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HLT-RESP80-06 · Lesson 6 · 40 clock hours · practice

Airway Management: Intubation Assistance, Suctioning, and Artificial Airway Care

Objective. Students will perform endotracheal tube cuff management, closed and open suctioning, and tracheostomy care on simulated airway models, and correctly assist a provider during a simulated oral intubation using proper positioning, equipment preparation, and monitoring.

⚠ Pending professional review

This lesson, its worked examples and its practice questions has not yet been verified by a licensed clinician in the field or by a certification or approval body. It is a study draft and may contain errors. Do not use it to make decisions about any patient or medication. Always follow your instructor, your supervising professional, and current official references and regulations.

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Airway Management: Intubation Assistance, Suctioning, and Artificial Airway Care

Airway management is one of the most critical competencies in respiratory therapy. Whether you are caring for a patient on mechanical ventilation, assisting during an emergency intubation, or maintaining a tracheostomy, every step you take directly affects patient safety. This lesson walks through the essential skills you will practice at today's simulation stations.

Endotracheal Tube Cuff Management

An endotracheal tube (ETT) sits in the trachea with an inflatable cuff that seals the airway, allowing positive-pressure ventilation and reducing aspiration risk. The cuff must be inflated to a pressure high enough to create a seal but low enough to protect tracheal mucosal perfusion.

The accepted target range for cuff pressure is 20–30 cmH₂O. Pressures below 20 cmH₂O risk aspiration around the cuff and an inadequate ventilator seal. Pressures above 30 cmH₂O can impair mucosal blood flow and, over time, lead to tracheal injury, including tracheomalacia or stenosis.

To measure cuff pressure, connect a cuff pressure manometer directly to the pilot balloon valve. Read the pressure on the gauge and add or release air using the manometer's release button until you reach the target range. Document the measurement and your adjustment in the patient record. Check cuff pressure at least every shift and after any repositioning of the patient or tube.

Suctioning: Open and Closed Techniques

Suctioning clears secretions from the airway and is indicated when you observe or hear secretions, notice increased airway pressures, or see decreased oxygen saturation that may result from mucus plugging. Suctioning is never performed on a routine schedule alone—it is always based on patient assessment.

Open suctioning requires disconnecting the patient from the ventilator circuit and using a single-use sterile catheter. Use sterile gloves, maintain a sterile field throughout, and limit suction application to no more than 10–15 seconds per pass. Pre-oxygenate the patient before each suction pass, and allow the patient to recover between passes. The catheter is discarded after use.

Closed in-line suctioning uses a catheter enclosed in a sterile sleeve that remains attached to the ventilator circuit. The patient does not need to be disconnected, preserving PEEP and oxygenation. This approach is preferred for patients on high FiO₂ requirements or high PEEP, or when there is a risk of aerosolization. Apply suction only while withdrawing the catheter, not during insertion.

For both techniques, use the minimum effective suction pressure (typically –80 to –120 mmHg for adults) to clear secretions without causing mucosal trauma. Never apply suction while advancing the catheter.

Tracheostomy Care

Patients with a tracheostomy require routine care to prevent infection, skin breakdown, and tube displacement. Key steps include:

Never remove a tracheostomy tube unnecessarily. If accidental decannulation occurs within the early postoperative period, this is a medical emergency—call for help immediately and maintain the airway with BVM ventilation until a qualified provider can replace the tube.

Assisting with Oral Intubation

As the respiratory therapist assisting during intubation, your role is essential. Before the procedure:

1. Select the correct ETT size (commonly 7.0–8.0 mm internal diameter for adult women and men, respectively, but confirm with the provider).

2. Insert the stylet and bend the tube to a gentle hockey-stick curve; the stylet tip must remain at least 1 cm proximal to the Murphy eye.

3. Test the cuff by inflating it, checking for symmetry and leaks, then deflate fully before insertion.

4. Confirm the laryngoscope blade is the correct type and that the light source is working.

5. Have suction ready and turned on.

During the procedure, apply cricoid pressure (Sellick maneuver) only when directed by the physician or CRNA, maintaining firm, straight downward pressure on the cricoid cartilage.

After tube placement, confirm position immediately using waveform capnography (the gold standard) and auscultation of bilateral breath sounds and epigastric region. A colorimetric CO₂ detector provides a quick secondary check. Secure the tube, document the centimeter marking at the teeth, and obtain a chest radiograph per protocol.

Managing Unexpected Extubation

Accidental extubation is an emergency. Your priorities are:

1. Call for help — use the SBAR format (Situation, Background, Assessment, Recommendation) to communicate clearly.

2. Maintain the airway immediately with bag-valve-mask (BVM) ventilation using a proper mask seal (E-C clamp technique). Add a PEEP valve when indicated.

3. Position the patient: head extended, jaw thrust if needed.

4. Set up for re-intubation: gather the ETT, laryngoscope, suction, and medications while continuing BVM ventilation.

Time is critical. These steps must occur within minutes to prevent hypoxic injury.

Safety Reminders

Key terms10

Cuff pressure manometerA handheld device used to measure and adjust the pressure inside an endotracheal or tracheostomy tube cuff; target range for adults is 20–30 cmH₂O.
Closed in-line suctioningA suctioning technique using a catheter enclosed in a sterile sleeve attached to the ventilator circuit, allowing secretion removal without disconnecting the patient from the ventilator.
Open suctioningA suctioning technique requiring disconnection from the ventilator circuit and insertion of a single-use sterile catheter; requires sterile gloves and field throughout.
Waveform capnographyContinuous monitoring of exhaled CO₂ displayed as a waveform; the gold standard for confirming endotracheal tube placement in the trachea and not the esophagus.
Cricoid pressure (Sellick maneuver)Firm downward pressure applied to the cricoid cartilage by an assistant during intubation, applied only on the provider's instruction, intended to reduce risk of regurgitation.
StyletA semi-rigid wire inserted inside an endotracheal tube to help shape and stiffen it for insertion; the tip must remain proximal to the Murphy eye and the stylet is removed after the tube is placed.
TracheomalaciaSoftening and weakening of the tracheal cartilage, which can result from prolonged excessive ETT cuff pressure impairing mucosal blood flow.
SBARA structured communication framework (Situation, Background, Assessment, Recommendation) used to relay urgent clinical information clearly and efficiently to other healthcare providers.
Murphy eyeA small lateral opening near the distal tip of an endotracheal tube that allows ventilation to continue if the main lumen becomes occluded; the stylet tip must not extend past it.
Bag-valve-mask (BVM)A manual resuscitation device consisting of a self-inflating bag, one-way valve, and face mask used to deliver positive-pressure ventilation to a patient who is not breathing adequately.

Worked examples4

1. You measure a patient's ETT cuff pressure and the manometer reads 38 cmH₂O. How much should you adjust the pressure, and what is the target?
  1. Identify the acceptable cuff pressure range: 20–30 cmH₂O.
  2. Current reading is 38 cmH₂O, which is 8 cmH₂O above the upper limit of 30 cmH₂O.
  3. Use the manometer's release button to slowly deflate the cuff while watching the gauge.
  4. Stop releasing air when the gauge reads within 20–30 cmH₂O; aim for approximately 25 cmH₂O as a midpoint target.
  5. Document the initial reading (38 cmH₂O), the action taken (deflated), and the final reading.
Answer: Release air from the cuff until the manometer reads 20–30 cmH₂O (approximately 25 cmH₂O). The original pressure of 38 cmH₂O exceeds the safe limit and poses a risk of tracheal mucosal injury.
2. You check the cuff and your manometer reads 14 cmH₂O. The patient is on mechanical ventilation. What is the problem and what do you do?
  1. Identify the acceptable cuff pressure range: 20–30 cmH₂O.
  2. 14 cmH₂O is 6 cmH₂O below the minimum of 20 cmH₂O.
  3. An under-inflated cuff risks an inadequate seal, causing leak around the cuff and potential aspiration of oral or gastric secretions.
  4. Connect the manometer to the pilot balloon and slowly add air while watching the gauge.
  5. Stop adding air when the reading reaches 20–30 cmH₂O.
  6. Reassess the ventilator for any persistent leak and document both readings and the action taken.
Answer: Add air to the cuff until pressure reaches 20–30 cmH₂O. A pressure of 14 cmH₂O is insufficient to seal the airway, increasing aspiration risk and potentially causing a ventilator circuit leak.
3. During open suctioning, you apply suction for one continuous pass. The stopwatch shows 18 seconds of suction time. Is this within safe limits? What is the recommended maximum?
  1. Recall the recommended maximum duration for a single suction pass in adults: no more than 10–15 seconds.
  2. 18 seconds exceeds the upper limit of 15 seconds by 3 seconds.
  3. Prolonged suctioning depletes oxygen from the airway and can cause hypoxia and mucosal trauma.
  4. Correct practice: withdraw the catheter and stop suction by 10–15 seconds; allow the patient to recover and monitor SpO₂ before any additional pass.
Answer: 18 seconds exceeds the safe limit. The recommended maximum for a single suction pass is 10–15 seconds. Stop suctioning by 15 seconds, allow recovery, and pre-oxygenate before any repeat pass.
4. After assisting with intubation, the colorimetric CO₂ detector shows purple after six ventilations. Waveform capnography shows a flat line. What does this mean and what must you do?
  1. A colorimetric detector shows yellow-to-tan color when CO₂ is detected (tracheal placement) and remains purple when little or no CO₂ is detected, suggesting esophageal placement.
  2. Waveform capnography showing a flat line also indicates absence of exhaled CO₂ — confirming no tracheal ventilation.
  3. These findings together strongly indicate esophageal intubation, a critical life-threatening error.
  4. Immediately alert the provider and remove the tube from the esophagus.
  5. Resume BVM ventilation to oxygenate the patient.
  6. Prepare for immediate re-intubation with monitoring active.
Answer: Purple on the colorimetric detector combined with a flat capnography waveform indicates esophageal intubation. Remove the tube immediately, ventilate with BVM, and prepare for re-intubation. This is a critical patient safety emergency.
In class: Airway care stations: each student independently performs (a) cuff pressure measurement and adjustment using a manometer on an intubated manikin, (b) open-suction technique on a tracheostomy manikin using sterile technique, and (c) closed in-line suctioning on a ventilated lung model—documenting findings and technique decisions at each station. · Intubation assistance simulation: in teams of two, one student plays the role of the physician/CRNA inserting a laryngoscope and ETT into an intubation manikin while the partner (RT student) prepares the ETT with stylet and cuff checked, applies cricoid pressure on instruction, confirms tube placement by auscultation and waveform capnography, and secures the tube. · Emergency scenario: a simulated unexpected extubation is staged; students must manage the patient's airway with bag-valve-mask ventilation, call for help using SBAR, and set up for re-intubation within a timed 3-minute window, with instructor scoring the response.
Materials: Intubation manikin (adult), tracheostomy care manikin, ventilated lung model with closed suction circuit, cuff pressure manometer, suction catheters (open and closed), sterile gloves, BVM with PEEP valve, laryngoscope with blades, endotracheal tubes (multiple sizes), stylet, colorimetric CO2 detector, waveform capnography display, securement tape/device, stopwatch
Check: Three-station skills checklist: students must pass all three airway care stations (100% of critical safety steps at each, zero unacceptable errors) and demonstrate correct BVM use during the emergency scenario; any critical safety error (unrecognized esophageal placement, non-sterile technique on suctioning) requires immediate remediation and retest.

Practice check8

Answer each question, then check it. Nothing is recorded; this is your own practice.

Airway Management
1. Which cuff pressure range is considered safe for an adult endotracheal tube to minimize the risk of tracheal mucosal injury while maintaining an adequate seal?
Therapeutic Procedures
2. A respiratory therapist is about to perform open suctioning on a patient with a tracheostomy. Which action is the highest priority before inserting the suction catheter?
Airway Management
3. During intubation assistance, the provider asks you to apply cricoid pressure. On which anatomical structure do you apply firm, downward pressure?
Patient Assessment and Monitoring
4. Which finding is the gold standard for confirming correct endotracheal tube placement in the trachea immediately after intubation?
Emergency and Critical Care
5. A patient on mechanical ventilation experiences accidental extubation. After calling for help, what is the respiratory therapist's immediate next action?
Therapeutic Procedures
6. When is closed in-line suctioning preferred over open suctioning in a mechanically ventilated patient?
Therapeutic Procedures
7. A student performing open suctioning applies suction while advancing the catheter into the patient's airway. What is wrong with this technique?
Airway Management
8. During the intubation assistance simulation, you notice the stylet tip is protruding 2 cm beyond the Murphy eye of the endotracheal tube. What action should you take before the tube is used?
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