Pediatric Nasal Suctioning

We very much agree that this is the standard of care for upper airway obstruction from nasal secretions in young children, especially since infants preferentially breathe through the nose, and nasopharyngeal obstruction can cause increased work of breathing and respiratory distress that can be effectively treated by relieving the obstruction.

As you’re aware, the Regulated Health Professions Act (RHPA) lists the medical acts that are restricted to Regulated Health Professionals and those who receive delegation from RHP's, and in the RHPA, deep suctioning of the nasopharynx is considered a controlled act.

“(2) A “controlled act” is any one of the following done with respect to an individual:

6. Putting an instrument, hand or finger,
ii. beyond the point in the nasal passages where they normally narrow,"
The point in the nasal passages where they normally narrow is typically not deeper than where the nose meets the plane of the face. Suctioning anterior to this narrowing can still be beneficial, and is authorized by the BLS PCS, but some children will benefit from suctioning deeper than this, which is a controlled act.

So, you were absolutely correct to ask us about the provision of this act, as it is controlled and does require delegation to be performed by paramedics.

Despite this skill being often the first line treatment for sick, congested kids and is routinely utilized at CHEO, it is not a currently skill delegated to Ontario paramedics.

So, in the interest of patient-centered care, what do we do with this?

In Spring CME 2022, we had an hour-long video with a MD and RN from the CHEO ED to talk about peds respiratory (croup vs asthma vs bronchiolitis). I highly recommend you take a look (https://mediclearn.rppeo.ca/course/view.php?id=691).

Having said that, many PCPs may not have seen this video as Spring CME 2022 was primarily for ACPs. There’s a lot of other great resources in that link as well to help manage these patients.

As part of that discussion, we spent a few minutes on the skill of NP suctioning (35:58 of the video) that I think is really what you’re after here.

Given that deep NP suctioning is a controlled act that paramedics with training can safely perform, the RPPEO is amenable to delegating this to paramedics in certain circumstances.

Similar to double sequential external defib, if a medic has been trained on a skill, they are permitted to patch to discuss performing the act. The same can be said in this scenario.

If the medic has been trained (i.e. watched this video), and feels comfortable with the skill, they are permitted to patch to discuss this order. Remember that nasal suctioning anterior to the narrowing in the nose can be beneficial, and this skill does not require an order from a physician.