If the patient doesn't have a patent and self-maintained airway, their hemodynamics and overall clinical status is going to decline with 100% certainty. Many times, under normal circumstances patients in a disease-free state will be able to clear secretions on their own, while continuing to oxygenate and ventilate with ease. However, let's say the patient is obtunded, and they don't have the ability to clear their secretions... the answer to mitigate this potential life threat is to obviously clear the airway on their behalf. Suction is a vital skill that also requires mastery, but like any other intervention it must be done in a skillful and strategic manner.... this blog will look at the most current evidence-based guidelines from cradle to grave. Consider the youngest cohort -- Is routine suctioning necessary in the newborn with an adequate APGAR? What if meconium staining is present? Are all rigid suction devices equal? Is the Yankauer falling out of style?? So much to discuss.... let's get started with our youngest population first.
Guidance for routine newborn care + neonatal resuscitation
Routine suctioning of the neonate (mouth then nose) was the standard of care for all newborns for decades. However, some evidence over the past 10 years or so has pushed many healthcare providers to rethink this approach. They are not saying that suctioning should be considered obsolete, but they are saying that maybe it should be reserved for certain presentations/circumstances. Some even suggest that you should attempt to let the newborn clear meconium on their own if it is present in the intrapartum period. Bottom line: Routine suctioning, whether oral, nasal, oropharyngeal, or endotracheal, is not recommended because of a lack of benefit and running the even greater risk of bradycardia -- which we know the pediatric population doesn't like.
It may be hard to comprehend because this goes against everything we were ever taught, but according to AAFP, many multicenter randomized trials showed that suctioning doesn't reduce the risk of meconium aspiration, and that endotracheal suctioning in a vigorous infant is just not beneficial. Vigorous was defined as the baby having good muscle tone and a HR>100. Mortality was also shown to not decrease as well when these interventions of old were regularly performed.
At the end of the day - there is some overwhelmingly good news. Approximately 10% of infants require help to begin breathing at birth, and only 1% need intensive resuscitation. Save suctioning for when it is clinically indicated -- you'll definitely know when it is needed. Remember that Pediatric Assessment Triangle?
Other suction devices to replace or compliment the Yankauer device in your rig
Think back to your last experience with the traditional Yankauer suction. How did it perform? What was the airway contaminant you were battling? Are you hindered when you lead with suction before every intubation? Have you had challenges with viewing the glottic opening and had this mainstay device that's been around 100+ years not meet your emergent needs?
Maybe there is a better way! EMS has been no stranger to innovation and when it comes to airway management, an anesthesiologist from Milwaukee, WI named James DuCanto was frustrated with the markets current suction offerings and decided to come up with his own.... safe to say he has managed the airways of more than a few critically ill patients. The suction catheter that bears his name is in the image above on the far-left hand side. What do you notice when compared to its counterparts on the right? You guessed it - the lumen at the distal tip is markedly larger, which means it could put up a better fight when thick secretions and yesterday's chili try to ruin your attempt to provide a patent airway. The device is always on, and many providers park it in the hypopharynx and let it do its job when the secretions and solid emesis are continuous.
Regardless of what device you employ at your agency; when suction is a regular part of your peri-intubation procedures and standard resuscitative care bundles - you are reducing the risk for aspiration, which is a common complication in more than half of your post cardiac arrest patients. You are also improving your chances of first pass success with advanced airways. If you've not heard of the SALAD (Suction Assisted Laryngoscopy and Airway Decontamination) technique that Dr. DuCanto also evangelizes -- there are several tutorial videos on the web for your viewing pleasure.
Establish good habits now and go ahead and bring the suction to the patient's side, valuable time can be wasted here when you or your partner have to go back to the truck to retrieve it. Our patients and their families expect us to bring our "A game" every day.
**Disclaimer - This is not a formal endorsement of any specific product -- we are simply educated the masses on what other products may be available to you and your EMS service. We are here to facilitate healthy discussion at your place so you can collectively find out what methods, materials, and vendors work best for your organization.
December 23, 2024
Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP
Pass with PASS, LLC
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