Suctioning through a tracheostomy

Suctioning through a tracheostomy clears secretions the patient cannot cough out, but every pass also draws oxygen out of the airway, stimulates the vagus nerve and can injure the tracheal lining, so the nurse suctions only when the patient needs it and never on a timetable — secretions seen or heard in the tube, coarse crackles or rhonchi over the trachea, a wet cough the patient cannot clear, rising work of breathing or a falling saturation, and in the ventilated patient a high-pressure alarm or a sawtooth pattern on the waveform — after first asking the patient who can cough to cough; preoxygenates before the catheter goes in; keeps open suctioning sterile, with a catheter small enough to leave room for air to flow around it and the suction pressure kept as low as clears the secretions rather than raised for thick ones; passes the catheter without suction only as far as the end of the tube, going deeper only when shallow suctioning has failed, rather than until it meets resistance; applies suction only while withdrawing, keeps each pass as brief as possible, and lets the patient reoxygenate and recover before any further pass, limiting how many are made; and does not instil saline, which does not thin secretions or help them out but lowers oxygenation and washes bacteria deeper — while watching throughout for the harms the procedure itself causes, hypoxaemia, a slowing heart or a dysrhythmia, bronchospasm, bleeding from traumatised mucosa and a rise in intracranial pressure, any of which means suctioning stops and the patient is oxygenated before anything else, judging the result by breath sounds that have cleared, easier breathing and the amount, colour and consistency of what was removed rather than by the saturation alone, and treating a catheter that will not pass as a blocked or displaced tube rather than as secretions to be suctioned harder.