practical situation.

Suction therapy is
not without risk for the patient and, I

Evidence-based although
therapy
Emergency
the frequency
is far less in Accident
of suction

(A & E) than in the

and

suction Intensive Care Unit, the potential

dangers remain the same. In order to
minimize some of the dangers and

management in reduce confusion

paper concludes
recommendation
amongst
with a
staff, this

for a degree of

Accident and standardization in suction catheter use.

Emergency: a vital INTRODUCTION

component of Effective respiratory care, or airway manage-

ment, aims to establish and/or maintain a
patent airway to ensure adequate alveolar venti-

airway care lation (Dolan 1991). Every course in life-saving

practice begins with the ‘ABCs’ - ‘Airway
(with C-spine precautions for trauma patients),
Breathing, Circulation.’ Establishing an airway
is the first step of the ABCs, although guide-
B. Dean lines from the European Resuscitation Council
(ERC) do advocate prior defibrillation if ven-
tricular fibrillation (VF) is the known cause of
collapse (ERC 1992). However, in most other
instances in all critical care situations, whether
pre-hospital, Accident and Emergency (A & E)
or Intensive Care Unit (ITU), the management
of the airway to ensure optimal oxygenation
and ventilation is of prime importance.
Effective airway management aims to Vigilant airway monitoring and possible use
establish and maintain a patent airway of an airway adjunct are indicated in the fol-
to ensure adequate alveolar ventilation lowing circumstances (Pierce 1995):
and patient survival. Suction therapy
l Partial or complete upper airway obstruction.
must be regarded as a vital component
l Prevention of aspiration when upper airway
of airway care, with all staff who are
protective reflexes are inadequate.
required to perform this procedure
l Facilitation of secretion removal.
being aware of the principles of safe,
l Provision of a closed system for the initiation
effective suctioning.
of mechanical ventilation.
This paper provides an outline of the
types of suction catheters available for In all of the above, suction therapy is a
use in the emergency care setting, and vital component of effective airway care with
describes the safe procedures to be airway management equipment and procedures
followed for both endotracheal and designed to facilitate removal of secretions
oro-pharyngeal suctioning. Potential should they accumulate or be aspirated. An
complications are discussed under the artificial airway is often used to protect the
headings of respiratory, cardiovascular, lower respiratory tract from aspiration of gastric
immunological and traumatic, all of content or foreign particles, whilst specific air-
which are relevant to safe patient care way management equipment is used to provide
whatever the setting, and all of which a closed system for the administration of
should be recognizable by any staff ventilatory support, thereby ensuring adequate
undertaking this procedure. The final cellular oxygenation and maintenance of
Barbara Dean MSc, SRN,
ENB 199, ENB 100, Stster. section looks at the ways in which some homeostasis.
Accident and Emergency of the complications can be minimized Although suction therapy, particularly via
Department, Royal Lancaster
Infirmary. Lancaster UK or detected by relating some of the the endotracheal route, is not performed as fre-
more important theoretical points quently in the A & E department as in ITU, the
Manuscript accepted I2 July
1996 discussed throughout the paper to the principles for safe, effective suctioning remain

Arodent and Emergency Nursing (I 997 92-98 0 Pearson Profewonal I997


the same and should be applied, \vhntevcr the
circumstCtliceS. III the xtthor’s experience. this
is not &vays so, \bith many qualified staff.
including some nnaestheti5ts, being utia\v,irc‘ of
conic necessnry techniqurs and principles. Thic
paper atii~s to consider the cqutp”iuit, procc-
dure ,md complicntions oi suction thcrdp);
thereby informing staff xvho drr unsure of this
itiipot-tatit ,II-cd of cut‘.
SUCTION THERAPY
Although the purpose of suction therapy is the
rnnovJ of secretions, it should only bc per-
formed \~,hcn needed and not ds d routine pro-
cedut-c (l)olai 1Wl : Pierce 1995); this to
nunitnire the hazards associated with such thcr-
~pv (these hazx-d\ will be outliwd 3s the article
progresses). Signs and sytttptoms which indicate
:I need for suctioning include: pxient restless-
ness or xnuiety; di.lphoresis; m increase in
blood pressure and hw-t rate; an incraw in the
rcspirdtory raw ,tnd pattern; and the presence of
rJc\ md rhonchi on auscultaion (Allen 198X;
I >olm 109 1 : Pierce 199.5).
Within A & E. visul inspection of the air-
uxy tndy ~1~0 itidic,ite d nwd for suctioning,
\vhilst ;I patient rcceivin, 0 tiirchanical wntila-
tion (either in A & E no\\:ndnys or during sec-
otidnry transfer) ma): dewlop incrensing pak
inspiratot-y airw,y pressures x J result of a build
up of secretiotts. The peak inspirCxtory pressure
(I’ll’) is t-elated to pittmoti~iry compti~ince dnd
ait-\va): resistance, aid the normal for d p&w
on ,I \uttilatot- IS bct\\wn 20-30 cmH,O
(Pierce 1O(X), nlthough these prcswt-es do LG*-y
\vtth the individual, dcpcttding on the degrw
of pultltonary d~magc. As \vith 113anyobsrrv;t-
tioits iixtde. importCwcc should be attached to
trends r,tther than singulu twdings. An>
incre,tw in nirw.iy prei5ures x d result of sc‘crr-
Cons C‘JNbe a mechanism tilt- ittcrcxing risk of
barott-auma. Thus. the nurse‘ cdt-ins ior ,tny
p,ttient likely to requiw suction therapy should
br ala-t ro the potettttal problems, md kno\\
ho\v tu alleviate these with minini,il patictit tii\-
coinfor or adverw physiolo+dl effects.
Suction therapy: equipment
Suction units used xtithttt A & E and other crit-
ical care tmvtronmcnts cm be fixed or portable.
I<egardlcss of this distinction, the units operxc
through the generation of a v~cuu~n or negative
pressure. nte~sured with J cJibrated gauge to
twsurc that the pre\cure used is not excer5ive.
Most authors recotmncttd that suction pressures.
~vhett sttctioning \-i,t an endotracheal, sltould he
tu the rajon of -80 to -120 mmHg. (Altcn
Ewdence based suction management 93
198X; (Idrr011 10X9; I’ilb~atn 1992; Ode11 et ‘11
100.3: Pierce 1CNi), although. as I’ierw (tSO5)
coitiiiicnts, rrcotiitiiend3tiotis in the literaturr
vxc Houwwr, both Pierce md I’ilbean suggest
tlldt the pressure should nt’ver csceed
-150 mmHg if cotttplic,ttions such JS trCtutttd
~tid atelecta5is dre to be avoided. In contrast,
Ode11 ct dl (1903) feel that, clinicdlly, this le\,el
tn,ty not br enough to rstrxt secrctiotts md
suggc\t J higher figure of 200 nlmHg Jthough
they ,tppex to bc thr only ;luthot-s u4io do so.
Also required is a ttowbrcnk~~ble collrctiott
bottle (IXIII~ uc:ts IIO\V USCJ plasttc outer bot-
tic cont,lining d st3tcd dispos,~ble intiu collect-
trig bdg) and n stiff transpxwt collcctittg tube,
tong cttough to reach c,tsily to the patictit’s
head (Ciroline 1 Wl). In ,tdditioti to ttiesc, ;I
varict) of dicposablc suction c,tthetet-s drr
requirrd, along \vttli aterilc ~~1o~csFiat- both
patient .und st.iff protection, a supply of water
for t-ittstng the system ,tnd stet-tie \\atet-/sJittr
fi,r inst,tlLttiott (the Intter is ttot often needed in
the A & E setting).
Suction catheters
Suction cdthetcrs coiiit‘ in tL50 forms rind drt‘
generally for single uw only. Tliev dre iiidtl~t~
fxturrd’ from pol\~viIiylchloride which ~110~~~s
for bcttet- inspection of the aspirate for quxitit):
colour md character (Pierce 1095). The rigid
tonsil-tip suction catheter (Yanknuer) is a plastic
catheter \I,hich is very useful for suctioning the
mouth xid ph;irytix of xi uricoiibcious patient.
being easier to direct than its mot-c flexible
cousin. This is a longer, soficr JIICI tnore pli,ibtc
version of catheter, Lvhich is the catheter of
choice for suctioning through an endotrachedl
(ET) tube or vi‘1 the nao-pharyngtxl route.
Ho~vever, \\hichevcr type of cathetcr i5
used. thct-c must lx d tncthod of pcriodicdlly
ittttwuptittg the suction xvithout hwing to
witch the ~vholc unit off. This is import,mt for
two redsons: it allows for the cdthetct- to bc
itttroduced \vithout applied wction; ,~nd it
Ctllo~z~sf6r intermittent suction \vhcn with-
draving the‘ c,ttheter. This method of v~cuuttt
cotttrol cxi be r&y dchicved by h%tviiig .i cott-
trol titechnnistn close to the pCttient rxher &iii
relying oti the on/off s\vitch oti the suction
unit. This control device, usually an opening
built itiro the suction circuit, is ,I tiicch~uiistii
which nllows suction to bc controlled by the
operator dt the snmr time ,IS the catheter i\
being introduced or \vithdra\w. The control
pot-t cm etther bc built tttto thr catheter or cm
lx ,i srpxitc connector hct\veen the cxhetu
and connecting tubing. Ftgttw I and 3 illw-
tr.tte the differetit suction c;ithcter\ aid xi
cxa1llplc of how the tllul1tb call be used to
operate thevacumti control port.
94 Accident and Emergency Nursing

Colour code for size

OZI ---- __- -

D

Fig. I Examples of suction catheters.

IA: Rigid, tonsil-tip or Yankauer
I B-D: Flexible suction catheters
I A/B have integral suction control ports
I C/D require a separate suction control connector between the catheter and connecting tubing

Fig. 2 Position of gloved hands.

2A: Dominant hand to control and guide the suction
catheter (during endotracheal suctioning)
28: Non-dominant hand controls the vacuum and timing
of suction.

Attempting to insert any type of catheter
without this control means that the vacuum (or
negative pressure) is being exerted, thereby
allowing the catheter to adhere to its first point
of contact, i.e. the sides of the ET tube or the
mucosa of the patient’s mouth. Either way, the
goal of effective suctioning, the removal of
secretions for optimal ventilation and airway
patency, will not be realized and some degree
of trauma to the mucosa will be inevitable. In
the author’s opinion, this aspect of suction ther-
apy would appear to be one of which many
people performing suction are unaware.
Even catheters which have only one eye at
the tip have been associated with increased
mucosal trauma and inadequate contact with
secretions (Pierce 1995). Therefore, many
catheters now have multiple eyes or other design
features which aim to reduce such tissue damage
and improve aspirations of secretions (see Fig. 1).
It is also possible to obtain suction connect-
ing tubing which is packaged together with
one adaptor for extending the tubing and one
which acts as a control port. However, if care is
not taken to ensure that the control port
remains with the tubing, ready for use when

catheter requirements change from rigid to
flexible, the problem outlined above, i.e. mser-
tion of the catheter under vacuum, arises,
particularly where staff are unsure of suction
therapy procedures.
Suction therapy: the procedure
Although there are some differences to be
noted bct\veen suctioning of the mouth and
pharynx and through an ET tube, some aspects
of suction therapy are common to both. As
with any procedure, the patient should be
warned of what is to occur to minimize dls-
comfort, stress and pain. As Fiorentini (lY92)
observes, the pain can be from the suction
catheter and actual procedure, but also from
induced coughing. This coughing can came
increased pressures (Lvithin the intrathoracic,
intra-abdominal and mtracerebral cavities),
generating further complications in an already
severely traumatized/ill patient.
It is obviously important to ensure that the
equipment to be used is always in working
order, with checks made routinely and after
each USC and change of circuit. An adequate
supply of suction catheters should be readill
available, in a variety of sizes to cater for the
\I-ide age range of patients presenting in A & E.
Sterility of Euch catheters should be ensured, as
should the availability of sterile glove?.
The importance of a suction control device,
as described above, cannot be stressed too
highly; no suction should be applied during
catheter insertion into the airway (Allen 1988:
Dolan 1YYl; Caroline 1991 ; Pilbeam 1YY2;
Pierce 1995). Not only will this cause trauma,
as stated, but will also ‘steal’ oxygen from the
airway (Ilolan 19Yl), as suctioning removes air
as well as liquids, thereby depleting the residual
gas volume. This is particularly so when suc-
tioning via an ET tube, so hyperoxygenation of
the patient must be considered if there is a like-
lihood of rapid desaturation and consequent
hypoxaemia (Dolan lY91; Pierce 1995). This
Amy well be the case in trauma patients requir-
ing high concentrations of oxygen.
A final universal dictate is the prescribed
duration of the suctioning. This should be lin-
ited to 1O-1 5 seconds (Caroline 199 1; Pilbeam
lYY2; Pierce lY95), with suction being contin-
uous or intermittent as the catheter is with-
drawn (Pierce lYY5). However, Pierce also
makes the point that research into the efficacy
of either method is as yet inconclusive due to
variations in catheters used and the amount of
suction applied. Continuous suction is thought
to improve secretion removal but at the same
time increase the removal of air from the
patient’s lungs, especially in the closed tracheal
suction systems (CTSS) often found in ITU.
Evidence based suction management 95
Dolan (1 OY 1) advocates that continuous suction
should be avoided to prevent m~~cosal trauma,
with intermittent suction being recommended
Lvhenever the catheter may make contact with
the mucosa. generally in naso-pharyngeal
suctioning (Pierce IYYS). Again, however, the
ability of the operator to control the vacuuni
and suctioning can be seen as important, in this
case during withdrawal of the catheter.
Suctioning the mouth and pharynx
The most effective catheter for this area is a
rigid Yankauer catheter as not only is it easier
to direct, as mentioned above, but it allows for
the removal of large volumes of fluid quickly,
along with small particles of food (Caroline
I YY 1). It is thus ideal for clearing vomitus from
the mouth of a semi-conscious patient or
purely for clearing secretions during intuba-
tion. When performing this technique, consid-
eration should be given to the following:
0 Use this type of catheter only under direct
vision; it should not be inserted blindly into
the patient’s mouth or throat (Caroline 1YY 1).
l Insert the suction catheter so that the convex
side goes along the roof of the pharynx;
occlude the control port, moving the
catheter tip around the mouth and pharynx.
l Be aware of the increased risk of gagging or
vomiting in the semi-conscious patient if
the back of the throat is touched (TNC(:
Provider Manual, 1095).
l Carefully time the suction; release the
vacuum and withdraw the catheter.
l Oxygenate if required prior to further
suctioning.
Suctioning through an endotracheal
tube
Endotracheal suctioning should be an aseptic
procedure, using sterile gloves and disposable
sterile catheters, having assessed the need for
suction and adhered to strict handwashing pro-
cedures (this latter is not always possible when
working in the pre-hospital environment).
Therefore, for a variety of reasons, a good rule
to follow is: do f10t pc$&~ cndotvil~hcnl t&c (ET)
s~rrtion 4~rr nbsolrrtely IZCCPLVZY~
(Caroline 199 1;
Pierce 1995). Attention to this maxim will
ensure that issues of infection control are
addressed and complications of ET suctioning
minimized. However, if ET suctioning is
unavoidable, it should be performed with
regard to the following:
l Monitor the patient’s electrocardiogram, if
not already being done.
l Preoxygenate the patient with 100% oxygen
and hyperventilate with care.
96 Accident and Emergency Nursing
l Maintain strict asepsis, i.e. handwashing and
use of sterile catheters and gloves, using the
dominant hand for inserting the catheter and
the non-dominant hand for control of
suction (see Fig. 2).
l Insert the catheter as far as possible, without
force, remembering that no s~rtiorz slrould De
applied during itzsertion into the airway
(Caroline 1991; Pilbeam 1992; Pierce 1995)
l Withdraw the catheter 1 cm to free f?om
respiratory mucosa, apply intermittent suction
by occluding the control port with a thumb
(as in Fig. 2), and withdraw using a rotational
movement. This exposes the eyes to a greater
surface area and thus removes more secretions
(Pierce 1995).
l The entire procedure should be performed in
10-15 seconds and the patient reoxygenated
again with 100% Oa.
l The catheter is then disposed of, not re-
used.
l If problems arise during suctioning, e.g.
bronchospasm, arrhythmias, STOP, remove
the catheter and ventilate with 100% Oa
(Caroline 199 1).
COMPLICATIONS
Although suction therapy provides the means
to ensure patent airways and optimal ventila-
tion, the procedure is not without risks. Any
person performing such therapy needs to be
aware of the potential complications and how
to minimize these.
Respiratory complications
A significant danger of suctioning is the devel-
opment of hypoxaemia, often as a result of the
disruption of gas flow when the ventilator sys-
tem is opened to allow passage of the suction
catheter (Knox 1993). This can be detrimental
to the patient who requires high Oa concentra-
tions, e.g. the trauma patient. Desaturation can
also occur as a result of suctioning for more
than 15 seconds, suctioning more frequently
than is necessary and using a catheter with too
large a diameter. Excessive negative pressure
further aggravates the hypoxia (Knox 1993).
Absorption atelectasis can occur if a catheter
becomes impacted in an airway; air can be
sucked out of the alveoli causing collapse.
Again, the use of a catheter of too large a diam-
eter can contribute to this problem (Fiorentini
1992), as can too high a pressure (Pierce 1995).
Tracheal and/or oro-pharyngeal stimulation
by suction catheters can induce coughing
episodes, retching, gagging and vomiting in any
patient. This can increase pain and discomfort,
extend pathophysiological processes and intro-
duce new pathology An example of this latter
can be seen if stomach contents are aspirated.
Resulting problems can include damage to
alveolar and capillary endothelial cells, bron-
chospasm, intrapulmonary shunt, hypoxaemia
and infection (Ihde et al 1987). Coughing and
vomiting can also lead to a further increase in
intracranial pressure in an already compromised
individual.
Cardiovascular complications
Cardiovascular complications can occur as a
result of procedure induced hypoxaemia or
from tracheal stimulation (Pierce 1995). They
can manifest as either hyper- or hypotension,
tachycardia or bradycardia, ventricular arrhyth-
mias and, ultimately, cardiac arrest. Vagal stimu-
lation may occur when suctioning the pharynx,
larynx or trachea, leading to bradyarrhythmias
and/or hypotension (Dolan 1991). In individu-
als who have lost sympathetic nervous system
(SNS) control, e.g. following spinal cord injury
above Tl, bradycardia from unopposed vagal
activity may ensue (Pierce 1995).
The opposite may occur, i.e. tachycardia
and/or hypertension, when SNS activity
increases as a result of hypoxaemia or stress and
anxiety that the patient experiences during the
procedure (Pilbeam 1992).
Trauma
As mentioned before, mucosal trauma from
over zealous suctioning techniques is a very real
problem. Excessive vigour or too much force
during catheter insertion can all add to the
problem, as can mucosal invagination into the
catheter eyes. Sackner et al (1973), Landa et al
(1980) (both cited in Fiorentini, 1993) and
Pierce (1995) describe the results of this trauma
as defoliation of ciliated epithelium (thereby
impairing mucociliary function), oedema
formation and small areas of haemorrhage,
evidenced by blood streaking in the aspirate.
Infection
Once intubated, the patient becomes a ‘com-
promised host’ from a respiratory point of view,
but even before this damage to the mucosa of
the oro-pharynx can allow entry of pathogens
to deeper tissues. A major risk in airway man-
agement arises from disruption of the normal
integrity of the respiratory tract, which nor-
mally has a complex system of host defence
mechanisms revolving around the cleansing and
protective function of the muco-ciliated
epithelium and the mechanical clearing actions
of coughing, sneezing and chest mobility.

In ‘Idditioii, there ,11-cthe interactions of
secretory antibody IgA (Imi~~unoglobulin A).
the lytic action oflysozyinc on the peptodigly-
C~II of bdcteridl cell walls and the engultinent
nlechmisms of ph‘~gocytes. In ewnce, the
rccpirdtory tr,lct i5 conjidcred to be sterile
belo~v the level of the ~0~31 cords (1)&n 1 00 1 ;
Hoyt 1004).
ET intubation ‘straightens out’ the t\vists
~~iid turns of the m~~toiiiic~~l airwdy rendcriiig
nerodyim~iic filtration ineffective and ,Illo\ving
iiicre,lriiig qmiititics of infectious materinl to
reach the lmw respiratory tract. Intub‘ltion
trCiuind can i-esult in further loss of intcgity to
iiiucoscil surf,lces. Even in dn othcrwisc healthy
Indi\-idual, intubaion can lewd to the develop-
iiient of nosoconiidl infection. in this c;Ise
pncunioiiid, \zithin 73 liourc of admission to
hospital (Fiorelltini 1SC)?).
I’,iticnts \\:ho are intubatcd require pmodic
suctioning. below the level of the voc.il cords,
i.c. the sterile p”rt of the lungs, and if this is iiot
carried out ~wptically, the11 the riyk of iatro-
genie infection i\ increCised. Cm+1 adherence
to infection control policies \vill help to reduce
bdctcrial coloiiizatioii md cro5s coiitaniindtion
of the trachea (Link et ~1 (1076), cited in O&II
et ‘11100.3).
I ; ;“.. ; i^l
PREVENTIVE PRACTICES
Although staff in A P; E may perceive scme of
these complications as having more relevance
to ITU staff, it is encumbent 011 all staff to
ensure th,lt ii0 action or omission is detrimentnl
to the condition or safety of patients (UKCC:
1003). Through an understanding of the r&-
ndlr behind suction therapy and by following
good clinical practice, prevention of such cm-
plic‘ltions cm begin in the A & E unit or in the
prc-hospital phase. Although some aspects of
good practice arc evident fi-oni the ,lbove dlc-
cussion, J brief outline follmvs here.
Hyperinflationlhyperoxygenation
Hyperinflation is the delivery of breaths that
art‘ 1.50’%~of the normal tidal volunir (Pierce
1995). combined with the delivery of 100%
0, (hyperoxygenation). This combination for
three to five breaths before, during and after
suctioning consistently produces the greatest
incraw in the partial pressure of alveolar oxy-
gen (Pierce 1995). However, the need for this
should be assessedwith ench individual patient
and cnrc taken where there is a possibility of J
pneuniothora, as this procedure cm result in
such a complication or worseii an existing one.
The procedure has also been associated with
Evidence based suction management 97
increases in ~nc,unarterial pressure and therefore
cdre should br taken \vhen suctioning the
head-injured patient.
Correct use of suction equipment
This rel,ltcs to ;III understanding of s,ife ,lirw,q
prwurcs. the LISCof d c,diett7m the outer dim-
eter of Lvhich does not ezcecd one third to OIIC
half the inner diameter of the ,iir\\,.iy (l)oldn
1WI ; I’ilbeain 1902; I’icrce 199.5) and the use
of ,I unction control port. Suctioning through
the capped opening of the smivel dd;iptor of the
cdtheter iiiount is also ,idvised.
Correct suctioning procedure
This umils using the correct suction cdthetcr
for the task, md ensuring sterility of all equip-
ment prior to use. including sterile gloves.
Although a YnnkCluer catheter is often LIW~
inore than once during an emergency proce-
dure. e.g. &a-ing the mouth of a patient \\ho
is undergoing gastric l;ivage, 5uction c,ithetcrs
used for ET suctioning should be disposed of
&r single use. Catheter iiisertiori should bc
Lvith the ~ic~i~iiii OK, md should be ii0 longci-
tll<lll 1o-1 5 SCCOd.
* = i
Adequate monitoring
This mill ensure that any cardiovascular prob-
lems uc noted imnlrdi~~tely and JSO allo\v for
observation of oxygen smlration. Auscultation
of the chest between suctioning will alert the
practitioner to the possibility of increasing bronm
chospasm. Monitoring of intracrmial pressure is
not us~~allyfound 111A K E, but even m,herc this
is avnilable, suctioning of 3 severely head injwcd
patient should be avoided unless absolutely net-
essary and then with great cution.
A\v,lrelless end ,Idherence to these points
should allou. st,lff performing suction therap)
to reduce sonic’ of the complications of suc-
tioning dt m early st,lge, bringing benefit to
the patient.
CONCLUSIONS
As this discussion has demonstrated, suction
therapy IS an iniportant part of overall airmq
ninnagement. It is not, however, without daii-
gers. Although it is not performed x frequrntl)
in A & E JS in ITU, the potential for complicClm
tiom rcrnains the same. Thus, every effort
sl~o~~ld be made by all staff who nre likely to
hove to perforln this procedure to understmd
their ‘lctions during suctioning and the rcasom
for them.
98 Accident and Emergency Nursing
The intention of this paper has been to
inform practice amongst A & E staff by exam-
ining suctioning equipment, procedures and
complications and, although it does not pur-
port to be a piece of research, the author would
make one recommendation based on personal
observation and knowledge of equipment avail-
able for use in A & E.
Staff who are unsure of suction therapy
procedure would undoubtedly benefit from
standardization of suction catheters in a depart-
ment. Different makes and designs of these
cause confusion and are often used incorrectly.
Therefore, the use of one type of rigid catheter
and one type of flexible catheter is advocated,
with the suction control port built into each
type, ensuring that when staff need to change
from rigid to flexible, there is no confusion over
how best to control the vacuum. The catheters
illustrated in Figures 1A and 1B would seem to
meet this personal recommendation.
There is far more to suction therapy than
many people realize and this article has left out
much more than it has included. If it only
causes people to reflect on their own practice
next time they carry out suction therapy, it will
have achieved its aim.
REFERENCES
Allen 11 1988 Makmg Sense of Suctmning. Nurmg
T11nes X4(10): 46-47
Book Review
Training pack: pregnancy loss and
the death of a baby
N Kohner, A Leftwich
~Vational Extenrion College irl associationwith SANDS,
SAFTA and the Miscarriage Association, 1995. ISBh’
1 85356 609 8, 132pp, L60.00
Providing care for acutely bereaved families is
an area that often causes great anxiety for emer-
gency nurses and other health professionals, and
the skills necessary to give appropriate individ-
ualized care are difficult to develop without
practical experience.
This training pack provides a comprehensive
guide for staff involved in training nurses and
other professionals in the care of acutely
bereaved families. Although written specifically
for pregnancy loss and the death of a baby in
early infancy, the information contained can
easily be adapted for training staff to care for
any bereaved family. The preparation for train-
ing, both of leaders and participants is extensive
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and is followed by clearly marked sections on
the practical aspects of bereavement care:
understanding loss; giving care; self-awareness
and skills; working with difference; and work-
ing in a supportive environment. Some theory
is included in the training pack, along with
clear handout notes, but most of the informa-
tion relates to practical exercises which lead
to experiential learning. I particularly like the
exercises which can be altered to suit any clini-
cal area and a wide variety of situations. The
training pack is a flexible resource that can
be used to provide different kinds of training
at many different levels and would certainly
be of benefit to those training emergency
department staff.
G. Silk Rh! RSCN, B Ed,
Clitzical Nurse Educator
Emergency G Comrw~ity Division
Royal Children’s Hospital
Melbourne, Victoria, Australia