NREMT Vent Management/Suction

[Markhk]

Hi there,

The current paramedic Ventilatory Management - Adult testing station currently requires paramedic students to provide endotrachael suction to a patient.

I have noticed that during the section where the student is tested, questions arise on how to achieve the requirement to measure the soft tip catheter.

Specifically, the evaluation sheet states:

"Marks maximum insertion length with thumb and forefinger"

"At proper insertion depth, covers catheter port and applies suction while withdrawing catheter"

What is your preferred method of determining maximum insertion length? I have heard three, very different variations as the "right" answer:
- Using the stylette as a guide to maximum insertion length
- Measuring from the tip of the tube to the sternal notch
- Using another endotrachael tube as a guide

In fact, in two textbooks which follow the National Standard Curriculum, (Blendose and Nancy Caroline), there is no mention on maximum insertion length, rather, that the suction catheter should only be inserted until resistance is felt.

So what is NREMT talking about?

[uscgk9]

My students have been either using the stylette or an equal sized tube. As long as they have an understanding that they should not exceed the lenght of the tube they are fine.

[uscgk9]

My students have been either using the stylette or an equal sized tube. As long as they verbalize that they do not exceed the length of the tube they are fine.

[MSDeltaFlt]

In fact, in two textbooks which follow the National Standard Curriculum, (Blendose and Nancy Caroline), there is no mention on maximum insertion length, rather, that the suction catheter should only be inserted until resistance is felt.

Unless I'm mistaken, Vent correct me if I'm wrong, the NREMT is referring to the carinii. You could use the catheter from the tip of the tube to the sternal notch, but be careful. Tracheal suctioning is an aseptic technique. If you touch the sterile catheter to anywhere outside your sterile field other than the ETT, you have just contaminated to catheter; thus ruining it. You'll need to get another one.

I advance the soft tip cath quickly but gently to the carinii, then apply suction on the way out.

[MSDeltaFlt]

In fact, in two textbooks which follow the National Standard Curriculum, (Blendose and Nancy Caroline), there is no mention on maximum insertion length, rather, that the suction catheter should only be inserted until resistance is felt.

Unless I'm mistaken, Vent correct me if I'm wrong, the NREMT is referring to the carinii. You could use the catheter from the tip of the tube to the sternal notch, but be careful. Tracheal suctioning is an aseptic technique. If you touch the sterile catheter to anywhere outside your sterile field other than the ETT, you have just contaminated to catheter; thus ruining it. You'll need to get another one.

I advance the soft tip cath quickly but gently to the carinii, then apply suction on the way out.

[VentMedic]

The problem with "until resistance" is that you can slip past the carina and into one of the bronchi. It is actually possible to pierce through the bronchus creating a significant air leak - pneumo - in need of surgery type of damage.

So, know your catheter depths. Be gentle. Remember the 15 second rule.

Every time you hit the carina you leave a mark. If the patient is on anticoagulants or platelets are low that mark can result in frank bleeding which will create more problems.

Also, never apply suction until you have pulled off that resistance.

The catheters with the cm markings are easiest as you can take the cm mark the tube is secured at and then measure to the tip of the tube. You can also play with an ETT by setting your lip mark at 23 cm and then using your hand, fingers, pen or whatever to judge the depth to familiarize yourself with length to the tube tip for the times you won't be able to do all the other steps in real life. Remember the total length of the tube varies with tube size so go with the one you use most often (7.5 or 8.0) and adjust accordingly.

If you have a pt with a trach, be very careful since that tube is short and it is very easy to do serious damage as the tube may also be angled to put you toward the bronchus thus missing the carina and damaging the small branches of the airway.

Look at an anatomy picture of the lung and use common sense for you are inside the lungs and the tissue is very, very delicate.