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## Complete Summary

#### GUIDELINE TITLE

Nasotracheal suctioning --- 2004 revision & update.

#### BIBLIOGRAPHIC SOURCE(S)

American Association for Respiratory Care. Nasotracheal
suctioning\--2004 revision & update. Respir Care 2004 Sep;49(9):1080-4.
\[62 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American Association for
Respiratory Care (AARC). AARC clinical practice guideline. Nasotracheal
suctioning. Respir Care 1992 Aug;37(8):898-901.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Pulmonary disease

#### GUIDELINE CATEGORY

Management\
Treatment

#### CLINICAL SPECIALTY

Critical Care\
Emergency Medicine\
Family Practice\
Geriatrics\
Internal Medicine\
Nursing\
Pediatrics\
Pulmonary Medicine

#### INTENDED USERS

Respiratory Care Practitioners

#### GUIDELINE OBJECTIVE(S)

-   To improve the consistency and appropriateness of respiratory care
    and serve as a guide for education and research

-   To provide clinical practice guidelines on nasotracheal suctioning

#### TARGET POPULATION

Patients of all ages requiring maintenance of a patent airway and
removal of saliva, pulmonary secretions, blood, vomitus, or foreign
material from the trachea and nasopharyngeal area

This guideline applies to patients in a wide variety of settings,
including critical care, emergency room or department, inpatient acute
care, extended care and skilled nursing facility care, home care, and
outpatient or ambulatory care.

#### INTERVENTIONS AND PRACTICES CONSIDERED

Nasotracheal suctioning

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Consultants to the Working Group may review the initial draft of the
guideline. After completion by the Working Group, the draft is reviewed
by the entire Steering Committee and then by a Review Panel (i.e.,
persons engaged in all facets of the delivery of respiratory care who
have volunteered to review drafts of the Guidelines before publication).

The 2004 Update was approved by the 2003 Clinical Practice Guideline
(CPG) Steering Committee.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Procedure**

Nasotracheal suctioning (NTS) for tracheal aspiration is a component of
bronchial hygiene therapy.

**Description/Definition**

NTS is intended to remove accumulated saliva, pulmonary secretions,
blood, vomitus, and other foreign material from the trachea and
nasopharyngeal area that cannot be removed by the patient\'s spontaneous
cough or other less invasive procedures. NTS has been used to maintain a
patent airway thus ensuring adequate oxygenation and ventilation and
avoiding intubation that was solely intended for the removal of
secretions.

NTS refers to the insertion of a suction catheter through the nasal
passage and pharynx into the trachea without a tracheal tube or
tracheostomy (although a nasopharyngeal airway may be used) in order to
aspirate accumulated secretions or foreign material.

The clearance of secretions is accomplished by application of
subatmospheric pressure applied to a sterile, flexible, multi-eyed
catheter on withdrawal only. Appropriate subatmospheric pressures are

-   Neonates: 60-80 mm Hg

-   Infants: 80-100 mm Hg

-   Children: 100-120 mm Hg

-   Adults: 100-150 mm Hg

Negative pressures should not exceed 150 mm Hg as higher pressures have
been shown to cause trauma, hypoxemia, and atelectasis.

**Settings**

NTS is performed in a wide variety of settings, and this guideline
applies to patients of all ages.

-   Critical care

-   Emergency room or department

-   Inpatient acute care

-   Extended care and skilled nursing facility care

-   Home care

-   Outpatient or ambulatory care

**Indications**

The need to maintain a patent airway and remove saliva, pulmonary
secretions, blood, vomitus, or foreign material from the trachea in the
presence of:

-   Inability to clear secretions when audible or visible evidence of
    secretions in the large/central airways that persist in spite of
    patient\'s best cough effort. This is evidenced by one or more of
    the following

    -   Visible secretions in the airway

    -   Chest auscultation of coarse, gurgling breath sounds, rhonchi,
        or diminished breath sounds

    -   Feeling of secretions in the chest (increased tactile fremitus)

    -   Suspected aspiration of gastric or upper airway secretions

    -   Clinically apparent increased work of breathing

    -   Deterioration of arterial blood gas values suggesting hypoxemia
        or hypercarbia

    -   Chest radiographic evidence of retained secretions resulting in
        atelectasis or consolidation

    -   Restlessness

-   To stimulate cough or for unrelieved coughing

-   To obtain a sputum sample for microbiological or cytological
    analysis

**Contraindications**

Refer to the \"Contraindications\" field or see the original guideline
document.

**Hazards/Complications**

Refer to the \"Potential Harms\" field or see the original guideline
document for information.

**Limitations of Method**

-   NTS is a blind procedure with inherent risks (refer to
    complications).

-   Risks are increased in a combative or uncooperative patient.

-   Duration of application of subatmospheric pressure, or suction,
    should be limited to no greater than 15 seconds.

-   Controversy exists concerning possible overuse of this procedure.

**Assessment of Need**

-   Personnel should perform a baseline assessment for indications of
    respiratory distress and the need for NTS as recognized by
    presenting indications listed above. This should include but not be
    limited to:

    -   Auscultation of chest

    -   Monitor patient\'s heart rate

    -   Respiratory rate

    -   Cardiac rhythm

    -   Oxygen saturation

    -   Skin color and perfusion

    -   Personnel should assess effectiveness of cough.

-   Prepare the patient for the procedure by providing an appropriate
    explanation along with adequate sedation and pain relief as needed.

**Assessment of Outcome**

Effectiveness of NTS should be reflected by assessing patient post
suction for:

-   Improved breath sounds

-   Removal of secretions

-   Improved blood gas data or pulse oximetry

-   Decreased work of breathing (decreased respiratory rate or dyspnea)

**Resources**

-   Equipment:

    -   Vacuum source

    -   Calibrated, adjustable regulator

    -   Collection vessel and connecting tubing

    -   Sterile, flexible, multiple-eyed suction catheter of appropriate
        caliber

    -   Sterile disposable gloves

    -   Sterile water and cup

    -   Water-based lubricant and/or normal saline

    -   Local anesthetic is sometimes used to reduce discomfort.

    -   Nasopharyngeal airway when frequent NTS is required

    -   Resuscitation bag with mask

> In the acute care setting, with initiation of NTS, or when working
> with the unstable patient, the following are recommended:

-   Electrocardiogram (EKG) monitor

-   Oxygen (hyperoxygenation with appropriate delivery device as
    indicated)

-   Personnel protective equipment for Standard Precautions

-   Stethoscope

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-   Personnel:

    -   **Level I** caregiver may be the provider of service *after*
        Level II personnel have established need by patient assessment
        and the first NTS episode has been completed. Level I personnel
        must demonstrate:

        -   Knowledge of proper assembly and use of equipment

        -   Knowledge of upper airway anatomy and physiology

        -   Ability to recognize secretion retention on auscultation

        -   Ability to monitor vital signs and assess patient\'s
            condition and response to procedure

        -   Ability to recognize and respond to adverse reactions and
            complications of procedures

        -   Ability to employ technique of cardiopulmonary resuscitation
            when indicated

        -   Ability to evaluate and document procedure effectiveness and
            patient response

    -   **Level II** provider initially assesses the patient, determines
        the need for NTS, and evaluates response to and effectiveness of
        first episode. **Level II** personnel have all the skills of
        Level I providers plus:

        -   Knowledge and understanding of patient\'s disease, goals,
            and limitation of NTS

        -   Recognition and understanding of basis of pathophysiology

        -   Ability to perform initial treatment and be available to
            troubleshoot the procedure

        -   Ability to modify techniques and equipment and take
            definitive action in response to adverse reaction

        -   Ability to detect adverse reactions and avoid patient harm
            by employing techniques of cardiopulmonary resuscitation
            with mechanical airway adjuncts and bag-mask devices

        -   Knowledge of basic electrocardiogram (EKG) and dysrhythmia
            recognition

        -   Knowledge of signs and symptoms of decreased cardiac output,
            oxygenation, and perfusion

        -   Ability to teach Level I and lay personnel providing home
            care

    -   Home care should be provided by lay personnel trained and
        knowledgeable in

        -   Proper assembly and use of equipment

        -   Correct positioning of patient

        -   Proper suctioning technique

        -   Signs and symptoms of respiratory distress

        -   Assessment of patient response to procedure

        -   Response to adverse reaction

        -   Care and cleaning of equipment

**Monitoring**

The following should be monitored before, during and following the
procedure.

-   Breath sounds

-   Skin color

-   Breathing pattern and rate

-   Pulse rate, dysrhythmia, electrocardiogram (EKG) if available

-   Color, consistency, and volume of secretions

-   Presence of bleeding or evidence of physical trauma

-   Subjective response including pain

-   Cough

-   Oxygenation (pulse oximeter)

-   Intracranial pressure (ICP), if equipment is available

-   Laryngospasm

**Frequency**

Nasotracheal suctioning should be performed by a skilled caregiver when
indicated and when other methods to remove secretions from airway have
failed.

**Infection Control**

-   The Centers for Disease Control and Prevention (CDC) Guidelines for
    Standard Precautions should be adhered to.

-   All equipment and supplies should be appropriately disposed of or
    disinfected.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Improved bronchial hygiene

-   Effective nasotracheal suctioning, resulting in improved breath
    sounds and blood gas data or pulse oximetry, removal of secretions,
    and decreased respiratory rate.

#### POTENTIAL HARMS

-   Mechanical trauma (mucosal hemorrhage, tracheitis, epistaxis from
    laceration of nasal turbinates, and perforation of the pharynx)

    -   Laceration of nasal turbinates

    -   Perforation of the pharynx

    -   Nasal irritation/bleeding

    -   Tracheitis

    -   Mucosal hemorrhage

    -   Uvular edema

-   Hypoxia/hypoxemia

-   Cardiac dysrhythmias/arrest

-   Bradycardia

-   Increase in blood pressure

-   Hypotension

-   Respiratory arrest

-   Uncontrolled coughing

-   Gagging/vomiting

-   Laryngospasm

-   Bronchoconstriction/bronchospasm

-   Discomfort and pain

-   Nosocomial infection

-   Atelectasis

-   Misdirection of catheter

-   Increased intracranial pressure (ICP)

    -   Intraventricular hemorrhage

    -   Exacerbation of cerebral edema

-   Pneumothorax

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

Listed contraindications are relative unless marked as absolute.

-   Occluded nasal passages

-   Nasal bleeding

-   Epiglottitis or croup (absolute)

-   Acute head, facial, or neck injury

-   Coagulopathy or bleeding disorder

-   Laryngospasm

-   Irritable airway

-   Upper respiratory tract infection

-   Tracheal surgery

-   Gastric surgery with high anastomosis

-   Myocardial infarction

-   Bronchospasm

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

Controversy exists concerning possible overuse of nasotracheal
suctioning.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Safety

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

American Association for Respiratory Care. Nasotracheal
suctioning\--2004 revision & update. Respir Care 2004 Sep;49(9):1080-4.
\[62 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1992 Aug (revised 2004 Sep)

#### GUIDELINE DEVELOPER(S)

American Association for Respiratory Care - Professional Association

#### SOURCE(S) OF FUNDING

American Association for Respiratory Care (AARC)

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Author*: Kim Bennion, RRT, Primary Children\'s Medical Center,
Salt Lake City, Utah

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American Association for
Respiratory Care (AARC). AARC clinical practice guideline. Nasotracheal
suctioning. Respir Care 1992 Aug;37(8):898-901.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American Association for Respiratory Care (AARC) Web
site](http://www.rcjournal.com/contents/09.04/09.04.1080.pdf).

Print copies: Available from the American Association for Respiratory
Care (AARC), CPG Desk, 11030 Ables Ln, Dallas, TX 75229-4593; Web site:
[www.aarc.org](http://www.aarc.org/).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on November 30, 1998. The information
was verified by the guideline developer on December 15, 1998. This NGC
summary was updated by ECRI on March 21, 2005.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008