ET CARE & SUNCTIONING

PURPOSE
 Endotracheal tube (ETT) suctioning is performed to ensure artificial airway patency, to optimize gas exchange, and to
collect lab specimens.
 Oral and oropharyngeal care are performed to prevent breakdown of oropharyngeal and buccal tissues from the ETT;
provide patient comfort; promote ventilation; and reduce the risk of ventilator associated pneumonia.

NURSING ALERT:
• Complications associated with ETT suctioning include: respiratory arrest, cardiac arrest, cardiac arrhythmias,
hypertension, increased intracranial pressure, bronchospasm, pulmonary hemorrhage, infection and decreased arterial
oxygenation.
• If respiratory arrest, cardiac arrest, or hemorrhage occurs during suctioning, proceed only if clinically indicated.
• Ensure emergency resuscitation equipment is readily available i.e.: Bag-Valve-Mask (BVM) device connected to
oxygen flow meter and set at 15 L/min.
• The incidence of ventilator associated pneumonia (VAP) is increased in patients intubated for longer than 24 hours.
• Three recognized risk factors for VAP are:
 Oropharyngeal colonization
 Oral secretions that migrate to the subglottal area
 Dental plaque
• Endotracheal tube cuff care and repositioning of the ETT is the responsibility of the Respiratory Therapist (RT).

A. Oral Care for Ventilated Adult Patients

EQUIPMENT
1. Personal protective equipment
2. Wall suction device, canister with connecting tube and insufflation filter
3. #14 Fr disposable sterile suction catheter
4. SAGE® Suction Swab System Kit (includes suction swab packages with sodium bicarbonate/hydrogen peroxide
solution, suction toothbrush packages, applicator swabs, tube of mouth moisturizer)
5. Chlorhexidine Gluconate Oral rinse 0.12% (PeridexTM)

PROCEDURE
1. Elevate head of bed (HOB) to 45° when possible, otherwise attempt to maintain HOB greater than or equal to 30°
on all ventilated patients, unless medically contraindicated.
NOTE: Positioning patients with HOB elevated reduces risk of aspiration.
2. Ensure suction equipment is properly assembled.
3. Wash hands and don appropriate personal protective equipment.
4. Explain the procedure and its purpose to patient.
5. Assess patient’s oral cavity and lips. Report any breakdown to physician and respiratory therapist (RRT).
NOTE: Early recognition of pressure or drainage allows for prompt intervention.
NOTE: ETT placement will be change q12h by RRT. Notify RRT sooner if areas of breakdown are noted.
6. Ask patient whether or not there is any oral discomfort throughout the procedure, using questions that can be
answered by nodding “yes” or shaking head “no”.
7. Perform subglottic (oropharyngeal) suctioning every 12 hours and PRN with #14 Fr disposable suction catheter or
the oropharyngeal suction catheter available in the SAGE® oral care kits to remove secretions that have
accumulated above ETT cuff.
NOTE: This step is not indicated in the presence of an ETT with continuous subglottic suction (EVAC
ETT).
NOTE: The space between the mouth and ETT cuff is not a sterile cavity and therefore clean technique is
appropriate when performing this step. Removal of pooled secretions above the ETT cuff may reduce risk
of aspiration.
8. Clean mouth every two to four hours with oral swabs containing 1.5% hydrogen peroxide and sodium bicarbonate
solution (Perox-A-Mint® solution).
• Squeeze the pouch that contains the oral toothettes
• Allow toothettes to become saturated prior to opening package.
• Connect to suction and scrub along teeth, tongue, inside of cheeks and gum line without applying suction.
• Clean oral cavity with suction. Apply suction by placing finger over suction vent.
NOTE: This solution has antimicrobial properties and acts as an oral debriding agent. It helps dissolve
mucous and maintain oral pH. Discontinue use if irritation occurs.
NOTE: Overuse can lead to drying of oral mucosa.
9. Brush patient’s teeth every 12 hours for one to two minutes using the applied suction toothbrush dipped in the
chlorhexidine gluconate oral rinse 0.12% solution. Gently brush the surface of the tongue.
• Dip suction toothbrush into Peridex bottle allowing it to become saturated
• Connect to suction and scrub along teeth, tongue, inside of cheeks and gum line without applying suction.
• Clean oral cavity with suction. Apply suction by placing finger over suction vent
 NOTE: For pediatric patients without teeth, wipe gums with a clean moistened gauze pad.
NOTE: This solution has antimicrobial properties. Discontinue if irritation occurs.
NOTE: Overuse can lead to drying of oral mucosa and staining of teeth.
10. Apply mouth moisturizer to oral mucosa and lips every two to four hours and PRN to keep tissue moist.
NOTE: Drying of oral mucosa contributes to microsites and gram-negative bacteria colonization.
11. Rinse oral suction device with sterile water or normal saline after each use.
12. Document procedure on appropriate RQHR form.

B. Closed Suction Method

 Involves using an enclosed suction catheter with a sleeve that is connected between ETT and oxygen source.

EQUIPMENT
1. Personal protective equipment (PPE)
2. Closed suction set up with catheter of the appropriate size, supplied by the RRT
3. Wall suction and canister with connecting tube and insufflation filter
4. Suction connection tubing
5. Sterile normal saline (NS)

PROCEDURE
NURSING ALERT:
 Suctioning should not be performed as a routine procedure.
 Routine instillation has been demonstrated to be more harmful than beneficial in most suctioning scenarios.
 Clinical indications for suctioning include, but are not limited to: maintain patency of and integrity of artificial
airway, collect sputum sample, coarse or wheezy breath sounds, decreased oxygen saturation, increased or
decreased respiratory rate, decreased breath sounds, increased or decreased HR, secretions in the airway,
ineffective coughing, cyanosis, suspected aspiration, restlessness and increased peak inspiratory pressures.

1. Perform hand hygiene.

2. Don appropriate personal protective equipment (PPE).
3. Verify correct patient using two patient-identifiers.
NOTE: For pediatric suctioning two qualified staff are recommended. One staff member to provide
suctioning and the second staff member to ensure stability of airway, and monitor patient response to the
procedure.
4. Explain the procedure to the patient/family.
5. Position the patient in a position that is comfortable for both the patient and nurse if time allows.
NOTE: It is recommended that semi-fowler or high-fowler positions be used if possible.
6. Ensure ETT is secure.
7. Ensure the suction tubing is connected to the inline suction catheter.
8. Assemble and prepare supplies.
9. Ensure suction is “on” and regulated at set pressures as outlined below:
 80-150mmHg (Adults)
 80-120mmHg (Children)
 60-80mmHg (Infants)
NURSING ALERT:
• Suctioning a patient with pressures greater than recommended may cause tracheal mucosal damage,
hemorrhage, hypoxemia and atelectasis. The amount of suction applied should be only enough to remove
the secretions.
10. Pre-oxygenate the patient for at least 30 seconds by activating the hyper-oxygenation function on the ventilator if
time allows.
NURSING ALERT:
• Pediatric pre-oxygenation is recommended to be greater than or equal to 60 seconds.
11. Support the ETT with the non-dominant hand.
12. Advance catheter slowly until the tip of the catheter extends just beyond the end of the ETT indicated by resistance
or a cough reflex (1-2 cm in adults and 0.5-1 cm in pediatrics).
NURSING ALERT:
o Correct suctioning depth is essential to minimize tracheal mucosal damage.
o Pediatrics: Do not insert suction catheter until resistance is felt. Instead, only insert catheter down ETT a
premeasured distance. After a pediatric patient is intubated, the following information will be documented
by RRT:
 Size of ETT
 Size of suction catheter to be used
 Depth of catheter for suctioning
o This information is to be posted at head of bed/crib. Premeasured distance is determined by length of ETT
that has been inserted (each ETT has remarked centimeter increments) plus one centimeter. Refer to
Appendix A for a diagram of observation area when using pediatric closed suction catheter. To assist with
 measuring correct distance to insert suction catheter, nurse may use a measuring tape for a guide. Refer to
the following diagram.
Measurement for Pediatric Suction Depth

NOTE: Deep suctioning has not shown superior benefit over shallow suctioning and may be associated
with more adverse events.
13. Apply continuous suction and withdraw the suction catheter.
NURSING ALERT:
 To reduce the risk of hypoxemia, cardiopulmonary complications and patient discomfort it is
recommended that ETT suctioning take no longer than 15 seconds in adults, and be limited to two to three
suction passes.
 For pediatrics, suctioning should take no longer than 5-10 seconds for neonates and infants, and 10
seconds for pediatrics. If secretions have not been adequately cleared on first attempt, it is recommended
to allow for several recovery breaths prior to repeating a suction procedure.
14. Allow patient to rest before continuing unless clinically contraindicated. A 30 second hyper-oxygenation is
recommended before and after each suction pass.
15. Repeat as necessary.
16. Clear catheter secretions by instilling NS into irrigation port of suction catheter while applying suction, taking care
not to lavage down ETT.
17. Disconnect In-line suction from wall-suction tubing.
18. Clear wall-suction tubing with sterile water, to transfer secretions from tubing to wall- suction canister.
19. Reconnect In-line suction to wall-suction tubing.
20. Document procedure according to flowsheet guidelines.

C. Open Suction Method

 Involves disconnecting the ETT from the oxygen source and then suctioning with a sterile, single use, disposable
suction catheter.

NURSING ALERT:
 Open Suction is NOT the recommended method for suctioning an ETT.
 Notify Respiratory Therapy to obtain an “In-line” closed suction system for intubated patients as soon as possible.
 Suctioning should not be performed as a routine procedure.
 Routine instillation has been demonstrated to be more harmful than beneficial in most suctioning scenarios.
 Clinical indications for suctioning include, but are not limited to: maintain patency of and integrity of artificial
airway, collect sputum sample, coarse or wheezy breath sounds, decreased oxygen saturation, increased or
decreased respiratory rate, decreased breath sounds, increased or decreased HR, secretions in the airway, ineffective
coughing, cyanosis, suspected aspiration, restlessness and increased peak inspiratory pressures.

EQUIPMENT
1. Personal protective equipment (PPE)
2. Appropriate sized suction catheter
NOTE: Determine the appropriate sized suction catheter, for smaller sized ETT’s by using the following
formula:
ETT size (mm) X 2 = catheter size (Fr)
For example:
4.0mm X 2 = 8Fr suction catheter
The largest sized suction catheter is 14Fr
3. Wall suction and canister
4. Suction connection tubing with connecting tube and insufflation filter
5. Sterile normal saline – 250 mL bottle
6. Bag/valve manual ventilation device with reservoir (BVM) connected to oxygen flow meter set at 15 L/min
NOTE: For effective ventilation of full term newborns, infants and children up to 25 kg, the BVM should
have a minimum volume of 450-500 ml.

PROCEDURE
1. Perform hand hygiene.
2. Don appropriate personal protective equipment (PPE).
3. Verify correct patient using two patient-identifiers.
 NOTE: Pediatric suctioning; two qualified staff are recommended. One staff member to provide
suctioning; and the second staff member to manually ventilate, ensure stability of airway, and monitor
patient response to the procedure.
4. Explain the procedure to the patient/family.
5. Position the patient in a position that is comfortable for both the patient and nurse if time allows.
NOTE: It is recommended that semi-fowler or high-fowler positions be used if possible.
6. Ensure ETT is secure.
7. Ensure suction is “on” and regulated at set pressures as outlined below:
 80-150mmHg (Adults)
 80-120mmHg (Children)
 60-80mmHg (Infants)
NURSING ALERT:
 Suctioning a patient with pressures greater than recommended may cause tracheal mucosal damage,
hemorrhage, hypoxemia and atelectasis. Amount of suction applied should be only enough to remove
secretions.
8. Open the sterile catheter package.
NOTE: The inside wrapping of the sterile package will be the sterile field.
9. Don sterile gloves.
10. Connect the suction catheter to the suction tubing.
NOTE: It is important to maintain sterility of the catheter and of the hand inserting the catheter.
11. Pre-oxygenate patient for at least 30 seconds by activating hyper-oxygenation function on ventilator or by
providing breaths using the BVM. Additional person may be required to activate hyper-oxygenation function if
unable to maintain sterility of catheter.
NURSING ALERT:
• Pediatric pre-oxygenation is recommended to be greater than or equal to 60 seconds.
12. Remove oxygen source, insert catheter quickly, but gently, down the ETT without activating negative suction.
Additional person may be required to remove oxygen source, if unable to maintain sterility of catheter.
13. Advance catheter slowly until tip of catheter extends just beyond the end of ETT indicated by resistance or a cough
reflex. (Premeasured distance for Pediatrics).
NURSING ALERT:
 Correct suctioning depth is essential to minimize tracheal mucosal damage.
 Pediatrics: Do not insert suction catheter until resistance is felt. Instead, only insert catheter down ETT a
premeasured distance. After a pediatric patient is intubated, the following information will be documented
by RRT:
 Size of ETT
 Size of suction catheter to be used
 Depth of catheter for suctioning
 This information is to be posted at head of bed/crib. Premeasured distance is determined by length of ETT
that has been inserted (each ETT has remarked centimeter increments) plus one centimeter. Refer to
Appendix A for a diagram of observation area when using pediatric closed suction catheter. To assist with
measuring correct distance to insert suction catheter, nurse may use a measuring tape for a guide. Refer to
the following diagram:

Measurement for Pediatric Suction Depth

14. Apply continuous suction and withdraw the suction catheter.

15. Reattach ETT to original oxygen source. Additional person may be required to apply oxygen source, if unable to
maintain sterility of catheter.
16. Hyper-oxygenate the patient as described in step 11 for at least 30 seconds post- suctioning procedure.
17. Flush suction catheter as necessary using sterile NS, to clear secretions from tubing to wall-suction canister.
18. Allow patient to rest before continuing unless clinically contraindicated. A 30 second hyper-oxygenation is
recommended before and after each suction pass.
NURSING ALERT:
 To reduce the risk of hypoxemia, cardiopulmonary complications and patient discomfort it is
recommended that ETT suctioning take no longer than 15 seconds in adults, and be limited to two to three
suction passes.
 For pediatrics, suctioning should take no longer than 5-10 seconds for neonates and infants, and 10
seconds for pediatrics. If secretions have not been adequately cleared on first attempt, it is recommended
to allow for several recovery breaths prior to repeating a suction procedure.
 19. Dispose of the suction catheter following infection control disposal guidelines.
NOTE: Observe clinical condition and reassess as necessary. Report persistent complications of
suctioning to the physician.
20. Document procedure according to flowsheet guidelines.
D. Collecting a Sputum Specimen

EQUIPMENT
1. Personal protective equipment (PPE)
2. Appropriate size suction catheter
3. Wall suction and canister
4. Suction connection tubing
5. Sterile NS
6. Sterile gloves
7. Sputum specimen trap

PROCEDURE
1. Obtain a physician’s order.
NOTE: Reasons to obtain a sputum specimen may include presence of fever, thick yellow or green,
copious secretions and a persistent cough.
2. Perform hand hygiene.
3. Don appropriate PPE including sterile gloves.
4. Explain procedure to patient/family.
5. Obtain a specimen trap collection device.
6. Attach the specimen trap to both the suction tubing and suction catheter, while maintaining sterile connection site,
as outlined below.

7. Ensure specimen trap lid is screwed on tightly.

8. Suction patient by using the open method (Section B).
NOTE: Only use a closed suction catheter if it is brand new (Section A).
9. Remove the suction catheter and suction tubing from the trap, once specimen obtained.
10. Close suction trap by connecting the catheter site to the suction site, maintaining sterile connections.
11. Send specimen trap to the lab following lab collection and infection control protocols.
NOTE: Label according to laboratory services manual.
12. Document procedure in patient’s chart according to flowsheet guidelines.