Performing Suctioning

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. Match the catheter to the airway. The AARC recommends a catheter that occludes less than 50% of the lumen of the endotracheal tube in children and adults (less than 70% in infants and neonates) so airflow is not fully cut off (AARC).
3. Insert only to the tip of the artificial airway, not deeper, to avoid mucosal trauma and bleeding.
4. Estimate catheter French size from the tube (1 mm diameter is roughly 3 French).
5. Use the lowest effective suction pressure. In adults this is generally under 150 mmHg, with 80 mmHg to 120 mmHg preferred; pressures up to 200 mmHg are used only when needed with an appropriately sized catheter. Set 80 mmHg to 120 mmHg in neonates (AARC).
6. Do not routinely instill normal saline before suctioning, per the American Association for Respiratory Care (AARC).
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.

Frequently Asked Questions

How long should a single suction pass last? Limit each pass to no more than 15 seconds. Suctioning removes oxygen along with secretions, so a longer pass risks hypoxia (AARC).

What suction pressure is safe? Use the lowest pressure that clears secretions. In adults this is generally under 150 mmHg, with 80 to 120 mmHg preferred, and 80 to 120 mmHg in neonates. Higher pressure increases mucosal trauma and atelectasis (AARC).

Should you instill saline before suctioning? No. The AARC recommends against routine normal saline instillation before suctioning; it does not thin secretions effectively and can push bacteria into the lower airway and drop oxygen levels.

Why is suctioning done only as needed? Suctioning is assessed, not scheduled. You suction when there are signs of retained secretions (visible mucus, coarse breath sounds, rising work of breathing, falling SpO₂), because each pass carries risks of hypoxia, trauma, and bradycardia.

What size catheter should be used with an artificial airway? One that occludes less than 50% of the endotracheal tube lumen in children and adults (less than 70% in infants and neonates), so the patient can still move some air around the catheter (AARC).

What complications should the nurse watch for during suctioning? Hypoxia, mucosal trauma and bleeding, bradycardia from vagal stimulation, bronchospasm, atelectasis, infection, and patient anxiety. Monitor heart rate and SpO₂ continuously and stop if the patient destabilizes.