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 in Skill 14-9 outlines several methods for determining appropriate suction catheter depth. The suction catheter should be small enough not to occlude the airway being suctioned but large enough to remove secretions; 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). 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 (Figure 1) (Burns & Delgado, 2019; Hess et al., 2021; Pasrija & Hall, 2020). Closed-system suction 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. One drawback of closed suctioning may be the hindrance of the sheath when rotating the suction catheter upon removal.

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, and 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 in Skill 14-9. 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 an appropriate position based on assessment of individual circumstances. 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. Positioning of the unconscious patient is based on the circumstances of the individual patient; health status, health problems, presence of drains and/or monitoring devices, etc. The overbed table provides a work surface and maintains sterility of the objects on the work surface.
9. Adjust suction to the appropriate pressure (Hess et al., 2021) (Figure 2): 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.
10. 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.	The glove prevents contact with blood and body fluids. Checking pressure ensures the equipment is working properly.
11. Open the package of the closed suction device using aseptic technique. Make sure that the device remains sterile.	The device must remain sterile to prevent a nosocomial infection.
12. Put on sterile gloves.	Gloves deter the spread of microorganisms.
13. If a closed suctioning device is not in place, continue with Step 14. If this device is already in place, continue with Step 17.
14. Using your nondominant hand, disconnect the ventilator from the endotracheal tube. Place the ventilator tubing in a convenient location so that the inside of the tubing remains sterile, or continue to hold the tubing in your nondominant hand.	This provides access to the endotracheal tube while keeping one hand sterile. The inside of the ventilator tubing should remain sterile to prevent a nosocomial infection.
15. Using your dominant hand and keeping the device sterile, connect the closed suctioning device so that the suctioning catheter is in line with the endotracheal tube.	Keeping the device sterile decreases the risk for a nosocomial infection.
16. Keeping the inside of the ventilator tubing sterile, attach the ventilator tubing to the port perpendicular to the endotracheal tube. Attach the suction connecting tubing to the suction catheter.	The inside of the ventilator tubing must remain sterile to prevent a nosocomial infection. By connecting the ventilator tubing to the port, the patient does not need to be disconnected from the ventilator to be suctioned.
17. Pop the top off the sterile normal saline dosette. Open the plug to the port by the suction catheter and insert the saline dosette or syringe.	The saline will help to clean the catheter between suctioning.
18. Hyperoxygenate the patient by using the sigh button on the ventilator before suctioning. Turn the safety cap on the suction button of the catheter so that the button is depressed easily.	Hyperoxygenating before suctioning helps to decrease the effects of oxygen removal during suctioning. The safety button keeps the patient from accidentally depressing the button and decreasing the oxygen saturation.
19. Grasp the suction catheter through the protective sheath, about 6 inches (15 cm) from the endotracheal tube. Gently insert the catheter into the endotracheal tube (Figure 3). Release the catheter while holding on to the protective sheath. Move your hand farther back on the catheter. Grasp the catheter through the sheath and repeat the movement, advancing the catheter to the predetermined length. Do not occlude the Y-port when inserting the catheter.	The sheath keeps the suction catheter sterile. 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.
20. Apply intermittent suction by depressing the suction button with the thumb of your nondominant hand (Figure 4). Gently rotate the catheter with the thumb and index finger of your dominant hand as the catheter is being withdrawn. 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). Hyperoxygenate with the sigh button on the ventilator (as prescribed or as identified in facility policy) for a minimum of 30 seconds (Burns & Delgado, 2019).	Turning the catheter while withdrawing it helps clean the surfaces of the respiratory tract and prevents injury to the tracheal 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. Hyperoxygenation reoxygenates the lungs and helps prevent suction-induced hypoxemia.
21. Once the catheter is withdrawn back into the sheath (Figure 5), depress the suction button while gently squeezing the normal saline dosette until the catheter is clean. Allow at least a 30-second to 1-minute interval if additional suctioning is needed (Burns & Delgado, 2019). Do not make more than three suction passes per suctioning episode.	Flushing cleans and clears the catheter and lubricates it for the next insertion. Allowing a time interval and replacing the oxygen delivery setup help compensate for hypoxia induced by the suctioning. Excessive suction passes contribute to complications.
22. When the procedure is completed, ensure that the catheter is withdrawn into the sheath and turn the safety button. Remove the normal saline dosette and apply the cap to the port.	By turning the safety button, the suction is blocked at the catheter so the suction cannot remove oxygen from the endotracheal tube.
23. Suction the oropharynx with a separate single-use, disposable catheter (Skill 14-7) and perform oral hygiene (oral hygiene measures are discussed in Chapter 7). Remove gloves. Perform hand hygiene. Turn off suction.	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. Proper removal of PPE and hand hygiene reduce transmission of microorganisms and contamination of other items.
24. Assist the patient to a comfortable position. Raise the bed rail and place the bed in the lowest position.	This ensures patient comfort. Proper positioning with raised side rails and the proper bed height provides for patient comfort and safety.
25. Reassess the patient's respiratory status, including respiratory rate, effort, oxygen saturation, lung sounds, tracheal sounds, and 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.
26. 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.