CLINICAL PROCEDURE MUHCmuhcnicu.weebly.com/uploads/2/4/3/...nasopharyngeal... · Clinical Procedure – Peds Oro & Nasopharyngeal Suction – Final Update April 6, 2017 2 3. INDICATIONS

Clinical Procedure – Peds Oro & Nasopharyngeal Suction – Final Update April 6, 2017 1

CLINICAL PROCEDURE – MUHC

Medication included No Medication included

THIS IS NOT A MEDICAL ORDER

Title: Oropharyngeal and nasopharyngeal suction for neonatal and pediatric patients

This procedure is attached to:

Interprofessional protocol: Ventilator associated pneumonia in the neonatal and pediatric population: Prevention, surveillance, diagnosis and treatment

Interprofessional protocol: Installation and maintenance of bubble continuous positive airway pressure (CPAP)

MUHC Infection Control Guidelines

MUHC Hand Hygiene Policy

MUHC Policy: Patient Double Identification

Routine Practices for Acute Care In-patient Settings and the Emergency Room – Adults and Pediatrics

Collective order: Initiation of Oxygen Pediatric Site

1. DEFINITION AND PURPOSE

The purpose of this protocol is to describe the procedure for oropharyngeal and nasopharyngeal suction for the neonatal and pediatric population.

Note: For guidelines for oropharyngeal and nasopharyngeal suction for patient on bubble CPAP, refer to the interprofessional protocol: Installation and maintenance of bubble CPAP

2. PROFESSIONALS INVOLVED

Nurses, physiotherapists and respiratory therapists who care for neonatal and pediatric patients requiring oropharyngeal and nasopharyngeal suctioning and have reviewed the protocol

Candidate to the Practice of Nursing (CPNs) and licensed practical nurses (LPNs) who meet the above criteria, working within the limits of their role and in collaboration with a nurse


3. INDICATIONS

Note: Suctioning should be performed only when clinically indicated due to invasiveness of the procedure

and the potential to cause harm.

A patient may require suction when:

Unable to clear their own secretions or cough effectively

Oxygen saturation is below acceptable level for patient’s condition as per collective order or

individual order

Presence of visible or audible secretions

Increased respiratory effort

Poor or difficult feeding secondary to nasal congestion

Change in skin color compatible with poor oxygenation (Note: Cyanosis is a late sign of hypoxia)

4. CONTRAINDICATIONS

Absolute contraindications:

Suspected epiglottitis or croup

Basal skull fracture

Head injury until basal skull fracture is ruled out

Relative contraindications:

Oesophageal fistulae

Occluded nasal passage

Severe bronchospasm

Stridor at auscultation

High intracranial pressure (ICP)

Leakage of cerebral spinal fluid

Severe epistaxis

Post-tonsillectomy/post-adenoidectomy

Post-operative period for surgeries involving the nose, throat or palate

Neutropenia

* Consult physician prior to initiating the procedure in the presence of a relative

contraindication

5. PRECAUTIONS

For patients with a platelet count less than 30 000 (30 X 109) or with a bleeding disorder (such as

hemophilia) proceed with caution and be aware that suctioning may provoke bleeding. Ensure appropriate monitoring.


6. POTENTIAL COMPLICATIONS

Infection

Hypoxia

Trauma to pharynx or bleeding

Cardiovascular disturbances (hypertension, arrhythmia, bradycardia)

Laryngospasm/bronchospasm

Increased ICP

Vomiting

7. PROCEDURE

Procedure for oro or nasopharyngeal suctioning using a suction catheter:

Equipment needed:

Sterile suction catheter or suction kit containing the required size suction catheter. Refer to the

Table 1 for guidance in selecting the appropriate catheter size. Note: Catheter must not exceed

more than 50% of the internal diameter of the nostril.

Table 1: Guidelines for selecting suction catheter size

Age of child Catheter size

Premature baby 6 French

Neonate 6 to 8 French

Child 1 month to1 year of age 8 to10 French

Child 1 to 8 years of age 10 French

Child greater than 8 years old 10 to 14 French


Sterile water or sodium chloride 0.9% (NS) to rinse catheter

Suction source with suction gauge and suction canister

Oxygen source and appropriately sized equipment to administer oxygen available if required

Mask, protective eyewear, and gown

Lubricant

Eye protection for the patient (for example glasses) if required

If not using suction kit the following additional equipment is required:

A clean container such as a disposable cup in which to pour sterile water or NS

used to rinse suction catheter

Non-sterile gloves

Procedure:

General principles:

Nasopharyngeal suction is performed as a “clean” procedure but a sterile catheter should be

used. The use of sterile gloves is not necessary.

Normal saline does not mix with mucus so does not thin or mobilize secretions. The practice of

instilling normal saline (NS) to facilitate secretion removal is not supported in the literature so has

not been included in this procedure.

1. Explain procedure to the patient and/or family.

2. Assemble necessary equipment. Ensure that oxygen is available at the bed side; equipment must

be checked to ensure it is fully operational.

3. Consider having a second person to assist if required

4. Set wall suction to the appropriate setting as per guidelines below.

Age of child Suction gauge setting

Neonate/Infant 80-100 mmHg

Child 100-120 mmHg

Adult 100-150 mmHg

5. Wash hands according to MUHC infection control guidelines.

6. Don gown, gloves, mask and protective eyewear.

7. Position patient appropriately to provide ease of access for the procedure and promote patient

comfort.

8. If there is a risk of secretions falling into the patient’s eyes during the procedure, consider

covering the patient’s eyes

9. Using a clean technique, open suction kit or suction catheter and prepare equipment for

suctioning. Pour sterile water or normal saline into sterile container provided in suction kit or a

clean container.


10. Test suction level by occluding thumb port. Suction should be adjusted if it exceeds

recommended level.

11. The length of catheter to be inserted is determined by the distance from the tip of the nose to the

angle of lower jaw. (see image 1)

Image 1: Length of catheter to be inserted

Nose Suctioning

#1948 December 2013 Page 2 of 2

Steps (Continued)

9. Test the suction. Put the tube in the bowl of water. Put your finger over the suction

port. Suction a small amount of water with the tube. This will check the suction. It will

also make the suction tube e

10.

This may help loosen thick mucous.

11. Measure for correct suction depth. Put the tube

face. Measure from the tip of the nose to the tip of the ear lobe with the tube.

Keep your fingers on this spot so you do not suction too

far.

12. Gently put the tip of the tube into the nostril.

13. Point the suction tube straight back toward the ear, not up

toward the eye.

Do not:

Go any deeper than the length you measured.

Suction as you put in the tube.

Force the tube. If the tube does not go in easy,

pull back, adjust your angle and try again.

14. After the tube is in, out. open and close the port often as you pull the tube out of the

nose. Do not do suction longer than 10 seconds each time you enter the nose.

15. After you are done suctioning your child, suction a small amount of water into the tube

to clear it of mucous. The mucous and water will go into the storage jar of the suction

machine. Empty this storage jar every day. Teaching sheet #1462- Portable Home

Suction will teach you how to clean the machine.

Repeat steps #11 to 15 until most of the mucous is gone from

are clear. When suctioning is done, rinse the tube one last time. Turn the suction machine off

and take out the tube. Store the tube in the original container. You may re-use the same tube

for one day (24 hours).

ALERT: your child has special health care needs not covered by this information.

This teaching sheet is meant to help you care for your child. It does not take the place of medical care. Talk with your healthcare provider for diagnosis, treatment, and follow-up.

Measure tip of nose to ear lobe

12. Lubricate catheter by aspirating sterile water or NS. This also permits verification of catheter

patency and adequacy of negative pressure. Lubricant can also be used if required.

13. Catheter should be inserted gently into the nostril. Hold the catheter so that its natural curve is

aligned with the child’s trachea. Without applying suction, insert catheter into child’s nostril, using

an upward motion until the nasal septum is passed and then using the downward motion until the

epiglottis is felt or you have reached the pre-measured distance. Do not proceed if resistance is

felt. Remove catheter and attempt using other nostril.

14. During withdrawal, apply constant suction limited to no more than 10-15 seconds. Catheter must

not be rotated on removal but withdrawn straight out of airway. Always withdraw the suction

catheter away from (not over) the patient’s eyes.

15. Suction sterile water or normal saline through the catheter to rinse in between suction passes and

at the end of suction procedure.

16. Proceed to suction the other nostril using the same technique allowing a few seconds between

passes for the patient to recover.


17. While performing the procedure, the child must be continuously observed for signs of

deterioration. Monitor respiration rate and quality, colour, heart rate, SpO2 (if already monitored),

and aspirate obtained (quantity, colour, viscosity, and odour).

18. Discard used equipment and wash hands. See page 5 for recommendations for the management

of equipment used for oral or nasopharyngeal suction.


Procedure for oral or nasal suctioning using an oral/ nasal suction device (such as Little

Sucker®):

Equipment needed:

Oral and nasal suction device such as Little Sucker®

Non-sterile gloves

Sterile water or NS to rinse catheter

Mask, protective eyewear and gown if required

Oxygen source

Clean container such as a disposable cup in which to pour sterile water or NS to rinse catheter

Procedure:

1. Explain procedure to patient and/or family

2. Assemble necessary equipment. Ensure oxygen is available at the bedside. Check equipment to

ensure it is fully operational prior to initiating procedure.

3. Consider having a second person assist if required.




Child 100-120 mmHg

Adult 100-150 mmHg

5. Wash hands as per MUHC infection control guidelines

6. Don gloves and personal protective equipment if required.

7. If suctioning both the oropharynx and the nasopharynx, the nasopharynx should be suctioned

first. Avoid returning to the nasopharynx after having suctioned the patient’s mouth.

8. Test suction level by occluding thumb port. Suction should be adjusted if it exceeds

recommended level.

9. Insert suction device without applying suction.

10. Block thumb port with thumb to begin suctioning. Unblock thumb port to stop suctioning. Suction

mouth or nares with intermittent suction.


11. Suction sterile water or NS through the catheter to rinse in between suction passes and at the

end of suction procedure.

12. Discard used equipment and wash hands. See below for recommendations for the management

of equipment used for oral or nasopharyngeal suctioning.


Procedure for oral suctioning using an oral suction device:

Equipment needed:

Oral suction device such as a Yankauer suction tip

Non-sterile gloves

Sterile water or NS to rinse catheter

Mask, protective eyewear and gown if required

Clean container such as a disposable cup in which to pour sterile water or NS to rinse catheter

Procedure:

1. Explain procedure to patient and/or family

2. Assemble necessary equipment. Ensure that oxygen is available at the bed side; equipment must

be checked to ensure it is fully operational.

3. Consider having a second person to assist if required




Child 100-120 mmHg

Adult 100-150 mmHg

5. Wash hands as per MUHC infection control guidelines.

6. Don gloves and personal protective equipment if required

7. Suction oropharyngeal secretions as required. Never use an oral suction tip to suction the nasopharynx. Intermittent suction is not available when using this device and could result in mucosal injury.

8. Suction sterile water or NS through the catheter to rinse in between suction passes and at the

end of suction procedure.

9. Discard used equipment and wash hands. See below for recommendations for the management of equipment used for oral or nasopharyngeal suctioning.


Recommendations for the management of equipment used for oro or nasopharyngeal suction

Suction catheters, suction kits and clean container used to rinse catheter are single use and must

be discarded after use

The suction canister lining should be changed when ¾ full

The suction tubing must be changed at least every 7 days and when visibly soiled to prevent

growth of bacteria according to unit practice

Oral/nasal suction devices (Little Sucker®) and oral suction devices (Yankauer suction tip) should

be changed every 24h or when visibly soiled to prevent growth of bacteria. In between changes,

the suction device should be kept in its protective sheath or packaging or in a clean plastic bag.

8. DOCUMENTATION IN CHART

Document procedure in the patient’s medical record: describe quantity, color, viscosity, and odour of

secretions as applicable; report any abnormal findings and adverse clinical reactions (such as

desaturation, bradycardia, hypertension, apnea or laryngospasm).

MAIN AUTHOR:

Vincent Ballenas, MSc, NPDE pediatric medicine

Eren Alexander, MSc, Nursing Practice Consultant

CONSULTANTS:

Johanne Boyer, Technical Coordinator Respiratory Therapy

Marco Bianchi, Nurse clinician ENT clinic

NPDQM Committee

Martine Lafond, Infection control nurse

Caroline Foucault, Interim NPDE Pediatric ER

Stephanie Lepage, NPDE pediatric surgery

Margaret Powell, NPDE PICU

Deborah Meldrum, NPDE Hem Onc

Manon Ranger, PhD, Evidence-Informed Decision Making Advisor


9. APPROVAL PROCESS

Committees Date

[yyyy-mm-dd]

Clinical Practice Review Committee (if applicable) 2017-01-19

Updated

2017-04-06

Adult Pharmacy and Therapeutics (if applicable) N/A

Pharmacy and Therapeutics Pediatrics (if applicable) N/A

MUHC Pediatric Medication Administration Policy (PMAP) (if applicable) N/A

10. REVIEW DATE

To be updated in maximum of 4 years (2021) or sooner if presence of new evidence or need for practice change.

11. REFERENCES

1. Advanced Paediatric Life Support Group (2011). Advanced Paediatric Life Support- The Practical

Approach (5th Ed.). BMJ books. Oxford, UK: Wiley-Blackwell publishing.

2. Carsten, J. (2010). Evidence Summary: Pharyngeal Suction- Clinician Information. The Joanna

Briggs Institute. Accessed online: 21/02/2012

http://www.jbiconnectplus.org/ViewDocument.aspx?0=3927

3. Day T., Farnell, S., and Wilson-Barnett, J. (2002). Suctioning: a review of current research

recommendations. Intensive and Critical Care Nursing 18(2), 79-89.

4. Glass, CA, Grap, MJ. (1995). Ten tips for safer suctioning. American Journal of Nursing 5, 51-53.

5. Griggs, A. (2008). Oral/Nasal-pharyngeal suctioning. Royal Free Hampstead, National Health

Service (NHS) Trust. Accessed online: 13/02/2012 http://www.royalfree.nhs.uk/

6. Hayes, JS and Czarnecki, CL. (1999). Infant Nasal-Pharyngeal Suctioning: Is it Beneficial?

Pediatric Nursing 25(2),193-198.

7. Little Sucker® Oral and Nasal Suction Device, Neotech Products Inc. Directions for use.

8. Macmillan, C. (1995). Nasopharyngeal suction study reveals knowledge deficit. Nursing Times

91(50), 28-30.

9. Matthews, PJ. (1994). Six Steps for Safe Suctioning. Nursing 24(2), 18.

10. Simpson, S. (2011). Airway Suction. Clinical Guidelines/Health professionals/Great Ormond

Street Hospital. Accessed online: 13/02/2012 http://www.gosh.nhs.uk/health-

professionals/clinical-guidelines/airway-suction/

11. Western Sydney Health Service (2003). Oropharyngeal & Nasopharyngeal Suctioning. Intensive

Care. Evidence Based Practice Guidelines. Accessed online: 13-02-2012.

http://intensivecare.hsnet.nsw.gov.au/five/doc/suctioning_upper_airways_V_swahs.pdf

http://www.jbiconnectplus.org/ViewDocument.aspx?0=3927

http://www.royalfree.nhs.uk/

http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/airway-suction/

http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/airway-suction/

http://intensivecare.hsnet.nsw.gov.au/five/doc/suctioning_upper_airways_V_swahs.pdf


Appendix 1

Comparative table of different suction equipment used for oral or nasal suctioning

Type of suction equipment Type of suction

Indication

Suction catheter

Intermittent

Oropharyngeal and nasopharyngeal suction

Little sucker™

Intermittent

Oral and nasal suction

Oral suction device

Continuous

Oral suction

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CLINICAL PROCEDURE MUHCmuhcnicu.weebly.com/uploads/2/4/3/...nasopharyngeal... · Clinical Procedure – Peds Oro & Nasopharyngeal Suction – Final Update April 6, 2017 2 3. INDICATIONS