Endotracheal Tube and Tracheostomy Tube Suctioning - CE/NCPD

ALERT

Suction the patient’s artificial airway only as clinically indicated and not as a routine, fixed-schedule treatment.^{undefined#ref1">1} Limit each pass to less than 15 seconds.¹

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

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

OVERVIEW

Endotracheal (ET) or tracheostomy tube suctioning is performed to maintain the patency of the artificial airway and prevent complications. The presence of an artificial airway impairs effective coughing and secretion removal, which may result in the need for periodic removal of pulmonary secretions with suctioning. In acute care situations, suctioning is always performed as a sterile procedure to prevent hospital-acquired pneumonia. Suctioning may result in serious complications, such as hypoxemia, arrhythmias, hypertension or hypotension, increased ICP, bronchospasms, trauma to the mucosa, pain, and anxiety. Evidence shows that ICP can take up to 10 minutes to return to baseline levels after suctioning.³ In brain-injured patients, it is recommended to allow 10 minutes after suctioning before performing other procedures.³

Suctioning is performed by using either an inline (multi-use) suction catheter or a flexible (single-use) suction catheter. The patient should be left connected to the ventilator throughout the suctioning procedure.⁴ The closed-suction technique is the preferred method for suctioning because it facilitates continuous mechanical ventilation and oxygenation during the suctioning procedure. The closed-suction technique allows for a continued tidal volume delivery to the patient with minimal loss of lung volume. Closed system suctioning is suggested for an adult patient with high fraction of inspired oxygen (FIO₂) or positive end-expiratory pressure (PEEP) or for a patient who is at risk for lung derecruitment.¹

An inline suction catheter consists of a catheter inside a sterile plastic sleeve that is attached to the ventilator circuit. It is inserted through a special diaphragm attached to the end of the ET or tracheostomy tube (Figure 1). Sterile technique is used when suctioning with a flexible (single-use) suction catheter.

Suctioning should be ceased immediately if the patient develops any adverse effects. Adverse effects of ET suctioning include:

• Hypoxemia
• Pulmonary hemorrhage or bleeding
• Arrhythmias (tachycardia, bradycardia, heart blocks)
• Increased ICP
• Bronchospasm
• Atelectasis
• Mucosal trauma
• Hypertension or hypotension
• Cardiac arrest
• Respiratory arrest

Adequate systemic hydration and supplemental humidification of inspired gases assist with thinning secretions for easier aspiration from airways. Routine instillation of 0.9% sodium chloride solution before ET suctioning is not recommended.¹ Evidence shows an association between instillation of 0.9% sodium chloride solution and ventilator-associated pneumonia (VAP), and hemodynamic changes.²

Administering 100% oxygen presuction and postsuction reduces hypoxemia; however, it is not without risks such as absorption atelectasis. Administering 100% oxygen must be considered if the patient has experienced a clinically significant reduction in oxygen saturation with suctioning, has high oxygen and PEEP requirements, or has a compromised cerebral circulation.² A decrease in partial pressure of arterial oxygen (PaO₂) along with an increased partial carbon dioxide pressure (PaCO₂) results in an increase in vasodilatation. This vasodilation can then increase cerebral blood flow and consequently elevate ICP and decrease cerebral perfusion pressure (CPP).

For an adult patient, the size of the suction catheter should be one half the inner diameter of the artificial airway, providing a lumen diameter ratio of 0.5.¹ Closed-suction catheters are available in two lengths: one for ET tubes (approximately 56 cm [22 inches]), which is sufficient to reach the main stem bronchi, and one for tracheostomy tubes (approximately 30.5 cm [12 inches]).⁵ A curved tip or coudé catheter is available for selective left main stem bronchial access.⁵

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.
• Provide the patient with an explanation of the equipment and the procedure.
• Explain to the patient that suctioning may be uncomfortable, causing temporary shortness of breath or coughing.
• Explain to the patient how to use nonverbal cues to assist the health care team with understanding what the patient may be experiencing.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. 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.
2. Introduce yourself to the patient.
3. Verify the correct patient using two identifiers.
4. Assess the patient for signs of airway compromise or inadequate oxygenation.
   1. Thick secretions in the airway that cannot be cleared with coughing
   2. Decreased or absent breath sounds
   3. Adventitious lung sounds (e.g., wheezes, rhonchi, crackles)
   4. Restlessness or decreased level of consciousness
   5. Acute respiratory distress
   6. Tachypnea
   7. Tachycardia or bradycardia
   8. Cyanosis or pallor
   9. Hypertension or hypotension
   10. Shallow respirations
   11. Use of accessory muscles
   12. Decreased oxygen saturation
   13. Increased peak airway pressure
   14. Sawtooth pattern on the flow-volume loop on the ventilator monitor⁴

       Rationale: A sawtooth pattern on the flow-volume loop on the monitor screen of the ventilator is a strong indicator of retained pulmonary secretions.⁴

Preparation

1. Provide reassurance and support to the patient to demonstrate an understanding of the patient’s dependence and vulnerability.

   Rationale: Patients experience a loss of control over themselves and their situation because of the degree of physical dependence when they are mechanically ventilated.

2. Assist the patient to a comfortable position, generally a semi-Fowler or Fowler position.
3. Prepare a work area in a clean, accessible location and assemble the necessary supplies.
4. Determine the appropriate depth to advance the suction catheter.
5. Identify the proper size of suction catheter to use by first multiplying the tube’s inner diameter by 2 and then selecting the next smallest size catheter.⁵

PROCEDURE

Suctioning with an Inline Suction Catheter

1. Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. Explain the procedure and ensure that the patient agrees to treatment.
4. Verify that the suction apparatus is on.
5. Unlock the suction control valve (thumb valve), depress the valve completely, and adjust the vacuum regulator so that the suction pressure is less than 150 mm Hg.¹

   Use only the amount of suction necessary to remove secretions effectively. High negative-pressure settings may increase tracheal mucosal damage.⁴

6. Release the suction control valve.
7. Consider administering 100% oxygen via the ventilator for 30 to 60 seconds before suctioning.¹

   Administer 100% oxygen to prevent a decrease in oxygen saturation during the suctioning procedure.¹

   Leave the patient connected to the ventilator throughout the suctioning procedure.⁴

8. Pause the ventilator alarm and the monitoring alarms as needed.
9. Using the nondominant thumb and forefinger, stabilize the patient’s artificial airway and ventilator tubing.
10. With the dominant hand, gently but quickly insert the catheter into the artificial airway without depressing the suction control valve (the suction is off).
    1. In patients at high risk for suction-related complications, insert the catheter into the artificial airway until it just passes the end of the airway.²
    2. In patients not at risk for suction-related complications, insert the catheter into the artificial airway until resistance is met and then pull it back 1 to 2 cm.²
11. Using the dominant thumb, depress the suction control valve to apply continuous suction while withdrawing the catheter into the sterile catheter sleeve within 15 seconds.¹ Using the nondominant thumb and forefinger, stabilize the airway while withdrawing the catheter.

    Ensure that each suction pass lasts less than 15 seconds to minimize decreases in oxygen saturation.¹

    Do not instill 0.9% sodium chloride solution before suctioning.²

12. Stop the withdrawal when the black marker ring on the catheter appears inside the sleeve. Release the suction control valve.
13. Perform an additional pass of the suction catheter if secretions remain in the airway and the patient is tolerating the procedure. Multiple suctioning passes may be needed to clear secretions.

    Rationale: The number of suction passes should be based on the amount of secretions and the patient’s clinical assessment.

    Do not exceed four passes per suctioning procedure to minimize oxygen desaturation and cardiopulmonary complications.¹ Allow adequate time between passes for the patient to recover before the next pass.

14. Consider administering 100% oxygen for at least 60 seconds after suctioning.¹
15. Monitor the patient for adverse reactions.
16. Rinse the catheter and connecting tubing with a sterile 0.9% sodium chloride solution.
    1. Verify that the black marker ring on the catheter is visible in the sleeve.
    2. Open the cap on the irrigation port.
    3. Attach a tube of sterile 0.9% sodium chloride solution (i.e., saline bullet, saline aliquot) to the irrigation port.
    4. Depress the suction control valve and gently squeeze the tube of solution.

       Do not instill the solution down the ET tube.

    5. Continue to irrigate until the catheter and tubing are clear.

       Rationale: Irrigating removes buildup of secretions in the connecting tubing and the inline suction catheter.

17. Lock the suction control valve.

    Rationale: Locking the suction control valve prevents accidental depression when not in use.

18. Verify that the FIO₂ is returned to the previous level.
19. Enable the ventilator alarm and the monitoring alarms as needed.
20. Assess the volume, consistency, and color of the airway secretions.

    Notify the practitioner of changes in the airway secretions, which could be a sign that the patient is developing pneumonia or other adverse effects.

21. Discard supplies, remove PPE, and perform hand hygiene.
22. Document the procedure in the patient’s record.

Suctioning with a Flexible Suction Catheter

1. Perform hand hygiene. Don appropriate PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. Explain the procedure and ensure that the patient agrees to treatment.
4. Turn the suction apparatus on.
5. Adjust the vacuum regulator so that the suction pressure is less than 150 mm Hg.¹

   Use only the amount of suction necessary to remove secretions effectively. High negative-pressure settings may increase tracheal mucosal damage.⁴

6. Using aseptic technique, open the flexible catheter package on a clean surface, using the inside of the wrapping as a sterile field; open the package just enough to expose the connecting end.

   Rationale: Catheters and solutions that come in direct contact with the lower airways during suctioning must be sterile to decrease the risk of hospital-acquired pneumonia.

7. Pour a sterile 0.9% sodium chloride solution or sterile water into a sterile container.

   Rationale: A sterile container may be provided in the kit with the suction catheter. The solution is used to irrigate the suction catheter.

8. Pause the ventilator alarm and the monitoring alarms as needed.
9. Perform hand hygiene and don sterile gloves.
10. With the dominant hand, pick up the suction catheter, taking care to avoid touching any nonsterile surfaces. With the nondominant hand, pick up the connecting tubing. Connect the suction catheter to the connecting tubing.

    Ensure that the dominant hand does not come in contact with the connecting tubing. Wrap the suction catheter around the sterile dominant hand to help prevent inadvertent contamination of the catheter.

11. Consider administering 100% oxygen for 30 to 60 seconds before suctioning via the ventilator.¹

    Administer 100% oxygen before suctioning to prevent a decrease in oxygen saturation during the suctioning procedure.¹

12. With the nondominant hand, open the access port (swivel adaptor) on the ventilator tubing to allow for passage of the catheter into the artificial airway.

    Leave the patient connected to the ventilator throughout the suctioning procedure.⁴

13. With the dominant hand, gently but quickly insert the catheter into the artificial airway with the control vent of the suction catheter open.
    1. In patients at high risk for suction-related complications, insert the catheter into the artificial airway and advance it to the distal end of the ET (shallow suctioning).²
    2. In patients not at risk for suction-related complications, insert the catheter into the artificial airway until resistance is met and then pull it back 1 to 2 cm (deep suctioning).²

       Ensure that each suction pass lasts less than 15 seconds to minimize decreases in oxygen saturation.¹

       Do not instill a 0.9% sodium chloride solution routinely before suctioning.¹

14. Using the nondominant thumb, occlude the control vent of the suction catheter to apply continuous suction while completely withdrawing the catheter within 10 to 15 seconds.¹
15. Perform an additional pass of the suction catheter if secretions remain in the airway and the patient is tolerating the procedure. Multiple suctioning passes may be needed to clear secretions.

    Rationale: The number of suction passes should be based on the amount of secretions and the patient’s clinical assessment.

    Do not exceed four passes per suctioning procedure to minimize oxygen desaturation and cardiopulmonary complications.¹ Allow adequate time between passes for the patient to recover before the next pass.

16. Consider administering 100% oxygen for at least 60 seconds after suctioning.¹
17. Monitor the patient for adverse reactions.
18. Insert the end of catheter into the container of sterile 0.9% sodium chloride solution or sterile water and suction up the solution until the suction connecting tubing is clear.

    Rationale: Suctioning up the solution removes buildup of secretions in the connecting tubing.

19. Wrap the catheter around the dominant hand after the upper airway suctioning is complete. Pull the glove off inside out; the catheter remains in the glove. Pull the other glove off in the same manner and discard.
20. Turn the suction device off.
21. Enable the ventilator alarm and the monitoring alarms as needed.
22. Verify that the FIO₂ is returned to the previous level.
23. Assess the volume, consistency, and color of the airway secretions.

    Notify the practitioner of changes in the airway secretions, which could be a sign that the patient is developing pneumonia or adverse effects.

24. Discard supplies, remove PPE, and perform hand hygiene.
25. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Ensure that ventilator and oxygen settings are as ordered.
2. Monitor the patient’s cardiopulmonary status before, during, and after the suctioning period.

   Reportable conditions: Decreased oxygenation, cardiac arrhythmias, bronchospasm, respiratory distress, cyanosis, increased blood pressure or ICP, anxiety, agitation, pain, changes in mental status

3. Reassess the patient for signs of suctioning effectiveness. If the patient is able to communicate, ask whether breathing is easier and congestion is decreased.

   Rationale: Asking the patient whether breathing is easier and congestion is decreased provides subjective confirmation that the suctioning procedure has relieved airway compromise.

   Reportable conditions: Diminished or absent breath sounds, decreased oxygenation, increased peak airway pressure, coughing, increased work of breathing

4. Maintain the suction collection tubing and canisters for subsequent suctioning episodes. Follow the organization’s practice for changing the sterile solutions, the suction cannisters and tubing, and the inline (multi-use) suction catheter.

EXPECTED OUTCOMES

• Removal of secretions from the airway
• Improved gas exchange
• Airway patency
• Amelioration of clinical signs or symptoms that indicated need for suctioning (e.g., adventitious breath sounds, coughing, high airway pressure)

UNEXPECTED OUTCOMES

• Cardiac arrhythmias
• Increased ICP
• Hypoxemia
• Bronchospasm
• Atelectasis
• Mucosal trauma
• Hypertension or hypotension
• Ventilator-associated pneumonia
• Blood in sputum
• Inability to pass the suction catheter

DOCUMENTATION

• Education
• Patient’s tolerance of the procedure
• Respiratory assessment, including clinical indication for suctioning
• Administration of 100% oxygen, if used
• Number of passes of the suction catheter
• Volume, color, and consistency of secretions obtained
• Unexpected outcomes and related interventions

REFERENCES

1. American Association for Respiratory Care (AARC). (2010). AARC clinical practice guidelines. Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respiratory Care, 55(6), 758-764. (Level D)
2. 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 D)
3. Galbiati, G., Paola, C. (2015). Effects of open and closed endotracheal suctioning on intracranial pressure and cerebral perfusion pressure in adult patients with severe brain injury: A literature review. Journal of Neuroscience Nursing, 47(4), 239-246. doi:10.1097/JNN.0000000000000146 (Level C)
4. Kacmarek, R.M., Li Bassi, G. (2019). Endotracheal tube management during mechanical ventilation: Less is more! Intensive Care Medicine, 45(11), 1632-1634. doi:10.1007/s00134-019-05777-w (Level C)
5. 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.

Adapted from Johnson, K.L. (Ed.). (2024). AACN procedure manual for progressive and critical care (8th ed.). St. Louis: Elsevier.

AACN Levels of Evidence

• Level A - Meta-analysis of quantitative studies or metasynthesis of qualitative studies with results that consistently support a specific action, intervention, or treatment
• Level B - Well-designed, controlled studies, with results that consistently support a specific action, intervention, or treatment
• Level C - Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results
• Level D - Peer-reviewed professional organizational standards with clinical studies to support recommendations
• Level E - Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations
• Level M - Manufacturer's recommendations only

Clinical Review: Ashley Hinman, MSN, RN

Published: December 2023