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Objectives

  1. Describe techniques for airway clearance in mechanically ventilated patients.

  2. List complications of endotracheal suction.

  3. List techniques to reduce suction-related complications in mechanically ventilated patients.

  4. Describe the effects of lateral and prone positioning on oxygenation.

Introduction

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

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 used to improve airway clearance in intubated patients include suctioning, postural drainage therapy with or without percussion and/or vibration, positioning, and bronchoscopy.

Suctioning

Although not a benign procedure, suctioning is an important aspect of airway care. Complications of endotracheal suctioning are listed in Table 36-1. Suction-related complications can often be avoided by use of appropriate technique (Table 36-2). 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; a curved tip catheter is most successful.

Table 36-1Complications of Suctioning
Table 36-2Techniques to Avoid Suctioning-Related Complications

The closed-suction system consists of a catheter within a protective sheath that fits between the ventilator circuit and the airway. The catheter thus becomes part of the ventilator circuit. The sheath protects the catheter from external contamination, and the patient is suctioned without removal from the ventilator. Closed suction prevents alveolar de-recruitment during suctioning and prevents contamination of clinicians during the suction procedure. Because the closed-suction catheter is used repeatedly and because it does not need to be changed at regular intervals, its use is also cost-effective.

Saline Instillation

In the past, saline was often instilled ...

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