Tracheostomy Suctioning – Clean Technique

*THIS PROCEDURE IS TYPICALLY PERFORMED BY A REGISTERED NURSE

The use of this procedure guideline assumes that the registered nurse has the nursing education and skills to perform this task. This procedure guideline does not replace nursing clinical judgment.

This procedure is a general guideline and as this is a complex procedure for the school setting, the school nurse should communicate with the student’s parents/guardians and health care providers to determine how the procedure should be performed.

Considerations:

• When caring for a student who has a tracheostomy, the school nurse should always know the reason for the tracheostomy, the student’s underlying health conditions and whether the student needs the tracheostomy to breathe.
• Attempt to provide the student with as much privacy as possible, given the urgency of the situation.
• Is suctioning necessary or can the student “cough out the secretions?”
  • Encourage the student to cough to expel the secretions.
  • If secretions clear and there are no signs of respiratory distress, do not suction.
• There should always be a “GO BAG” (Emergency Travel Bag) accessible when completing any tracheostomy procedure.
• If student’s “GO BAG” contains a battery charged suction machine, the school nurse should check the battery charge level daily to ensure that it is fully charged.
• The school nurses should establish a schedule to periodically check the “GO BAG” to ensure all necessary supplies are available, not expired, and are in working condition.
• “Deep suctioning” up to or beyond the tracheal carina (point of bronchial bifurcation and tissue resistance) should not be indicated in a school setting, as it may cause epithelial damage.
• Each student will have an absolute length of catheter insertion, “measured length”.
  • When suctioning, the catheter should not be inserted deeper than the absolute length of catheter insertion.
• When suctioning, determine what the family has been taught related to applying suction on insertion and when withdrawing catheter or just when withdrawing.
• The student can be suctioned with clean technique or sterile technique per the health care provider’s order.
• Review the health care provider’s order to determine suction setting.
• The use of normal saline to lavage the tracheostomy tube is no longer routinely recommended and is based on the health care provider’s order and, if indicated, to assist with the removal of thick secretions, needs to be used judiciously (Blakeman, et al., 2022)

Supplies:

“GO BAG” (Emergency Travel Bag) Equipment:

The essential equipment to be kept with the student at all times is as follows:

• Gloves
• Portable oxygen (if ordered) with appropriate sized Ambu-bag
• Appropriate size Ambu-bag face mask (for emergencies when unable to reinsert a new tracheostomy tube)
• Portable suction machine that can operate with battery or electricity
  • Battery should have a full charge
• Sterile suction catheters
• Sterile saline vials
• Water-based lubricant
• Distilled or sterile water
• 4×4 gauze
• Split gauze dressing (if student uses)
• Unscented and dye free soap
• Syringe, if needed for tracheostomy tube cuff
• Sterile water for cuffed trach filled with water
• Two spare tracheostomy tubes (including obturator) — one the size the student currently uses and one that is a size smaller in the event that the tube needs to be changed and there is difficulty passing it through the stoma
• Obturator, if applicable
• Spare tracheostomy ties
• Blunt scissors
• Emergency phone numbers
• Pulse oximeter — may be optional if student is not on oxygen or mechanical ventilation

Additional supplies:

• Student’s Individualized Health Care Plan (IHCP) and /health care provider’s order
• Parent/Guardian authorization form
• Oxygen source or ambu-bag
• Suction machine
• Suction tubing
• Suction catheters
• Stethoscope
• Cup of tap water
• Sterile water
• Saline
• Tissues
• Small towel
• Personal protective equipment
  • Goggles
  • Mask
  • Gloves
    

Procedure:

1. Review health care provider’s order and the student’s IHCP
2. Ensure proper documentation of parent/guardian authorization to perform this procedure
3. Clean the work station with soap and water or disinfecting wipe
4. Wash hands
5. Assemble supplies
6. Review health care provider’s order/ Student’s Individual Health Care Plan
7. Perform respiratory assessment
   1. The respiratory assessment should be an ongoing process to determine:
      1. How well the student is tolerating the procedure
      1. The amount of time and suction attempts that are clinically indicated
8. Given the urgency and needs of the student; position the student to provide for the most privacy
   1. students in wheelchairs or other supportive seating devices can remain sitting upright or reclined up to, but not exceeding, semi-fowlers or 45 degrees
   1. students who are recumbent should be turned on their side (this position may be commonly associated with a student experiencing a seizure who may require supplemental oxygen and/or suctioning)
9. Explain the procedure to the student at a level the student understands
10. If ordered, place pulse oximeter on student’s finger, toe, or ear lobe during and after the procedure
11. Turn on suction machine and check for function
12. For suction machines that have suction measurements in mm Hg
    1. Ensure the suction machine has the appropriate level of subatmospheric pressure:
       1. standard maximal pressure for children ranges from 50–100 mm Hg; and
       1. standard maximal pressure adolescents ranges 80-120 mm Hg
       1. maximal pressure may be determined by turning on suction and occluding extension tubing by folding it in half
       1. pressure reading on the gauge when the tubing is completely occluded is the maximal suction pressure
13. For suction machines that have a dial with numbered suction settings (i.e. 1, 2, 3), use the lowest level of suctioning that will remove the secretions
    1. Start at the lowest suction level and increase as needed 
14. Put on clean gloves
15. Choose one hand (usually dominant hand) to keep clean for handling the suction catheter and the other hand to manipulate the unclean equipment
16. Attach top of catheter to suction tubing
17. Do not touch the end that will go into the tracheostomy tube
18. Hold the suction catheter at the absolute length of catheter insertion, “measured length”
19. Remove tracheostomy mask, artificial nose or ventilator connection and preoxygenate prior to suctioning
20. Suction a small amount of saline into the catheter
21. Promptly insert catheter while gently rotating within the cannula
22. Advance catheter into tracheostomy tube to the “measured length” with or without suction (based on how the procedure is completed in the home setting and health care provider’s order)
23. Apply suctioning by covering and uncovering the suction valve
24. Twirl catheter between fingers as it is pulled out of tracheostomy tube, staying in no more than 5 seconds
    1. When suction catheter is inserted into tracheostomy tube, the student’s airway is occluded, total suction time should not exceed 5 seconds
    1. The entire suctioning procedure should take no longer than 15 seconds
25. Suction a small amount of sterile saline, sterile water, or tap water (per student’s IHCP) with the suction catheter to clear any residual debris/secretions
26. Allow student to rest and return to normal breathing
    1. If student was receiving oxygen and humidification by mask before the suctioning, reapplication of the mask between suctioning passes or 3-5 breaths with manual resuscitator bag with oxygen attached may be warranted
    1. If student is not on oxygen, give 3 to 5 extra breaths with the resuscitator bag, if needed
27. Repeat a suctioning pass until secretions are removed
    1. Note the color, presence of odor, and consistency of secretions
28. Complete suctioning
29. Turn off the suction machine
30. For students on oxygen
    1. Replace mask, artificial nose or ventilator connection on student
31. For students without oxygen:
    1. Give 3 to 5 extra breaths with the resuscitator bag, if needed                     
32. Assess respiratory status
33. Rinse suction catheter with ½ strength hydrogen peroxide or vinegar water; then rinse catheter with sterile water  (or procedure indicated in student’s IHCP)
34. Place suction catheter in a clean container
    1. The suction catheter can be used up to 8 hours
35. Remove gloves
36. Rinse suction machine tubing with tap water
37. Wash hands
38. Document assessment, procedure, and outcomes in student’s health care record
39. Report any concerns to parents/guardian and health care provider
    1. Such as green/yellow or foul smelling secretions
40. Replenish supplies as needed

Procedure for cleaning suction catheter:   See above #25

---

References:

Blakeman, T. C., Scott, J. B., Yoder, M. A., Capellari, E., & Strickland, S. L. (2022). AARC Clinical Practice Guidelines: Artificial Airway Suctioning. Respiratory care, 67(2), 258–271. https://doi.org/10.4187/respcare.09548

Children’s Hospital St. Louis. (n.d.) Tracheostomy home care. Retrieved June 7, 2023, from https://media.bjc.org/sitelinks/tracheostomy/a001_introduction_welcome.html

Children’s Mercy Kansas City. (2018). Office of evidence based practice (EBP) – Critically appraised topic: Tracheostomy emergency supplies. Retrieved June 8, 2023 from https://www.childrensmercy.org/contentassets/878a471901cd4e858cc27ae0d82f441e/trach-go-bag-cat.pdf 

Children’s Mercy Kansas City. (n.d.) Tracheostomy care- suctioning. Retrieved June 7, 2023, from https://www.childrensmercy.org/siteassets/media/departments-and-clinics/otolaryngology/tracheostomy-care—suctioning1.pdf

Children’s Mercy Kansas City. (n.d.). Tracheostomy tube. Retrieved June 7, 2023, from https://www.childrensmercy.org/siteassets/media/departments-and-clinics/otolaryngology/tracheostomy-care-parent-card.pdf

Lawrence, P. R., Chambers, R., Faulkner, M. S., & Spratling, R. (2021). Evidence-based care of children with tracheostomies: Hospitalization to home care. Rehabilitation nursing : the official journal of the Association of Rehabilitation Nurses, 46(2), 83–86. https://doi.org/10.1097/RNJ.0000000000000254

Lynn, P. (2019). Suctioning a tracheostomy: Open system. In Skill checklists for Taylor’s clinical nursing skills. A nursing process approach. (5th ed.) (pp. 328-330).

Pediatric Home Service. (2018). Trach tube suction technique (Técnica de succión de tubo traqueal). . Retrieved June 7, 2023, from https://www.pediatrichomeservice.com/tips-how-tos/trach-tube-suction-technique/?play=1

Perry, A. G., Potter, P. A., Ostendorf, W., & Laplante, N. (2021). Skill 25.2 Airway suction. In Clinical nursing skills and techniques. (10th ed.). (pp. 763-772). St. Louis, MO: Elsevier.

Porter, S. M., Page, D., Engholm. H., & Somppi, C. (2019). Students supported by medical technology. In J. Selekman, Shannon, R.A., Yonkaitis, C.F. (Eds.). School nursing, a comprehensive text (3rd ed., pp. 721-740). Philadelphia PA.: F. A. Davis Co.

Potter, P. A., Griffin Perry, A. G., Stockert, P. A., & Hall, A. (2023). Chapter 41 Oxygenation. In Fundamentals of Nursing. (11th ed.). (pp.1008-1014). St. Louis, MO: Elsevier.

Toothaker, R., & Cook, P. (2018). A review of four health procedures that school nurses may encounter. NASN school nurse (Print), 33(1), 19–22. https://doi.org/10.1177/1942602X17725885

The StayWell Company, LLC. (2021). Step-by-step: Suctioning a child’s tracheostomy. Retrieved June 7, 2023, from https://stlouischildrens.staywellsolutionsonline.com/MultimediaRoom/VideoLibrary/?e=0#player:138,A90942

UC Davis Children’s Hospital, Olarewaju, A. (2019). Ear, nose, and throat (ENT) pediatric tracheostomy handbook. Retrieved June 7, 2023, from https://health.ucdavis.edu/media-resources/children/documents/patient-education-A-to-Z/peds-tracheostomy-handbook.pdf
________________________________________

Acknowledgment of Reviewers:

Angie Bulmahn, MSN, RN, NCSN
School Nurse Specialist
Missouri Department of Health and Senior Services

Marjorie Cole, MSN, RN, FASHA
State School Nurse Consultant
Missouri Department of Health and Senior Services

Renee Falkner, BSN, RN
School Nurse Supervision Specialist | Therapylog

Debra Funk, BSN, RN
Director of Practice
Missouri State Board of Nursing

Katherine Park, DNP, RN, NCSN
Nationally Certified School Nurse, Pierremont Elementary
Adjunct Professor, Maryville University School of Nursing

________________________________________

Page last updated: February 20, 2024
________________________________________

The information and materials presented in this Website are intended for informational purposes only and are not designed to diagnose or treat a health problem or disease, or assist in diagnosis or treatment of the same. The information is not intended to substitute for, supplement or replace clinical judgment. If there are any concerns or questions about or relating to a nursing or medical procedure, contact the individual’s healthcare provider. The information provided on this Website is not intended to be a substitute for medical orders and persons without the proper education, training, supervision and/or licensure should not perform the procedures.

Skill Competency Download