Suctioning: Artificial Airway During Mechanical Ventilation (Respiratory Therapy)

ALERT

Suction airways during mechanical ventilation only when clinically indicated and not as a routine, fixed-schedule treatment.

If the patient develops respiratory distress or cardiac decompensation during the suctioning procedure, immediately withdraw the catheter, supply additional oxygen, and deliver manual breaths as needed.

Suctioning can cause elevations in intracranial pressure (ICP) in patients with head injuries.

Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions.

OVERVIEW

Endotracheal (ET) and tracheostomy tubes are used to maintain a patent airway and to facilitate mechanical ventilation. ET or tracheostomy tube suctioning is performed to maintain the patency of the artificial airway and to improve gas exchange, decrease airway resistance, and reduce infection risk by removing secretions from the trachea and mainstem bronchi. Suctioning also may be performed to obtain samples of tracheal secretions for laboratory analysis.

ET and tracheostomy tubes prevent effective coughing and natural secretion removal, which necessitates the need for periodic suctioning to remove pulmonary secretions. In acute care situations, suctioning is always performed as a sterile procedure to prevent hospital-acquired pneumonia.

Indications for suctioning include:

Auscultation of adventitious lung sounds (rhonchi) or course crackles over the trachea, mainstem bronchi, or both
Gradual or sudden decrease in oxygen saturation
Increase in peak airway pressures when the patient is receiving mechanical ventilation
Identification of a sawtooth waveform pattern on the ventilator
Increased respiratory rate, frequent coughing, or both
Secretions in the artificial airway
Sudden onset of respiratory distress when airway patency is questioned
Suspected aspiration of gastric or upper airway secretions

There are two basic methods of suctioning. In the open-suction technique, after disconnection of the ET or tracheostomy tube from any ventilatory circuit or oxygen sources, a sterile single-use suction catheter is inserted into the open end of the tube. This technique is often used for the patient with a tracheostomy who is not receiving mechanical ventilation support.^{undefined#ref4">4}

In the closed-suction technique, also referred to as “in-line suctioning,” a multiuse suction catheter inside a sterile plastic sleeve is inserted through a special diaphragm attached to the end of the ET or tracheostomy tube (Figure 1). The closed-suction technique allows for the maintenance of oxygenation and ventilation support, which may be beneficial in patients with moderate to severe pulmonary insufficiency. In addition, the closed-suction technique decreases the risk for aerosolization of tracheal secretions during suction-induced coughing. Use of the closed-suction technique should be considered for patients who develop cardiopulmonary instability during suctioning with the open-suction technique; in patients who have high levels of positive end-expiratory pressure (PEEP), inspired oxygen, or both; or in patients who have grossly bloody pulmonary secretions or in whom airborne transmission of disease, such as active pulmonary tuberculosis, is suspected.

Oxygen should always be provided at 100% before and after each pass of the suction catheter into the ET tube, whether suctioning is done with the open- or the closed-suction method.⁴

The suction catheter should not be any larger than one half of the internal diameter of the ET or tracheostomy tube.⁴ Closed- or in-line suction catheters are available in two lengths: a longer one for ET tubes and a shorter one for tracheostomy tubes.

Adequate systemic hydration and supplemental humidification of inspired gases help thin secretions for easier aspiration from airways. Instillation of a bolus of sterile 0.9% sodium chloride solution is not a recommended routine practice.²

Complications associated with artificial airway suctioning during mechanical ventilation include:

Bronchospasm
Cardiac arrest
Cardiac arrhythmias (premature contractions, tachycardia, bradycardia, heart blocks)
Decreases in mixed venous oxygen saturation (SVO₂)
Hypertension or hypotension
Hypoxemia
Increased ICP
Pain and anxiety
Tracheal mucosal trauma
Pulmonary hemorrhage or bleeding
Respiratory arrest

Tracheal mucosal damage (e.g., epithelial denudement, hyperemia, loss of cilia, edema) occurs during suctioning when tissue is pulled into the catheter-tip holes. These areas of damage increase the risk of infection and bleeding.

Suctioning is a necessary procedure for patients with artificial airways. No absolute contraindication to suctioning exists when clinical indicators point to the need for it.

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
Explain that suctioning may be uncomfortable and may cause the patient to experience shortness of breath.
Explain the patient’s role in assisting with secretion removal by coughing during the procedure.
Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

Perform hand hygiene before patient contact. Don appropriate PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
Introduce yourself to the patient.
Verify the correct patient using two identifiers.
Assess for signs of airway obstruction.
1. Cyanosis
2. Decreased breath sounds
3. Decreased level of consciousness
4. Expiratory crackles
5. Hypertension or hypotension
6. Ineffective coughing
7. Inspiratory wheezes
8. Restlessness
9. Secretions in the airway
10. Shallow respirations
11. Tachycardia or bradycardia
12. Tachypnea
13. Ventilator high-pressure alarm sounding
If peak airway pressures on the ventilator are high, expect that mucus is partially occluding the patient’s airway and that suctioning is required.
Evaluate the patient’s oxygen saturation.
Assess for signs of inadequate breathing patterns.
1. Dyspnea
2. Frequent triggering of ventilator alarms
3. Increased respiratory rate
4. Intercostal and suprasternal retractions
5. Shallow respirations
6. Patient-ventilator dyssynchrony

Preparation

Unless medically contraindicated, keep the head of the patient’s bed elevated 30 to 45 degrees to prevent aspiration and reduce the risk of ventilator-associated pneumonia.⁴
Open-suction technique only: Secure additional personnel to assist with the manual resuscitation bag (MRB) to provide supplemental breaths with 100% oxygen.

PROCEDURE

Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or risk of exposure to bodily fluids.
Verify the correct patient using two identifiers.
Explain the procedure and ensure that the patient agrees to treatment.
Turn on the suction apparatus and set the vacuum regulator to less than 150 mm Hg.⁴ Follow the manufacturer’s directions for suction pressure levels when using closed-suction catheter systems.
Rationale: The amount of suction applied should be only enough to effectively remove secretions. High negative-pressure settings may increase tracheal mucosal damage.¹
Secure one end of the connecting tube to the suction source and place the other end within reach.
Prepare to suction.
1. Open-suction technique:
  1. Open the sterile catheter package on a clean surface, using the inside of the wrapping as a sterile field.
  2. Depending upon the manufacturer, set up the sterile solution container or sterile field. Use a prefilled solution container or an open empty container, being careful not to touch the inside of the container. Fill the container with a sterile 0.9% sodium chloride solution or sterile water.
  3. Don sterile gloves over gloved hands.
    If one sterile glove and one nonsterile glove are used, don the nonsterile glove on the nondominant hand and the sterile glove on the dominant hand. Handle all nonsterile items with the nondominant hand.
  4. Pick up the suction catheter, being careful to avoid touching nonsterile surfaces. With the nondominant hand, pick up the connecting tubing. Secure the suction catheter to the connecting tubing.
    Do not allow the dominant hand to come in contact with the connecting tubing. Wrap the suction catheter around the sterile dominant hand to prevent inadvertent contamination of the catheter.
  5. Check equipment for proper functioning by suctioning a small amount of sterile solution from the container.
2. Closed-suction technique: Connect the suction tubing to the closed system suction port or unlock the thumb valve, according to manufacturer’s guidelines.
Administer 100% oxygen to the patient for 30 to 60 seconds¹ using one of these methods:
Rationale: The administration of 100% oxygen helps prevent a decrease in arterial oxygen levels during the suctioning procedure.¹
1. Press the 100% suction button on the ventilator with the nondominant hand.¹
2. Increase the baseline fraction of inspired oxygen (FIO₂) level on the mechanical ventilator.
  Return the FIO₂ to the baseline level after completing suctioning.
3. Open-suction technique only: Disconnect the ventilator or gas delivery tubing from the end of the ET or tracheostomy tube and attach the MRB to the tube with the nondominant hand. Attach a PEEP valve to the MRB if the patient is receiving PEEP. Verify that the MRB has a reservoir to deliver the highest level of oxygen possible.
  Rationale: Some models of MRBs (without reservoirs) entrain room air and deliver lower levels of oxygen.
Insert the suction device.
1. Open-suction technique: Remove the ventilator circuit or MRB with the nondominant hand.
2. With the control vent of the suction catheter open, gently but quickly insert the catheter with the dominant hand into the artificial airway.
  Do not instill a 0.9% sodium chloride solution into the artificial airway before suctioning.²
3. Advance the catheter to the predetermined depth.
  Rationale: In select patient populations (those with a lung transplant or pulmonary surgery), the depth of suctioning may be restricted. Advance the catheter to the identified depth.
  1. In a patient at high risk for suction-related complications, insert the catheter into the ET or tracheostomy tube no farther than the end of the artificial airway.²
  2. In a patient, not at risk for suction-related complications, insert the catheter into the ET or tracheostomy tube until resistance is met and then pull back 1 to 2 cm before applying suction.²
    Due to the potential for airway trauma, deep suctioning should generally be used only when shallow suctioning is ineffective.²
4. If the catheter does not advance past the end of the ET tube, it may be caught in the side hole at the distal end of the ET tube or there may be a mucous plug at the end of the ET tube. Rotate the catheter to reposition it away from the side hole or withdraw it slightly and reinsert it with the next inhalation.
  Rationale: In most cases, the catheter meets resistance at the carina. Acute onset of coughing is one indication the catheter is at the carina because it contains many cough receptors.
Place the nondominant thumb over the control vent of the suction catheter to apply continuous suction.
1. Place and maintain the catheter between the dominant thumb and forefinger while completely withdrawing the catheter into the sterile catheter sleeve (closed-suction technique) or out of the open airway (open-suction technique). Suction for 15 seconds or less.¹
2. In cases when repeated suction is needed, use caution when withdrawing the suction catheter. Do not allow the catheter to touch the patient’s face or other nonsterile surfaces.
  Rationale: Suction should be applied only as needed to remove secretions and for as short a time as possible to minimize decreases in arterial oxygen levels.
  
  Keep suction periods brief to keep decreases in oxygen saturation to a minimum.¹
Administer 100% oxygen again for 1 minute.¹
Rationale: The administration of 100% oxygen helps prevent a decrease in arterial oxygen levels during the suctioning procedure.¹
If secretions remain in the airway and the patient is tolerating the procedure, consider performing one or two more passes with the suction catheter. Administer 100% oxygen for 1 minute before and after each pass of the suction catheter.⁴
Rationale: The number of suction passes should be based on the amount of secretions and the patient’s clinical assessment. Arterial oxygen desaturation and cardiopulmonary complications increase with each successive suction catheter pass.

Rationale: The administration of 100% oxygen helps prevent a decrease in arterial oxygen levels during the suctioning procedure.¹
If the patient does not tolerate suctioning despite the administration of 100% oxygen, try these steps:
1. Ensure that 100% oxygen is being delivered to the patient.¹
2. Ensure that PEEP is maintained on the mechanical ventilator during suctioning.
3. Ensure that the PEEP valve is attached properly to the MRB if using that method for oxygen administration.
4. Switch to another method of suctioning (e.g., closed-suction technique), if needed, and allow longer recovery intervals between suction passes.
5. Consider hyperventilation using either the MRB or the ventilator only in situations in which the patient does not tolerate suctioning in conjunction with the administration of 100% oxygen alone.
  Rationale: Use of a different suctioning technique may be physiologically less demanding.
Cleanse the suction catheter.
1. Closed-suction technique only:
  1. Align the suction port of the catheter with the side port.
  2. Apply continuous suction; simultaneously instill a sterile 0.9% sodium chloride solution or water into the side port of the in-line catheter using a syringe or saline bullet, taking care not to lavage down the ET tube.
  3. Repeat until the catheter is clear.
    Rationale: Rinsing the catheter removes secretion buildup in the connecting tubing and, when using the closed-suction catheter system, in the in-line suction catheter.
2. Open-suction technique only:
  1. Rinse the catheter and connecting tubing with a 0.9% sodium chloride solution or sterile water until clear.
  2. Remove sterile glove(s) and dispose of catheter after completion of upper-airway suctioning.
  3. Wrap the catheter around the dominant hand.
  4. Pull off sterile glove from the dominant hand inside out. The catheter should remain in the glove. Discard the glove and the catheter.
  5. Pull off the sterile glove from the nondominant hand in same fashion and discard it.
Turn off the suction device.
Discard suction collection tubing and canisters when completely full. Suction collection tubing and canisters may remain in use for multiple suctioning episodes.
Rationale: Solutions and catheters, which come in direct contact with the lower airways during suctioning, must be sterile to decrease the risk for hospital-acquired pneumonia. Devices that are not in direct contact with lower airways have not been shown to increase infection risk.
Discard supplies, remove PPE, and perform hand hygiene.
Document the procedure in the patient’s record.

MONITORING AND CARE

Monitor the patient’s cardiopulmonary status before, during, and after the suctioning period for signs of complications and return to baseline.
Reassess the patient for signs of suctioning effectiveness.
Replace the connecting tubing every 24 hours or when visibly soiled with blood or vomitus.³
Replace the disposable suction cannister per the organization’s practice.³
Observe the patient for signs or symptoms of pain. If pain is suspected, report it to the authorized practitioner.

EXPECTED OUTCOMES

Removal of secretions from the large airways
Improved gas exchange
Airway patency
Amelioration of clinical signs or symptoms that indicated the need for suctioning
Sample obtained for laboratory analysis

UNEXPECTED OUTCOMES

Cardiac arrhythmias
Hypoxemia
Bronchospasm
Excessive increases in arterial blood pressure
Increase in ICP
Cardiopulmonary distress
Decreased level of consciousness
Airway obstruction
Ventilator-associated pneumonia

DOCUMENTATION

Education
Presuctioning and postsuctioning assessment
Clinical indication for suctioning
Suctioning of ET or tracheostomy tube
Type of oxygenation method used
Volume, color, and consistency of secretions obtained
Any difficulties during catheter insertion
Patient’s tolerance of suctioning procedure
Ventilator pressures before and after suctioning
Vital signs including oxygen saturation before, during, and after suctioning
Cardiac rhythm before, during, and after suctioning
Unexpected outcomes and related interventions

HOME CARE CONSIDERATIONS

Family members or caregivers should perform this procedure in the home setting only if they have been well-educated and trained in suctioning. Explain suctioning and the risks associated with the procedure thoroughly to patients, family members, and caregivers. Recommend that they request extra education from their home health nurses or therapists.

REFERENCES

American Association for Respiratory Care (AARC). (2010). Endotracheal suctioning of mechanically ventilated patients with artificial airway 2010. Respiratory Care, 55(6), 758-764. (Level VII)
American Association for Respiratory Care (AARC). (2022). AARC Clinical Practice Guidelines: Artificial Airway Suctioning. Respiratory Care, 67(2), 258-271. doi:10.4187/respcare.09548. (Level VII)
Joint Commission, The. (2017). Medical suction and fluid waste management: Patient and workplace safety considerations for health care organizations. Retrieved December 11, 2023, from http://www.jointcommissioninternational.org/assets/3/7/JCI_WP_Med_Suction_and_Fluid_Waste_Mgt_Final_(1).pdf (Level VII)
La Vita, C.J. (2021). Chapter 37: Airway management. In R.M. Kacmarek, J.K. Stoller, A.J. Heuer (Eds.), Egan’s fundamentals of respiratory care (12th ed., pp. 748-787). St. Louis: Elsevier.

Elsevier Skills Levels of Evidence

Level I - Systematic review of all relevant randomized controlled trials
Level II - At least one well-designed randomized controlled trial
Level III - Well-designed controlled trials without randomization
Level IV - Well-designed case-controlled or cohort studies
Level V - Descriptive or qualitative studies
Level VI - Single descriptive or qualitative study
Level VII - Authority opinion or expert committee reports

Clinical Review: Genevieve L. Hackney, MSN, RN

Published: February 2024