Suctioning in Respiratory Care: Key Clinical Concepts

Suctioning is an airway management procedure used to remove retained secretions, blood, vomitus, or other material from the airway when a patient cannot clear it effectively. It is commonly performed by respiratory therapists in patients with artificial airways, weak cough, altered mental status, excessive secretions, or impaired airway clearance.

Although suctioning can be lifesaving, it can also cause complications if performed without a valid clinical indication.

For this reason, safe suctioning requires patient assessment, correct equipment selection, proper technique, oxygenation support, infection control, and careful monitoring before, during, and after the procedure.

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What Is Suctioning?

Suctioning is the application of negative pressure to the airway through a suction device, such as a flexible catheter or rigid suction tip. The goal is to remove secretions or other material that may obstruct airflow, impair ventilation, reduce oxygenation, or increase the patient’s work of breathing.

In respiratory care, suctioning is most often used to maintain airway patency. This is especially important when a patient has an artificial airway, such as an endotracheal tube or tracheostomy tube, because normal airway clearance mechanisms are bypassed or impaired.

A healthy person can usually clear secretions through coughing, swallowing, mucociliary transport, and normal upper airway function. However, many patients cannot do this effectively due to weakness, sedation, neurologic impairment, thick secretions, excessive mucus production, or the presence of an artificial airway.

When secretions remain in the airway, they can increase airway resistance, worsen gas exchange, and contribute to complications such as atelectasis, hypoxemia, hypercapnia, infection, and respiratory distress.

Why Suctioning Is Important

The airway must remain open for oxygen to enter the lungs and carbon dioxide to leave the body. Retained secretions can narrow or obstruct the airway, making breathing more difficult.

In patients receiving mechanical ventilation, secretions can collect inside the endotracheal tube and reduce its internal diameter. Even a small reduction in tube diameter can significantly increase airflow resistance. This means the ventilator or patient must generate more pressure to move the same amount of gas.

Suctioning helps prevent or correct problems caused by retained secretions, including:

• Increased work of breathing
• Decreased oxygen saturation
• Increased peak airway pressure
• Decreased delivered tidal volume
• Atelectasis
• Airway obstruction
• Poor secretion clearance
• Increased risk of infection
• Difficulty weaning from mechanical ventilation

Note: Suctioning should not be treated as a routine task performed on a schedule. It is a clinical procedure that should be performed only when assessment findings support the need for it.

Indications for Suctioning

A major principle of suctioning is that it should be performed based on clinical need. The presence of an artificial airway alone does not automatically mean the patient needs suctioning at a specific time interval.

Suctioning may be indicated when the patient has signs of retained secretions or airway obstruction. Common indications include:

• Visible secretions in the mouth, airway, endotracheal tube, or tracheostomy tube
• Coarse crackles or rhonchi on auscultation
• Weak, ineffective, or loose cough
• Increased work of breathing
• Decreased oxygen saturation
• Suspected aspiration of gastric or oral contents
• Increased peak inspiratory pressure during volume-control ventilation
• Decreased delivered tidal volume during pressure-control ventilation
• Difficulty passing air through an artificial airway
• Need to obtain a sputum specimen
• Atelectasis suspected from retained secretions
• Patient report of secretions that cannot be cleared

In mechanically ventilated patients, retained secretions may be suspected when the ventilator shows a change in airway mechanics. For example, in volume-control ventilation, secretions may cause peak inspiratory pressure to rise. In pressure-control ventilation, secretions may cause delivered tidal volume to fall.

Note: These changes are not specific to secretions, but when combined with abnormal breath sounds or visible mucus, suctioning may be appropriate.

When Suctioning Should Be Avoided or Delayed

Suctioning should be avoided when there is no clear indication. Unnecessary suctioning can irritate the airway, cause hypoxemia, trigger bronchospasm, increase discomfort, and lead to mucosal trauma.

Nasotracheal suctioning has additional concerns because the catheter passes through the nose, pharynx, and larynx before entering the trachea. This route increases the risk of trauma, bleeding, gagging, vomiting, and laryngospasm.

Absolute contraindications for nasotracheal suctioning include:

• Epiglottitis
• Croup
• Basilar skull fracture

Relative contraindications include:

• Nasal obstruction
• Nasal bleeding
• Facial, head, or neck trauma
• Bleeding disorder
• Upper airway infection
• Recent nasal, oral, or tracheal surgery
• Irritable airway
• Bronchospasm
• Laryngospasm

Note: Nasotracheal suctioning should also be used cautiously in patients with a low platelet count or neutropenia because of the increased risk of bleeding or infection.

Types of Suctioning

Suctioning can be classified by airway location, device type, and technique. The correct method depends on where the secretions are located and what type of airway the patient has.

Oropharyngeal Suctioning

Oropharyngeal suctioning removes secretions, blood, vomitus, saliva, or food particles from the mouth and pharynx. This is usually performed with a rigid suction device called a Yankauer suction tip.

A Yankauer is commonly used when material is visible in the mouth or when the patient cannot manage oral secretions. It is often used in unconscious patients, postoperative patients, trauma patients, and patients at risk for aspiration.

Oropharyngeal suctioning is considered a clean procedure rather than a sterile procedure because the oral cavity is not sterile. The device may be used more than once for the same patient, depending on facility policy, as long as it is handled properly.

Common uses of oropharyngeal suctioning include:

• Removing oral secretions
• Clearing vomitus from the mouth
• Reducing aspiration risk
• Clearing blood from the upper airway
• Assisting patients who cannot swallow secretions effectively

Note: Because this type of suctioning does not enter the lower airway, sterile technique is not required. However, infection control and proper equipment handling are still important.

Nasotracheal Suctioning

Nasotracheal suctioning is used to remove secretions from the trachea when the patient does not have an artificial airway. A flexible suction catheter is passed through the nostril, into the pharynx, through the larynx, and into the trachea.

This technique may be used when the patient has retained secretions but cannot cough effectively. It should usually be considered after less invasive airway clearance methods have failed.

Before inserting the catheter, the therapist should lubricate it with sterile water-soluble jelly. The catheter is inserted gently through the nostril and directed along the floor of the nasal cavity. If resistance is met, force should not be used. The catheter may be gently rotated or withdrawn and attempted through the other nostril.

Positioning can improve the chance of entering the trachea. The patient is often placed in an upright or Fowler’s position with the neck slightly extended in a modified sniffing position. Advancing the catheter during inspiration may help because the vocal cords abduct during inspiration.

Signs that the catheter has entered the trachea include coughing, airflow movement through the catheter, or resistance at the lower airway.

Nasotracheal suctioning can cause complications such as:

• Nasal trauma
• Bleeding
• Gagging
• Vomiting
• Laryngospasm
• Bronchospasm
• Mucosal injury
• Hypoxemia
• Bradycardia
• Contamination of the lower airway

Note: Patients who require repeated nasotracheal suctioning may benefit from a nasopharyngeal airway, also called a nasal trumpet. This can reduce repeated trauma to the nasal passages.

Endotracheal and Tracheostomy Suctioning

Endotracheal and tracheostomy suctioning involve passing a sterile suction catheter into an artificial airway to remove secretions from the trachea or large airways.

This type of suctioning is used in patients with:

• Endotracheal tubes
• Tracheostomy tubes
• Mechanical ventilation
• Artificial airways requiring secretion management

Unlike oropharyngeal suctioning, suctioning through an artificial airway requires sterile technique because the catheter enters the lower respiratory tract. If the catheter or sterile glove becomes contaminated, it should be replaced.

Note: The main goals are to maintain tube patency, improve secretion clearance, support ventilation, and prevent obstruction.

Open Suctioning

Open suctioning requires disconnecting the patient from the ventilator or oxygen source. A sterile suction catheter is inserted into the artificial airway, suction is applied while the catheter is withdrawn, and the patient is reconnected after the pass.

Open suctioning may be used for patients with a tracheostomy who are receiving humidified gas by tracheostomy collar and are not connected to a ventilator. It may also be used when a closed system is not available.

Note: The main disadvantage of open suctioning is that disconnecting the patient can cause oxygen loss, loss of PEEP, lung derecruitment, and interruption of ventilation. These effects can be significant in patients who require high FiO₂ or PEEP.

Closed Suctioning

Closed suctioning uses an in-line suction catheter enclosed in a protective plastic sleeve. The catheter remains attached to the ventilator circuit, allowing suctioning without disconnecting the patient from ventilatory support.

Closed suctioning is preferred for many mechanically ventilated patients because it helps maintain ventilation, oxygen delivery, PEEP, and lung volume during the procedure.

Closed suctioning is especially useful for:

• Patients receiving mechanical ventilation
• Patients requiring high FiO₂
• Patients requiring PEEP
• Patients at risk for lung derecruitment
• Neonates and infants
• Patients needing frequent suctioning
• Patients who become unstable when disconnected
• Patients receiving inhaled nitric oxide or heliox
• Patients under airborne or droplet precautions

Note: Closed suction systems may reduce circuit contamination and are often changed only when soiled, malfunctioning, or according to facility policy. However, routine daily changes do not necessarily reduce ventilator-associated pneumonia risk.

Deep vs. Shallow Suctioning

Suctioning may also be described as deep or shallow.

• Deep suctioning involves advancing the catheter until resistance is met, then withdrawing slightly before applying suction. This may stimulate coughing and help remove secretions, but it also increases the risk of airway trauma, vagal stimulation, hypoxemia, and mucosal irritation.
• Shallow suctioning involves advancing the catheter only to a predetermined depth, usually just beyond the tip of the artificial airway. This method is designed to remove secretions while reducing airway trauma.

Shallow suctioning is generally preferred in infants and children because they are more vulnerable to airway injury, oxygen loss, and lung derecruitment. It is also often safer for adults when deep suctioning is not necessary. The safest approach is to insert the catheter only as far as needed to clear secretions effectively.

Suction Catheter Size

Choosing the correct catheter size is essential. A catheter that is too large can obstruct the airway during suctioning and remove excessive gas from the lungs. This can worsen hypoxemia, cause atelectasis, and increase airway trauma.

For adults and children, the suction catheter should occlude no more than 50% of the internal diameter of the artificial airway. For infants, the catheter should occlude no more than 70% of the airway lumen.

A commonly used formula for estimating the maximum suction catheter size is:

ET tube or trach tube ID × 3 ÷ 2 = maximum suction catheter size in French

For example, with an 8.0 mm endotracheal tube:

8 × 3 ÷ 2 = 12 Fr

This means a 12 Fr catheter would be the recommended maximum size.

Note: A smaller catheter may be used when secretions are thin or easy to remove. Smaller catheters remove less air from the lungs and may reduce the risk of suction-related hypoxemia.

Suction Pressure Settings

Suction pressure should be strong enough to remove secretions but low enough to reduce mucosal trauma and lung volume loss. Excessive negative pressure can damage airway tissue, worsen hypoxemia, and contribute to atelectasis.

Commonly recommended suction pressure ranges include:

• Adults: 100 to 150 mm Hg
• Children: 100 to 120 mm Hg
• Infants: 80 to 100 mm Hg

Some references list adult suction pressure as 120 to 150 mm Hg, while others recommend approximately 100 mm Hg for endotracheal suctioning. The safest approach is to use the lowest pressure that effectively clears secretions.

Note: Suction pressure should be checked by occluding the tubing while adjusting the regulator. The therapist should also confirm that the suction system is functioning before beginning the procedure.

Equipment Needed for Suctioning

The required equipment depends on the type of suctioning being performed. In general, suctioning requires a vacuum source, collection system, tubing, and the correct suction device.

Common equipment includes:

• Wall vacuum or portable suction source
• Vacuum regulator
• Collection canister
• Connecting tubing
• Yankauer suction tip or flexible suction catheter
• Sterile gloves for artificial airway suctioning
• Clean gloves for oropharyngeal suctioning
• Sterile water or saline for flushing the catheter
• Water-soluble lubricant for nasotracheal suctioning
• Oxygen delivery device
• Pulse oximeter
• Manual resuscitation bag when appropriate
• Sputum collection trap when a specimen is needed

Portable suction may be needed during transport, in home care, or in settings where wall suction is unavailable. Portable systems may be electric, battery-powered, or hand-powered.

Before suctioning, the respiratory therapist should make sure the collection canister is not full, the float valve is not closed, the tubing is not kinked, the regulator is connected, and the vacuum source is working.

Preoxygenation and Oxygen Support

Hypoxemia is one of the most important complications of suctioning. Suctioning can remove air and oxygen from the lungs, interrupt ventilation, and cause lung derecruitment. To reduce this risk, many patients should be oxygenated before and after suctioning.

For adults and children, 100% oxygen is commonly delivered for 30 to 60 seconds before suctioning, especially when the patient is at risk for desaturation. Mechanically ventilated patients can often be preoxygenated using the ventilator’s 100% oxygen function.

For neonates, oxygen is usually increased by about 10% above baseline rather than automatically using 100% oxygen. This helps reduce the risk of oxygen toxicity while still supporting oxygenation during the procedure.

Note: Patients should be reoxygenated between suction passes. If the patient desaturates, becomes unstable, or develops significant distress, suctioning should be stopped and oxygenation should be restored.

Suction Duration

Suctioning should be brief. Prolonged suctioning increases the risk of hypoxemia, atelectasis, mucosal trauma, and arrhythmias.

For adults, suctioning is generally limited to 10 to 15 seconds per pass. For pediatric patients, suctioning time is shorter, often about 5 seconds. The exact duration depends on the patient’s condition, size, oxygen reserve, and response.

Note: Repeated passes should be performed only when necessary. The patient should be reassessed and reoxygenated before each additional suctioning attempt.

Normal Saline Instillation

Routine instillation of normal saline into the airway before suctioning is not recommended. Although saline has traditionally been used to loosen secretions or stimulate coughing, evidence does not support routine use.

Normal saline instillation may:

• Destabilize the patient
• Worsen oxygenation
• Increase coughing and discomfort
• Move bacteria into the lower airway
• Increase infection risk
• Fail to effectively thin secretions

If secretions are extremely thick, the therapist should first consider other causes, such as inadequate humidification or dehydration. In some cases, medications such as acetylcysteine or sodium bicarbonate may be ordered, but these require appropriate clinical judgment and usually a provider’s order.

Note: Adequate humidification, hydration, airway clearance therapy, and correct artificial airway care are preferred strategies for managing thick secretions.

Complications of Suctioning

Suctioning can cause serious complications, especially when performed too frequently, too deeply, too long, or with excessive suction pressure.

Common complications include:

• Hypoxemia
• Atelectasis
• Lung derecruitment
• Bronchospasm
• Bradycardia
• Tachycardia
• Cardiac dysrhythmias
• Hypertension
• Hypotension
• Mucosal trauma
• Bleeding
• Increased intracranial pressure
• Infection
• Patient discomfort
• Accidental extubation
• Respiratory arrest
• Cardiac arrest

Note: Many complications are related to oxygen loss, airway stimulation, vagal reflexes, mucosal injury, or interruption of ventilation. The respiratory therapist must monitor the patient closely during the procedure and be prepared to stop suctioning if the patient becomes unstable.

Vagal Stimulation During Suctioning

The suction catheter can stimulate receptors in the hypopharynx, trachea, and bronchi. This may trigger vagal stimulation and cause bradycardia, bronchospasm, or hypotension.

Bradycardia is especially concerning because it can reduce cardiac output and worsen oxygen delivery. Coughing may also increase intrathoracic pressure and temporarily reduce venous return.

If bradycardia, wheezing, or hypotension occurs, suctioning should be stopped. The patient should be oxygenated and allowed to recover before another attempt is considered.

Ways to reduce vagal stimulation include:

• Avoiding unnecessary deep suctioning
• Limiting suction duration
• Using the correct catheter size
• Avoiding excessive suction pressure
• Withdrawing slightly when resistance is met
• Applying suction only while withdrawing the catheter
• Monitoring heart rate and oxygen saturation

Note: In selected patients with elevated intracranial pressure or severe airway reactivity, aerosolized lidocaine may be ordered before suctioning to reduce coughing and airway irritation.

Preventing Atelectasis and Lung Derecruitment

Atelectasis occurs when alveoli collapse. Suctioning can contribute to this by removing gas from the lungs, interrupting ventilation, and causing loss of PEEP during ventilator disconnection. This is a major concern in patients with acute lung injury, ARDS, high oxygen requirements, or high PEEP needs.

To reduce atelectasis and derecruitment:

• Use closed suctioning when appropriate
• Avoid disconnecting the ventilator when possible
• Limit suction duration
• Use proper catheter size
• Use the lowest effective suction pressure
• Reoxygenate between passes
• Maintain PEEP during manual ventilation when needed

Note: If manual ventilation is unavoidable, a PEEP valve should be used when the patient requires PEEP.

Infection Control and Sterile Technique

Infection control is an important part of suctioning. The technique depends on the airway being suctioned.

Oropharyngeal suctioning is a clean procedure because the mouth is not sterile. Endotracheal and tracheostomy suctioning are sterile procedures because the catheter enters the lower airway.

Sterile technique helps reduce the risk of introducing pathogens into the trachea and lungs.

For artificial airway suctioning, the therapist should:

• Wash hands before the procedure
• Use sterile gloves or follow closed suction system protocol
• Keep the catheter sterile
• Replace contaminated equipment
• Avoid touching nonsterile surfaces with the sterile hand
• Use sterile water to flush the catheter when needed
• Follow facility policy for equipment changes
• Avoid routine saline instillation

Note: Closed suction systems help maintain catheter sterility because the catheter is enclosed in a protective sleeve. However, proper handling is still required.

Suctioning and Mechanical Ventilation

Suctioning is especially important in mechanically ventilated patients because artificial airways interfere with natural secretion clearance. Secretions can accumulate inside the tube or lower airway, increasing airway resistance and impairing ventilation.

In volume-control ventilation, retained secretions may cause peak airway pressure to rise. Plateau pressure may remain unchanged if the problem is airway resistance rather than reduced lung compliance. In pressure-control ventilation, retained secretions may reduce delivered tidal volume.

Suctioning may improve ventilator mechanics by removing secretions and restoring airway patency.

After effective suctioning, the therapist may observe:

• Improved breath sounds
• Lower peak inspiratory pressure in volume control
• Increased delivered tidal volume in pressure control
• Improved oxygen saturation
• Reduced work of breathing
• Improved patient comfort
• Better secretion clearance

Note: Suctioning should not be the automatic response to every ventilator alarm. The therapist should assess the patient, breath sounds, tubing, artificial airway, and ventilator graphics when available.

Subglottic Secretion Drainage

Subglottic secretion drainage is a suction-related strategy used in some intubated patients to reduce secretions pooled above the endotracheal tube cuff. These secretions can leak past the cuff and contaminate the lower airway, contributing to ventilator-associated pneumonia.

Special endotracheal tubes may include a separate suction port located above the cuff. This port connects to low suction, often around 20 mm Hg, to remove secretions from the subglottic area. This suction line must be clearly labeled to avoid confusion with the cuff inflation line or feeding tubes.

Note: Subglottic suctioning is not the same as routine endotracheal suctioning. It targets secretions above the cuff rather than secretions inside the tube or lower airway.

Suctioning in Pediatric and Neonatal Patients

Pediatric and neonatal patients require special caution during suctioning. Their airways are smaller, their oxygen reserves are lower, and they are more vulnerable to trauma and lung derecruitment.

In infants and children, suctioning may cause:

• Hypoxemia
• Bradycardia
• Atelectasis
• Increased intracranial pressure
• Airway trauma
• Infection
• Accidental extubation
• Hypercapnia
• Pneumothorax

Shallow suctioning is generally preferred because it reduces airway irritation and trauma. Closed suction systems are often helpful for neonates and infants receiving mechanical ventilation because they help maintain lung volume and oxygenation.

For neonates, oxygen should be increased carefully, often about 10% above baseline rather than automatically using 100% oxygen. The patient’s oxygen saturation, heart rate, and clinical response should be monitored closely.

Assessing Effectiveness After Suctioning

The procedure is not complete until the patient is reassessed. The therapist should determine whether suctioning improved airway patency and whether the patient tolerated the procedure.

Assessment after suctioning may include:

• Breath sounds
• Oxygen saturation
• Heart rate and rhythm
• Blood pressure
• Respiratory rate
• Work of breathing
• Sputum amount, color, and consistency
• Ventilator pressures
• Delivered tidal volume
• Patient comfort
• Signs of airway trauma or bleeding

Suctioning is considered effective when secretions are removed and the patient shows improvement in airway clearance, breath sounds, oxygenation, ventilation, or airway mechanics.

If breath sounds remain coarse, peak pressure remains elevated, or secretions are still visible, another suction pass may be needed. However, the patient should be reoxygenated and allowed to recover first.

Troubleshooting Suction Equipment

Before suctioning, the therapist must confirm that the suction system works correctly. Equipment failure can delay airway clearance and place the patient at risk.

If suction is weak or absent, the therapist should check:

• Whether the vacuum source is turned on
• Whether the portable suction unit is plugged in or charged
• Whether the wall regulator is connected to the correct outlet
• Whether the regulator is set correctly
• Whether the collection canister is full
• Whether the float valve is closed
• Whether the canister lid is sealed
• Whether tubing connections are tight
• Whether tubing is kinked or obstructed
• Whether the catheter is blocked

Note: The system should not be used if it cannot generate the necessary negative pressure.

Suctioning in Home Care and Transport

Some patients require suctioning outside the hospital, especially those with tracheostomy tubes or chronic secretion clearance problems. In these settings, portable suction equipment may be used.

Home suction systems typically include a portable suction pump, collection bottle, connecting tubing, and suction catheters or tips. Patients and caregivers must be taught how to use the equipment safely.

Education should include:

• When suctioning is needed
• How to assemble the system
• How to check suction pressure
• How to maintain cleanliness
• How to recognize complications
• How to clean the equipment
• When to seek medical help

Daily cleaning and maintenance are important to reduce infection risk and keep the equipment functioning properly.

During transport, suction equipment should be available for patients at risk for airway obstruction, vomiting, aspiration, or secretion retention. Battery-powered or hand-powered suction may be needed when wall suction is unavailable.

Board Exam Considerations

For respiratory therapy students, suctioning questions often focus on assessment, safety, catheter size, pressure settings, technique, and patient response.

Important exam points include:

• Suction only when clinically indicated
• Do not suction on a fixed schedule without need
• Use a Yankauer for oropharyngeal suctioning
• Use sterile technique for endotracheal and tracheostomy suctioning
• Use clean technique for oropharyngeal suctioning
• Choose the correct catheter size
• Limit suction pressure to the lowest effective level
• Preoxygenate patients at risk for hypoxemia
• Use closed suctioning for ventilated patients requiring high FiO₂ or PEEP
• Avoid routine normal saline instillation
• Stop suctioning if severe bradycardia, desaturation, or instability occurs
• Reassess breath sounds and ventilator mechanics after suctioning

A common exam scenario may describe an intubated patient with rhonchi, rising peak pressures, and decreasing oxygen saturation. In that case, suctioning may be the appropriate intervention if retained secretions are suspected.

Note: Another common scenario may describe bradycardia or desaturation during suctioning. The best response is to stop suctioning, oxygenate the patient, and reassess before continuing.

Suctioning Practice Questions

1. What is the primary purpose of suctioning in respiratory care?
Suctioning is used to remove retained secretions or other material from the airway when the patient cannot clear them effectively.

2. Why should suctioning be performed only when clinically indicated?
Unnecessary suctioning can cause complications such as hypoxemia, bronchospasm, mucosal trauma, discomfort, and airway irritation.

3. What is suctioning?
Suctioning is the application of negative pressure to the airway through a suction catheter or suction tip to remove secretions or other material.

4. What type of suction device is commonly used for oropharyngeal suctioning?
A Yankauer suction tip is commonly used for oropharyngeal suctioning.

5. Is oropharyngeal suctioning considered clean or sterile?
Oropharyngeal suctioning is considered a clean procedure because the oral cavity is not sterile.

6. What type of suctioning requires sterile technique?
Endotracheal and tracheostomy suctioning require sterile technique because the catheter enters the lower airway.

7. What breath sound commonly suggests secretions in the airway?
Rhonchi commonly suggest secretions in the airway.

8. What is the main advantage of closed suctioning in mechanically ventilated patients?
Closed suctioning allows suctioning without disconnecting the patient from the ventilator, helping maintain PEEP, FiO₂, and lung volume.

9. What is open suctioning?
Open suctioning requires disconnecting the patient from the ventilator or oxygen source before inserting a sterile suction catheter.

10. Why can open suctioning be risky for ventilated patients?
Open suctioning can cause loss of oxygen, loss of PEEP, lung derecruitment, and interruption of ventilation.

11. When is closed suctioning especially useful?
Closed suctioning is especially useful in patients requiring high FiO₂, high PEEP, frequent suctioning, or continuous ventilatory support.

12. What is the recommended maximum catheter diameter for adults and children with artificial airways?
The suction catheter should occlude no more than 50% of the internal diameter of the artificial airway.

13. What is the recommended maximum catheter diameter for infants with artificial airways?
The suction catheter should occlude no more than 70% of the internal diameter of the artificial airway.

14. What formula can be used to estimate suction catheter size?
ET tube or trach tube ID × 3 ÷ 2 = maximum suction catheter size in French.

15. What suction catheter size is recommended for an 8.0 mm endotracheal tube using the formula?
An 8.0 mm endotracheal tube would use a maximum suction catheter size of 12 Fr.

16. What suction pressure range is commonly recommended for adults?
Adult suction pressure is commonly set between 100 and 150 mm Hg.

17. What suction pressure range is commonly recommended for children?
Children generally require suction pressure around 100 to 120 mm Hg.

18. What suction pressure range is commonly recommended for infants?
Infants generally require suction pressure around 80 to 100 mm Hg.

19. Why should suction pressure be kept as low as effective?
Lower suction pressure helps reduce mucosal trauma, hypoxemia, and lung volume loss.

20. What is deep suctioning?
Deep suctioning involves advancing the catheter until resistance is met, then withdrawing slightly before applying suction.

21. What is shallow suctioning?
Shallow suctioning involves advancing the catheter only to a predetermined depth, usually just beyond the tip of the artificial airway.

22. Why is shallow suctioning preferred in infants and children?
Shallow suctioning helps reduce airway trauma, hypoxemia, and lung derecruitment in smaller, more vulnerable airways.

23. Should normal saline be routinely instilled before suctioning?
No. Routine normal saline instillation is not recommended because it has no proven benefit and may increase infection risk or destabilize the patient.

24. Why is preoxygenation often used before suctioning?
Preoxygenation helps reduce the risk of suction-induced hypoxemia.

25. How long should suctioning usually last in adults?
Suctioning should usually be limited to 10 to 15 seconds per pass in adults.

26. What is postoxygenation after suctioning?
Postoxygenation is the delivery of oxygen after suctioning to help the patient recover from oxygen loss caused by the procedure.

27. Why should the patient be reoxygenated between suctioning passes?
The patient should be reoxygenated between passes to reduce the risk of hypoxemia before another suctioning attempt.

28. What complication may occur when suctioning removes air from the lungs?
Atelectasis may occur when suctioning removes air from the lungs and contributes to alveolar collapse.

29. Why can suctioning cause bradycardia?
Suctioning can stimulate the vagus nerve, which may slow the heart rate and cause bradycardia.

30. What should the respiratory therapist do if bradycardia occurs during suctioning?
The therapist should stop suctioning, oxygenate the patient, and allow the patient to recover before considering another attempt.

31. What should the therapist do if resistance is met during catheter insertion?
The therapist should avoid forcing the catheter, withdraw slightly, and proceed carefully to reduce airway trauma.

32. Why should suction be applied only while withdrawing the catheter?
Suction should be applied while withdrawing the catheter to remove secretions while reducing mucosal injury.

33. Why is catheter rotation sometimes used during suctioning?
Catheter rotation helps remove secretions more effectively while the catheter is being withdrawn.

34. What is a major risk of using a suction catheter that is too large?
A catheter that is too large can obstruct the airway, remove excessive lung volume, and worsen hypoxemia.

35. What is a major risk of using excessive suction pressure?
Excessive suction pressure can cause mucosal trauma, bleeding, atelectasis, and oxygen desaturation.

36. What should be assessed before deciding to suction a patient?
The therapist should assess breath sounds, visible secretions, oxygen saturation, work of breathing, cough effectiveness, and ventilator changes.

37. What finding may suggest retained secretions during volume-control ventilation?
An increase in peak inspiratory pressure may suggest retained secretions during volume-control ventilation.

38. What finding may suggest retained secretions during pressure-control ventilation?
A decrease in delivered tidal volume may suggest retained secretions during pressure-control ventilation.

39. Why can retained secretions increase work of breathing?
Retained secretions narrow the airway, increase airway resistance, and make airflow more difficult.

40. What is the purpose of suctioning an artificial airway?
The purpose is to maintain patency of the endotracheal or tracheostomy tube by removing secretions, blood, or debris.

41. Why does an artificial airway increase the need for suctioning?
An artificial airway bypasses normal airway clearance mechanisms and can allow secretions to collect inside the tube.

42. What role does humidification play in secretion management?
Humidification helps keep secretions moist and mobile, making them easier to clear from the airway.

43. Why can inadequate humidification increase suctioning difficulty?
Inadequate humidification can make secretions thick, dry, and harder to remove with a suction catheter.

44. What is a Lukens trap used for?
A Lukens trap is used to collect sputum specimens during suctioning while reducing contamination of the sample.

45. When might a Coude suction catheter be selected?
A Coude catheter may be selected when the goal is to direct suctioning toward a specific bronchus.

46. What device may help reduce nasal trauma during repeated nasotracheal suctioning?
A nasopharyngeal airway, or nasal trumpet, may help reduce trauma during repeated nasotracheal suctioning.

47. Why should water-soluble lubricant be used during nasotracheal suctioning?
Water-soluble lubricant helps the catheter pass through the nasal passage more easily and reduces mucosal trauma.

48. Why should force be avoided during nasotracheal suctioning?
Force can injure the nasal mucosa, cause bleeding, or increase the risk of airway trauma.

49. What position is commonly used to help guide the catheter into the trachea during nasotracheal suctioning?
A modified sniffing position may help align the airway and improve the chance of entering the trachea.

50. Why is vigorous coughing during nasotracheal suctioning significant?
Vigorous coughing often indicates that the suction catheter has entered the trachea.

51. What are absolute contraindications for nasotracheal suctioning?
Epiglottitis, croup, and basilar skull fracture are absolute contraindications for nasotracheal suctioning.

52. Why is epiglottitis a contraindication for nasotracheal suctioning?
Epiglottitis is a contraindication because airway stimulation can worsen obstruction and trigger a dangerous airway emergency.

53. Why is croup a contraindication for nasotracheal suctioning?
Croup is a contraindication because upper airway inflammation can worsen with catheter stimulation.

54. Why is a basilar skull fracture a contraindication for nasotracheal suctioning?
A basilar skull fracture is a contraindication because nasal catheter insertion may cause serious injury if the catheter passes incorrectly.

55. What are relative contraindications for nasotracheal suctioning?
Relative contraindications include nasal bleeding, blocked nasal passages, bleeding disorders, facial trauma, upper airway infection, laryngospasm, and bronchospasm.

56. Why should nasotracheal suctioning be avoided soon after meals or tube feeding?
It should be avoided soon after meals or tube feeding because gagging and coughing may cause vomiting and increase aspiration risk.

57. What complication may occur if the suction catheter enters the esophagus during nasotracheal suctioning?
The patient may gag, cough, vomit, or experience ineffective secretion removal because the catheter is not in the trachea.

58. Why should the catheter be advanced during inspiration in nasotracheal suctioning?
The vocal cords open during inspiration, which improves the chance of the catheter entering the trachea.

59. What should the therapist do if the catheter will not pass through one nostril?
The therapist should withdraw the catheter and try the other nostril rather than forcing it.

60. Why is bleeding risk assessed before nasotracheal suctioning?
Bleeding risk is assessed because the nasal passages are highly vascular and can bleed with catheter trauma.

61. What is one sign that suctioning has been effective?
Improved breath sounds after secretion removal are one sign that suctioning has been effective.

62. What change in oxygen saturation may indicate effective suctioning?
An improvement in oxygen saturation after secretion removal may indicate effective suctioning.

63. What ventilator change may occur after effective suctioning in volume-control ventilation?
Peak inspiratory pressure may decrease after secretions are removed in volume-control ventilation.

64. What ventilator change may occur after effective suctioning in pressure-control ventilation?
Delivered tidal volume may increase after secretions are removed in pressure-control ventilation.

65. What should be documented after suctioning?
The therapist should document the indication, route, amount and appearance of secretions, patient response, oxygenation changes, and complications if present.

66. What does blood-tinged sputum after suctioning suggest?
Blood-tinged sputum may suggest mucosal trauma from catheter insertion, excessive suction pressure, or deep suctioning.

67. What should the therapist do if blood-tinged secretions occur after suctioning?
The therapist should reassess the technique, reduce trauma risk, consider shallow suctioning, and notify the appropriate provider if bleeding persists or worsens.

68. What is the purpose of subglottic secretion drainage?
Subglottic secretion drainage removes secretions that collect above the endotracheal tube cuff.

69. How can subglottic secretion drainage help reduce infection risk?
It may reduce the chance that secretions above the cuff leak into the lower airway and contribute to ventilator-associated pneumonia.

70. What suction pressure is commonly used for continuous aspiration of subglottic secretions?
Continuous aspiration of subglottic secretions commonly uses low suction around 20 mm Hg.

71. Why should the subglottic suction line be clearly labeled?
It should be clearly labeled to avoid confusion with the cuff inflation line or feeding tubes.

72. Why can suctioning increase intracranial pressure?
Suctioning can stimulate coughing, agitation, hypoxemia, and hemodynamic changes, which may temporarily increase intracranial pressure.

73. What may be ordered before suctioning a patient with elevated intracranial pressure?
Aerosolized lidocaine may be ordered to reduce coughing and airway irritation during suctioning.

74. Why can suctioning cause hypertension?
Suctioning can cause stress, coughing, pain, hypoxemia, and sympathetic stimulation, which may increase blood pressure.

75. Why can suctioning cause hypotension?
Suctioning can cause hypotension through bradycardia, reduced cardiac output, hypoxemia, or decreased venous return during coughing.

76. What is the most appropriate response if a patient desaturates during suctioning?
The therapist should stop suctioning, oxygenate the patient, and reassess before attempting additional suctioning.

77. Why should suctioning be limited to the shortest effective duration?
Short suctioning time reduces the risk of hypoxemia, atelectasis, mucosal trauma, and dysrhythmias.

78. What should be done before suctioning a mechanically ventilated patient at high risk for hypoxemia?
The patient should be preoxygenated, preferably through the ventilator, and monitored closely during the procedure.

79. Why is manual ventilation before suctioning not recommended routinely?
Manual ventilation may require ventilator disconnection, cause lung derecruitment, and deliver excessive pressure if performed incorrectly.

80. When manual ventilation is needed before suctioning, what should be used for patients requiring PEEP?
A PEEP valve should be used on the manual resuscitation bag to help maintain alveolar recruitment.

81. What is the risk of disconnecting a patient from the ventilator during suctioning?
Disconnecting the patient can cause loss of PEEP, oxygen loss, interruption of ventilation, and lung derecruitment.

82. What type of suction system is preferred for patients receiving high PEEP?
A closed in-line suction system is preferred because it helps maintain PEEP during suctioning.

83. Why is closed suctioning useful for patients receiving inhaled nitric oxide?
Closed suctioning allows suctioning without interrupting delivery of inhaled nitric oxide.

84. Why is closed suctioning useful during airborne or droplet precautions?
Closed suctioning may reduce exposure to contaminated secretions by keeping the ventilator circuit closed.

85. Does closed suctioning eliminate the need for infection control?
No. Proper handling, hand hygiene, and equipment care are still required even when using a closed suction system.

86. Do closed suction catheters need to be changed daily to prevent VAP?
No. Routine daily changes do not reduce VAP risk and catheters are usually changed when soiled, malfunctioning, or per facility policy.

87. What should be done with a closed suction catheter after suctioning?
The catheter should be fully retracted until the tip is visible in the sleeve.

88. Why should the closed suction catheter be fully retracted after use?
If the catheter remains advanced, it can increase airway resistance, increase work of breathing, or interfere with ventilation.

89. What should be done with the suction control valve after closed suctioning?
The suction control valve should be locked in the off position after suctioning.

90. Why should the lavage port on a closed suction system be capped after use?
The lavage port should be capped to prevent contamination and maintain the integrity of the closed system.

91. What can happen if a closed suction catheter is withdrawn too far?
Ventilator gas may enter and inflate the protective sleeve.

92. What type of suction should be used for airway suctioning?
Continuous suction should be used for airway suctioning rather than intermittent suction.

93. What are the three basic components of a suction system?
A suction system includes a vacuum source, a collection system, and a suction device.

94. What should the therapist check if a portable suction unit is not working?
The therapist should check the power source, battery charge, on/off switch, pressure setting, tubing connections, canister seal, and possible obstructions.

95. What should be checked if a suction collection bottle is not generating vacuum?
The therapist should check that the lid is sealed, tubing is connected tightly, the float valve is open, and the canister is not full.

96. Why should a full suction canister not be used?
A full canister may reduce or stop suction and can allow the float valve to close.

97. How is suction pressure usually set before suctioning?
Suction pressure is set by occluding or crimping the tubing while adjusting the vacuum regulator.

98. What should be done if the suction system cannot generate the required negative pressure?
The system should not be used until the problem is corrected or another functioning suction source is obtained.

99. Why should patients and caregivers receive suctioning education before discharge?
They need to know when suctioning is needed, how to use the equipment, how to clean it, and when to seek help.

100. What is the overall goal of safe suctioning?
The goal is to remove secretions while protecting oxygenation, ventilation, airway tissue, lung volume, hemodynamic stability, and infection control.

Final Thoughts

Suctioning is a necessary airway management procedure, but it must be performed with care. The goal is to remove secretions while protecting oxygenation, ventilation, airway tissue, lung volume, and hemodynamic stability.

Safe suctioning begins with assessment, not habit. The respiratory therapist must recognize when secretions are present, choose the proper suction device, use the correct catheter size and pressure, limit suction time, avoid unnecessary saline instillation, and monitor the patient closely.

When performed correctly, suctioning helps maintain airway patency, improve ventilation, reduce secretion-related obstruction, and support safer respiratory care.