Performing Suctioning

Suctioning mechanically clears secretions from the airway when a patient cannot do it themselves: intubated, sedated, neurologically impaired, or with a weak cough. Artificial airways bypass the body's normal defenses and the cough reflex, so mucus builds up and you have to clear it. Done wrong, suctioning causes hypoxia, trauma, and bradycardia, so technique and limits matter.

What is Suctioning?

Suctioning clears the airway of mucus, secretions, or obstructions with a suction catheter. You use it when a patient cannot clear the airway from weakness, sedation, or a compromised cough, as with intubation or a tracheostomy. It keeps the airway patent and prevents hypoxia and infection.

Indications

• Visible secretions in the mouth, nose, or artificial airway.
• Ineffective cough (sedation, neurological impairment, weakness).
• Abnormal breath sounds (gurgling, crackles, rhonchi).
• Artificial airway (endotracheal or tracheostomy tube).
• Increased work of breathing (labored or rapid breathing, nasal flaring, accessory muscle use).
• Decreased SpO₂, suggesting hypoxia from obstruction.
• Changes in heart rate or blood pressure from hypoxia or distress.
• Ineffective respiratory drive (head injury, stroke, coma).

Contraindications

Assess and weigh the risk for:

• Severe hypoxemia (suctioning drops oxygen further).
• Bradycardia or cardiac instability (vagal stimulation).
• Increased intracranial pressure (ICP) (suctioning raises ICP).
• Recent nasal or oral surgery (bleeding, disrupted site).
• Active airway bleeding.
• Tracheoesophageal fistula.
• Unstable respiratory status or severe bronchospasm.

Types

• Oropharyngeal. Clears the mouth and upper throat; for conscious patients who need help with visible secretions.
• Nasopharyngeal. Catheter through the nostril to the nasopharynx; for weak cough or upper airway congestion.
• Nasotracheal. Catheter through the nostril into the trachea; for lower airway secretions without an artificial airway.
• Endotracheal. Through an ET tube in intubated patients, to clear the trachea and lower airways.
• Tracheostomy. Through a tracheostomy tube.
• Yankauer. A rigid, curved oral suction tip for thick oral secretions, common in surgery.

Assessment

• Respiratory status: distress signs like labored breathing, accessory muscle use, nasal flaring.
• Breath sounds: crackles, wheezes, rhonchi.
• SpO₂: below baseline or 90% may signal hypoxia.
• Rate and depth: shallow or irregular patterns may signal distress.

Supplies

• Suction machine (portable or wall-mounted)
• Suction catheter, appropriate size:
• Oropharyngeal: Yankauer catheter, clean gloves
• Nasopharyngeal: sterile suction catheter kit (12-18 French [Fr] for adults; 8-10 Fr for children; 5-8 Fr for infants), sterile and clean gloves
• PPE: mask, goggles or face shield, gown as needed
• Sterile water to flush between passes
• Water-soluble lubricant (nasopharyngeal)
• Connecting tubing
• Pulse oximeter
• Towel or disposable drape
• Stethoscope

Oropharyngeal and Nasopharyngeal Suctioning

1. Verify the order and gather supplies.
2. Explain the procedure.
3. Hand hygiene and PPE.
4. Position: a conscious patient with a gag reflex in semi-Fowler's, head turned for oral or neck hyperextended for nasal; an unconscious patient lateral, facing you.
5. Check equipment and set suction pressure.
6. Pre-oxygenate if needed to limit hypoxia.
7. Lubricate the catheter for nasopharyngeal suctioning with water-based lubricant. Avoid oil-based.
8. Insert the catheter. Oral: along the side of the mouth to avoid gagging. Nasal: gently through the nostril into the pharynx.
9. Apply suction by covering the port while gently rotating and withdrawing. No longer than 10-15 seconds.
10. Flush with sterile or distilled water between passes to prevent clogging.
11. Let the patient rest 20-30 seconds between passes to regain oxygenation.
12. Monitor the response.
13. Dispose of supplies and remove PPE.
14. Wash your hands.
15. Ensure safety: call light and table in reach, bed low and locked, side rails secured, hazards removed.
16. Document the time, duration, reason, response, and any complications.

For tracheostomy suctioning, see the Tracheostomy Nursing Care Plans.

Complications

• Hypoxia from prolonged suctioning without rest.
• Mucosal trauma from force or excessive suction pressure.
• Infection from contamination.
• Bronchospasm, especially in reactive airways like asthma.
• Bradycardia from vagal stimulation.
• Atelectasis from excessive suction pressure.
• Discomfort and anxiety.

Nursing Considerations

1. Keep equipment, including a correctly sized catheter, at the bedside, and monitor heart rate and SpO₂ continuously.
2. The catheter should occupy less than 70% of the ETT lumen for infants, children, and adults.
3. Insert only to the tip of the artificial airway, not deeper, to avoid mucosal trauma and bleeding.
4. Use a catheter less than 50% of the ETT internal diameter (1 mm diameter ≈ 3 French).
5. Keep suction pressure below 200 mmHg in adults; set it between 80 mmHg and 120 mmHg in neonates.
6. Follow the American Association for Respiratory Care recommendation against saline use during artificial-airway suctioning.
7. No more than 15 seconds per attempt.
8. Give 10-15 seconds to rest and re-oxygenate between attempts.
9. Follow standard infection control, including PPE.
10. Suction only as needed, not on a set schedule.
11. Prefer shallow over deep suctioning; use deep only if shallow proves ineffective.
12. Avoid oral suctioning after recent head and neck surgery.