Skill 14-12

Suctioning a Tracheostomy: Open System

The purpose of suctioning is to maintain a patent airway and remove pulmonary secretions, blood, vomitus, and foreign material from the airway. When suctioning via a tracheostomy 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). In the home setting and other community-based settings, clean technique is used, as the patient is not exposed to disease-causing organisms that may be found in health care settings, such as hospitals (Sterni et al., 2016).

Because suctioning removes secretions not accessible to bypassed cilia, the recommendation is to insert the catheter only as far as the end of the tracheostomy 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; 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.

Note: In-line, closed suction systems are available to suction mechanically ventilated patients. The use of closed suction catheter systems may avoid some of the infection control issues and other complications associated with open suction techniques. Open- and closed-system suctioning is discussed in the introduction to Skills 14-9 and 14-10. The closed suctioning procedure is the same for patients with tracheostomy tubes and endotracheal tubes connected to mechanical ventilation. Refer to details in Skill 14-10.

Delegation Considerations

Suctioning a tracheostomy is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, suctioning of a tracheostomy in a stable situation, such as long-term care and other community-based care settings, 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 (see General Considerations) or
Sterile suction catheter with Y-port in the appropriate size
Sterile, disposable container
Sterile gloves
Towel or waterproof pad
Goggles and mask or face shield; N95 mask or equivalent, based on patient's health status
Additional PPE, as indicated
Disposable, clean gloves
Resuscitation bag connected to 100% oxygen

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, 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, demonstrate a respiratory rate and depth within acceptable parameters, and 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. 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 (Figure 1). 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 the 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 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. 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. If using a resuscitation bag, place it connected to oxygen within convenient reach.	The glove prevents contact with blood and body fluids. Checking pressure ensures that equipment is working properly. Preparation allows for an organized approach to the procedure.
12. 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.
13. Put on a face shield or goggles and a mask (Figure 3). 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 (Figure 4).	This maintains sterility of the suction catheter.
15. Moisten the catheter by dipping it into the container of sterile saline, unless it is a silicone catheter (Figure 5). Occlude the Y-tube to check suction (Figure 6).	Lubricating the inside of the catheter with saline helps move secretions in the catheter. Silicone catheters do not require lubrication. Checking ensures that equipment is working properly.
16. Using your nondominant hand, remove the ventilator tubing or oxygen source (if in use) from the tracheostomy 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 tracheostomy tube. Alternatively, open the adapter on the mechanical ventilator tubing.	This exposes the tracheostomy tube without contaminating your sterile gloved hand.
18. Using your dominant hand, gently and quickly insert the catheter into the tracheostomy tube. 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 7). 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 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, 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 around your hand 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. If the patient is spontaneously breathing, encourage them to cough and deep breathe between suctioning attempts. Suction the oropharynx after suctioning the trachea (refer to Skill 14-7). Do not reinsert the tracheostomy 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 completed, coil the catheter in one hand. Remove the glove from the hand over the coiled catheter (the catheter remains inside the glove), pulling the glove off inside out (Figure 8). Remove the glove from the other hand, pulling inside out, and dispose of gloves, catheter, and container with 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 supplemental oxygen placed for suctioning, if appropriate. Remove the face shield or goggles and mask. Perform hand hygiene.	Proper removal of PPE 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 presence/absence of secretions in artificial airway, and the patient's response to the intervention.	This assesses the 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.

Documentation

Guidelines

Document the time of suctioning, assessments before and after interventions, the reason for suctioning, oxygen saturation levels, and the characteristics and amount of secretions.

Sample Documentation

9/1/25

1515 Yellow secretions noted in opening of tracheostomy tube; coarse crackles noted to auscultation over trachea. Lungs auscultated for wheezes in upper and lower lobes bilaterally. Respirations at 24 breaths/min. Weak, ineffective cough noted. Tracheal suction completed with 12-Fr catheter. Large amount of thick, yellow secretions obtained. Specimen for culture collected and sent. After suctioning, no secretions noted in tracheostomy tube, auscultation over trachea clear, faint wheezing persists, oxygen saturation at 97%, respirations 18 breaths/min.

—C. Bausler, RN

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient coughs hard enough to dislodge tracheostomy: Keep a spare tracheostomy and obturator at the bedside. Insert the obturator into the tracheostomy tube and reinsert the tracheostomy into the stoma. Remove the obturator. Secure the ties and auscultate lung sounds. Palpate the tracheostomy site for any subcutaneous emphysema , a result of air or gas collecting under the skin (crepitus).
Tracheostomy becomes dislodged and is not easily replaced: Notify the health care team immediately. This is an emergency situation. Cover the tracheostomy stoma. Assess the patient's respiratory status. Anticipate the possible need for maintaining ventilation using a manual resuscitation device and mask and for possible oro- or nasotracheal intubation.
Lung sounds do not improve greatly, and oxygen saturation remains low after three suctioning attempts: Allow the patient time to recover from previous suctionings. If needed, hyperoxygenate again. Suction the patient again and assess whether the oxygen saturation increases, lung sounds improve, and secretion amount decreases.
Patient develops signs of intolerance to suctioning; oxygen saturation level decreases and remains low after hyperoxygenation; patient becomes cyanotic; or patient becomes bradycardic: Stop suctioning. Auscultate lung sounds. Consider hyperventilating the patient with a manual resuscitation device. Remain with the patient. Alert staff to notify the health care team of the change in the patient's status.

Special Considerations

General Considerations

Determine the size of the catheter to use by the size of the tracheostomy tube. 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). Larger catheters can contribute to trauma and hypoxemia.
If the patient eats by mouth, it is recommended that the tracheostomy tube be suctioned prior to eating to prevent the need for suctioning during or after meals, which may stimulate excessive coughing and could result in vomiting (Hess et al., 2021, p. 429).
The practice of instillation of saline solution directly into the airway during tracheal suctioning is not supported by evidence and is not recommended for inclusion as part of evidence-based practice and suctioning (AARC, 2010; Boroughs & Dougherty, 2015; Burns & Delgado, 2019; Leddy & Wilkinson, 2015; Owen et al., 2016; Wang et al., 2017).
Keep emergency equipment easily accessible at the bedside. Keep a bag-valve mask, oxygen, the obturator from the current tracheostomy, a spare tracheostomy of the same size, a spare tracheostomy one size smaller, and suction equipment at the bedside of a patient with a tracheostomy tube at all times (Dawson, 2014; Patton, 2019). If the patient is currently using a tracheostomy without a cuff, keep a spare tracheostomy of the same size with a cuff at the bedside for emergency use.

Infant and Child Considerations

Insertion of the suction catheter to a predetermined distance, no more than the tip of the artificial airway to no more than 0.5 cm past the length of the endotracheal tube avoids contact with the trachea and carina, reducing the effects of tracheal mucosal damage (Boroughs & Dougherty, 2015; Kendrick, 2020).
The maximal time for application of negative pressure (suction) for neonates, children, and adolescents should be less than 5 to 10 seconds (Boroughs & Dougherty, 2015; Dawson et al., 2012, as cited in Edwards, 2018, p. 51; Hockenberry et al., 2019).

EVIDENCE FOR PRACTICE

Tracheostomy Tubes and Patient Communication

Placement of a tracheostomy tube results in the inability to speak, at least initially, for patients; once a patient is stable, the use of certain types of tracheostomy tubes may be appropriate to provide a patient with the ability to talk and communicate verbally. Difficult communication can prevent tracheostomy patients from expressing their needs and emotions, and collaborating in the planning of care, and it may contribute to ineffective responses to patient concerns and needs (Tollotti et al., 2018). What is the experience of patients with a tracheostomy who are unable to communicate verbally?

Related Research

Tolotti, A., Bagnasco, A., Catania, G., Aleo, G., Pagnucci, N., Cadorin, L., Zanini, M., Rocco, G., Stievano, A., Carnevale, F. A., & Sasso, L. (2018). The communication experience of tracheostomy patients with nurses in the intensive care unit: A phenomenological study. Intensive & Critical Care Nursing, 46, 24-31. https://doi.org/10.1016/j.iccn.2018.01.001

The purpose of this phenomenologic study was to describe the experience and sources of comfort and discomfort in tracheostomy patients when they communicate with nurses in the intensive care unit (ICU). The study took place in an ICU of a teaching hospital in Northern Italy. Participants included adult patients with a tracheostomy who were intubated for more than 5 days, mechanically ventilated, and not under sedation (n = 8) and the nurses (n = 7) who the patients remembered best in relation to their communication experiences in the ICU. During the patients' stay in the ICU, observation of the communication interactions between patients and nurses took place. The data collected through the observations were used during the interviews to gain a better understanding of the problems the patients reported in their narrations and during data analysis to gain a clearer and wider view of the context in which the communication events occurred. Within days after discharge from the ICU, semistructured in depth interviews with patients were conducted to explore the difficulties experienced by the patients during their communication experience with the nurses and to identify which elements had facilitated or hindered their communication. Patients were asked which nurses they remembered in particular, and short semistructured interviews were conducted with these nurses to explore the communication events and the context. All interviews were audiorecorded and transcribed verbatim. Transcripts of each patient interview were read and reread and then a line-by-line thematic analysis was conducted. Main themes were identified and grouped into categories. A thematic analysis of the transcripts of the nurses' interviews was completed to identify the similarities and the differences between the patients' and the nurses' transcripts, focusing on the communication difficulties experienced by the patients and comfort and discomfort factors when communicating with the nurses. An analysis of all cases and situations was completed to identify and describe commonalities and differences in the experiences reported by the patients. An examination of which communication comfort and discomfort factors were considered more important by the patients and which by the nurses was also completed. Two main themes were identified in relation to patients' communication experience with the nurses: (1) feeling powerless and frustrated, (2) facing continual misunderstanding, resignation and anger. The main communication discomfort factors identified were struggling with not knowing what was happening, feeling like others had given up on me, living in isolation and feeling invisible. The main comfort factors identified were being with family members, feeling reassured by having a call bell nearby and nurses' presence. The researchers concluded the results highlighted the importance of communication for tracheostomy patients and how communication is intrinsically linked to many aspects of the patient's experience, which cannot be reduced merely to the inability to use their voice.

Relevance for Nursing Practice

Effective communication is a cornerstone of professional nursing care. Communication strategies for patients who are unable to communicate verbally are a critical part of the provision of care. Good communication enables nurses to provide appropriate and person-centered nursing care. Nurses have a responsibility to develop and implement communication strategies to meet the needs of all patients in their care.

section name header

Skill 14-12

EVIDENCE FOR PRACTICE