The purpose of suctioning is to maintain a patent airway and remove pulmonary secretions, blood, vomitus, or foreign material from the airway. When suctioning via an endotracheal tube, the goal is to remove secretions that are not accessible to cilia bypassed by the tube itself. Tracheal suctioning can lead to hypoxemia, cardiac dysrhythmias, airway trauma, atelectasis, hyperinflation, infection, bleeding, and pain. Therefore, it is imperative to be diligent in maintaining aseptic technique and in following best practice and facility guidelines and procedures to prevent potential hazards. Tracheal 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). Indications for the need for suctioning include audible and/or visible secretions, reduced oxygen saturation, presence of coarse crackles over the trachea, deterioration of arterial blood gas values, reduced breath sounds, the patient's inability to generate an effective spontaneous cough, acute respiratory distress, and suspected aspiration of secretions (AARC, 2010; Patton, 2019).

Because suctioning removes secretions not accessible to bypassed cilia, the recommendation is to insert the catheter only as far as the end of the endotracheal tube. Catheter contact and suction can cause tracheal mucosal damage, loss of cilia, edema, and fibrosis and increase the risk of infection and bleeding. Insertion of the suction catheter to a predetermined distance, no more than the tip of the artificial airway to no more than 1 cm past the length of the endotracheal tube (adults) and 0.5 cm (pediatric patients) (Boroughs & Dougherty, 2015; Hess et al., 2021; Kendrick, 2020), avoids contact with the trachea and carina, reducing the effects of tracheal mucosal damage (Boroughs & Dougherty, 2015; Hahn, 2010; Ireton, 2007; Pasrija & Hall, 2020; Pate & Zapata, 2002). Box 14-2 outlines several methods for determining the appropriate suction catheter depth. The suction catheter should be small enough not to occlude the airway being suctioned but large enough to remove secretions; use a suction catheter that occludes less than 50% of the lumen of the endotracheal tube (AARC, 2010; Pasrija & Hall, 2020).

Tracheal suctioning is an uncomfortable procedure at a minimum, 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). Anticipate the administration of pharmacologic (analgesic medication) and use of nonpharmacologic interventions for the patient before suctioning. As mentioned previously, perform suctioning only when clinically necessary because of the many potential risks, including hypoxia, infection, tracheal tissue damage, dysrhythmias, and atelectasis.

Open-system suctioning and closed-system suctioning are equally effected at secretion clearance (Hess et al., 2021). The open suctioning system requires disconnection of the endotracheal or tracheostomy tube from the ventilator or oxygen therapy source and insertion of a suction catheter each time the patient requires suctioning (Burns & Delgado, 2019), but it is associated with gas exchange deterioration and hypoxia (Burns & Delgado, 2019), potential contamination (Hess et al., 2021), and bioaerosol exposure risk for caregivers (Imbriaco & Monesi, 2021). In closed-system suction, a sterile multiple-use catheter enclosed in a plastic sheath is connected to the ventilation circuit and allows periodic insertion of the suction catheter without disconnection of the endotracheal or tracheostomy tube from the ventilator or oxygen therapy source (Burns & Delgado, 2019; Hess et al., 2021; Pasrija & Hall, 2020). Closed-system suctioning prevents gas exchange deterioration, atelectasis, and hypoxia; is cost-effective because only one catheter is used daily; and reduces bioaerosol exposure risk for caregivers and contamination of the surrounding environment (Hess et al., 2021; Imbriaco & Monesi, 2021; Yazdannik et al., 2019). Closed-system suctioning is recommended for use with patients who are mechanically ventilated; refer to facility policies for specifics of use (AARC, 2010; Morton & Fontaine, 2018; Pasrija & Hall, 2020; Raimundo et al., 2021). Refer to Skill 14-10 for guidelines related to closed-system suctioning.

Assessment

Assess for indications for the need for suctioning: audible and/or visible secretions, reduced oxygen saturation, presence of coarse crackles over the trachea, deterioration of arterial blood gas values, reduced breath sounds, the patient's inability to generate an effective spontaneous cough, acute respiratory distress, or suspected aspiration of secretions (AARC, 2010; Patton, 2019; Sole et al., 2015). Assess lung sounds. Wheezes, coarse crackles, gurgling or diminished breath sounds may indicate the need for suctioning. Assess for the presence of visualized secretions in the artificial airway, audible secretions, and ineffective coughing (Morton & Fontaine, 2018; Sole et al., 2015). Assess the oxygen saturation level. Deterioration in oxygen desaturation may be an indication of the need for suctioning (AARC, 2010). Assess respiratory status, including respiratory rate 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 for pain and the potential to cause pain during the intervention (Arroyo-Novoa et al., 2008; Chaseling et al., 2014; Wrona et al., 2021; Düzkaya & Kuğuoğlu, 2015). Anticipate the administration of pharmacologic (analgesic medication) and use of nonpharmacologic interventions for the patient before suctioning (Arroyo-Novoa et al., 2008; Düzkaya & Kuğuoğlu, 2015). Assess the appropriate suction catheter depth. Refer to Box 14-2. 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
• Impaired gas exchange

Outcome Identification and Planning

The expected outcome to achieve is that the patient will exhibit a clear, patent airway. Other outcomes that may be appropriate include that the patient will exhibit an oxygen saturation level within acceptable parameters, will demonstrate a respiratory rate and depth within acceptable parameters, and will remain free from any signs of respiratory distress and adverse effect.

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.	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). 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, the nurse should explain what is happening. Any procedure that compromises respiration is frightening for the patient.
8. Adjust the bed to a comfortable working position (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 overbed 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 overbed table provides a work surface and maintains sterility of the objects on the work surface.
9. Place a towel or waterproof pad across the patient's chest.	This protects bed linens and the patient.
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.	Higher pressures can cause excessive trauma, hypoxemia, and atelectasis.
11. 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. Place the resuscitation bag connected to oxygen within convenient reach, if using.	The glove prevents contact with blood and body fluids. Checking pressure ensures the equipment is working properly. Having the resuscitation bag within easy reach allows for an organized approach to the procedure.
12. 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.	Sterile normal saline or water is used to lubricate the outside of the catheter, minimizing irritation of mucosa during introduction. It is also used to clear the catheter between suction attempts.
13. Put on a face shield or goggles and a 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.	Handling the sterile catheter using a sterile glove helps prevent introducing organisms into the respiratory tract; the clean glove protects the nurse from microorganisms.
14. 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.	Sterility of the suction catheter is maintained.
15. Moisten the catheter by dipping it into the container of sterile saline, unless it is a silicone catheter. Occlude the Y-tube to check suction.	Lubricating the inside of the catheter with saline helps move secretions in the catheter. Silicone catheters do not require lubrication. Checking suction ensures the equipment is working properly.
16. Using your nondominant hand, remove the ventilator tubing or oxygen source from the endotracheal tube and attach the manual resuscitation bag. Hyperoxygenate the patient using your nondominant hand and the manual resuscitation bag for a minimum of 30 seconds (Burns & Delgado, 2019). Alternatively, use the sigh mechanism on a mechanical ventilator.	Hyperoxygenation aids in preventing hypoxemia during suctioning.
17. Using your nondominant hand, remove the manual resuscitation bag from the endotracheal tube. Alternatively, open the adapter on the mechanical ventilator tubing.	This exposes the endotracheal tube without contaminating your sterile gloved hand.
18. Using your dominant hand, gently and quickly insert the catheter into the endotracheal tube (Figure 2). Advance the catheter to the predetermined length. Do not occlude the Y-port when inserting the catheter.	Catheter contact and suction cause tracheal mucosal damage, loss of cilia, edema, and fibrosis and increase the risk of infection and bleeding. Insertion of the suction catheter to a predetermined distance, no more than the tip of the artificial airway to no more than 1 cm past the length of the endotracheal tube (adults) and 0.5 cm (pediatric patients) (Boroughs & Dougherty, 2015; Hess et al., 2021; Kendrick, 2020) avoids contact with the trachea and carina, reducing the effects of tracheal mucosal damage (Boroughs & Dougherty, 2015; Hahn, 2010; Ireton, 2007; Pasrija & Hall, 2020; Pate & Zapata, 2002). If resistance is met, the carina or tracheal mucosa has been hit. Withdraw the catheter at least 0.5 inch before applying suction. Occluding the Y-port (i.e., suctioning) when inserting the catheter increases the risk for trauma to the airway mucosa and increases the risk of hypoxemia.
19. Apply suction by intermittently occluding the Y-port on the catheter with the thumb of your nondominant hand, and gently rotate the catheter as it is being withdrawn (Figure 3). Do not suction for more than 10 to 15 seconds at a time (AARC, 2010; Burns & Delgado, 2019; Hess et al., 2021; Pasrija & Hall, 2020).	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 (AARC, 2010; Pasrija & Hall, 2020). Suctioning too quickly may be ineffective at clearing all secretions.
20. Hyperoxygenate the patient using your nondominant hand and a manual resuscitation bag for a minimum of 30 seconds (Burns & Delgado, 2019). Replace the oxygen delivery device, if applicable, using your nondominant hand, and have the patient take several deep breaths. If the patient is mechanically ventilated, close the adapter on the mechanical ventilator tubing, or replace the ventilator tubing and use the sigh mechanism on a mechanical ventilator.	Suctioning removes air from the patient's airway and can cause hypoxemia. Hyperoxygenation can help prevent suction-induced hypoxemia.
21. Flush the catheter with saline. 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 the next insertion. Reassessment determines the need for additional suctioning. Wrapping the catheter prevents inadvertent contamination of the catheter.
22. Allow at least a 30-second interval if additional suctioning is needed (Burns & Delgado, 2019). Do not make more than three suction passes per suctioning episode. Suction the oropharynx after suctioning the trachea (refer to Skill 14-7). Do not reinsert it in the endotracheal tube after suctioning the mouth.	The interval allows for reventilation and reoxygenation of airways. Excessive suction passes contribute to complications. Suctioning the oropharynx clears the mouth of secretions. Routine oral suctioning to aspirate secretions that accumulate above the cuff of the tube is also necessary to reduce the risk of pneumonia and provide patient comfort (AACN, 2018; Hess et al., 2021; Morton & Fontaine, 2018). More microorganisms are usually present in the mouth, so it is suctioned last to prevent transmission of contaminants.
23. Perform oral hygiene after tracheal 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, are unpleasant for the patient, and contribute to the colonization of the oropharyngeal secretions by respiratory pathogens. 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).
24. 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. Assist the patient to a comfortable position. Raise the bed rail and place the bed in the lowest position.	This technique of glove removal, disposal of equipment, and hand hygiene reduces transmission of microorganisms. Proper positioning with raised side rails and the proper bed height provides for patient comfort and safety.
25. Turn off the suction. Remove the face shield or goggles and mask. Perform hand hygiene.	Removing the face shield or goggles and mask properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.
26. Reassess the patient's respiratory status, including respiratory rate, effort, oxygen saturation, lung sounds, tracheal sounds, and the presence/absence of secretions in artificial airway, and the patient's response to the intervention.	These assess effectiveness of suctioning and the presence of complications.
27. 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 exhibited a clear, patent airway; an oxygen saturation level within acceptable parameters; and a respiratory rate and depth within acceptable parameters; and the patient has remained free from any signs of respiratory distress and adverse effect.