Describe techniques for airway clearance in mechanically ventilated patients.
List complications of endotracheal suction.
List techniques to reduce suction-related complications in mechanically ventilated patients.
Describe the effects of lateral and prone positioning on oxygenation.
Airway clearance is important in the care of mechanically ventilated patients. These therapies include suctioning, saline instillation, bronchoscopy, postural drainage therapy, and positioning. Failure to adequately attend to the bronchial hygiene needs of the patient can complicate the course of mechanical ventilation.
Airway clearance is impaired in intubated patients due to decreased mucociliary activity and inability to cough effectively. Mucociliary activity is impaired due to the presence of the artificial airway, airway trauma due to suctioning, inadequate humidification, high Fio2, drugs (eg, narcotics), and underlying pulmonary disease. Cough effectiveness is impaired due to the presence of the artificial airway and depressed neurologic status. Methods commonly used to improve secretion clearance in intubated patients include suctioning, postural drainage therapy with or without percussion and/or vibration, positioning, and bronchoscopy.
Hyperinflation of the lungs with a manual ventilator is a technique that has been used to facilitate secretion clearance in intubated patients. However, high level evidence is lacking that this technique improves secretion clearance. Moreover, it may increase the likelihood of lung injury and hemodynamic complications due to the high airway pressures that might be applied during hyperinflation therapy.
Although not a benign procedure, suctioning is an important aspect of airway care. Complications of endotracheal suctioning are listed in Table 34-1. Suction-related complications can often be avoided by use of appropriate technique (Table 34-2). Techniques to facilitate selective endobronchial suctioning (particularly of the left) include use of curved tip catheters, turning the patient's head to the side (eg, turning the head to the right to facilitate suctioning of the left bronchus), and lateral positioning. Of these, the use of a curved tip catheter is most successful.
Table 34-1Complications of Suctioning ||Download (.pdf) Table 34-1 Complications of Suctioning
• Airway trauma
• Cardiac arrhythmias
• Selective secretion clearance from the right bronchus
• Increased intracranial pressure
• Coughing and bronchospasm
Table 34-2Techniques to Avoid Suctioning-Related Complications ||Download (.pdf) Table 34-2 Techniques to Avoid Suctioning-Related Complications
• Hyperoxygenation with = 1
• Use closed-suction catheter
• Use proper catheter size
• Use least amount of vacuum necessary to evacuate secretions
• Use a gentle technique
• Limit the time of each suction attempt
• Suction only during withdrawal of the catheter
The closed-suction system consists of a catheter within a protective sheath that fits between the ventilator circuit and the airway. The ...