests.
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Tracheostomy Tube: These are curved tubes used in case of emergencies when other devices cannot be used and during prolonged ventilation. These are inserted into the slits made in the neck and trachea (windpipe) to enable breathing.
When Should Artificial Airways Be Suctioned?
When an artificial airway is placed, the tubes get blocked with secretions, blood, or other materials, affecting the airflow to the lungs. Suctioning helps to maintain hygiene and improves breathing by rapidly clearing out the blocks. It is done as an integral procedure to maintain artificial airways and, whenever necessary, to keep the airway tubes clear (patent). The ventilator (the machine that helps a sick person to breathe) is observed for waveform (the curves and loops seen on the monitor). The presence of a specific pattern (saw-tooth pattern) in the ventilator monitor indicates the need for suctioning the artificial airway. The presence of visible secretions in the tubes and abnormal respiratory sounds also mandate the need for suctioning.
How Is Artificial Airway Suctioning Performed?
Artificial airway suctioning is a quick procedure. Suctioning is done as an integral procedure, as part of the protocol, or at different times depending on the patient’s need. It is usually performed by respiratory therapists, physicians, trained nurses, and at times caregivers (with proper training). During the procedure, the patient’s heart rate and blood oxygen levels are continuously monitored. A sterile suction catheter (small tube) attached to the suction is inserted into or attached to the artificial airway to remove secretions blocking it. The catheter is inserted to an appropriate depth to avoid bleeding or trauma. Care is also taken to choose an appropriately sized catheter. A suction pressure of less than 200 mmHg is used for adults. The suction tube or catheter can be single-use and disposable, or it may be continuously attached to the artificial airway. This helps maintain a clear pathway for airflow. Each insertion of the suction catheter is kept short (less than 15 seconds), and the patient is allowed to recover between each insertion of the suction catheter tube.
Is Pre-oxygenation Necessary for Artificial Airway Suctioning?
Before suctioning, the patient is given 100 % oxygen (FiO2 - a fraction of inspired oxygen) with a self-inflating bag or through the ventilator (in case of mechanical ventilation). This process of administering oxygen before the procedure is called preoxygenation or hyperoxygenation. This is important as airway suctioning can cause a significant reduction in the blood oxygen level or hypoxemia during the process. The blood oxygen levels are continuously monitored throughout the suctioning procedure.
What Is Open and Closed System Suctioning?
There are two methods to perform suctioning of artificial airways - open suctioning and closed suctioning. In the open suctioning procedure, the patient has to be disconnected from the ventilator (the machine that helps with breathing) to clear the artificial airway. It was commonly used initially as the standard of care for intubated patients. The single-use catheter or suctioning tube is used in open suctioning. However, at present, closed suctioning is the standard method used. Closed suctioning involves in-line suctions - suction tubes inserted into the artificial airway tubes such as the endotracheal tubes. As the suction tube is attached as a part of the ventilator circuit, it prevents the need to disconnect from the ventilators during suctioning. This is considered the safer method. Open suctioning offers several advantages, including:
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Improved oxygenation.
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Decreased loss of blood oxygen levels.
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Limited contamination (of the personnel and the patient). Prevents cross-contamination and infections.
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Minimal disruption to the patient and better lung health.
What Are Superficial and Deep Suctioning Techniques?
The depth to which the suction tube or catheter is inserted depends on the need of the patient. In the superficial suctioning technique, the suction tube is inserted only up to the end of the artificial airway tubes (endotracheal or tracheostomy tubes). This method is most commonly used as it is safer and minimizes injury to the airway mucosa. Deep suctioning is used only when shallow suctioning is ineffective and involves going deeper with the suction tube till resistance is met. Careful monitoring is essential in deep suctioning as there is a higher risk of trauma to the tissues.
Are There Any Risks for Artificial Airway Suctioning?
Suctioning artificial airways have some risks and complications associated with the procedure. Common risks include:
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Discomfort.
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Injury to the airway tissues.
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Bleeding in the airway.
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Decreased oxygen levels in the blood.
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Slow heart rate.
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Infections.
These issues can be prevented and managed by the clinical staff by careful monitoring and following the standards of care during suctioning.
Conclusion:
Suctioning is an integral component of artificial airway management. It is done as needed, based on the patient’s clinical condition, blood oxygen level, respiratory rate, and the presence of visible secretions in the airway. This procedure helps to improve airflow to the lungs. However, there are several risks and complications associated. The potential risks and benefits for the patient must be assessed before performing the procedure.
