Airway Suctioning Techniques

Airway Suctioning Techniques

Airway suctioning is one of the most frequently performed — and most consequential — skills in respiratory therapy. When a patient cannot clear secretions effectively, those secretions obstruct airflow, impair gas exchange, and create a breeding ground for infection. Proper suctioning restores airway patency, but improper technique can cause hypoxemia, mucosal trauma, cardiac arrhythmias, or infection. Mastering suctioning means mastering both the mechanical steps and the patient-monitoring habits that go with them.

Indications for Suctioning

Suction only when there is a clinical reason to do so — not on a fixed schedule. Indications include: visible or audible secretions in the airway, decreased breath sounds caused by secretions, increasing airway pressures on a ventilator, a drop in SpO2 or oxygen saturation without another clear cause, and a patient's inability to cough effectively. Unnecessary suctioning stresses the patient and increases the risk of complications.

Oropharyngeal Suctioning

Oropharyngeal suctioning uses a rigid Yankauer catheter to clear the mouth and back of the throat. It is used for patients who cannot swallow or cough out oral secretions. This is a clean — not sterile — procedure, though you must still use good infection-control practices. Insert the Yankauer along the inside of the cheek toward the pharynx, apply suction during withdrawal, and limit each pass to approximately 10–15 seconds. Avoid triggering the gag reflex, and watch for the patient biting the catheter.

Nasopharyngeal Suctioning

Nasopharyngeal suctioning uses a flexible catheter passed through a naris to reach secretions in the nasal passages and upper pharynx. It is indicated when the oral route is inaccessible or contraindicated (for example, wired jaws). This procedure uses sterile technique. Lubricate the catheter with sterile water-soluble lubricant. Pass it gently along the floor of the nasal passage without applying suction; suction only during slow, rotating withdrawal. Each pass should last no longer than approximately 10–15 seconds. Avoid this route in patients with skull-base fractures, coagulopathy, or recent nasal surgery.

Endotracheal Suctioning — Open Technique

Open suctioning requires disconnecting the patient from the ventilator circuit briefly. Before you begin, pre-oxygenate the patient with 100% oxygen for approximately 30 seconds to build oxygen reserve and reduce the risk of suction-induced hypoxemia. Assemble a sterile field: sterile gloves, sterile suction catheter, and sterile saline if lavage is used (note that routine saline lavage is not recommended by current evidence). Set suction pressure to the lowest effective level — generally no more than 80–120 mmHg for adults, and lower for pediatric patients. Insert the catheter to the appropriate depth (to the carina, then withdraw slightly), apply suction only during withdrawal, and limit each pass to approximately 10 seconds. Reconnect the ventilator immediately after each pass and allow the patient to recover SpO2 before suctioning again. If SpO2 drops below 90% — or below the patient's baseline — stop suctioning and restore oxygenation.

Endotracheal Suctioning — Closed (In-Line) Technique

Closed suction catheters are housed in a protective plastic sleeve attached permanently to the ventilator circuit. The patient is never disconnected from the ventilator, so oxygenation and PEEP are maintained throughout. Closed technique is preferred for patients requiring high PEEP, FiO2 above 0.60, or who desaturate quickly. The mechanics are similar — insert without suction, suction only on withdrawal, limit each pass — but the closed system significantly reduces the risk of aerosolizing infectious secretions, making it the safer choice in airborne-precaution situations. After each use, flush the catheter sleeve with the manufacturer's recommended volume of sterile saline.

Suction Pressure and Catheter Size

For adult patients, suction pressure is generally set between 80 and 120 mmHg. Pressure higher than needed increases mucosal trauma and atelectasis. Choose a catheter no larger than half the internal diameter of the artificial airway. A catheter that is too large occludes the airway and dramatically worsens hypoxemia during suctioning.

Monitoring During Suctioning

Never leave the patient unobserved during suctioning. Watch SpO2 continuously. Monitor heart rate and rhythm: suctioning can stimulate the vagus nerve and cause a vasovagal response characterized by sudden bradycardia and hypotension. If this occurs, stop suctioning immediately, oxygenate the patient, and notify the supervising clinician. Document all findings — SpO2 before and after, suction pressure used, catheter size, secretion characteristics, and any adverse responses.

Sterile Technique: Non-Negotiable

Breaking sterile technique during endotracheal or nasopharyngeal suctioning introduces pathogens directly into the lower airway. Use a new sterile catheter for each suctioning episode. Do not allow the catheter to contact non-sterile surfaces. Keep your dominant (catheter-holding) gloved hand sterile at all times. Ventilator-associated pneumonia (VAP) is a serious and largely preventable complication; meticulous technique is your primary defense.

Documenting in the Lab Log

In clinical practice and in today's lab, thorough documentation is as important as the procedure itself. Record: indication for suctioning, suction pressure setting, catheter size and type, number of passes, duration of each pass, pre- and post-suction SpO2, description of secretions (color, consistency, estimated amount), and any adverse events and interventions. Accurate records protect patients and demonstrate professional accountability.