7.3 Nebulizer Treatments, Oral Suctioning & Airway Clearance

Nebulizer Treatments, Oral Suctioning & Airway Clearance

Three NCCT tasks focus on the airway outside of oxygen therapy (Section 7.2): assist with patient-administered nebulizer treatments, perform oral suctioning (for example, bulb or Yankauer), and assist the patient with coughing and deep-breathing exercises (for example, spirometry). Incentive spirometry after surgery is taught in Section 7.4; this section covers nebulizers, suctioning, and other airway-clearance techniques.

Nebulizer Treatments

A small-volume nebulizer (SVN) turns liquid medication into a fine mist that the patient breathes deep into the lungs. Common medications include albuterol (a bronchodilator that opens the airways) and ipratropium; inhaled steroids and saline are also given this way.

The PCT's Role

The medication is prescribed by a provider and prepared by the nurse or respiratory therapist, or it is the patient's own ordered medication that the patient self-administers under facility policy. The PCT does not add, mix, or change medications. The PCT may set up the equipment, position and coach the patient, monitor them, and clean the equipment, as delegated.

Assisting With a Treatment

1. Verify the order and the patient's identity, perform hand hygiene, and explain.
2. Position the patient upright (high Fowler's in bed or sitting in a chair) to allow full lung expansion.
3. Assemble the nebulizer cup, T-piece, and mouthpiece (or a mask for patients who cannot hold a mouthpiece, such as young children).
4. Connect the tubing to the compressed air or oxygen source ordered, at the flow rate specified (commonly about 6 to 8 L/min) until a steady mist appears.
5. Coach the patient: seal the lips around the mouthpiece, breathe in slowly and deeply through the mouth, hold each breath briefly if able, and breathe out normally.
6. Continue until the mist stops or the cup begins to sputter, usually about 10 to 15 minutes. Tapping the side of the cup helps the last drops nebulize.
7. Monitor during and after: heart rate, breathing effort, SpO2, and skin color. Albuterol commonly causes a faster heart rate, jitteriness, and hand tremor. Stop and report palpitations, chest pain, a sharp rise in heart rate, or worsening shortness of breath or wheezing right away.
8. After an inhaled steroid, have the patient rinse the mouth and spit to prevent oral thrush.
9. Clean the equipment per policy, usually by rinsing the parts with sterile water, letting them air-dry, and storing them in a clean labeled bag. Nebulizers are single-patient use.
10. Document the time, the patient's tolerance, and vital signs before and after if ordered.

Oral Suctioning

Suctioning removes secretions a patient cannot clear by coughing or swallowing, preventing aspiration. PCTs perform oral and oropharyngeal suctioning only; deep tracheal or endotracheal suctioning belongs to the nurse or respiratory therapist (Section 7.2).

Yankauer (Tonsil-Tip) Suctioning

1. Explain, perform hand hygiene, and put on gloves, adding eye protection or a face shield if splashing is likely.
2. Position the patient in semi-Fowler's, or on the side facing you if the patient is unconscious.
3. Check the equipment: turn on the suction and set the pressure according to facility policy (adult settings commonly stay at or below about 150 mm Hg). Test it by suctioning a little sterile water.
4. Insert the Yankauer tip into the mouth and move it along the gum line and inside the cheeks, then into the oropharynx as needed. Avoid the back of the throat, which triggers gagging and vomiting.
5. Suction while gently moving the tip, and limit each pass to about 10 to 15 seconds. Let the patient breathe between passes.
6. Rinse the tip by suctioning water, and repeat only as needed.
7. Watch color, breathing, and SpO2. Stop and report a falling SpO2, slowing heart rate, vomiting, or distress.
8. Provide oral care afterward, store the Yankauer in a clean covered package (never on the floor or bed), and change it per policy.
9. Document the amount, color, and consistency of the secretions.

Bulb Syringe Suctioning (Infants)

1. Squeeze the bulb before inserting it to push the air out.
2. Insert the tip into the side of the mouth (the cheek pocket), not straight back toward the throat.
3. Release the bulb slowly to draw up the secretions, remove it, and squeeze the contents into a tissue.
4. Suction the mouth before the nose. Nasal suctioning can make the infant gasp and breathe in any secretions still pooled in the mouth.
5. Suction each nostril gently at the opening only, and clean the bulb after use.

Coughing, Deep Breathing, and Airway Clearance

• Deep breathing and coughing: sit the patient up, have them take slow deep breaths, hold each breath for a few seconds, and then cough forcefully. After surgery, splint the incision with a pillow while coughing (Section 7.4).
• Huff coughing: a gentler technique for patients who tire easily. The patient takes a medium breath and breathes out forcefully with the mouth open, as if fogging a mirror, several times, then coughs.
• Pursed-lip breathing for patients with COPD: breathe in through the nose for about 2 counts, then out slowly through pursed lips, as if whistling, for about 4 counts. This keeps the airways open longer and helps empty trapped air.
• Diaphragmatic (belly) breathing: one hand on the chest and one on the abdomen; the abdomen should rise with each breath while the chest stays still.
• Incentive spirometry: slow, deep inhalation with a breath-hold, about 10 times per waking hour (Section 7.4).
• Frequent position changes, walking as ordered, and adequate fluids keep secretions thin and easier to clear.

Clinical Trap: The Fast Heart Rate Nobody Reported

During an albuterol treatment, a patient's heart rate climbs from 88 to 138 beats per minute and she says her heart is racing. The PCT assumes this is a normal side effect and leaves. Some rise in heart rate is expected, but a large jump with palpitations must be reported to the nurse so the treatment and the patient can be evaluated.