Airways suctioning is indicated for multiple reasons. Most commonly, suctioning is done for the removal of secretions from the respiratory tract, but sometimes also for the removal of blood or other materials like meconium in specific cases. Airway suctioning is also performed for diagnostic purposes. For example, airway secretions may be sent for microbiological and histological review. Additionally, suctioning is performed to maintain the patency of artificial airways such as an endotracheal tube or a tracheostomy tube.

Contraindications

While there are no absolute contraindications, the healthcare provider must consider the clinical condition of the patient and possible adverse events that may occur with suctioning.

Equipment

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.
• A sterile suction catheter (preferably 2 different sizes, one being smaller than the appropriate size needed
• Additional medications as needed for comfort

Preparation

After having appropriate equipment within easy reach and pulse oximetry (ideally) setup, the patient should be pre-oxygenated with 100% fraction of inspired oxygen (FiO2) either with a self-inflating bag or through the ventilator if already being mechanically ventilated.

Technique

The patient should be educated about the procedure (if awake and interactive) and the possibility of discomfort. Ensure preoxygenation with 100% FiO2 was done with adequate pulse oximetry measurements. Preoxygenation is required because an airway suctioning procedure may be associated with significant hypoxemia.  Suctioning of the lower airways should be done in a sterile manner with single-use gloves and suction catheters to prevent contamination and secondary infection.

After preparation with appropriate equipment at the bedside and monitoring continuous heart rate and oxygen saturation (as available), the patient should be suctioned with the appropriately sized equipment for their airway. The catheter should be introduced to a depth no more than the tip of the artificial airway to prevent trauma and bleeding from airway mucosa. Suction pressure should be kept at less than 200 mmHg in adults. It should be set at 80 mmHg to 120 mmHg in neonates.[3] The catheter size used for suction should be less than 50% of the internal diameter of the endotracheal tube. A common conversion is that a 1 mm diameter is equal to a 3 French. 

The use of normal saline while suctioning is not recommended by the American Association of Respiratory Care. The duration of suctioning should be less than 15 seconds per suction attempt. Following airway suction, the patient should be allowed to recover for at least 10 to 15 seconds and re-oxygenate as needed before re-suctioning occurs. Standard precautions should be followed while suctioning by the care provider.

Superficial vs. deep

Superficial suctioning implies going down with the suction catheter only up to the end of the artificial airway (endotracheal or tracheostomy tube), whereas deep suctioning implies going down with the catheter till resistance is met, which can theoretically be until the carina or primary bronchi are reached. Superficial suctioning is the most advisable to avoid mucosal injury and trauma.

Complications

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