What is the appropriate suction pressure setting and regimen for a patient with fragile skin and medications affecting blood clotting or skin integrity requiring thin suction for chronic respiratory diseases or post-surgical care?

Management of Thin Suction

For patients with fragile skin and coagulopathy requiring airway suction, use assessment-based suctioning with the premeasured technique, applying 80-100 mm Hg pressure for rapid passes of less than 5 seconds, while avoiding deep suctioning to minimize epithelial trauma and bleeding risk. 1

Suction Technique: Premeasured vs. Deep Suctioning

The premeasured technique is mandatory for all routine suctioning to minimize airway trauma, which is particularly critical in patients with fragile tissues or bleeding risk. 1

• Insert the catheter only to a premeasured depth where the most distal side holes just exit the tip of the tracheostomy tube 1
• Use premarked catheters to ensure accurate insertion depth and prevent epithelial damage 1
• Measure the exact depth using a tracheostomy tube of the same size as the one in place 1

Deep suctioning should be avoided as animal studies clearly demonstrate denuded epithelium and inflammation with routine deep suctioning, creating unacceptable bleeding risk in anticoagulated patients. 1, 2

Catheter Manipulation Technique

• Twirl or rotate the catheter between fingers and thumb (not stirring with the entire hand) to reduce friction and suction secretions from all areas of the tube wall 1
• This helical motion minimizes mucosal contact time and trauma 1

Suction Pressure Settings

Use 80-100 mm Hg for pediatric patients, with adequate vacuum to efficiently remove secretions in a few seconds. 1

• The suction must generate sufficient vacuum to clear secretions rapidly, minimizing exposure time 1
• For patients with thick secretions, a stationary machine generating greater vacuum may be necessary in addition to portable units 1
• Apply suction both while inserting and removing the catheter for maximum efficiency 1

Critical caveat: In patients on anticoagulation or with thrombocytopenia, verify the home suction machine can adequately clear secretions before discharge to avoid prolonged suctioning attempts that increase trauma risk. 1

Duration of Suctioning

Complete each suction pass in less than 5 seconds to prevent atelectasis and minimize mucosal trauma. 1

• Rapid technique is vital when using larger catheters relative to tube size 1
• Prolonged suctioning increases risk of both atelectasis and bleeding from traumatized mucosa 1

Frequency and Timing

Perform suctioning based on clinical assessment only, not on a fixed schedule. 1, 2

Assessment indicators include:

• Visible or audible secretions 2
• Changes in respiratory pattern or work of breathing 1
• Decreased oxygen saturation 1
• Increased peak airway pressures 3

Minimum frequency: For stable patients without secretions, suction at minimum twice daily (morning and bedtime) to assess tube patency, as tubes can obstruct without clinical symptoms. 1, 2

Common pitfall: Routine scheduled suctioning (e.g., every 2 hours) increases airway trauma, infection risk, and cardiovascular instability without clinical benefit. 2, 3

Catheter Size Selection

Use the largest catheter that fits inside the tracheostomy tube to remove secretions efficiently and quickly, reducing total suctioning time and trauma exposure. 1

• This contradicts older recommendations for catheters one-half the internal diameter 1
• Larger, firmer catheters allow rapid secretion removal and better detection of partial tube obstruction 1
• Atelectasis risk is minimized by the rapid premeasured technique (< 5 seconds) rather than catheter size 1

Infection Control Measures

Use sterile technique with single-use catheters for each suction pass. 1

• Wear gloves for handling respiratory secretions 1
• Change gloves and wash hands after each patient contact and between contaminated sites 1
• Use only sterile fluid to clear the catheter if re-entering the lower respiratory tract 1
• Wear gown if soiling with secretions is anticipated 1

Saline Instillation

Do not routinely instill normal saline as it decreases oxygen saturation, does not thin mucus, and may contaminate lower airways. 1

• Proper humidification is more effective than saline for maintaining thin secretions 1
• Saline cannot mix with mucus to provide thinning effect 1

Special Considerations for Fragile Skin/Coagulopathy

For patients on anticoagulants, antiplatelet agents, or with thrombocytopenia:

• Strictly adhere to premeasured technique to avoid deep mucosal trauma 1
• Minimize suction frequency by optimizing humidification to reduce secretion viscosity 1
• Use rapid passes (< 5 seconds) to limit mucosal contact time 1
• Avoid saline instillation which increases coughing and potential for mucosal injury 1
• Monitor for blood-tinged secretions as indicator of excessive trauma requiring technique modification 4