Airway suctioning is an essential medical procedure used to maintain a clear air passage, particularly for patients who are unable to effectively clear secretions or obstructions from their respiratory tract.
Performed in various settings ranging from emergency scenarios to routine patient care, this technique ensures unobstructed ventilation, enhances oxygenation, and reduces the risk of aspiration.
This article breaks down the indications, techniques, and potential complications of airway suctioning and its clinical practice guidelines.
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What is Airway Suctioning?
Airway suctioning is a medical procedure used to remove mucus, secretions, or foreign materials from the respiratory tract to prevent aspiration and maintain an unobstructed airway. It’s essential for patients who can’t clear their airways independently, ensuring efficient ventilation and optimal oxygenation.
There are several potential indications for airway suctioning, including the following:
- Accumulation of secretions in the airway
- Audible or visible secretions in the upper airway
- Signs of respiratory distress or increased work of breathing
- Presence of an artificial airway, like a tracheostomy or endotracheal tube
- A decline in oxygen saturation or PaO2 levels
- Ineffective cough or inability to clear secretions
- Presence of atelectasis caused by mucus plugging
- Aspiration of foreign material or vomitus
- During resuscitative measures or in postoperative care to maintain a clear airway
- Frequent or sudden onset of respiratory infections
Note: While these are common indications, the decision to suction should be based on individual patient assessment and clinical judgment.
While there are no absolute contraindications for airway suctioning, there are situations where it might not be advisable.
For instance, if a patient can effectively clear their airway through coughing, that method is preferable to suctioning.
Furthermore, suctioning should be avoided if it would significantly distress the patient.
For successful and safe airway suctioning, a range of equipment is necessary. Here’s a list of the typical suctioning equipment:
- Suction Machine/Unit: This generates the negative pressure required for suctioning. It usually has adjustable settings to control the suction strength.
- Suction Catheters: These are the tubes inserted into the airway. They come in different sizes and types. The choice of size and type is based on the patient’s size and the specific clinical need.
- Connecting Tubing: Links the suction catheter to the suction machine.
- Yankauer Suction Tip: A rigid, large-bore suction device, mainly used for oral suctioning.
- Sterile Water or Saline Solution: Used for moistening the catheter tip and for rinsing it between suctioning passes.
- Gloves: For maintaining sterile or clean technique.
- Protective Eyewear and Mask: Protects the healthcare worker from potential splashes or secretions.
- Lubricant: Sterile lubricant can facilitate the insertion of the catheter, especially for nasal or nasopharyngeal suctioning.
- Collection Canister: Collects the aspirated secretions.
- Oxygen Delivery Equipment: Such as a bag-valve-mask (BVM) or supplemental oxygen, to deliver oxygen before and after suctioning, if necessary.
- Oropharyngeal and Nasopharyngeal Airways: Helps in maintaining an open airway during suctioning, especially in unresponsive patients.
- Sterile Basin: For holding the catheter and other sterile items.
- Sterile Towel/Drapes: Used to lay out the equipment in a sterile fashion.
- Suction Meter (or Regulator): Allows the caregiver to adjust the level of suction being applied.
Note: Every time suctioning is performed, the healthcare provider must ensure that all equipment is in working order, and sterile supplies are within their expiration date. Proper equipment preparation can help ensure patient safety and the effectiveness of the suctioning procedure.
Types of Suctioning
Airway suctioning can be categorized based on the location where suctioning is performed, the method applied, or the device used.
Here are the primary types of suctioning:
- Nasal suctioning
- Oral suctioning
- Pharyngeal suctioning
- Deep suctioning
Each of these suctioning techniques plays a vital role in various clinical scenarios, and the choice of method is determined by the patient’s specific needs and the location of the accumulated secretions.
Proper training and technique are essential to ensure patient safety and the effectiveness of the procedure.
Nasal suctioning involves the removal of secretions from the nostrils and nasal passages. It’s typically performed using a soft-tipped, flexible suction catheter.
Nasal suctioning is common in neonates and infants since they are obligate nasal breathers, meaning they predominantly breathe through their noses.
It helps to clear obstructed nasal passages to facilitate better breathing, especially when the baby has a cold or other respiratory issues.
Oral suctioning targets the removal of secretions from the mouth and the anterior part of the throat. A Yankauer suction tip is often the preferred instrument for this type of suctioning because of its rigidity and larger bore.
It is frequently used post-operatively, or for patients with a decreased level of consciousness, to prevent aspiration of oral secretions.
Pharyngeal suctioning is geared towards removing secretions from the back of the throat or oropharynx. It can be achieved with either a soft catheter or a Yankauer suction tip.
This type of suctioning is essential for patients at risk of aspiration, especially if they have difficulty swallowing or clearing secretions from their throat.
Deep suctioning involves removing secretions from the trachea or lower respiratory tract. A sterile, flexible suction catheter is usually passed through the nose or mouth or directly through an artificial airway like a tracheostomy or an endotracheal tube.
This type of suctioning is deeper and more invasive than the others, and it’s crucial in maintaining patency in patients with artificial airways or those unable to clear secretions from their lower airways.
Other Types of Suctioning
Apart from the primary types of suctioning, there are other specialized forms that cater to specific clinical needs. These include:
- Endotracheal suctioning
- Nasotracheal suctioning
- Bulb suctioning
- Oropharyngeal suctioning
- Nasopharyngeal suctioning
- Tracheostomy suctioning
Endotracheal suctioning involves the removal of secretions directly from the trachea through an endotracheal tube (ETT) that has been inserted into the patient’s airway, often in intubated patients.
A sterile technique is imperative, given the direct access to the lower respiratory tract.
The suction catheter is introduced through the ETT, and secretions are aspirated to ensure the tube remains patent and the patient can be ventilated effectively.
Nasotracheal suctioning is performed when a patient requires tracheal suctioning but does not have an artificial airway in place (like an ETT or tracheostomy tube).
A suction catheter is passed through the nostril and down into the trachea. This method is often utilized in patients who retain secretions and are unable to effectively cough them up.
Proper lubrication and technique are essential to minimize discomfort and potential trauma to the nasal passages.
Bulb suctioning is a method often used for neonates and infants. A bulb syringe is used to gently aspirate secretions from the mouth or nostrils.
After squeezing the bulb to create a vacuum, it’s placed into the nostril or mouth and then released, allowing the bulb to draw up the secretions.
This method is commonly employed immediately post-birth to clear secretions and help initiate effective breathing in the newborn.
Oropharyngeal suctioning focuses on the removal of secretions from the mouth and the back of the throat or oropharynx.
It’s often done using a Yankauer suction tip, which is rigid and suited to access the oral cavity without causing tissue trauma.
This method is particularly useful for patients who have difficulty clearing their own secretions due to decreased consciousness, post-operative status, or other medical conditions.
Nasopharyngeal suctioning involves clearing secretions from the nasopharynx, the upper part of the throat behind the nose.
A soft, flexible catheter is inserted through the nostril and advanced to the nasopharynx to aspirate secretions.
It’s a less invasive alternative to nasotracheal suctioning, often used when there’s a need to remove secretions behind the nasal passages in patients who can’t clear them independently.
Tracheostomy suctioning is specifically for patients who have a tracheostomy tube—a surgically created opening through the neck into the trachea.
Using a sterile technique, a suction catheter is passed through the tracheostomy tube to remove secretions from the trachea and ensure the patency of the artificial airway.
Regular suctioning is crucial for these patients to prevent tube blockage, reduce the risk of infection, and maintain effective ventilation.
Note: Knowing when and how to use each type of suctioning is vital for healthcare professionals. The choice often depends on the clinical need, the patient’s anatomy and condition, and the setting in which care is being provided. Proper training is crucial to ensure patient safety and the effective removal of secretions or obstructions.
What is the Normal Suction Vacuum Pressure?
Using proper levels of pressure when suctioning is important when it comes to the patient’s health and the effectiveness of therapy.
The key is to make sure that the pressure level is strong enough to remove the secretions but not so strong that it can cause damage to the patient’s airway.
Here are the normal pressure levels for suctioning:
- Adults: -100 to -120 mmHg
- Children: -80 to -100 mmHg
- Infants: -60 to -80 mmHg
Note: In general, the suction pressure should be set at the lowest effective level for secretion removal.
How to Estimate Catheter Size for Suctioning
When performing airway suctioning, it’s important to use a catheter that is properly sized for each individual patient.
In order to select the correct catheter size, you can simply multiply the tube’s inner diameter by 2. Then use the next smallest size.
For example, the catheter size for a size 8 mm endotracheal tube is calculated as follows:
8 x 2 = 16
Then, according to the rule mentioned above, you must use the next smallest catheter size (in French units), which would be size 14 fr.
Airway Suctioning Practice Questions
1. How can you prevent hypoxemia during suctioning?
Pre-oxygenate the patient with 100% oxygen for 1-2 minutes before applying suction.
2. What factors indicate that the outcome of suctioning was beneficial?
Decreased WOB, sputum removal, improved heart rate, and improved respiratory rate
3. How far should you insert the catheter during suctioning?
The catheter should be inserted approximately 8-10 inches or until the patient coughs.
4. How long should you suction a patient?
The application of vacuum should be no longer than 15 seconds.
5. What is a whistle tip catheter?
A catheter with a tip that is cut at an angle and has one or more ports on the side.
6. What is the advantage of a catheter that has a port?
It keeps the vacuum pressure from harming the mucosal during suctioning.
7. Why is a closed suction system recommended?
It is primarily used as a faster and more convenient way to deep suction in a sterile manner. It also helps to keep the patient’s tidal volume, FiO2, and PEEP in the optimal range.
8. What is a rigid tonsillar?
It’s a hard plastic catheter specifically for oropharyngeal suctioning and is also known as a Yankauer.
9. What is a suction regulator?
It reduces the high negative pressure to a manageable and safe physiological level.
10. What is the normal suction pressure for adults?
-100 to -120 mmHg
11. What is the normal suction pressure for peds?
-80 to -100 mmHg
12. What is the normal suction pressure for neonates?
-60 to -80 mmHg
13. What are the contraindications of suctioning?
Occluded nasal passages, nasal bleeding, epiglottis or croup, acute head face or neck injury, bleeding disorder, laryngospasm, irritable airway, and upper respiratory tract infection.
14. What is a Lukens trap?
It is a specimen trap that can be placed in a vacuum circuit to collect a sputum sample.
15. What is the only suction catheter that can go down the left mainstem bronchus?
Coude tip catheter
16. What is the biggest hazard of suctioning?
17. What are the hazards of suctioning?
Mechanical trauma, laceration of the nasal turbinate, bleeding, tracheitis, hypoxemia, cardiac dysrhythmia, bradycardia, hypertension or hypotension, respiratory arrest, uncontrolled cough, gag, vomiting, laryngospasm, bronchospasm, pain, infection, and atelectasis.
18. How can suctioning cause atelectasis?
Atelectasis can occur if the catheter is too big or if the suction pressure is too high.
20. Why can suctioning cause bradycardia?
Contacting the carina with the catheter can stimulate the vagus nerve.
21. What are the best patient outcomes of suctioning?
Improved breath sounds and removed secretions.
22. Patient monitoring during suctioning should include what?
Breath sounds, skin color, breathing pattern and rate, pulse, rhythm, sputum, bleeding or evidence of trauma, patient subjective response, cough, SPO2, and ICP.
23. What level should the manual resuscitator flow be set at prior to suctioning?
24. What does a suction kit include?
Sterile catheter, gloves, and basin.
25. Equipment preparation for suctioning includes what?
Manual resuscitator, suction kit, goggles or face mask, sterile normal saline, sterile distilled water, vacuum regulator, suction trap, and lubricant jelly.
26. What are the indications for using a closed suction system?
PEEP greater than 10, inspiratory time greater than 1.5 seconds, FiO2 greater than 60, MAP greater than 20, or if a respiratory infection is present.
27. What is the best position for the patient during suctioning?
Semi-fowler, sniffing, or supine if they are unable to get in the semi-fowler position.
28. How much saline can be instilled in the artificial airway if secretions are thick?
Approximately 3 cc
29. How often should you oxygenate patients when suctioning down an artificial airway?
Between each pass
30. How can you estimate the size of a suction catheter?
Multiply the ET tube size by 2, then go one size down.
31. What is likely the problem when a respiratory therapist is ready to suction the patient, but there is no suction pressure?
There could be a leak, the canister could be full, or the suction pressure may not be turned on.
32. What should you do if the patient has a premature ventricular contraction during suctioning?
Stop the treatment, provide 100 % oxygen, and notify the physician.
33. How can you reduce trauma to the mucosa during suctioning?
Rotate the catheter and do not exceed the recommended pressure.
34. What is an absolute contraindication for suctioning?
There is no absolute contraindication for suctioning; however, it may not be recommended if a patient is diagnosed with epiglottitis or croup.
35. What is the cause of expiratory wheezing after suctioning?
36. When should you perform suctioning?
Suctioning should only be performed on an as-needed basis. It should never be scheduled.
37. How can you collect a sputum sample?
Attach the Lukens trap and perform suctioning as you normally would.
38. What are the complications associated with tracheal suctioning?
Hypoxemia, vagal stimulation, trauma, dysrhythmias, hemoptysis, atelectasis, and bronchospasm.
39. How can you prevent complications during suctioning?
Use the correct pressure setting, be gentle, hyperoxygenate the patient, and apply suction pressure for no longer than 15 seconds.
40. When do you apply suction pressure?
Pressure should only be applied when you’re withdrawing the catheter. Never apply pressure during insertion.
41. What is the purpose of suctioning?
To maintain a patent airway by removing secretions.
42. When is a lavage needed?
To break up thick mucus
43. What is the most common solution used during a lavage?
44. What is a disadvantage of performing a lavage?
It can affect a sputum sample.
45. When is the appropriate time to perform a lavage?
Right before suctioning
46. What types of patients require suctioning?
Those with nervous system depression, abnormal pulmonary mechanics, thick secretions, pain, and post-operation.
47. What is the primary upper airway suction device?
48. What are the indications for tracheal suctioning?
Visible secretions in the airway, audible gurgling, increased tactile fremitus, prolonged cough, and a sudden increase in respiratory distress.
49. How far can a catheter be inserted during deep suctioning?
It can pass beyond the trachea until it reaches the carina.
50. What is Ballard suctioning?
A Ballard suctioning catheter is an in-line suction catheter that is often used on patients who are intubated and receiving mechanical ventilation.
FAQs About Airway Suctioning
What are the Patient Outcomes of Airway Suctioning?
After performing airway suctioning, a practitioner may expect the following patient outcomes:
- Decreased work of breathing
- Improved blood pressure
- Improved heart rate
- Improved respiratory rate
- Improved breath sounds
- Increased oxygen saturation
- Improved chest movement
- Removed copious secretions
Note: The primary goal of suctioning is to clear the airway of secretions, which can lead to one or more of the patient outcomes listed above.
What is Closed (in-line) Suctioning?
The closed or in-line suctioning technique involves the use of a catheter that is enclosed within a protective sheath. It is most commonly used in intubated patients who are receiving mechanical ventilation.
This type of suctioning is useful because a patient does not need to be disconnected from the ventilator.
Instead, the suction catheter is attached directly to the artificial airway, which allows continuous ventilation while suctioning is performed.
How to Obtain a Sputum Sample?
A sputum sample can be obtained with the following steps:
- Gather all equipment
- Wash your hands thoroughly
- Explain the procedure to the patient to establish rapport
- Place the patient in the semi-fowler’s position
- Instruct the patient to rinse their mouth with water
- Place a linen or towel on the patient’s chest to avoid the spillage of secretions
- Put on a face shield or goggles for protection
- Instruct the patient to take a deep breath, cough, and expectorate into a sterile container
- Immediately close the container, label it, and place it in a biohazard bag
- Provide mouth care for the patient
- Wash your hands thoroughly
- Transport the sample to the lab for analysis
Note: If the patient has an artificial airway in place, you must connect an in-line collection container to the suction tubing in order to obtain the sample.
What are the Risks and Hazards of Suctioning?
The risks and hazards associated with airway suctioning include the following:
- Vegas nerve stimulation
- Mucosal trauma
- Cardiac dysrhythmias
- Increased intracranial pressure
- Pain and other discomforts
Note: Each patient will react differently to suctioning. However, these are some of the potential risks and hazards that could occur.
What is a Soft Suction Catheter vs. Rigid?
A soft suction catheter is a long, thin tube that is used for suctioning and secretion removal. It is made of a soft, pliable material that has more maneuverability within the patient’s airway.
A rigid suction catheter is a shorter, stiffer tube that is also used for secretion removal. However, it is not as maneuverable; therefore, it is used for oral, nasal, and pharyngeal suctioning. An example of a rigid suction catheter is a Yankauer.
What are the Complications of Suctioning a Patient?
The complications of suctioning a patient include the following:
- Increased intracranial pressure
- Mucosal trauma
- Cardiac arrest
Note: Suctioning is a necessary medical procedure; however, it can also be dangerous if not performed correctly. These are some of the potential complications that could occur.
What is the Purpose of Suctioning?
The purpose of suctioning is to remove secretions from the patient’s airway. This can be done orally, nasally, or deeper into the trachea.
Suctioning is important because it helps to keep the airway clear and prevents secretions from pooling and causing respiratory distress.
How Long Should You Suction a Patient?
The length of time that you suction a patient will depend on the type of suctioning being performed.
However, in general, the maximum suction time for each attempt should be 15 seconds or less.
Why is Sterility Maintained During Suctioning?
It is important to maintain sterility during suctioning in order to prevent the spreading of an infection to the patient.
During suctioning, a catheter is inserted into the patient’s airway, which is a sensitive area.
If the catheter is not sterile, it can introduce bacteria and other microorganisms into the airway, which can cause infection.
What is the Proper Technique for Suctioning the Oropharynx?
The proper technique for suctioning the oropharynx involves the insertion of a catheter into the patient’s mouth and throat.
The practitioner must keep their thumb off of the suction control port until the catheter is in the correct place.
Then suctioning is performed with the use of negative pressure, which helps with secretion removal from the back of the throat.
What is a Coude Tip Suction Catheter?
A coude tip suction catheter is a tube used in airway suctioning that has an angled tip.
This helps it navigate around obstacles in the airway and is useful for suctioning the left mainstem bronchus.
Airway suctioning is a fundamental procedure in respiratory care, vital for sustaining clear airways and optimizing patient oxygenation.
While it offers considerable benefits in preventing respiratory distress and other complications, it’s imperative for healthcare professionals to remain well-informed and skilled in its application.
Proper training and adherence to guidelines ensure that the procedure is executed with minimal risk and maximum efficacy for the patient’s well-being.
John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.
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