Airway Suctioning

Overview

An artificial airway bypasses the upper airway and blunts the cough, so secretions that would normally be cleared collect in the tube and large airways. Endotracheal and tracheostomy suctioning removes them to maintain a patent airway and adequate gas exchange. It is one of the most common procedures in critical care — and one of the most over-performed.

The governing principle, from the AARC clinical practice guideline, is that suctioning is performed only when it is clinically indicated, not on a fixed schedule. Each pass carries real risk — hypoxemia, vagally mediated bradycardia, mucosal trauma, derecruitment — so the procedure is reserved for the patient who actually has retained secretions and performed with technique that minimizes harm.

Key Concepts

Suction when the patient shows a sign of retained secretions, not because a set interval has elapsed. The following findings indicate a pass is warranted.

When a pass is indicated, the technique parameters below keep it safe. They are the numbers the boards test and the bedside demands.

• Closed (in-line) systems preserve PEEP. A closed system suctions without disconnecting the patient from the ventilator, so PEEP and oxygenation are maintained, derecruitment is reduced, and staff and environmental exposure to secretions falls. It is preferred at high PEEP or FiO₂ and for infection control.
• Open systems have a narrower role. An open system, which requires disconnection, is reserved for thick secretions or when the closed system cannot clear the airway adequately. It demands sterile technique because the airway is opened to the environment.
• Shallow beats deep. Advancing the catheter only to the tube tip clears the airway with far less mucosal trauma than deep suctioning, which drives the catheter against the carina and bronchial wall.

Assessment & Findings

Monitoring during and after the pass is how you catch a complication before it becomes an event. Anticipate the following.

• Hypoxemia. Suction removes gas along with secretions, so SpO₂ commonly dips around a pass — the reason for hyperoxygenation before and after and for limiting the duration.
• Bradycardia and vagal effects. Catheter stimulation of the airway can trigger vagally mediated bradycardia and hypotension; stop suctioning and reoxygenate if the rate falls.
• Arrhythmias. Hypoxemia and vagal stimulation together can provoke dysrhythmias, so the rhythm is watched throughout the procedure.
• Mucosal trauma and bleeding. An oversized catheter, excessive pressure, or deep suctioning abrades the mucosa and can produce bloody secretions.
• Bronchospasm. Mechanical irritation of the airway can trigger bronchoconstriction, especially in reactive airways.
• Raised intracranial pressure. Coughing and the stress response during suctioning can raise ICP — a particular concern in the neurologically injured patient.
• Atelectasis and derecruitment. Evacuating lung volume — worse with an open system or an oversized catheter — collapses alveoli and can drop oxygenation.
• Infection. Breaks in technique introduce organisms into the lower airway, contributing to ventilator-associated infection.

RT Priorities / Interventions

The RT owns the decision to suction and the technique that keeps it safe.

• Assess the need first. Confirm a genuine indication — secretions, coarse sounds, a sawtooth loop, rising PIP or falling Vt, a falling SpO₂, or suspected aspiration — rather than reaching for the catheter on a schedule.
• Hyperoxygenate before and after. Deliver 100% O₂ for roughly 30–60 seconds around the pass to build a reserve against the inevitable dip in saturation.
• Use sterile technique with an open system. When disconnecting for an open pass, maintain sterility to avoid seeding the lower airway; a closed in-line system avoids the disconnection entirely.
• Limit the pass duration. Keep each pass to ≤ 15 seconds, applying suction for ≤ 10 seconds, and size the catheter to no more than half the ETT internal diameter at −80 to −150 mmHg.
• Monitor throughout and reassess after. Watch SpO₂, heart rate, and rhythm during the pass, stop if the patient destabilizes, and reassess breath sounds, ventilator graphics, and oxygenation afterward to confirm the airway is clearer.

Common Pitfalls

• Routine scheduled suctioning. Suctioning a stable patient every few hours by the clock exposes them to all of the risk with none of the indication. Suction only when a sign of retained secretions is present.
• Deep suctioning that traumatizes the mucosa. Driving the catheter past the tube tip into the carina abrades the airway and causes bleeding; shallow suctioning to the tip is preferred.
• Using too large a catheter. A catheter over half the ETT internal diameter seals too much airway and strips out lung volume, driving derecruitment and hypoxemia.
• Prolonged passes. Holding suction for too long deepens the oxygen debt; cap the pass at ≤ 15 seconds with suction applied ≤ 10 seconds.
• Routine saline instillation. Instilling normal saline to “loosen” secretions is not routinely recommended — it can worsen oxygenation and dislodge biofilm into the lower airway.
• Failing to hyperoxygenate. Skipping pre- and post-oxygenation leaves no reserve for the saturation drop that the pass will cause.

Board Exam Pearls

FAQ

Related Resources

Sources

1. American Association for Respiratory Care. AARC clinical practice guidelines: endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respir Care. 2010;55(6):758-764.
2. Kacmarek RM, Stoller JK, Heuer AJ. Egan's Fundamentals of Respiratory Care. 12th ed. Elsevier; 2021.