Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [198], C).
2. 2.Show
   This is a clean procedure.
   To ensure patient safety (NTSP [206], C).
3. 3.Show
   Cleanse hands with soap and water or an alcohol‐based handrub.
   To minimize the risk of infection (NHS England and NHSI [179], C).
4. 4.Show
   Help the patient to sit in a semi‐recumbent position with the neck slightly extended.
   To ensure patient comfort and allow easy access to the neck area (NTSP [206], C).
5. 5.Show
   Ensure the following are readily available in case required:

   • oxygen supply and masks/tubing
   • resuscitation trolley
   • emergency airway trolley
   • bedside tracheostomy box
   • additional staff.
   To ensure patient safety in the event of an airway emergency (NTSP [206], C).
6. 6.Show
   If the secretions are tenacious, consider nebulizing 0.9% sterile sodium chloride or other prescribed mucolytic agents.
   To loosen dry and thick secretions (Bonvento et al. [28], C).
7. 7.Show
   If the patient is oxygen dependent, pre‐oxygenate them for a period of 1 minute.
   To minimize the risk of hypoxia (Greenwood and Winters [95], C).
8. 8.Show
   If the patient has a fenestrated outer tube, ensure that a plain (non‐fenestrated) inner tube is inserted prior to suctioning.
   Suctioning via a fenestrated inner and outer tube may cause trauma to the tracheal wall (Morris et al. [167], C).

Procedure

1. 9.Show
   Cleanse hands with an alcohol‐based handrub and put on disposable plastic apron, gloves and eye protection.
   To minimize the risk of cross‐infection (NHS England and NHSI [179], C).

   Manipulation of the patient's airway may cause the patient to cough. Eye protection should therefore be worn (NICE [193], C).
2. 10.Show
   1. Turn the suction on and ensure that the pressure is set to an appropriate level. It should not exceed 20 kPa (150 mmHg).
   2. Select the correct size of catheter (see Box 12.8).
   To minimize the risk of atelectasis and mucosal trauma (ICS [116], C; NTSP [206], C).

   A catheter that is too small a diameter may not be effective in removing thick secretions. A catheter that is too big will occlude the tube, cause hypoxia and distress the patient (NTSP [206], C).
3. 11.Show
   Keeping the suction catheter in the sterile pack, open the end and attach it onto the suction tubing. The suction catheter should not be removed from the sterile pack until ready.
   To keep the catheter as sterile as possible, minimizing the risk of cross‐infection. E
4. 12.Show
   Apply an additional clean disposable glove onto the dominant hand.
   To facilitate easy disposal of the suction catheter after use and minimize the risk of cross‐infection. E
5. 13.Show
   Remove oxygen therapy (if applicable).
   To allow access to the tracheostomy tube. E
6. 14.Show
   If performing a shallow suction: remove the catheter from the sterile pack and introduce it into the tracheostomy tube. Ask the patient to cough, then apply suction as secretions meet the catheter. Suction is created by placing a thumb over the suction port.

   If performing a deep suction: introduce the catheter to about one‐third of its length (approximately 10–15 cm) or until the patient coughs. If resistance is felt, withdraw the catheter 1–2 cm before applying suction then slowly withdraw the catheter out.
   Suction is only applied on withdrawal and never on insertion to reduce the risk of mucosal trauma (NTSP [206], C).

   The catheter should go no further than the carina and should be withdrawn slightly before suction is applied to prevent trauma (Greenwood and Winters [95], C).
7. 15.Show
   Suction the patient for no more than 10 seconds.
   Prolonged suctioning may result in acute hypoxia, cardiac arrhythmias, mucosal trauma and significant distress for the patient (NTSP [206], C).
8. 16.Show
   Wrap the catheter around the dominant hand and then pull the glove back over the soiled catheter. Discard immediately into the clinical waste.
   Wrapping the soiled catheter up in the glove minimizes the risk of cross‐infection. E

   Catheters are single use and should be disposed of as per infection control guidelines. E
9. 17.Show
   Repeat the procedure until the airway is clear. No more than three suction passes should be made during any one suction episode (unless in an emergency, such as tube occlusion). A new suction catheter should be used each time, and the patient should be allowed sufficient time to recover in between each suction.
   To minimize the risk of hypoxia, minimize the risk of infection, and cause minimal distress for the patient (NTSP [206], C).

Post‐procedure

1. 18.Show
   Reapply oxygen therapy (if applicable).
   To prevent hypoxia. E
2. 19.Show
   Clear the suction tubing of secretions by dipping it into the sterile water bottle and applying suction until the solution has rinsed the tubing through.
   To loosen and flush secretions that have adhered to the inside of the suction tubing (NTSP [206], C).
3. 20.Show
   Remove apron, gloves and eye protection and dispose of them in the clinical waste. Cleanse hands with soap and water or an alcohol‐based handrub.
   To minimize the risk of infection (NHS England and NHSI [179], C).
4. 21.Show
   Monitor the patient's respiratory status and observations/NEWS. Escalate any concerns or deterioration in condition/NEWS immediately.
   To identify any concerns or clinical deterioration early, and ensure timely escalation to senior staff if required (RCP [230], C).