A nurse is suctioning fluids from a client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning to a maximum of:
A. 5 seconds
B. 10 seconds
C. 30 seconds
D. 1 minute
Correct Answer: B. 10 seconds
Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells within the heart. A vasovagal response may occur causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds. It is of particular importance for patients with mechanical ventilators, endotracheal tube (ET) intubations, tracheostomies, or other airway adjuncts. Clearance of airway secretions is a normal process and is critical to the prevention of respiratory infections, atelectasis, and preservation of airway patency.
Option A: The catheter should be introduced to the desired depth, and then suctioning should be started. A brief, 10-second suction duration is usually recommended to avoid mucosal damage and prolonged hypoxia. Hypoxia can be profound from occlusion, interruption of oxygen supply, and prolonged suctioning.
Option C: The adequacy of suctioning can be assessed by the clearance of secretions, improved breath sounds, improved air entry, good pulse oximetry readings, and improvement in respiratory distress in a patient. Complications from airway suctioning are relatively uncommon if performed with care and adequate pre-oxygenation.
Option D: Preoxygenation with 100% oxygen should be initiated prior to suctioning. This is in preparation for the hypoxia that is precipitated by suctioning, both from mechanical interruption and cessation of oxygen flow briefly. Suctioning can stimulate the vagus nerve, predisposing the patient to bradycardia and hypoxia.
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