Suctioning the Oropharyngeal and Nasopharyngeal Airways

Skill 14-7

Suctioning the Oropharyngeal and Nasopharyngeal Airways

Skill Variation: Oropharyngeal Suctioning using a Yankauer Device

Skill Variation: Performing Nasotracheal Suctioning

Suctioning of the pharynx is indicated to maintain a patent airway and to remove saliva, pulmonary secretions, blood, vomitus, and foreign material from the pharynx. Suctioning of the oropharynx or nasopharynx may be indicated if the patient is able to raise secretions from the airways but unable to clear from the mouth. Nasotracheal suctioning may be indicated to help a patient who cannot clear their airway by coughing or is unable to raise secretions from the airways. The frequency of suctioning varies with the amount of secretions present but should be done often enough to keep ventilation effective and as effortless as possible. Suctioning should be performed only when clinically indicated based on assessment and not routinely (Burns & Delgado, 2019; Hess et al., 2021; Morton & Fontaine, 2018). Anticipate the administration of pharmacologic (analgesic medication) and use of nonpharmacologic interventions for the patient before suctioning.

A Yankauer device (tonsil-tip suction apparatus) may be used when performing oral suctioning and when secretions are visible in the oral cavity (Hess et al., 2021; Morton & Fontaine, 2018). A suction catheter may be used for oropharyngeal suctioning; a suction catheter is used for nasopharyngeal and nasotracheal suctioning.

When performing suctioning, position yourself on the appropriate side of the patient. If you are right-handed, stand on the patient's right side; if you are left-handed, stand on the patient's left side. This allows for comfortable use of your dominant hand to manipulate the suction catheter.

The following skill describes suctioning of the oropharyngeal and nasopharyngeal airways using a suction catheter. See the accompanying Skill Variation for a description of oropharyngeal suctioning using a Yankauer device. Suctioning of the nasotracheal airway is outlined in the subsequent accompanying Skill Variation. Suctioning of the airway in patients with artificial airways (endotracheal and tracheostomy tubes) is discussed in Skills 14-9, 14-10, and 14-12.

Delegation Considerations

Suctioning of the oropharyngeal airway may be delegated to assistive personnel (AP) who have received appropriate training. Depending on the state's nurse practice act and the organization's policies and procedures, the suctioning of the oropharyngeal and nasopharyngeal airways may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Portable or wall suction unit with tubing
A commercially prepared suction kit with an appropriate-size catheter or
- Sterile suction catheter with Y-port in the appropriate size (adult: 10 to 16 Fr)
- Sterile disposable container
- Sterile gloves
Sterile water or saline
Towel or waterproof pad
Goggles and mask or face shield; N95 mask or equivalent, based on patient's health status
Disposable, clean gloves
Water-soluble lubricant (nasopharyngeal and nasotracheal suctioning)
Additional PPE, as indicated

Assessment

Assess lung sounds. Patients who need to be suctioned may have coarse crackles or gurgling present and/or reduced breath sounds. Assess the oxygen saturation level. Oxygen saturation usually decreases when a patient needs to be suctioned. Assess respiratory status, including respiratory rate, rhythm, and depth. Patients may become tachypneic when they need to be suctioned. Assess the patient for signs of respiratory distress, such as nasal flaring, retractions, or grunting. Assess effectiveness of coughing and expectoration. Suctioning of the airway may be necessary for patients with an ineffective cough who are unable to expectorate secretions. Assess for history of a deviated septum, nasal polyps, nasal obstruction, nasal injury, epistaxis (nasal bleeding), or nasal swelling, which may influence the use of one or the other naris. Assess for pain. Assess the characteristics and amount of secretions while suctioning.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Ineffective airway clearance
Altered breathing pattern
Risk for aspiration

Outcome Identification and Planning

The expected outcome to achieve when suctioning the patient's oropharyngeal or nasopharyngeal airway is that the patient will exhibit improved breath sounds and a clear, patent airway. Other outcomes that may be appropriate include that the patient will exhibit an oxygen saturation level within acceptable parameters and will demonstrate effortless respirations within an acceptable and appropriate range, without evidence of respiratory distress.

Implementation

Action	Rationale
1. Gather equipment.	Assembling equipment provides for an organized approach to the task.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Assemble equipment on the overbed table or other surface within reach.	Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse.
5. Close the curtains around the bed and close the door to the room, if possible.	This ensures the patient's privacy.
6. Perform assessments to determine the need for suctioning. Verify the prescribed suctioning intervention in the patient's health record, if necessary. Anticipate the administration of pharmacologic (analgesic medication) and use of nonpharmacologic interventions for the patient before suctioning. Assess for pain or the potential to cause pain. Administer pain medication, as prescribed, before suctioning.	Suctioning should be performed only when clinically indicated based on assessment and not routinely (AARC, 2010; Burns & Delgado, 2019; Hess et al., 2021; Morton & Fontaine, 2018). Some facilities require that naso- and oropharyngeal suctioning are a prescribed intervention. At a minimum, suctioning is an uncomfortable procedure, and it can be a very painful and/or distressing experience. Individualized pain management must be performed in response to the patient's needs (Arroyo-Novoa et al., 2008; Chaseling et al., 2014; Wrona et al., 2021; Düzkaya & Kuğuoğlu, 2015).
7. Explain to the patient what you are going to do and why, even if the patient does not appear to be alert. Reassure the patient that you will interrupt the procedure if they indicate respiratory difficulty.	Explanation alleviates fears. Even if the patient appears unconscious, explain what is happening. Any procedure that compromises respiration is frightening for the patient.
8. Adjust the bed to a comfortable working height (VHACEOSH, 2016). Lower the side rail closest to you. If the patient is conscious, place them in a semi-Fowler position. If the patient is unconscious, place them in the lateral position, facing you. Move the bedside table close to your work area and raise it to waist height.	Having the bed at the proper height prevents back and muscle strain. A sitting position helps the patient to cough and makes breathing easier. Gravity also facilitates catheter insertion. The lateral position prevents the airway from becoming obstructed and promotes drainage of secretions. The bedside table provides a work surface and helps maintain sterility of objects on the work surface.
9. Place a towel or waterproof pad across the patient's chest.	This protects bed linens.
10. Adjust suction to the appropriate pressure (Hess et al., 2021) (Figure 1): No more than 150 mm Hg for adults and adolescents No more than 125 mm Hg for children No more than 100 mm Hg for infants Put on a disposable, clean glove and occlude the end of the connecting tubing to check suction pressure. Place the connecting tubing in a convenient location.	Higher pressures can cause excessive trauma, hypoxemia, and atelectasis.
11. Open the sterile suction package using aseptic technique. The open wrapper or container becomes a sterile field to hold other supplies. Carefully remove the sterile container, touching only the outside surface. Set it up on the work surface and pour sterile saline into it.	Sterile normal saline or water is used to lubricate the outside of the catheter, minimizing irritation of the mucosa during introduction. It is also used to clear the catheter between suction attempts.
12. Place a small amount of water-soluble lubricant on the sterile field, taking care to avoid touching the sterile field with the lubricant package.	Lubricant facilitates passage of the catheter and reduces trauma to mucous membranes.
13. Increase the patient's supplemental oxygen level, or apply supplemental oxygen per facility policy or prescribed intervention.	Suctioning removes air from the patient's airway and can cause hypoxemia. Hyperoxygenation can help prevent suction-induced hypoxemia (Morton & Fontaine, 2018).
14. Put on a face shield or goggles and mask. Put on sterile gloves. Your dominant hand will manipulate the catheter and must remain sterile. The nondominant hand is considered clean rather than sterile and will control the suction valve (Y-port) on the catheter. In the home setting and other community-based settings, maintenance of sterility is not necessary.	Gloves and other PPE protect the nurse from microorganisms. Handling the sterile catheter using a sterile glove helps prevent introducing organisms into the respiratory tract. In the home setting and other community-based settings, clean (instead of sterile) technique is used because the patient is not exposed to disease-causing organisms that may be found in health care settings, such as hospitals.
15. With your dominant gloved hand, pick up the sterile catheter. Pick up the connecting tubing with the nondominant hand and connect the tubing and suction catheter (Figure 2).	Sterility of the suction catheter is maintained.
16. Moisten the catheter by dipping it into the container of sterile saline (Figure 3). Occlude the Y-tube to check suction.	Lubricating the inside of the catheter with saline helps move secretions in the catheter. Checking suction ensures equipment is working properly.
17. Encourage the patient to take several deep breaths.	Hyperventilation can help prevent suction-induced hypoxemia (Hess et al., 2021).
18. Apply lubricant to the first 2 to 3 inches of the catheter, using the lubricant that was placed on the sterile field.	Lubricant facilitates passage of the catheter and reduces trauma to mucous membranes.
19. Remove the oxygen delivery device, if appropriate. Do not apply suction as the catheter is inserted. Hold the catheter between your thumb and forefinger.	Suctioning removes air from the patient's airway and can cause hypoxemia. Using suction while inserting the catheter can cause trauma to the mucosa and remove excessive oxygen from the respiratory tract.
20. Insert the catheter:
a. For nasopharyngeal suctioning, gently insert the catheter through the naris and along the floor of the nostril toward the trachea (Figure 4). Roll the catheter between your fingers to help advance it. Advance the catheter approximately 6 to 8 inches to reach the pharynx (Hinkle et al., 2022) (for guidelines for nasotracheal suctioning, see the accompanying Skill Variation). b. For oropharyngeal suctioning, insert the catheter through the mouth, along the side of the mouth toward the trachea. Advance the catheter 3 to 4 inches to reach the pharynx (for nasotracheal suctioning, see the accompanying Skill Variation).	The correct distance for insertion ensures proper placement of the catheter. The general guideline for determining insertion distance for nasopharyngeal suctioning for an individual patient is to estimate the distance from the patient's earlobe to the nose.
21. Apply suction by intermittently occluding the Y-port on the catheter with the thumb of your nondominant hand and gently rotating the catheter as it is being withdrawn (Figure 5). Do not suction for more than 15 seconds at a time (AARC, 2010; Hess et al., 2021).	Turning the catheter as it is withdrawn minimizes trauma to the mucosa. Suctioning for longer than 15 seconds robs the respiratory tract of oxygen, which may result in hypoxemia. Suctioning too quickly may be ineffective at clearing all secretions.
22. Replace the oxygen delivery device using your nondominant hand, if appropriate, and have the patient take several deep breaths.	Suctioning removes air from the patient's airway and can cause hypoxemia. Hyperventilation can help prevent suction-induced hypoxemia.
23. Flush the catheter with saline (Figure 6). Assess the effectiveness of suctioning and repeat, as needed, and according to the patient's tolerance. Wrap the suction catheter around your dominant hand between attempts.	Flushing clears the catheter and lubricates it for next insertion. Reassessment determines the need for additional suctioning. Wrapping prevents inadvertent contamination of the catheter.
24. Allow at least a 30-second interval if additional suctioning is needed. Alternate the naris, unless contraindicated, if repeated suctioning is required. No more than three suction passes should be made per suctioning episode. Do not force the catheter through the naris. Encourage the patient to cough and deep breathe between suctioning. Suction the oropharynx after suctioning the nasopharynx.	The interval allows for reventilation and reoxygenation of airways. Excessive suction passes contribute to complications. Alternating the naris reduces trauma. Suctioning the oropharynx after the nasopharynx clears the mouth of secretions. More microorganisms are usually present in the mouth, so it is suctioned last to prevent transmission of contaminants.
25. When suctioning is complete, remove the glove from your dominant hand over the coiled catheter, pulling it off inside out. Remove the glove from your nondominant hand, and dispose of gloves, catheter, and the container with the solution in the appropriate receptacle. Perform hand hygiene.	This technique of glove removal and hand hygiene reduces transmission of microorganisms.
26. Assist the patient to a comfortable position. Raise the bed rail and place the bed in the lowest position.	Proper positioning with raised side rails and the proper bed height provides for patient comfort and safety.
27. Turn off the suction. Remove the supplemental oxygen placed for suctioning, if appropriate. Remove the face shield or goggles and mask. Perform hand hygiene.	Proper removal of PPE and hand hygiene reduce the risk of transmission of microorganisms.
28. Perform oral hygiene after suctioning. Oral hygiene measures are discussed in Chapter 7.	Respiratory secretions that are allowed to accumulate in the mouth are irritating to mucous membranes, pose a risk for aspiration, and are unpleasant for the patient. Diligent oral hygiene care can improve oral health and limit the growth of pathogens in the oropharyngeal secretions, decreasing the incidence of aspiration pneumonia, community-acquired pneumonia, nonventilator health care-associated pneumonia (NV-HAP), and ventilator-associated pneumonia (VAP) (AACN, 2017; Chick & Wynne, 2020; Jenson et al., 2018; Quinn et al., 2020).
29. Reassess the patient's respiratory status, including respiratory rate, effort, oxygen saturation, and lung sounds, and their response to suctioning.	This assesses effectiveness of suctioning and the presence of complications.
30. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcomes have been met when the patient has demonstrated improved breath sounds and a clear, patent airway; has exhibited an oxygen saturation level within acceptable parameters; and has demonstrated effortless respirations within an acceptable and appropriate range, without evidence of respiratory distress.

Documentation

Guidelines

Document the time of suctioning, assessments before and after the intervention, the reason for suctioning, route used, and the characteristics and amount of secretions.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient vomits during suctioning: If the patient gags or becomes nauseated, remove the catheter; it has probably entered the esophagus inadvertently. If the patient needs to be suctioned again, change the catheter, because it is probably contaminated. Turn the patient to the side and elevate the head of the bed to prevent aspiration.
Epistaxis (bleeding) is noted with continued suctioning: Notify the health care team and anticipate the need for a nasal trumpet (see the Skill Variation in Skill 14-8: Inserting a Nasopharyngeal Airway). The nasal trumpet will protect the nasal mucosa from further trauma related to suctioning (Morton& Fontaine, 2018).

Special Considerations

General Considerations

The use of suction pressure higher than the pressure guidelines presented in the skill have been suggested by some researchers (Maras et al., 2020; Yazdannik et al., 2019).

Infant and Child Considerations

For infants, use a 5- to 6-Fr catheter.
For children, use a 6- to 10-Fr catheter.

Oropharyngeal Suctioning Using a Yankauer Device

A Yankauer device (tonsil-tip suction apparatus) (Figure A) may be used when performing oral suctioning and when secretions are visible in the oral cavity (Hess et al., 2021; Morton & Fontaine, 2018). This device is angled to allow it to follow the contour of the oral cavity along the palate to facilitate suctioning in the posterior oropharynx and the buccal pouches (Morton & Fontaine, 2018). The larger openings on the Yankauer tip allow for suctioning of thick or copious secretions better than other suction catheters designed for suctioning through the endotracheal or nasotracheal tubes, which are smaller in diameter (Morton & Fontaine, 2018). Alternatively, a suction catheter may be used for oropharyngeal suctioning (refer to Skill 14-7). The frequency of suctioning varies with the amount of secretions present but should be done often enough to keep ventilation effective and as effortless as possible. Suctioning should be performed only when clinically indicated based on assessment and not routinely (Burns & Delgado, 2019; Hess et al., 2021; Morton & Fontaine, 2018).

Perform hand hygiene. Put on PPE, as indicated.
Identify the patient.
Assemble equipment on the bedside stand or overbed table or other surface within reach.
Close the curtains around the bed and close the door to the room, if possible.
Perform assessments to determine the need for suctioning. Verify the prescribed suctioning intervention in the patient's health record, if necessary. Anticipate the administration of pharmacologic (analgesic medication) and use of nonpharmacologic interventions for the patient before suctioning.Assess for pain or the potential to cause pain. Administer pain medication, as prescribed, before suctioning.
Explain to the patient what you are going to do and why, even if the patient does not appear to be alert.
Adjust the bed to a comfortable working position. Lower the side rail closest to you.If the patient is conscious, place them in a semi-Fowler position. If the patient is unconscious, place them in the lateral position, facing you.Move the overbed table close to your work area and raise it to waist height.
Place a towel or waterproof pad across the patient's chest.
Turn the suction to the appropriate pressure. Put on a disposable, clean glove and occlude the end of the connecting tubing to check suction pressure.Place the connecting tubing in a convenient location.
Open the sterile suction package and carefully remove the sterile container, touching only the outside surface. Set it up on the work surface and pour saline into it.
Increase the patient's supplemental oxygen level, or apply supplemental oxygen per facility policy or prescribed intervention.
Put on a face shield or goggles and a mask (put on an N95 mask or equivalent, based on the patient's health status). Peel open the Yankauer device package and place it on the work surface with the Yankauer device sitting in the wrapper with the top side peeled back. Put on gloves.
With your dominant gloved hand, pick up the Yankauer device. Pick up the connecting tubing with your nondominant hand and connect the tubing and Yankauer device.
Moisten the catheter by dipping it into the container of sterile saline.
Remove the oxygen delivery device, if appropriate. Gently insert the Yankauer device into the oral cavity and move it along the contour of the oral cavity and the palate to suction the posterior oropharynx and the buccal pouches (Morton & Fontaine, 2018).Do not suction for more than 10 to 15 seconds at a time.
Replace the oxygen delivery device using your nondominant hand, and have the patient take several deep breaths.
Flush the Yankauer device with saline. Assess effectiveness of the suctioning and repeat, as needed, and according to the patient's tolerance. Encourage the patient to cough and deep breathe between suctioning.
When suctioning is complete, rinse the Yankauer device and store it for reuse as directed by facility policy. The outer wrapper may be used to store the Yankauer device between use. Replace the Yankauer device every 24 hours. Dispose of the waterproof pad and saline container.
Remove gloves. Remove the face shield or goggles and mask. Perform hand hygiene.
Turn off the suction. Remove the supplemental oxygen placed for suctioning, if appropriate. Assist the patient to a comfortable position.
Offer oral hygiene after suctioning.
Reassess the patient's respiratory status, including respiratory rate, effort, oxygen saturation, and lung sounds.
Remove additional PPE, if used. Perform hand hygiene.
Document the time of suctioning, your assessments before and after intervention, the reason for suctioning, the route used, the characteristics and amount of secretions, and the patient's response to the intervention.

Performing Nasotracheal Suctioning

Nasotracheal suctioning is indicated to maintain a patent airway and remove saliva, pulmonary secretions, blood, vomitus, and foreign material from the trachea. Tracheal suctioning can lead to hypoxemia, cardiac dysrhythmias, trauma, atelectasis, infection, bleeding, and pain. The frequency of suctioning varies with the amount of secretions present but should be done often enough to keep ventilation effective and as effortless as possible. Suctioning should be performed only when clinically indicated based on assessment and not routinely (Burns & Delgado, 2019; Hess et al., 2021; Morton & Fontaine, 2018). Anticipate the administration of pharmacologic (analgesic medication) and use of nonpharmacologic interventions for the patient before suctioning. A suction catheter is used for nasotracheal suctioning.

It is imperative to be diligent in maintaining aseptic technique and following facility guidelines and procedures to prevent potential hazards. In the home setting and other community-based settings, clean technique is used because the patient is not exposed to disease-causing organisms that may be found in health care settings, such as hospitals.

A suction catheter is used for nasopharyngeal and nasotracheal suctioning. In patients who require frequent nasotracheal suctioning, a nasopharyngeal airway may be used to prevent patient discomfort and minimize trauma from repeated introduction of the suction catheter through the nares (Morton & Fontaine, 2018). The Skill Variation at the end of Skill 14-8 outlines insertion of a nasopharyngeal airway.

Perform hand hygiene. Put on PPE, as indicated.
Identify the patient.
Assemble equipment on the bedside stand or overbed table or other surface within reach.
Close the curtains around the bed and close the door to the room, if possible.
Perform assessments to determine the need for suctioning. Verify the prescribed suctioning intervention in the patient's health record, if necessary. Anticipate the administration of pharmacologic (analgesic medication) and use of nonpharmacologic interventions for the patient before suctioning.Assess for pain or the potential to cause pain. Administer pain medication, as prescribed, before suctioning.
Explain to the patient what you are going to do and why, even if the patient does not appear to be alert.
Adjust the bed to a comfortable working position. Lower the side rail closest to you.If the patient is conscious, place them in a semi-Fowler position. If the patient is unconscious, place them in the lateral position, facing you.Move the overbed table close to your work area and raise it to waist height.
Place a towel or waterproof pad across the patient's chest.
Turn the suction to the appropriate pressure. Put on a disposable, clean glove and occlude the end of the connecting tubing to check suction pressure.Place the connecting tubing in a convenient location.
Open the sterile suction package using aseptic technique. The open wrapper becomes a sterile field to hold other supplies. Carefully remove the sterile container, touching only the outside surface. Set it up on the work surface and pour sterile saline into it.
Place a small amount of water-soluble lubricant on the sterile field, taking care to avoid touching the sterile field with the lubricant package.
Increase the patient's supplemental oxygen level, or apply supplemental oxygen per facility policy or prescribed intervention.
Put on a face shield or goggles and a mask (put on an N95 mask or equivalent, based on the patient's health status). Put on sterile gloves.Your dominant hand will manipulate the catheter and must remain sterile.The nondominant hand is considered clean rather than sterile and will control the suction valve.
With your dominant gloved hand, pick up the sterile catheter. Pick up the connecting tubing with your nondominant hand and connect the tubing and suction catheter.
Moisten the catheter by dipping it into the container of sterile saline. Occlude the Y-tube to check suction.
Encourage the patient to take several deep breaths.
Apply lubricant to the first 2 to 3 inches of the catheter, using the lubricant that was placed on the sterile field.
Remove the oxygen delivery device, if appropriate. Do not apply suction as the catheter is inserted. Hold the catheter in your thumb and forefinger. Gently insert the catheter through the naris and along the floor of the nostril toward the trachea. Roll the catheter between your fingers to help advance it. Advance the catheter approximately 8 to 9 inches to reach the trachea. Resistance should not be met. If resistance is met, the carina or tracheal mucosa has been hit. Withdraw the catheter at least 1 to 2 inches before applying suction.
Apply suction by intermittently occluding the Y-port on the catheter with the thumb of your nondominant hand and gently rotating the catheter as it is being withdrawn.Do not suction for more than 10 to 15 seconds at a time(AARC, 2010; Hess et al., 2021).
Replace the oxygen delivery device using your nondominant hand, and have the patient take several deep breaths.
Flush the catheter with saline. Assess effectiveness of the suctioning and repeat, as needed, and according to the patient's tolerance. Wrap the suction catheter around your dominant hand between attempts.
Allow at least a 30-second to 1-minute interval if additional suctioning is needed. No more than three suction passes should be made per suctioning episode.Alternate the naris, unless contraindicated, if repeated suctioning is required. Do not force the catheter through the naris. Encourage the patient to cough and deep breathe between suctioning. Suction the oropharynx after suctioning the trachea.
When suctioning is completed, remove the glove from your dominant hand over the coiled catheter, pulling it off inside out. Remove the glove from your nondominant hand and dispose of gloves, catheter, and the container with the solution in the appropriate receptacle. Remove the face shield or goggles and mask. Perform hand hygiene.
Turn off the suction. Remove the supplemental oxygen placed for suctioning, if appropriate. Assist the patient to a comfortable position.
Offer oral hygiene after suctioning.
Reassess the patient's respiratory status, including respiratory rate, effort, oxygen saturation, and lung sounds.
Remove additional PPE, if used. Perform hand hygiene.
Document the time of suctioning, your assessments before and after intervention, the reason for suctioning, the route used, the characteristics and amount of secretions, and the patient's response to the intervention.

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Skill 14-7