SUCTIONING

LOREIYNE GRACE M. ABALLE RN, MAN

 ● Define suctioning.
● Identify the different kinds of suctions and
routes for suctioning.
● Enumerate the indications and purposes of

OBJECTIVES performing suction to patients.

● Understand the step-by-step process of
suctioning and the principles to be observed.
● Evaluate and assess patient's complications
after the procedure.
● Properly document the procedure and
observations after suctioning.
 .

SUCTIONING
Aspiration of secretions through a
catheter connected to a suction machine
or wall suction outlet.
- Sterile Technique is
recommended
- Oropharyngeal and
nasopharyngeal suctioning
removes secretions from the upper
respiratory tract
- Nasotracheal suctioning provides
closer access to the trachea and
requires sterile technique.
TYPES OF SUCTION
CATHETER
- Suction catheters are flexible,
made of plastic
● whistle-tipped catheter is less
irritating to respiratory tissues
● open tipped catheter may be
more effective for removing
thick mucous plugs
Oral suction tube or Yankauer
suction tube is used to suction
the oral cavity.
This can be assigned to AP and
to the client or family, if
appropriate, since this is not a
sterile procedure.
Most suction catheters have a
thumb port on the side to
control the suction. The
catheter is connected to
suction tubing, which in turn is
connected to a collection
chamber and suction control
gauge.
 PURPOSES
• To remove secretions that
Oral,
obstruct the airway
Oropharyngeal,
• To facilitate ventilation
Nasopharyngeal, • To obtain secretions for
and Nasotracheal diagnostic purposes
Suctioning • To prevent infection that may
result from accumulated
secretions
ASSESSMENT Assess for clinical signs indicating the
need for suctioning:
• Restlessness, anxiety
• Noisy respirations
• Adventitious (abnormal) breath
sounds when the chest is
auscultated
• Change in mental status
• Skin color
• Rate and pattern of respirations
• Pulse rate and rhythm
• Decreased oxygen saturation
 ● Towel or moisture-resistant pad
● Portable or wall suction machine with tubing,

Equipment collection receptacle, and suction pressure gauge

• Sterile disposable container for fluids
Oropharyngeal,
• Sterile normal saline or water
Nasopharyngeal, & • Goggles or face shield, if appropriate

Nasotracheal • Moisture-resistant disposal bag

• Sterile gloves
Suctioning
• Sterile suction catheter kit (#12 to #18 Fr for adults,
(Using Sterile #8 to #10 Fr for children, and #5 to #8 Fr for infants)

Technique) • Water-soluble lubricant

• Y-connector
• Sputum trap, if specimen is to be collected
 • Apply clean gloves.
• Moisten the tip of the Yankauer or suction catheter with steri
water or saline. Rationale: This reduces friction and eases
For Oral and
insertion.
Oropharyngeal
• Pull the tongue forward, if necessary, using gauze.
Suction
• Do not apply suction (that is, leave your finger off the port)
during insertion. Rationale: Applying suction during insertion
causes trauma to the mucous membrane.
• Advance the catheter about 10 to 15 cm (4 to 6 in.) along one
side of the mouth into the oropharynx. Rationale: Directing the
catheter along the side prevents gagging.
• It may be necessary during oropharyngeal suctioning to apply
suction to secretions that collect in the mouth and beneath the
tongue.
• Remove and discard gloves.
 • Open the lubricant.
For Nasopharyngeal • Open the sterile suction package.
and Nasotracheal a. Set up the cup or container, touching only
Suction the outside.
b. Pour sterile water or saline into the
container.
c. Apply the sterile gloves or apply an unsterile
glove on the nondominant hand and then a
sterile glove on the dominant hand.
Rationale: The sterile gloved hand maintains
the sterility of the suction catheter, and the
unsterile glove prevents the transmission of
the microorganisms to the nurse.
• With your sterile gloved hand, pick up the
For Nasopharyngeal and Nasotracheal Suction

6. Test the pressure of the suction and the

patency of the catheter by applying your
sterile gloved finger or thumb to the port
or open branch of the Y-connector (the
suction control) to create suction.
• If needed, apply or increase
supplemental oxygen.
7. Lubricate and introduce the catheter.

Lubricate the catheter tip with sterile water, saline, or

water-soluble lubricant. Rationale: This reduces friction
and eases insertion.
• Remove oxygen with the nondominant hand, if appropriate.
• Without applying suction, insert the catheter into either
naris and advance it along the floor of the nasal cavity.
Rationale: This avoids the nasal turbinates.
• Never force the catheter against an obstruction. If one
nostril is obstructed, try the other.
8. Perform suctioning.
• Apply your finger to the suction control port to start suction,
and gently rotate the catheter. Rationale: Gentle
rotation of the catheter ensures that all surfaces are
reached and prevents trauma to any one area of the
respiratory mucosa due to prolonged suction.
• Apply suction for 5 to 10 seconds while slowly withdrawing
the catheter, then remove your finger from the control
and remove the catheter. Rationale: Intermittent suction
reduces the occurrence of trauma or irritation to the trachea
and nasopharynx.
• A suction attempt should last only 10 to 15 seconds. During
this time, the catheter is inserted, the suction applied and
discontinued, and the catheter removed,
9. Rinse the catheter and repeat suctioning as above if
necessary.
Rinse and flush the catheter and tubing with sterile water or saline.
• Relubricate the catheter and repeat suctioning until the air
passage is clear.
• Allow sufficient time between each suction for ventilation
and oxygenation. Limit suctioning to 5 minutes in total. Rationale:
Applying suction for too long may cause secretions to increase or
may decrease the client’s oxygen supply.
• Encourage the client to breathe deeply and to cough
between suctions. Use supplemental oxygen, if appropriate.
Rationale: Coughing and deep breathing help carry secretions from
the trachea and bronchi into the pharynx, where they can be
reached with the suction catheter. Deep breathing and
supplemental oxygen replenish the oxygen supply that was
10. Obtain a specimen if required.
• Use a sputum trap as follows:
a. Attach the suction catheter to the tubing of the
sputum trap.
b. Attach the suction tubing to the sputum trap air vent.
c. Suction the client. The sputum trap will collect the
mucus during suctioning.
d. Remove the catheter from the client. Disconnect the
sputum trap tubing from the suction catheter. Remove
the suction tubing from the trap air vent.
e. Connect the tubing of the sputum trap to the air vent.
Rationale: This retains any microorganisms in the sputum
trap.
• Connect the suction catheter to the tubing.
11. Promote client comfort.

• Offer to assist the client with oral or nasal

hygiene.
• Assist the client to a position that facilitates
breathing.
12. Dispose of equipment and ensure
availability for the next suction.
• Dispose of the catheter, gloves, water, and waste
container.
a. Rinse the suction tubing as needed by inserting the
end
of the tubing into the used water container.
b. Wrap the catheter around your sterile gloved hand
and hold the catheter as the glove is removed over it
for disposal.
• Perform hand hygiene.
• Empty and rinse the suction collection container as
needed or indicated by protocol. Change the suction
13. Assess the effectiveness of suctioning.

• Auscultate the client’s breath sounds to ensure

they are clear of secretions. Observe skin color,
dyspnea, level of anxiety, and oxygen saturation
levels.
14. Document relevant data.

• Record the procedure: the amount,

consistency, color, and odor of sputum (e.g.,
foamy, white mucus; thick, green-tinged mucus;
or blood-flecked mucus) and the client’s
respiratory status before and after the
procedure. This may include lung sounds, rate
and character of breathing, and oxygen
saturation.
LIFESPAN CONSIDERATIONS

INFANTS CHILDREN OLDER ADULTS

• A bulb syringe is • A catheter is used • Older adults often have

used to remove to remove secretions cardiac or pulmonary

secretions from an disease, thus increasing

from an older child’s
their susceptibility to
infant’s nose or mouth or nose.
hypoxemia related to
mouth. Care needs to
suctioning. Watch closely
be taken to avoid
for signs of hypoxemia. If
stimulating the gag noted, stop suctioning and
reflex. hyperoxygenate.
Suctioning a Tracheostomy or
Endotracheal Tube
Following endotracheal intubation or a
tracheostomy, the trachea and
surrounding respiratory tissues are
irritated and react by producing excessive
secretions.
- Must be sterile
- Frequency depends on the client’s
health and how recently the intubation
COMPLICATION
S
●Hypoxemia

●Trauma to the airway

●Healthcare-associated

infection; and
●Cardiac dysrhythmia, which is
related to the hypoxemia
 ●Suction only as needed.
●Sterile technique
TECHNIQUES TO ●No saline instillation.
MINIMIZE ●Hyperinflation.

COMPLICATIONS ●Hyperoxygenation.

●Safe catheter size

 Open suction system
If a client is connected to a
ventilator, the nurse disconnects
the client from the ventilator,
suctions the airway, reconnects
the client to the ventilator, and
discards the suction catheter.
Closed suction system
The suction catheter attaches
to the ventilator tubing and the
client does not need to be
disconnected from the
ventilator. The nurse is not
exposed to any secretions
because the suction catheter is
enclosed in a plastic sheath.
 PURPOSES
• To maintain a patent airway and
prevent airway obstructions
• To promote respiratory function

Suctioning a (optimal exchange of oxygen and

carbon dioxide into and out of the
Tracheostomy or
lungs)
Endotracheal
• To prevent pneumonia that may
Tube
result from accumulated
 • Resuscitation bag (bag valve
Additional Equipment mask) connected to 100%
for Tracheostomy or oxygen
Endotracheal Tube • Sterile towel (optional)
Suctioning • Goggles and mask (if
(Using Sterile necessary)
Technique) • Gown (if necessary)
• Sterile gloves
START WITH USUAL
PREPARATION…

4. Prepare the client.

• If not contraindicated, place the client in
the semi-Fowler’s position to promote deep
breathing, maximum lung expansion and
productive coughing.
Rationale: Deep breathing oxygenates the
lungs, counteracts the hypoxic effects of
suctioning, and may induce coughing.
Coughing helps to loosen and move
5. Prepare the equipment for an open
suction system
● Attach the resuscitation apparatus to the oxygen
source. Adjust the oxygen flow to 100%.
• Open the sterile supplies: a. Suction kit or catheter;
b. Sterile basin or container.
• Pour sterile normal saline or water into sterile
basin or container.
• Place the sterile towel, if used, across the client’s
chest below the tracheostomy or on a workspace.
• Turn on the suction and set the pressure in
accordance with agency policy. The suction pressure
should be set at what is needed to adequately
remove secretions. The recommended suction
pressure for the open suction system is 100–120 mm
5. (Continuation)
• Apply goggles, mask, and gown if necessary.
• Apply sterile gloves. Some agencies
recommend putting a sterile glove on the
dominant hand and an unsterile glove on the
nondominant hand. Rationale: The sterile
gloved hand maintains the sterility of the
suction catheter, and the unsterile glove
holds the suction connecting tubing and
prevents transmission of the microorganisms
to the nurse.
• Holding the catheter in the dominant hand
and the connector in the nondominant hand,
6. Flush and lubricate the catheter.

• Using the dominant hand, place the catheter tip in the

sterile saline solution.
• Using the thumb of the nondominant hand, occlude the
thumb control and suction a small amount of the sterile
solution through the catheter.
Rationale: This determines that the suction equipment is
working properly and lubricates the outside and the
lumen of the catheter. Lubrication eases insertion and
reduces tissue trauma during insertion. Lubricating the
lumen also helps prevent secretions from sticking to the
inside of the catheter.
7. If the client does not have copious secretions, hyperventilate
the lungs with a resuscitation bag before suctioning.
• Summon an assistant, if one is available, for this step.
• Using your nondominant hand, turn on the oxygen to 12 to
15 L/min.
• If the client is receiving oxygen, disconnect the oxygen
source from the tracheostomy tube using your nondominant
hand.
• Attach the resuscitator to the tracheostomy or ETT.
• Compress the resuscitation bag three to five times, as the
client inhales. This is best done by a second staff member who
can use both hands to compress the bag.
• Observe the rise and fall of the client’s chest to assess the
7. (Continuation)
• Remove the resuscitation device and place it on the bed
or the client’s chest with the connector facing up.

Variation: Using a Ventilator to Provide Hyperventilation

If the client is on a ventilator, use the ventilator for
hyperventilation and hyperoxygenation. Newer models
have a mode that provides 100% oxygen for 2 minutes
and then switches back to the previous oxygen setting as
well as a manual breath or sigh button. Rationale: The
use of ventilator settings provides more consistent
delivery of oxygenation and hyperinflation than a
resuscitation device.
8. If the client has copious secretions, do not
hyperventilate with a resuscitator. Instead:

• Keep the regular oxygen delivery device on

and increase the liter flow or adjust the FiO2 to
100% for several breaths before suctioning.
Rationale: Hyperventilating a client who has
copious secretion can force the secretions
deeper into the respiratory tract.
9. Quickly but gently insert the catheter without
applying any suction.
• With your nondominant thumb off the
suction port, quickly but gently insert the
catheter into the trachea through the
tracheostomy tube. Rationale: To prevent
tissue trauma and oxygen loss, suction is
not applied during insertion of
the catheter.
• Insert the catheter about 1 to 2 cm (1/2
to 1 in.) past the distal end of the tube
until resistance is felt, even if the client
10. Perform suctioning.
• Apply suction for 5 to 10 seconds by placing the
nondominant thumb over the thumb port. Rationale:
Suction time is restricted to 10 seconds or less to
minimize oxygen loss.
• Rotate the catheter by rolling it between your
thumb and forefinger while slowly withdrawing it.
Rationale: This prevents tissue trauma by minimizing
the suction time against any part of the trachea.
• Withdraw the catheter completely and release the
suction.
• Hyperventilate the client.
11. Reassess the client’s oxygenation status and
repeat suctioning. • Observe the client’s respirations and skin color. Check the
client’s pulse if necessary, using your nondominant hand. If
the client is on a cardiac monitor, assess the rate and
rhythm.
• Encourage the client to breathe deeply and to cough
between suctions.
• Allow 2 to 3 minutes with oxygen, as appropriate between
suctions when possible.
Rationale: This provides an opportunity for reoxygenation of
the lungs.
• Flush the catheter and repeat suctioning until the air
passage is clear and the breathing is relatively effortless and
quiet.
• After each suction, pick up the resuscitation bag with your
nondominant hand and ventilate the client with no more than
12. Dispose of equipment and ensure availability for
the next suction.
• Flush the catheter and suction tubing.
• Turn off the suction and disconnect the catheter from the
suction tubing.
• Wrap the catheter around your sterile hand and peel the glove off so that
it turns inside out over the catheter. Remove the other glove.
• Discard the gloves and the catheter in the moisture-resistant bag.
• Perform hand hygiene.
• Replenish the sterile fluid and supplies so that the suction is ready for use
again. Rationale: Clients who require suctioning often require it quickly, so
it is essential to leave the equipment at the bedside ready for use.
• Be sure that the ventilator and oxygen settings are returned to pre-
suctioning settings. Rationale: On some ventilators this is automatic, but
always check. It is very dangerous for clients to be left on 100% oxygen.
13. Provide for client comfort and safety.
-Semi-fowler’s (conscious)
-Sim’s position (unconscious)- to promote
drainage

14. Document relevant data.

• Record the suctioning, including the amount and
description
of suction returns and any other relevant
assessments.
Variation: Closed Suction System
If a catheter is not already attached, apply clean gloves,
aseptically open a new closed suction system catheter set, and
attach the ventilator connection on the T piece to the ventilator
tubing. Attach the client connection to the ETT or tracheostomy.
• Attach one end of the suction connecting tubing to the suction
connection port of the closed system and the other end of the
connecting tubing to the suction device.
• Turn suction on, occlude or kink tubing, and depress the
suction control valve (on the closed catheter system) to set
suction to the appropriate level. Release the suction control
valve.
• Use the ventilator to hyperoxygenate and hyperinflate the
client’s lungs.
Variation: Closed Suction System

• Unlock the suction control mechanism if

required by the manufacturer.
• Advance the suction catheter enclosed in
its plastic sheath with the dominant hand.
Steady the T piece with the nondominant
hand.
• Depress the suction control valve and
apply continuous suction for no more than
10 seconds and gently withdraw the
catheter.
• Repeat as needed remembering to provide
hyperoxygenation and hyperinflation as
Variation: Closed Suction System

• When suctioning is completed, withdraw the catheter

into its sleeve and close the access valve, if appropriate.
Rationale: If the system does not have an access valve on
the client connector, the nurse needs to observe for the
potential of the catheter migrating into and partially
obstructing the artificial airway.
• Flush the catheter by instilling normal saline into the
irrigation port and applying suction. Repeat until the
catheter is clear.
• Close the irrigation port and close the suction valve.
• Remove and discard gloves.
LIFESPAN CONSIDERATIONS
INFANTS OLDER ADULTS
• Healthcare-associated • Do a thorough lung
• Have an assistant
pneumonia and ventilator- assessment before
gently restrain the
associated pneumonia (VAP) can and after suctioning
child to keep the
occur because of infected to determine
child’s hands out of secretions in the upper airway. effectiveness of
the way. The Oral antiseptic rinses (e.g., suctioning and to be
assistant should chlorhexidine gluconate) reduce aware of any special
maintain the child’s the rate of healthcare-associated problems.
head in the midline pneumonia in critically ill clients

position. (“Prevention,” 2017).

 SUMMARY OF KEY DIFFERENCES AND SIMILARITIES OF THE
ROUTES FOR SUCTIONING
OROPHARYNGEAL NASOPHARYNGEAL ET/TT

POSITION OF CHOICE Semi-fowler’s Semi-fowler’s Semi-fowler

(conscious) (conscious) (conscious)
Turn head at side Hyperextend
LEVEL OF INSERTION Nose to earlobe (4-6in Nose to earlobe (4-6in Until resistance
or 10-15cm) or 10-15cm) or advance (carina)
it along the floor of the (1/2—1in or 1-2cm)
nasal cavity.
TIME 5-10 seconds 5-10 seconds 5-10 seconds
Maximum time 15 seconds 15 seconds 10 seconds
Interval Time 20-30 seconds 20-30 seconds 2-3 minutes
TOTAL 5 minutes 5 minutes 5 minutes
Approximate Recommended Suction
Pressure
PORTABLE WALL

INFANT 2-5 mmHg 50-95 mmHg

CHILD 5-10 mmHg 95-110 mmHg

ADULT 10-15mmHg 100-120 mmHg

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REFERENCE: Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier &
Erb’s fundamentals of nursing: Concepts, process, and practice (10th
ed.). Pearson Education, Inc.