Are you ready to learning about Suctioning in Respiratory Care? I sure hope so because that is what this study guide is all about. As a Respiratory Therapist, it goes without saying that you absolutely must know the ins and outs of how to suction a patient.

But the thing is, you have to know the indications suctioning and proper technique. You can’t just go shoving catheters down patients throats, am I right?

And that is exactly why we created this guide — to be an all-in-one resource to teach you everything you need to know about suctioning. Are you ready to get started?

What is Suctioning?

Suctioning is a method of removing retained secretions or other semi-liquid fluids from the patient’s airways. It works via the application of negative pressure to the airways through a collecting tube or catheter.

Suctioning can be applied to either the upper airway (oropharynx) or the lower airway (trachea and bronchi). With that being said, access to the lower airways is performed with a flexible suction catheter through the nose or artificial airway. We will discuss each of these methods in further detail below.

What Equipment is Needed for Suctioning?

To perform suctioning properly, it’s important to have the right equipment. You will need the following:

  • Vacuum source
  • Collection bottle
  • Connecting tubing
  • Disposable sterile gloves
  • Sterile suction catheter
  • Sterile water
  • Goggles, mask, etc.
  • Supplemental Oxygen source
  • Pulse oximeter
  • Stethoscope
  • Sterile sputum trap

What is the Normal Suctioning Pressure?

In order to suction a patient effectively, you need to set the proper suctioning pressure to ensure that a) it’s strong enough to remove the secretions, and b) it’s not dangerously strong enough to cause damage to the airway.

A general rule of thumb: The suction pressure should be set at the lowest effective level.

  • For adults, the suction pressure should be set from 120 to150 mm Hg.
  • For children, the suction pressure should be set from 100 to 120 mm.
  • For infants, the suction pressure should be set from 80 to 100 mm Hg.

How to Estimate the Proper Size of a Suction Catheter?

Here’s how to properly estimate the size of which suction catheter to use with a given airway tube:

Multiply the tube’s inner diameter by 2. Then use the next smallest size catheter.

It’s that simple!

For example, let’s say you have a size 8-mm endotracheal tube.

8 x 2 = 16.

So you would use the next smallest suction catheter (in French units), which would be a size 14F.

What are the Indications for Suctioning a Patient?

Suctioning is a medical procedure used to clear retained or excessive secretions in your lower respiratory tract in order to facilitate airway expansion. The main objective of suctioning is to maintain a patent airway so that the patient can breathe effectively on his or her own.

During the procedure, a suction tip is attached to an artificial airway (e.g. endotracheal or tracheostomy tube) or directly placed into the mouth or nose of the patient in order to remove secretions.

Clinical indications for suctioning include the following:

  • Absent or decreased chest movement
  • Blood pressure fluctuations
  • Bradycardia
  • Decreased tidal volume
  • Inability of the patient to generate an effective cough
  • Increased peak inspiratory pressure
  • Increased work of breathing
  • Low oxygen saturation
  • Monitoring the efficacy of a treatment
  • Patients with artificial airways such as endotracheal tube or tracheostomy
  • Presence of coarse crackles over the lung area
  • Presence of aspiration
  • Recent history of large amounts of thick/tenacious secretions
  • Respiratory distress due to copious amount of secretions
  • Sawtooth pattern on a flow-volume loop on the ventilator monitor
  • Tachycardia
  • Visible airway secretions

When suctioning is done, the Respiratory Therapist should observe for the following in order to determine the effectiveness of the therapy:

  • Decreased work of breathing
  • Improved blood pressure
  • Improved heart rate
  • Improved respiratory rate
  • Improvement in breath or lung sounds
  • Increased oxygen saturation
  • Presence of chest movement
  • Removal of copious amount of secretions

How to Perform Nasotracheal Suctioning?

As the name implies, nasotracheal suctioning involves the insertion of a flexible catheter through the nose in order to access the trachea (windpipe) and remove secretions, blood, or other foreign materials.

The following are the proper steps in performing a successful nasotracheal suctioning:

  1. Wash hands thoroughly.
  2. Explain the procedure to the patient to establish rapport and cooperation.
  3. Prepare the necessary materials: Suction apparatus, suction catheter kit, water-soluble lubricant, and a sterile container with a sterile water or normal saline solution.
  4. Position the patient on his back with the head and trunk raised to between 30 to 45 degrees (semi-Fowler’s position).
  5. Place a linen or towel on the chest of the patient to avoid spillage of any secretions.
  6. Put on a face shield or goggles to protect yourself from secretions.
  7. Hyperoxygenate the patient by providing him with 100% oxygen via facemask for 1 minute. Doing so will prevent the incidence of hypoxia (low oxygen levels).
  8. Turn on the wall suction or portable suction and set it to the prescribed pressure.
  9. Occlude the connection tubing to test for the presence of suction.
  10. Open the suction catheter kit and water-soluble lubricant.
  11. Dons sterile gloves to prevent infection.
  12. Using your dominant hand, pick up the suction catheter and attach it to the connection tubing of the apparatus while avoiding contact with any unsterile surface.
  13. Place the suction catheter tip into the sterile container to suction a small amount of sterile solution.
  14. Apply suction by placing your thumb over the port of the suction catheter.
  15. Advice the patient to take several slow deep breaths.
  16. Estimate the depth to insert the suction catheter by measuring the distance between the tip of the nose to the tip of the ear lobe and down to the base of the neck of the patient.
  17. Lubricate the tip of the catheter using the water -soluble lubricant.
  18. Using your dominant hand, gently insert the suction catheter into the naris and down into the pharynx with no suction applied. Make sure to advance the suction catheter as the patient breathes in.
  19. Place your thumb over the suction control port to apply suction.
  20. Suction secretions in less than 10 seconds.
  21. Remove your thumb over the suction control port and slowly withdraw the suction catheter.
  22. Place the tip of the suction catheter into the sterile solution to rinse it of any secretions.
  23. Lubricate the suction catheter and repeat nasotracheal suctioning as needed with an interval of at least 30 seconds.
  24. After suctioning, turn off the machine and disconnect the catheter from the connecting tubing.
  25. Coil the suction catheter and pull the sterile glove off over it. Remove the other glove and discard.
  26. Hyperoxygenate the patient by providing him with 100% oxygen via facemask for 1 minute.
  27. Return the equipment and place used materials in an infectious waste bin.
  28. Prepare new suction supplies for future suctioning.
  29. Provide mouth care.
  30. Wash hands thoroughly.

How to Perform Endotracheal Suctioning?

  1. Wash hands thoroughly.
  2. Prepare the necessary materials: Suction apparatus, suction catheter kit, water-soluble lubricant, and a sterile container with a sterile water or normal saline solution.
  3. Place the patient in a semi-Fowler’s position.
  4. Place a linen or towel on the chest of the patient to avoid spillage of any secretions.
  5. Put on a face shield or goggles to protect yourself from secretions.
  6. Hyperoxygenate the patient by providing him a few breaths with 100% oxygen for 1 minute. This can be performed by ventilating the patient with an increased FIO2 (a setting in the mechanical ventilator).
  7. Turn on the wall suction or portable suction and set it to the prescribed pressure.
  8. Occlude the connection tubing to test for the presence of suction.
  9. Open the suction catheter kit and water-soluble lubricant.
  10. Dons sterile gloves to prevent infection.
  11. Using your dominant hand, pick up the suction catheter and attach it to the connection tubing of the apparatus while avoiding contact with any unsterile surface.
  12. Place the suction catheter tip into the sterile container to suction a small amount of sterile solution.
  13. Apply suction by placing your thumb over the port of the suction catheter.
  14. Lubricate the tip of the catheter using the water-soluble lubricant.
  15. Using your dominant hand, gently insert the suction catheter into the endotracheal tube with no suction. Make sure to advance the suction catheter beyond the tip of the endotracheal tube into the trachea (deep suctioning).[i] Do this as the patient breathes in.
  16. Place your thumb over the suction control port to apply suction.
  17. Suction secretions in less than 10 seconds.
  18. Remove your thumb over the suction control port and slowly withdraw the suction catheter.
  19. Place the tip of the suction catheter into the sterile solution to rinse it of any secretions.
  20. Lubricate the suction catheter and repeat endotracheal suctioning as needed with an interval of at least 30 seconds.
  21. After suctioning, coil the suction catheter and pull the sterile glove off over it. Remove the other glove and discard.
  22. Hyperoxygenate the patient with 100% oxygen by increasing the FIO2 in the mechanical ventilator settings.
  23. Return the equipment and place used materials in an infectious waste bin.
  24. Prepare new suction supplies for future suctioning.
  25. Provide mouth care.
  26. Wash hands thoroughly.

What is In-Line Suctioning?

An inline suctioning technique, also known as closed suctioning technique, is used so that patients do not need to be disconnected from the mechanical ventilator.

This involves attaching the suction catheter into a valve in the endotracheal tube, thus allowing continuous ventilation during suctioning.

How to Perform Nasopharyngeal Suctioning?

The following are the proper steps in performing a successful nasopharyngeal suctioning:
  1. Wash hands thoroughly.
  2. Explain the procedure to the patient to establish rapport and cooperation.
  3. Prepare the necessary materials: Suction apparatus, suction catheter kit, water-soluble lubricant, and a sterile container with a sterile water or normal saline solution.
  4. Place the patient in a semi-Fowler’s position.
  5. Place a linen or towel on the chest of the patient to avoid spillage of any secretions.
  6. Put on a face shield or goggles to protect yourself from secretions.
  7. Hyperoxygenate the patient by providing him with 100% oxygen via facemask for 1 minute.
  8. Turn on the wall suction or portable suction and set it to the prescribed pressure.
  9. Occlude the connection tubing to test for the presence of suction.
  10. Open the suction catheter kit and water-soluble lubricant.
  11. Dons sterile gloves to prevent infection.
  12. Using your dominant hand, pick up the suction catheter and attach it to the connection tubing of the apparatus while avoiding contact with any unsterile surface.
  13. Place the suction catheter tip into the sterile container to suction a small amount of sterile solution.
  14. Apply suction by placing your thumb over the port of the suction catheter.
  15. Advice the patient to take several slow deep breaths.
  16. Estimate the depth to insert the suction catheter by measuring the distance between the tip of the nose to the tip of the ear lobe and down to the base of the neck of the patient.
  17. Lubricate the tip of the catheter using the water soluble lubricant.
  18. Using your dominant hand and with no suction, gently insert the suction catheter diagonally into the nostril until it reach the suprasternal notch (dip at the front base of the neck). Make sure to advance the suction catheter as the patient breathes in.
  19. When the desired depth is reached, place your thumb over the suction control port to apply suction.
  20. Suction secretions in less than 10 seconds.
  21. Remove your thumb over the suction control port and slowly withdraw the suction catheter.
  22. Place the tip of the suction catheter into the sterile solution to rinse it of any secretions.
  23. Lubricate the suction catheter and repeat nasopharyngeal suctioning as needed with an interval of at least 30 seconds.
  24. After suctioning, turn off the machine and disconnect the catheter from the connecting tubing.
  25. Coil the suction catheter and pull the sterile glove off over it. Remove the other glove and discard.
  26. Hyperoxygenate the patient by providing him with 100% oxygen via facemask for 1 minute.
  27. Return the equipment and place used materials in an infectious waste bin.
  28. Prepare new suction supplies for future suctioning.
  29. Provide mouth care.
  30. Wash hands thoroughly.

How to Suction a Tracheostomy?

The following are the steps in suctioning a tracheostomy:
  1. Wash hands thoroughly.
  2. Explain the procedure to the patient to establish rapport and cooperation.
  3. Prepare the necessary materials: Suction apparatus, suction catheter kit, water-soluble lubricant, and a sterile container with a sterile water or normal saline solution.
  4. Place the patient in a semi-Fowler’s position with his head and neck well-supported.
  5. Place a linen or towel on the chest of the patient to avoid spillage of any secretions.
  6. Put on a face shield or goggles to protect yourself from secretions.
  7. Hyperoxygenate the patient by providing him with 4 to 6 compressions using a manual ventilator bag connected to an oxygen supply. If the patient is on a mechanical ventilator, activate the hyperoxygenation button.
  8. Turn on the wall suction or portable suction and set it to the prescribed pressure.
  9. Occlude the connection tubing to test for the presence of suction.
  10. Open the suction catheter kit and water-soluble lubricant.
  11. Dons sterile gloves to prevent infection.
  12. Using your dominant hand, pick up the suction catheter and attach it to the connection tubing of the apparatus while avoiding contact with any unsterile surface.
  13. Place the suction catheter tip into the sterile container to suction a small amount of sterile solution.
  14. Apply suction by placing your thumb over the port of the suction catheter.
  15. Advice the patient to take several slow deep breaths.
  16. Lubricate the tip of the catheter using the water soluble lubricant.
  17. Using your dominant hand and with no suction, gently insert the suction catheter into the tracheostomy opening for a maximum of 6 inches or until resistance is felt.
  18. When the desired depth is reached, place your thumb over the suction control port to apply suction.
  19. Suction secretions in less than 10 seconds.
  20. Remove your thumb over the suction control port and slowly withdraw the suction catheter.
  21. Place the tip of the suction catheter into the sterile solution to rinse it of any secretions.
  22. Lubricate the suction catheter and repeat tracheostomy suctioning as needed with an interval of at least 30 seconds.
  23. After suctioning, turn off the machine and disconnect the catheter from the connecting tubing.
  24. Coil the suction catheter and pull the sterile glove off over it. Remove the other glove and discard.
  25. Hyperoxygenate the patient by providing him with 100% oxygen via facemask for 1 minute.
  26. Return the equipment and place used materials in an infectious waste bin.
  27. Prepare new suction supplies for future suctioning.
  28. Provide mouth care.
  29. Wash hands thoroughly.

How to Obtain a Sputum Sample?

In order to obtain a sputum sample, follow these steps:
  1. Wash hands thoroughly.
  2. Explain the procedure to the patient to establish rapport and cooperation.
  3. Position patient in high-Fowler’s position.
  4. Instruct patient to rinse mouth with water.
  5. Place a linen or towel on the chest of the patient to avoid spillage of any secretions.
  6. Put on a face shield or goggles to protect yourself from secretions.
  7. Instruct patient to take a deep breath, cough and expectorate into the sterile container.
  8. Close the container immediately.
  9. Provide mouth care.
  10. Wash hands thoroughly.
For patients with endotracheal tube or tracheostomy, connect in-line trap collection container to the suction tubing to obtain sputum sample.

What are the Risks and Hazards of Suctioning?

Suctioning has the following risks and hazards:
  • Abnormal heart rhythm
  • Aspiration
  • Bleeding
  • Can stimulate the vagus nerve
  • Changes in intracranial pressure
  • Gagging/vomiting
  • Laryngospasm or bronchospasm
  • Lesions in tracheal mucosa
  • Low oxygen levels
  • Lung collapse
  • Mechanical trauma to the airway
  • Pain and other discomforts
  • Respiratory arrest

What are the Contraindications for Suctioning?

Suctioning is not recommended for patients with the following conditions:
  • Basal skull fractures
  • Cerebral spinal fluid leak
  • Epiglottitis or croup
  • Facial injury
  • Hemodynamic instability
  • Increased intracranial pressure
  • Loose teeth, denture or crown
  • Nasal bleeding
  • Occluded nasal passage
  • Recent facial surgery
  • Severe bleeding disorder
  • Severe bronchospasm or laryngeal spasm
  • Severe gag reflex
  • Tracheo/oesophageal fistulae
So now that we know the ins and outs of suctioning, let’s go ahead and dive into some practice questions on the topic. This will really help you imbed this information into your brain. Are you ready to get started?

Suctioning Practice Questions:

1. How do we prevent hypoxemia in suctioning?
Preoxygenate the patient at 100 percent O2 for 1 to 2 minutes.

2. Why do we hyperinflate the patient prior to suctioning?
It helps to avoid hypoxemia and vagal stimulation in patients on the ventilator.

3. How far should you insert the catheter during suctioning?
8 to 10 inches or until the patient coughs.

4. How long do we suction a patient for?
The application of the vacuum should be no longer than 15 seconds.

5. What is a whistle tip catheter?
The tip is cut at an angle and has one or more eyes or ports cut in the side.

6. What is the advantage of an eye or port in a catheter?
It keeps the vacuum from harming mucosal during suctioning.

7. Besides convenience, why is a closed suction system used?
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 VT, FIO2, and PEEP levels up. It is cheap and there is less contamination.

8. What is a rigid tonsillar?
It is also known as a Yankauer. It’s a hard plastic catheter specifically for oropharynx suctioning.

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

11. What is the normal suction pressure for peds?
-80 to -100

12. What is the normal suction pressure for neonates?
-60 to -80

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 sputum.

15. What is the only suction catheter that can go down the left bronchus?
Coude tip catheter.

16. What is the biggest hazard of suctioning?
Hypoxia or hypoxemia.

17. What are the hazards of suctioning?
Mechanical trauma, laceration of nasal turbinate, bleeding, tracheitis, hypoxemia, cardiac dysrhythmia bradycardia, hyper or hypotension, respiratory arrest, uncontrolled cough, gag, vomit, laryngospasm, bronchospasm, pain, infection, and atelectasis.

18. How can suctioning cause atelectasis ?
The catheter is too big or the suction pressure is top high.

19. How can you perform an assessment of the need for suctioning?
Auscultation and the patient’s effectiveness of cough.

20. Why can suctioning cause bradycardia?
Touching the carina with the catheter can stimulate the vagus nerve.

21. When suctioning, what should the assessment of outcome be?
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 (if available).

23. Manual resuscitator flow should be set at what prior to suctioning?
10 to 15 L/min

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 if needed, and ky jelly.

26. Sterile distilled water needs to be replaced how often?
Every 72 hours (be sure to record the date when opening).

27. What is the best position of the patient for suctioning?
Semi-fowler, sniffing, or supine if they are unable to get in the semi-fowler position.

28. How much saline is instilled in artificial airway if secretions are thick?
About 3 cc

29. How often do we oxygenate patients when suctioning artificial airways?
Between each pass.

30. How do you estimate the size of a suction catheter?
Multiply the ET tube ID size by 2, then go one size down.

31. The respiratory therapist is ready to suction the patient but there is no suction pressure. What might be problem?
There is a leak at suction trap or vacuum line, the canister may be full, or the suction is not turned on.

32. If the patient has PVC’s during suction, what should you do?
Stop, give 100 % O2, and notify the physician. Once they are stable, then you can continue suctioning.

33. How can you reduce trauma to the mucosa during suctioning?
Rotate the catheter, do not exceed the recommended pressure, use largest catheter possible without going over 1/2.

34. An absolute contraindication for suctioning is?
Epiglottitis and croup.

35. How can you tell if the suctioning has worked?
The patient has decreased WOB, improved breath sounds, and you removed secretions.

36. When should you perform suctioning?
Only on an as-needed basis. It should never be scheduled.

37. What kind of catheter is used for the left mainstem bronchus?
Directional or Coude.

38. What do you do to collect sputum?
Attach the Leuken’s trap and perform suction as you normally would.

39. What are some complications for suctioning?
Bronchospasm and vagal stimulation (bradycardia).

40. How to prevent complications during suctioning?
Correct the pressure set, be gentle, hyperoxygenate, make sure it’s quick (no more than 15 seconds).

41. When do you suction?
Only apply suction when you’re withdrawing the catheter. Never on the way in.

42. What is the purpose of suctioning?
To maintain a patent airway by removing secretions, blood, or foreign material.

43. When is suctioning performed?
Only when needed, visible secretions or audible gurgling, and when there is a sudden increase in respiratory rate.

44. The retention of secretions can cause what?
Increased WOB, atelectasis, hypoxemia, hypercapnia, pulmonary infection, increased airway resistance.

45. What happens when you cough?
Large inspiration, glottis closed, diaphragm moves up, pressure builds up in thorax, glottis opens, secretions move out.

46. What are the indications for suctioning?
Prolonged coughing, patients request, and patients with artificial airways.

47. What types of patients require suctioning?
Nervous system depression (intoxicated, sedated), abnormal pulmonary mechanics, thick secretions, pain, and post-surgical patients.

48. What are the upper airway suction devices?
Oropharynx; clean (not sterile) Yaunker, flexible plastic or rubber catheter.

49. When do you instill lavage?
Only after you are completely prepared to begin the insertion and suction.

50. What should you know about suctioning in the home?
Make sure it is clean as possible, the catheter can be used up to 24 hours, equipment washed in vinegar 9:1, and boil if permitted.

51. What is the purpose of the coude tip catheter?
It is a curved directional tip catheter which may help in guiding it into the right or left mainstem bronchi.

52. What is the purpose of a sputum trap?
Used for sputum collection.

53. What is the purpose of tracheal suctioning?
To maintain a patent airway by removing secretions, blood, or foreign material and facilitate pulmonary hygiene.

54. What are the indications for tracheal suctioning?
Visible secretions in airway or audible gurgling, increased tactile fremitus, sudden increase in respiratory distress/dyspnea, and increase in pressures that require ventilating with IPPB or mechanical ventilation, and a prolonged cough.

55. What are the complications associated with tracheal suctioning?
Hypoxia, vagal stimulation, trauma, dysrhythmias, hemoptysis, atelectasis, and bronchospasm.

56. What is the cause of expiratory wheezing after suctioning?
Bronchospasm; things get irritated so they tighten up and the wheezes gets vibrant.

57. When is lavage needed?
To break up hard thick mucus.

58. What are the types of solution used for lavage?
Normal saline, Mucomyst, and Na Bicarb.

59. What are the disadvantages of lavage?
If you need a sputum sample, it will have to much saline in it. Also, some might get stuck way down and could cause infection.

60. When is the appropriate time to instill lavage?
Right before suctioning.

61. What are the indications for the use of closed suction techniques?
PEEP greater than 10, inspiratory time greater than 1.5 seconds, FiO2 greater than 60, MAP greater than 20, and respiratory infections present.

62. What are the factors that indicate the outcome of suctioning was beneficial to the patient?
The show a decreased WOB, you got sputum out, their heart rate went close to normal, and their respiratory rate decreased.

Final Thoughts

Thank you so much for reading all the way through to the end of our study guide on suctioning. The fact that you’re putting in the work to learn this information now is going to pay off for you in a big way in the future.

Continue to go through this study guide (and these practice questions) and I know the information will stick — no pun intended.

Thanks again for reading and as always, breathe easy my friend. 

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