SUCTIONING

INTRODUCTION

Suctioning is 'the mechanical aspiration of pulmonary secretions from a patient with

an artificial airway in place'. The procedure involves patient preparation, the
suctioning event(s) and follow-up care

Suction is used to clear retained or excessive lower respiratory tract secretions in

patients who are unable to do so effectively for themselves ]. This could be due to the
presence of an artificial airway, such as an endotracheal or  tracheostomy tube, or in
patients who have a poor cough due to an array of reasons such as excessive sedation
or neurological involvement . 

Having an artificial airway in situ impairs the cough reflex and may increase mucus
production. Therefore, in the neonatal and paediatric ICU, suctioning of an artificial
airway is likely to be the most common procedure.

Oropharangeal (OPA) and nasopharangeal (NPA)suction is a technique intended to

stimulate a cough to remove excess sputum and/or aspirate secretions from
the airways that cannot be removed from a patient’s own spontaneous effort. A cough
may be stimulated by a catheter in the pharynx (oropharangeal suction) or by passing
a catheter between the vocal cords and into the trachea to stimulate a cough
(nasopharangeal suction). The trachea is accessed by insertion of a suction catheter
either via the nasal passage and pharynx (nasotracheal suction) or via the oral cavity
and pharynx (orotracheal suction) using an airway adjunct. Nasotracheal suction may
be undertaken directly via the nostril without an airway adjunct. However, in some
situations, where repeated suction is anticipated and therefore a nasopharyngeal
airway should be utilised. Secretions are removed by the application of sub-
atmospheric pressure via wall mounted suction apparatus or portable suction unit.

OROPHARYNGEAL / NASO PHARYNGEAL SUCTIONING

Oral suctioning involves the mouth. Oropharyngeal involves the mouth and the pharynx and
sometimes the trachea. The pharynx and trachea can also be reached through the nose.
Suctioning via all of these routes are indicated when the patient has secretions in the pharynx and
upper airway that they cannot clear independently. The choice of route will depend on patient
factors like facial trauma, presence of airways, and the urgency of the situation. Symptoms to
suggest the patient may need tracheal suctioning include visible secretions in the airway, coarse
gurgling breath sounds, diminished breath sounds, suspected aspiration of gastric or upper
airway secretions, increased work of breathing, deteriorating SaO 2 or SpO2, restlessness. Because
 the suctioning occurs deeper into the respiratory tract, there is increased risk of respiratory
infection. As such the procedure must be sterile and thus observe principles of asepsis. Other
risks associated with oropharyngeal / tracheal suctioning include hypoxia, trauma, laryngospasm,
increased intracranial pressure for persons with head injury, cardiac dysrhythmias, and death

Respiratory assessment should always include underlying pathology including respiratory,

neuromuscular, musculoskeletal factors influencing respiratory status. Recent surgery, or trauma
to face or nose may influence the need and/or ability to insert suction catheters. Consider reasons
why the patient is unable to clear secretions independently and consider strategies that may
reduce the need for tracheal suctioning (i.e., humidity may help to liquefy secretions, sitting in
chair and/or ambulation may help the patient to clear secretions independently).

 PURPOSES

 To stimulate coughing.To stimulate coughing.        

 To provide effective ventilation.        
 To prevent lower respiratory tractTo prevent lower respiratory tract infection from
retained secretions.infection from retained secretions.
 To maintain a patent airway by removingTo maintain a patent airway by removing
retained tracheobroncheal secretions.retained tracheobroncheal secretions.

Equipments

This article will describe the procedure in an acute care setting in a patient with an artificial
airway.
 Oxygen source and vacuum with collection container (calibrated)
 Personal protective equipment including gloves, masks, and goggles (clean and sterile)
 Sterile saline
 Manual resuscitation bag for ventilation
 Monitoring equipment, including a stethoscope and continuous measurement of pulse
oximetry and heart rate.[1]
 A sterile suction catheter (preferably 2 different sizes, one being smaller than the
appropriate size needed
 Additional medications as needed for comfor

Safety considerations:

 Hand hygiene
 Review all safety considerations for oral suctioning.
 The mouth and pharynx contain bacteria that can potentially contaminate the trachea. If necessary,
suction the mouth with a different suction catheter / yankauer prior to beginning this procedure. Perform
regular good mouth care.
 Monitor the client throughout the procedure, and stop suctioning if the client experiences rapid changes in
status.
 Suctioning can cause increased intracranial pressure in patients with head injury. The nurse can reduce
this risk by hyper-oxygenating the patient before suctioning and/or limit the number of times a suction
catheter is inserted into the trachea.
 Use sterile technique for oropharyngeal suctioning.
 Perform point of care risk assessment for PPE.

Steps Additional Information

1. Assess  the need for suctioning including Perform baseline respiratory assessment including
respiratory assessment, signs of hypoxia, SpO2.
inability to clear own secretions adequately,
alterations in oxygenation levels Assess for additional factors that might influence
procedure, i.e., recent surgery; head, chest, or neck
tumors; facial or nasal trauma; and neuromuscular
diseases.

Determine if the patient is on any medications that

increase risk of bleeding

2. Explain the procedure in calm reassuring  Procedure can cause patient anxiety. This is part
manner explaining the benefits to remove of the consent procedure. Allow the patient an
secretions to make breathing easier. opportunity to ask questions.

3. Position the patient in semi to high Fowler’s  Promotes lung expansion and promotes secretion
– unless contraindicated. Drape chest with clearance.
towel or disposable pad.

4. Perform hand hygiene. Gather equipment.
Ensure suction set up is working.
Suction machine (portable or wall); canister &
liner; connective tubing (2), suction catheter,
lubricant, sterile saline or water (acts as lubricant),
PPE (sterile gloves, face shield and / or gown),
pulse oximeter.

5. Administer oxygen if needed Hyper-oxygenating might be necessary if the

patient is hypoxic or at risk of hypoxia during
procedure.

6. Estimate the appropriate suctioning depth by This is done with the suction catheter still in the
measuring the catheter from the tip of the sterile package. Ensures that the catheter remains
patient’s nose to the angle of the mandible or to sterile and at minimum reaches the pharynx.
the earlobe

7. Turn the suction device on, and set the
vacuum regulator to the appropriate negative
pressure. Set suction levels to medium /
moderate.
Attach the suction catheter to the tubing whilst
remaining in the sterile package.
Open the sterile water / saline.
If using lubricant, squeeze water soluble
lubricant onto sterile surface.
8. Hand hygiene & Donne PPE
9. Apply sterile gloves. With the non-dominant
hand, pick up the packaged connecting tubing.
Expose the suction catheter enough to allow
the dominant hand to grab the sterile catheter.
Wrap the sterile catheter around the dominant
hand.
Suction a small amount of sterile NS / water.
Apply lubricant if necessary (to 10 cm of
catheter tip)
Figure: Structures of the mouth and pharynx
Figure Suction regulator and canister
It is the tip of the catheter that you try to keep
sterile.
Suction setting:Adult 80 to 100 mmHg
Children 60 to 80 mmHg
*Not to exceed 150 mmgHg (AARC 2004)
At minimum PPE should include: sterile gloves &
face shield.
Sterile gloves reduce risk of transmitting
microorganisms into the lungs.
You can also apply a non sterile glove to the non
dominant hand and a sterile glove to the dominant
hand.
There is more than one way to remove the sterile
suction catheter from the package: the principle is
keep the dominant hand & the suction catheter tip
sterile.
Suctioning sterile NS/ water ensures properly
functioning equipment.
10. Insert suction catheter via route of choice
(oral / nasal) until you feel that you are in the
pharynx or until you feel resistance:
Oral (last resort)
Nasal
11. Apply intermittent suction as the catheter is
withdrawn. This means occluding and
releasing the catheter vent with the non-
dominant thumb. Some sources suggest
twisting catheter back and forth as the catheter
is withdrawn.  Always encourage the patient to
cough.
12. Replace the oxygen delivery device, if
applicable, and instruct the patient to take deep
breaths to encourage oxygenation.
13. Clear secretions from the suction catheter
by suctioning sterile water / saline to clear
tubing of secretions.
The route chosen will depend on the urgency of the
situation and presence of tubes and the skill level
of the nurse. Each route comes with inherit risks:
Oral (increases risk of respiratory infection by
introduction of oral bacteria to the trachea). This
route should be used as a last resort
Nasal (increases risk of nasal trauma – chose a
nare with least resistance). Can also be done
through a nasal airway
All: increased risk of vasovagal response
laryngospasm ( which could lead to airway
obstruction / hypoxia)
Important for this patient population is frequent
and adequate mouth care and collaboration with
respiratory therapy and physiotherapy
Introduction of the catheter sometimes stimulates a
cough response.
Suction applied during insertion increases risk of
mucosal damage and increases risk of hypoxia
Do not apply suction for longer than 10 to 15
seconds. Suction removes oxygen and increases
risk of hypoxia as oxygen is sucked out.
The need to rotate the catheter is questioned in the
literature because modern suction catheters have
multiple eyes / holes (Moore, 2003).
Encourage patient to cough to promote secretion
clearance.
Reapply oxygen delivery
device, if applicable
Clears tubing of secretions to maintain patency
14. Assess the need to repeat the procedure. Observe for changes to cardiopulmonary status.
Can often be done through observation of
breathing pattern including HR and SpO2.
If stethoscope is needed, hand hygiene and
reapplication of sterile gloves is necessary if you
are going to repeat the procedure.
When possible, provide recovery time (at least 1
minute) between suction passes to allow for
ventilation and oxygenation to occur.

15. Discard suction catheter, sterile saline /
water, lubricant, sterile gloves. Turn off
suction. Remove gloves. Perform hand
hygiene.  Ensure the patient is comfortable and
the call bell within reach.
Open suctioning method requires new suction
catheter after each round of suctioning. Reuse may
introduce microorganisms into the patient’s
respiratory tract increasing risk of infection

16. Document the procedure in the patient’s  Sample narrative documentation:

record.  
date/time: Patient drowsy. Audibly moist
respiration’s. Encourage to cough but unable to
clear secretions . T 37.5 HR 87 RR 26 BP 148/86.
SpO2 90%3L/prongs. Chest auscultated ++ course
crackles and ↓air entry throughout. Oropharyngeal
suctioning using #16 suction catheter for moderate
thick white / yellow secretions. Some coughing
noted through procedure. Resps now less audibly
moist. Chest sounds / vital signs unchanged
————-P. Lescgh RN
COMPLICATIONS

 Mucosal trauma
 Hypoxemia
 Bronchospasm
 Atelectasis
 Infection
 Pneumothorax
 Hypotension or hypertension
 Cardiac dysrhythmias
 Increased intracranial pressure

ENDOTRACHEAL SUNCTIONING
Suctioning is described as the mechanical aspiration of pulmonary secretions from a patient with
an artificial airway in position (American Association of Respiratory Care 2010)
Effective suctioning is an essential aspect of airway management in the intubated critically ill
patients

 Unable to maintain a patent airway

 Glottic closure is compromised
 Preventing cough reflex
 Increasing secretions
 Compromising their ability to clear endotracheal secretions

INDICATIONS
The decision to suction should be based on individual patient assessment and the following
clinical signs that may indicate the need for suctioning

 Suctioning should be done as rarely as possible and as frequently as needed

 Visible or audible secretions – rattling or bubbling sounds, audible with or without a
stethoscope
 Decreased oxygen saturation levels
 Bradycardia / tachycardia
 Increased pCO2
 Deteriorating blood gas values 
 Changes in respiratory rate and pattern with increase respiratory distress
 Change of colour (cyanosis, pallor, mottled)
 Suspected endotracheal tube obstruction
 Ventilator alarms i.e. Increased proximal airway pressure / decreased tidal volume 
 Decreased breath sounds / absent chest movement
 Increased airway pressure when ventilated (decreased tidal volumes)
 Decreased chest excursion / asymmetry
 Patient agitation

EQUIPMENTS
 Oxygen source / oxygen mixer for preterm / neonates
 Monitoring equipment – oxygen saturation, heart rate and blood pressure
 Suction apparatus
 Appropriately sized suction catheters
 Selection of clean disposable gloves
 Disposable plastic apron
 Goggles
 Alcohol hand rub
 Sterile Water for Irrigation
 PROCEDURE

STEPS RATIONALE
1. Turn on suction apparatus and set The amount of suction applied should be
vacuum regulator to 80-120mmhg only enough to remove secretions
effectively. High negative pressure settings
may increase tracheal mucosal damage.
2. Secure one end of the connecting tube Prepares suction apparatus
to the suction source and place the
other end in a convenient location
within reach
3. Monitor the patient’s cardiopulmonary Observes for signs and symptoms of
status before, during, and after the complications: decreased arterial and
suctioning period mixed venous oxygen saturation, cardiac
dysrhythmias, bronchospasm, respiratory
distress, derecruitment, cyanosis, increased
blood pressure or intracranial pressure,
anxiety, pain, agitation or changes in
mental status
4. a. open-suction technique only.
A. Open sterile catheter package on a Prepares catheter and pevents transmission
clean surface, with the inside of the of microorganisms
wrapping used as a sterile field
B. Depending on manufacturer, set up the Prepares catheter flush solution
sterile solution container or sterile
field. Use prefilled solution container
or open empty container, taking care
not to touch the inside of the
container. Fill with approximately
100ml of sterile normal saline solution
or sterile water
C. Don sterile gloves Prevents contamination of the open sterile
suction catheter
D. Pick up the suction catheter, with car Maintains catheter sterility.
to avoid touching non-sterile surfaces. Connects the suction catheter and
With the non-dominant hand, pick up connecting catheter and connecting tubing
the connecting tubing. Secure the
suction catheter to the connecting
tubing
E. Check equipment for proper Ensures equipment function
functioning by suctioning a small
amount of sterile solution from the
container
Proceed to step 6
4. b. Closed-suction technique only. Readies the suction setup for suctioning
B. Connect the suction tubing to the
closed system suction port or
unlock the thumb valve according
to manufacturer’s guidelines.

5. Hyperoxygenate the patient for atleast Hyperoxygenation with 100% oxygen is

30 seconds with one of the following
three methods
A. Press the suction
hyperoxygenation button on the
ventilator with the nondormant
hand
6. Remove the ventilator circuit or self-
inflating manual resuscitation bag-
valve device with the nondominant
hand. With the control vent of the
suction catheter open to air, gently but
guickly insert the catheter with the
dominant hand into the artificial
airway until resistance is met, then
pull back 1-2cm before applying
suction
7. Place the nondominant thumb over the
control vent of the sucton catheter to
apply continuous or intermittent
suction. Place and maintain the
catheter between the dominant thumb
and forefinger as you completely
withdraw the catheter for less than or
equal to 10 seconds into the sterile
catheter sleeve
8. Hyperoxygenate for 30 seconds
9. One or two more passes of the suction
catheter may be performed if
secretions remain in the airway and
patient is tolerating the procedure
10. When the airway has been cleared
adequately of secretions, perform
oropharyngeal suctioning
11. Rinse the catheter and connecting
tubing with sterile saline or sterile
water solution until clear
Open-suction : suction the unused
sterile solution until the tubing is
clear.
used to prvent a decrease in arterial oxygen
levels during the suctioning procedure
Hyperoxygenation with 100% oxygen is
used to orevent a decrease in arterial
oxygen levels during suctioning procedure
Suction should be applied only as needed
to remove secretions and for as short a time
as possible to minimize decreases in
arterial oxygen levels.
Tracheal damage from suctioning with the
intermittent or continuou suction
Decreases in arterial oxygen levels during
suctioning can be kept to a minimum with
the brief suction periods
The number of suction passes should be
based on the amount of secretions and the
clinical assessment due to the risk of
complications including pain and comfort
Enhances comfort and should be part of
oral hygiene programme
Rmoves buildup of secretions in the
connecting tubing and with the closed
suction catheter system, in the in-line
suction catheter
 Closed-suction: instill sterile saline or
water solution into the side port of in-
line suction catheter, taking care not
to lavage down endotracheal tube,
while applying continuous suction
until catheter is clear.
12. Open-suction technique only: on Reduces transmission of microorganisms
completion of upper-airway
suctioning, wrap the catheter around
the dominant hand. Pull glove off
inside out. Catheter remains in glove.
Pull off other glove in same fashion,
and discard. Turn off suction device.
13. Suction collention tubing and canisters Solutions and catheters that come in direct
may remain in use for multiple contact with the lower airways during
suctioning episodes suctioninig must be sterile to decrease the
risks for hospital-acquired pneumonia.
Devices that are not in direct contact with
the lower airways have not been shown to
increase infection risk
14. Remove PPE and discard used
supplies
15. Monitor the patient’s cardiopulmonary Observes for signs and symptoms of
status before, during, and after the complications
suctioning period
16. Reassess the patient for signs of Assess effectiveness of intervention and
suctioning effectiveness. possible indications for further suctioning
17. Follow institution standard for Identifies need for pain interventions
assessing pain. Administer analgesia
as prescribed

DOCUMENTATION
Documentation should include the following:

 Patient and family education

 Presuctioning assessment, including clinical indication for suctioning
 Suctioning of oral or endotracheal
 Size of endotracheal tube and suction catheter
 Type of hyperoxygenation method used
 Pain assessment, interventions and effectiveness
 Volume, color, consistency, and odor of secretions obtained
 Any difficulties during catheter insertion or hyperoxygenation
  Tolerance of suctioning procedure, including development of any unexpected outcoms
during or after the procedure
 Nursing interventions
 Post-suctioning assessment

COMPLICATIONS
 Respiratory complications
 Hypoxia
 Bronchospasm
 Tracheobronchial mucosal trauma resulting in potential pulmonary haemorrhage
 Contamination of airway leading to nosocomial infection
 Unplanned Extubation
 Atelectasis (loss of ciliary function / glottis closure)
 Right upper lobe collapse (excessive suction pressures)
 Pneumothorax (Morrow and Argent 2008)
 Neurological Complications
 Changes in cerebral blood flow velocity
 Raises intracranial pressure
 Decreased oxygen availability
 Increases risk of IVH
 Hypoxic-ischemic encephalopathy
 Cardiovascular complications
 Vagal response bradycardia
 Haemodynamic instability
 Pulmonary vasoconstriction
 Other complications Infections
 Nosocomial infections
 VAP Pain
 Behavioural pain response in infants

CONCLUSION
Suction is a routine procedure in Mobile ICU, ED, ICU and OT. Meticulous execution of
the procedure is important to ensure best patient care, avoid complications and untoward
events. Ensure the protocol based practice. It must be included in clinical protocol.
Infants, pediatric and high risk cases should be considered separately.

BIBLIOGRAPHY
1. American Association of Respiratory Care (ARCC) (2010) Endotracheal suctioning of
mechanical ventilated patients with artificial airways 2010. Respiratory Care, 55(6): 758-
764
2. Gillies, D. and Spence, D. (2013) Deep Versus Shallow Suction of Endotracheal Tubes in
Ventilated Neonates and Young Infants. Cochrane Database of systematic Reviews.
Available online: www.cochranelibrary.com
3. AARC and Respiratory Care Journal. Guidelines for noncommercial purposes of
scientific or educational advancement. May 1993;38(5): 500-504
4. Net reference:
 http://www.hopkinsmedicine.org/tracheostomy/living/suctioning.html
 https://www.rch.org.au/uploadedFiles/Main/Content/rchcpg/
hospital_clinical_guideline_index/Evidence%20Table% 20ETT%20Suction
%20Ventilated%20Neonates.pdf
 www.drvenu.blogspot.in drvenugopalpp@gmail.com 9847054747

ASSAM DOWNTOWN UNIVERSITY

 FACULTY OF NURSING
DEMONSTRATION

ON

SUCTIONING: OROPHARYNGEAL AND ENDOTRACHEAL

SUBJECT – MEDICAL SURGICAL NURSING

SUBMITTED TO: SUBMITTED BY:

MS.CYANOSURE SHARMA AMANDA KHARSAMAI

LECTURER 1ST YR. M.Sc. NURSING

FACULTY OF NURSING ROLL NO- 02

ASSAM DOWNTOWN UNIVERSITY ASSAM DOWNTOWN UNIVERSITY