The Importance of Suctioning Can’t Be Underscored Enough

There are few things in emergency care more important than a clear airway. I want to make a few points about the importance of suctioning because I believe it’s one of the most neglected areas in EMS care—an area where crews have become extremely complacent, too often leaving their portable suction units in their apparatus. I had a frightening experience recently when being prepped for a minor surgical procedure to one of my nasal sinuses. The doctor first sprayed an antihistamine into my nasal passage to shrink the inflamed sinus, then sprayed a strong numbing agent to partially numb the area before directly injecting a more powerful numbing agent. Some of the medication naturally flowed backward down my throat. It was an awful taste, so the doctor gave me a small cup of water to help dilute the residual medication, diminish the taste and keep it from numbing and masking my gag reflex. However, despite the flushing, it numbed the back of my throat and made every swallow feel like there was a golf ball stuck there. As he left the treatment room, he gave me another small cup of water and reminded me the spray would continue to numb my nose and throat, and that I would lose more of my gag reflex. He cautioned me to be careful and just take small sips so that water didn’t get diverted into my trachea.

All alone now, I took what I thought was a small sip. It immediately went into my trachea, causing me to cough violently, lose my breath and gasp. A nurse heard me and came rushing in. She grabbed a wide-bore suction catheter and removed excess fluid. I wondered what would’ve happened if I was all by myself without someone to suction my airway. I also reflected on the importance of effective suctioning when I went to the dentist recently for a normal filling. As he drilled and sent debris onto my tongue and down into my airway, his assistant periodically rinsed the area with a tiny stream of water and simultaneously suctioned the fluid away. The sound of suction removing fluid was comforting as I lay semi-reclined and somewhat helpless in the dental chair. (See photo 1) You have to wonder how you’d feel if there was no suction when you needed it, either while in a dentist chair or as a cardiac arrest or trauma victim. I’ve always appreciated the need to take a suction device with me on critical cases and, in particular, any unresponsive or "unknown problem" call. And I’ll admit I’ve been guilty on occasion of not taking suction on a call, sometimes perhaps being in more of a hurry to establish an airway with an endotracheal (ET) tube than I was to clear the airway first. I consider myself lucky never to have found a patient who desperately needed suctioning when I couldn’t perform it immediately. But, you might not be so lucky. When you place a laryngoscope into a patient’s mouth, you often see a small pool of fluid accumulates in the back of the airway due to gravity. Most often, you can slip a tube in over the top of that fluid and intubate the patient successfully. However, sometimes that fluid needs to be immediately and rapidly removed or it can leak or be aspirated into the trachea and cause pneumonia and other serious complications. It’s therefore critical that whenever you take an airway bag on a serious or potentially serious call, a suction device should either be in that bag or accompanying it. Today’s suction devices are much smaller than in the past so there’s no excuse for not taking one with you to serious or unknown patient cases. (See photos 5 and 7) Most knowledgeable first responders, EMS providers, medical directors and supervisors—and attorneys—consider failure to have suction at the patient’s side to be negligence on the part of a crew. BE STERILE How often do you see crews have the sterile packaging of a tracheal suction catheter open with the long, thin, spaghetti-like suction catheter attached to their suction unit’s wide tubing? They do this so the previously sterile catheter is ready to use after they intubate. They fail to realize that once they opened the package, they ruined sterility of the catheter and almost guarantee they’ll introduce harmful bacteria into their patient’s airway and cause a potentially deadly infection in their patient. I find that most responders were never taught about the high morbidity and mortality of ventilator-associated pneumonia (VAP) and the significant bacteria introduced by improper and non-sterile prehospital suction procedures and equipment.

Photo 1: A widebore catheter used in a dentist’s office.

They also often leave suction running while in a critical patient’s airway or trachea, robbing the patient of vitally needed oxygenation. Many suction catheters, particularly sterile suction catheters that are to be introduced through an ET tube or rescue airway, have a "whistle stop" opening or port that’ll prohibit suction from occurring until occluded by the rescuer. This ensures oxygen isn’t removed by suction when the airway isn’t being cleared. (See photo 2.)

Photo 2: Assorted whistle/controlled catheters. It’s called a whistle stop because, when it’s not included, you hear a sucking/whistling sound caused by air being pulled from the opening proximal from the tip of the catheter in the patient’s airway. Whenever suction is necessary, all the rescuer has to do is place their thumb over the whistle stop or port to cause suction to occur at the tip. Some catheters have a flap that can be rolled over that opening to keep suction occurring while the rescuer uses both of their hands to perform the suctioning. (See photo 2.) [if !supportLineBreakNewLine] [endif]

Photo 3A: Rigid tonsil-tip catheters. The reason wide-bore, rigid suction tips are most efficient and effective in the field during initial suctioning is because they can easily be directed to the source of the fluid to rapidly suck the fluid out of the airway. (See photos 3A and 3B.) [if !supportLineBreakNewLine] [endif]

Photo 3B: Circumference of various rigid tonsil-tip catheters. Trying to use a long, spaghetti-like sterile suction catheter to remove copious amounts of fluid is like trying to empty a swimming pool with a straw. It’s ineffective and the long, flexible tubing can’t be easily directed around the mouth, tongue and upper airway. (See photo 4.) [if !supportLineBreakNewLine] [endif]

Photo 4: A spaghetti-style suction catheter is too narrow for gross suctioning, but ideal for tracheal suctioning. There’s also no reason the large tubing attached to a suction device can’t be initially used to suck out large debris or copious clots of blood from an airway. Then, after this is accomplished with one or two seconds of suctioning, a rigid suction catheter such as a tonsil tip can be quickly placed into the suction tubing for finer suctioning.

[if !supportLineBreakNewLine]Photo 5: A Y-piece in line with Laerdal suction unit tubing. [endif]

Photo 6: Catheter and nasopharyngeal airway sized from nostril to earlobe and marked with a piece of tape.

Photo 7: A compact SSCOR Quickdraw suction unit with rechargeable battery can be stored in a gear bag without fear of power loss. Nancy Caroline, MD’s, famous paramedic textbook Emergency Care in the Streets (second edition, 1982) points out that tonsil suction catheters "are particularly useful in clearing secretions that obstruct the rescuers vision during attempts to intubate the trachea since the rigid catheter can be directed easily to the desired location." Caroline notes the suction catheter is best used under direct vision and "should not be jammed blindly into the mouth or throat."

Photo 8: Nasopharyngeal airway used as a catheter on a 60 cc Teleflex bulb syringe. [if !supportLineBreakNewLine] [endif]

Photo 9A: ET tube occluded with cream of mushroom soup.

Photo 9B: ET tube cut for training.

Photo 9C: My airway getting suctioned by a student. Other extremely important points made by Caroline that’s often forgotten by emergency responders is that the catheter should be cleared in sterile water or saline and that the patient should be oxygenated between suctioning attempts. She noted in bold print that "the patient must always initially be preoxygenated, suctioning should not continue for more than 10 seconds at a time and all patients undergoing tracheal suctioning should be monitored for cardiac dysrhythmias because ectopy can occur." The sixth and current edition now gets more specific: 15 seconds for adults, 10 for children and five for infants. She also presented a great sequential description of how to suction the trachea of a non-intubated patient that I’ll paraphrase: 1. Place the patient in a semi-sitting position. 2. Have the patient breathe 100% oxygen for at least three minutes. 3. Wear sterile gloves, place the prepared catheter on a sterile field and have a rinse solution available. When possible, have a glove-wearing assistant open the sterile package and hand the catheter to the suctioner. 4. Insert the sterile catheter through a nostril into the posterior pharynx with the suction not yet engaged. The patient may gag during the insertion. 5. Ask the patient to tilt their head back and cough or take slow, deep breaths, and advance the catheter beyond the vocal cords. 6. Continue gently until the catheter is advanced as far as possible, then withdraw it. Apply intermittent suction and rotate the catheter as it’s pulled out. The person performing this action should count slowly to 10 to keep track of the time elapsed. 7. Rinse the catheter between tracheal suction efforts and, if tracheal suctioning isn’t to be repeated, the suction catheter can be used to suction around the patients mouth. However, once a sterile catheter is removed from the tubing or used around the patient’s mouth and nose, it’s no longer sterile and shouldn’t be place into the trachea again. 8. If necessary to suction the patient again, the patient should again be preoxygenated for at least three minutes before resuctioning and a new, sterile catheter should be utilized.

Caroline also stressed that during suctioning in the intubated patient the suction catheter used should have a side thumb vent, or "Y tube," to permit intermittent suction, and that its external diameter should be no greater than one-third the internal diameter of the ET tube. She points out that a 14- or 16-gauge French catheter is adequate in most adult patients. (See photo 5) TEACHING TRICKS When I teach an airway class, I show students: >>How easy it is to carry and add a Y connector/controller to their suction device and measure and mark a long, flexible catheter so it can be continually used at an incident scene without being placed too far into the patient’s airway. Measuring and marking it with tape at a distance is determined by measuring from the patient’s mouth or nostril to their earlobe—the same way you size an oro- or nasopharyngeal airway. (See photo 6); >>How you can place the large suction unit tubing up against an inserted nasopharyngeal airway and have it suck out fluid and debris rapidly and effectively; and >>How a small, long-lasting battery-powered SSCOR Quickdraw suction unit with wide bore catheter and sterile 60 cc syringes can be carried in mass casualty incident kits and used with catheters and nasopharyngeal airways at multiple patient incidents where there are a shortage of suction units. (See photos 7 and 8) I also mix batches of delicious cream of mushroom and tomato soup, have students take a mouthful, lie supine and resist swallowing while I go retrieve a suction device (in another room) and prepare it for suctioning the fluid out of their airway. This can take up to three minutes—a long time when you have your mouth full of fluid and are trying not to swallow. It illustrates the need for suction to be immediately available at the patient’s location. I also cut an ET tube, fill my mouth with clam chowder, and have them clear that messy tube and airway. It’s an effective teaching process—one they seldom forget. (See photos 9A–9C.) Put suctioning techniques and equipment on your priority agenda every day and pass along the information and tips presented in JEMS to your students, coworkers and training officers.