Covers indications , complications, Preparation , Procedure ,post procedure care and special consideations

1. Endotracheal tube
suctioning : Principles
& Practice
Dr.Venugopalan P P
DA,DNB, MNAMS, MEM-GW
Director and Lead consultant in Emergency
Medicine : Aster DM Healthcare

2. Background
Effective suctioning is an essential aspect of airway
management in the intubated critically ill patients
● Unable to maintain a patent airway
● Glottic closure is compromised
● Preventing cough reflex
● Increasing secretions
● Compromising their ability to clear endotracheal
secretions

3. Background
Associated risks and
complications
Prior to suctioning
● Comprehensive patient
assessment
● Patient preparation
During suctioning
● Appropriate catheter selection
● Depth of insertion
● Suction pressure
● Duration of procedure
● Number of suction passes

4. Background
● Prevention of infection and maintenance of asepsis, i.e.
hand – washing, wearing gloves, aprons and goggles are
essential
● Suctioning is an invasive procedure and should only
be carried out if indicated and not on a routine basis
(Cordero et al. 2001, Morrow and Argent 2008).

5. What is meant by endotracheal Suction?
Suctioning is described as the mechanical
aspiration of pulmonary secretions from a patient
with an artificial airway in position
(American Association of Respiratory Care 2010).

6. ● Removal of secretions
● Tracheobronchial tree
● Through an endotracheal
tube
● Mechanical suction
device.

7. What are the indications ?
● The decision to suction should be based on individual
patient assessment and the following clinical signs that
may indicate the need for suctioning
● Suctioning should be done as rarely as possible and as
frequently as needed
(Corderro et al. 2001)

8. What are the Indications?
● Visible or audible secretions – rattling or bubbling sounds,
audible with or without a stethoscope
● Decreased oxygen saturation levels
● Bradycardia / tachycardia
● Increased pCO2
● Deteriorating blood gas values
●
(Moore 2003, Gardner and Shirland 2009, Royal Children’s Hospital 2012, Davies et al. 2015).

9. What are the Indications?
● Changes in respiratory rate and pattern with increase
respiratory distress
● Change of colour (cyanosis, pallor, mottled)
● Suspected endotracheal tube obstruction
● Ventilator alarms i.e. Increased proximal airway pressure /
decreased tidal volume
(Moore 2003, Gardner and Shirland 2009, Royal Children’s Hospital 2012, Davies et al. 2015).

10. What are the Indications?
● Decreased breath sounds / absent chest movement
● Increased airway pressure when ventilated (decreased
tidal volumes)
● Decreased chest excursion / asymmetry
● Patient agitation
(Moore 2003, Gardner and Shirland 2009, Royal Children’s Hospital 2012, Davies et al. 2015).

11. What are the equipment needed ?
● Oxygen source / oxygen mixer for preterm / neonates
● Monitoring equipment – oxygen saturation, heart rate and
blood pressure
● Suction apparatus
● Appropriately sized suction catheters
● Selection of clean disposable gloves
(OLHSC 2008, Dougherty and Lister 2015).

12. What are the equipment needed ?
● Disposable plastic apron
● Goggles
● Alcohol hand rub
● Sterile Water for Irrigation
(OLHSC 2008, Dougherty and Lister 2015).
●

13. Precautions with ETT suctioning
a. Pressure - Raised ICP
b. Pulmonary
Hypertension
c. Pulmonary Oedema
d. Pulmonary
Haemorrhage
These conditions may be exacerbated by suctioning and
extra precautions taken (Morrow and Argent 2008).
Four Ps of
Precautions

14. What are the potential
Complications of ETT
suctioning ??

15. Respiratory complications
● Hypoxia
● Bronchospasm
● Tracheobronchial mucosal trauma
resulting in potential pulmonary
haemorrhage
● Contamination of airway leading to
nosocomial infection

16. Respiratory complications
● Unplanned Extubation
● Atelectasis (loss of ciliary function / glottis
closure)
● Right upper lobe collapse (excessive
suction pressures) (Boothroyd et al.
1996)
● Pneumothorax (Morrow and Argent 2008)

17. Neurological Complications
● Changes in cerebral blood flow
velocity
● Raises intracranial pressure
● Decreased oxygen availability
● Increases risk of IVH
● Hypoxic-ischemic encephalopathy
●

18. Cardiovascular complications
● Vagal response
bradycardia
● Haemodynamic
instability
● Pulmonary
vasoconstriction
●

19. Other complications
Infections
● Nosocomial infections
● VAP
Pain
● Behavioural pain
response in infants
(Morrow and Argent 2008, Royal
Children’s Hospital 2012, GOSH 2014).
●

20. Endotracheal suction
- Procedure

21. Steps of ETT suction and its Rationale
Pre - Procedural preparation
Comprehensive
respiratory assessment
To minimise anxiety and
stress (Dougherty and Lister
2015)
Explain procedure to
Patient / Parents(Child)
Minimize anxiety and
stress
(Dougherty and Lister 2015).

22. Steps of ETT suction and its Rationale
Preparation of patient -
Physical
Psychological and
Pharmacological -sedation
Reduce the risk of
complications
(Dougherty and Lister
2015)
Ensure all necessary
equipment
To ensure effectiveness of
procedure and minimise
risk of complications
(Dougherty and Lister 2015, Lippincott
Williams and Wilkins 2011).

23. Ensure the correct suction
pressure is set
1. Neonate 50 – 80 mmHg
2. Paediatric 80 – 100
mmHg
3. Older Child 100 – 120
mmHg
4. Adult - 120 to 150 mmHg
5. Adult with thick secretion-
150 to 200 mmHg
High negative suction
pressures and deep
suctioning
1. Right upper lobe collapse
in children
2. Damage respiratory
mucosa
3. Destruction of epithelial
cilia of the airways (Boothroyd
et al. 1996, Gardner and Shirland 2009,
Hazinski 2013)

24. Calculate appropriate sized
suction catheter, double the
size of the endotracheal tube
Size of Catheter
Internal Diameter of ETT X 3
2
● Ensure effectiveness of
procedure
● Minimise risk of
complications
● Guarantee maximum of
50 of internal diameter of
ETT
● Creates less negative
pressure
● Prevents hypoxia
● Right upper lobe collapse
/ atelectasis.

25. Less than
50 percent
of internal
diameter of
ETT

26. ● Limits the risk of mucosal
trauma
● Too big a suction catheter
reduces the tidal volume
to < 10%.
(Morrow et al. 2004, Pederson et al. 2008,
Kiraly et al. 2009, AARC 2010)
● Decontaminate hands
prior to procedure
● Put on apron and goggles
● Maintenance of asepsis
● Prevention of cross
infection
● Protection of practitioner
(OLHSC 2007, OLCHC 2010, 2011).

28. ● Oxygen saturations, chest expansion
and underlying disease should be used
to determine the need for
preoxygenation and / or hyperinflation
(Gardner and Shirland 2009)
2009).
● Standard suction support
hyperoxygenation is 30% above
patients’ baseline oxygen
requirements using Servo I ventilation
Suction support
does not provide
hyperinflation
(Maquet 2008)

29. 1. If a patient has high oxygen and
PEEP requirements and/or is
known to desaturate to clinically
significant levels, pre-oxygenation
should be considered
2. If pre-oxygenating, use the
ventilator capability to deliver 100%
oxygen.

30. Preterm infants ensure
maximum of 10-20% pre-
oxygenation
To prevent
1. Hyperoxemia and oxygen
free-radical damage
2. Retinopathy of prematurity (ROP)
3. Periventricular leukomalacia (PVL)
4. Chronic lung disease
(Gardner and Shirland 2009)
Reduce hyperoxygenation in
the cardiac patient with
unbalanced circulation i.e.
Hypoplastic Left Heart
Syndrome (HLHS)
To prevent
1. Systemic steal
2. Over perfusion of circulation to the
lungs

31. Hyperventilate (up to five
breaths) using rebreathing
circuit as clinically indicated
1. Prevent hypoxaemia
2. Increases the residual
capacity of the lungs
3. Reduces the risk of
atelectasis
4. Reduce shunting
(Celik and Elbas 2000, AARC 2010).
Apply non-sterile glove to the
dominant hand
Maintain non-touch technique
ANTT level 3
(OLHSC 2007, OLCHC 2011)
OLCHC (2010) Guidelines on Hand Hygiene. Our Lady’s Children’s Hospital Crumlin: Dublin.
OLCHC (2011) Standard Universal Precautions. Our Lady’s Children’s Hospital Crumlin: Dublin.

32. Deep vs Closed ETS

33. Deep suctioning
● The catheter is inserted until it is beyond the tip of the ETT, or
until it touches the carina.
● Usually needed when there are large amounts of secretions in
the lower airways
The drawbacks
● Mucosal injury and the potential for bleeding
● Vagal stimulation and bradycardia
● Mucosal ulceration and necrosis
● Inflammation

34. Shallow (premeasured) suction technique
1. Minimally invasive
2. The catheter is inserted only to the tip of the ETT
3. Avoiding injury to the airway
4. No cough stimulated with shallow ETS
5. Maneuver will only clear secretions from within the lumen of
the ETT
● Premeasured suctioning requires that the approximate depth
to the tip of the ETT be estimated by using a suction catheter
that has graduated centimeter markings
● The centimeter marking of the ETT at the lip is then noted
before the suction catheter is inserted to the same distance
that exists from the lip to the tip of the ETT

35. Length of suction catheter (depth of suction) in cms =
Position at nares / mouth (in cms) + Distance from
nares / mouth to suction port (in cms)

36. ● Determine insertion
approximately 0.5 -1cm
beyond the length of the
endotracheal tube (Shallow
Suctioning)
● Check against a
predetermined length i.e.
paper tape measure posted
at bedside
● Remove the catheter from its
sheath using dominant hand
Shallow suction is
recommended
Deep suctioning : Adverse
events
1. Stimulates vagal nerve
predisposing to bradycardia and
hypotension
2. Prolongs coughing
3. Increasing intrathoracic pressure
Decreasing venous return
4. Increased risk of mucosal and cilia
trauma
5. Inflammation
6. Infection
7. Desaturation
(Gardner and Shirland 2009, AARC 2010, Gillies and Spence 2013)

37. Procedure: ETT
Suctioning

38. Open Endotracheal Suctioning (OES)
● Patient is temporarily removed from the
ventilator to breathe freely, or manually
ventilated, while ETS is performed
● Some studies have shown that there is more
secretion removal with OES
Closed System suctioning (CSS)
● Patient remains attached to the ventilator, or
their supplemental breathing device
● A reusable inline (enclosed) catheter is used for
ETS
Open or Closed suction systems

39. 1. Physiologically better tolerated
2. Less desaturation
3. Less incidence and length of bradycardia
4. Prevent hypoxia and decreases in lung volume
5. Lessening the spread of infection to patients and
staff
6. Most clinical staff prefer CSS for the ease of use,
less time involved, and better patient toleration
7. Patients with high positive end expiratory pressure
will usually tolerate CSS better than OES.
CSS is more preferred

40. Two practitioner technique is
recommended
1. Infant / child
2. Acutely ill / unstable pt
3. High risk of not tolerating
the procedure
4. Profound decrease in heart
rate, blood pressure and
oxygen saturation.
Frasier D et al
Monitor vital signs i.e. heart
rate and oxygen saturations
To have a baseline set of
observations and allow
monitoring throughout the
procedure
Frasier, D. (2013) Health problems in newborns. In: Hockenberry,
M.J. and Wilson, D. (eds) Wong’s Essentials of Pediatric Nursing,
9th Edition. Elevier Mosby: St Louis, 228-307

41. Disconnect patient from
ventilator and introduce
suction catheter gently to
required depth
1. To prevent mucosal
damage (Day et al. 2002)
2. To prevent suck out of
FRC
Withdraw the suction catheter
gently applying continuous
suction pressure by placing
the thumb over the suction
control port, maximum 5-10
seconds
To ensure patency of
endotracheal tube and
prevent hypoxia
(Moore 2003, GOSH 2014)

42. Observe the secretions
1. Colour
2. Consistency
3. Amount.
Take into consideration the
patient’s own respiratory /
ventilation rate and clinical
state (Trevisanuto et al. 2009)
Do NOT rotate the
suction catheter
Suction catheters have
multiple - eyes (holes) in their
diameters and therefore the
rotating method is not
necessary
(Moore 2003)

43. ● Recovery period : more
than one catheter pass is
needed
● Not more than three
passes during any one
suctioning session
To allow oxygen levels to
return to baseline and
minimise mucosal damage
(Gardner and Shirland 2009)
Suction catheter passes
should be kept to a minimum
and should not exceed 3
passes
(Skoble et al. 2001, Gardner and
Shirland 2009)

44. A new sterile catheter is used
for each suctioning session
unless contaminated
● Literature lacks consensus
on the number of passes a
single catheter
● It can be used for, ranging
from a single to multiple
passes
● Research studies have
shown no increase in
nosocomial infection after
using a single catheter for
up to 24 hours
(Skoble et al. 2001, Pederson 2009)

45. Oropharyngeal
/Nasopharyngeal suctioning
should be carried out first
A new / Separate suction
catheter must be used for oral
nasal and endotracheal
insertion
(Gardner and Shirland 2009)
Attach manual rebreathing
circuit to patient and provide
manual ventilation following
suctioning as clinically
indicated, observing airway
pressures on manometer
dial for infants
1. To reduce the amount of negative
pressure in the lung and to reduce
the level of hypoxia
2. Re–oxygenating to reverse hypoxia
or hypercarbia that may have
developed
3. To reduce the risk of barotrauma
(Hazinski 2013)

46. Recruitment maneuvers (RM)
● Performed after ETS to help recover any loss of lung volumes
that occur during suctioning
● RM is performed by applying a sustained inflation pressure, for
instance, 30 cm H2
O x 30 seconds, within the lungs for a short
time
Lung Volume Recruitment Maneuvers
Morrow BM, Argent AC. A comprehensive review of pediatric endotracheal suctioning: effects, indications, and clinical
practice. Pediatr Crit Care Med.2008;9:465-77.

47. End of Suctioning
● Reconnect pt back to
ventilator
● Check air entry
● Look for Vitals and SpO2

48. Routine Instillation of Normal Saline 0.9% prior to suctioning
is NOT recommended
● Detrimental effects demonstrated in adults and
of no theoretical benefit in Paediatrics
(Morrow and Argent 2008, Rauen et al. 2008, Gardner and Skirland
2009)
● Sputum and saline do not mix
● No increase in amount of secretion obtained
when saline instilled
● It adversely affects tissue and arterial
oxygenation

49. Routine Instillation of Normal Saline 0.9% prior to suctioning
is NOT recommended
● Infants / children have experienced significantly greater
desaturation following Normal Saline 0.9% instillation
and may last up to 2 minutes
(Riding, Martin and Bratton 2003, Barocco et al. 2009, Frasier 2013)
● Dislodges bacterial colonies contributing to lower airway
contamination (Halm and Krisko-Hagel 2008)
● Increased incidence of bradycardia and need for
increased FI.02 (Barocco et al. 2009, Trevisanuto et al. 2009)

50. Continuous or Intermittent Suction
● Pedersen et al’s systematic review of ETS, it was
determined that continuous suctioning rather than
intermittent suctioning should be used because there was
a study that showed that intermittent suctioning in dogs
caused significant damage to tracheal tissue
● Another study showed that there is a risk of alveolar
collapse when intermittent suction is used with a closed
suction catheter
Pedersen C, Rosendahl-Nielsen, Hjermind J, Egerod I. Endotracheal suctioning of the adult intubated patient—what is
the evidence? Intensive Crit Care Nurs.2009;25:21-30

51. Post procedure Care

52. Monitor the oxygen
saturation levels and heart
rate for any decrease
indicating hypoxaemia
throughout the procedure
● Early and timely
intervention for instability
(Day et al 2002)
● Reduce risk of
complications (OLHSC
2008; Dougherty and Lister 2015,
OLCHC 2011)
Post Procedure

53. ● Dispose of the suction
catheter in the clinical waste
bin
● Rinse tubing by dipping it in a
small container of sterile
water
● Dispose gloves in the clinical
waste bin adhering to
universal health and safety
precautions
To prevent cross
infection
Post Procedure
Discard container with
sterile water after each
suctioning episode

54. Evaluate effectiveness by
conducting a comprehensive
post suctioning respiratory
assessment, including breath
sounds
To ensure effectiveness of the
procedure (Gardner and Shirland
2009)
Wash hands after procedure Maintenance of asepsis
Post Procedure

55. Document procedure and
findings :
1. Color, Consistency
and amount of
Secretions
2. Tolerance
3. Significant events
Continuation of care &
maintains accountability
through accurate
recording intervention
(An Bord Altranais 2002)
Allow patient 20-30 mins
before taking a blood gas
To ensure an accurate
sample
Post Procedure

56. Pediatric / Infant Endotracheal suction
Special considerations

57. Family
Centred Care
It is the responsibility of the
clinician caring for the
infant requiring ETT suction
to ensure that the parents
understand the rationale for
the procedure, as well as
potential complications

58. Analgesia / Sedation
1. Some patients may require a pre-suction bolus
of analgesia or sedation where the need is
anticipated
2. Urgent suction should not be deferred for
analgesia
3. The need for this intervention is based on clinical
assessment

59. Open Suction for HFOV and HFJV
1. Most infants on HFOV and HFJV have in-line suction
connected to the circuit
2. Open suction may be indicated for infants on HFOV and
HFJV, as this can result in more effective removal of
thick secretions
3. The need for this intervention is not routine, and where
appropriate should be ordered by medical staff
http://www.bunl.com/uploads/4/8/7/9/48792141/suctioning_technical_bulletin_10-001.pdf

60. Patient safety
1. Where possible, ETT suction is a 2 person
procedure
2. The primary clinician suctions the ETT maintaining
infection control precautions
3. The assistant ensures the infant remains safe from
accidental extubation, adjusts ventilator settings
4. Provides containment and comfort to the infant

61. Recruitment post-suction should not be routine. It
1. May reduce atelectasis related to suction and
restore functional residual capacity (FRC) after
suctioning. Hyperinflation is achieved by
increasing the tidal volume (increasing PIP)
2. May result in pneumothorax due to poor or
rapidly changing alveolar compliance

62. Recruitment post-suction should not be routine
● Each infant should be assessed individually
regarding whether this is necessary.
● This is determined by the infant’s response to
ETT suction, and length of time it takes for the
infant to recover post suction

63. Hyperventilation pre-suction should not be
routine
● May reduce hypoxaemia related to suction and shorten
stabilisation and recovery times
● Each infant should be assessed individually regarding
whether hyperventilation pre-suction is necessary
● This is determined by the infant’s response to ETT
suction, and length of time it takes for the infant to
recover post suction

65. ● Endotracheal suction is a routine procedure in
Mobile ICU,ED, ICU and OT
● Meticulous execution of the procedure is
important to ensure best patient care, avoid
complications and untoward events
● Ensure the protocol based practice
● It must be included in clinical protocol
● Infants , pediatric and high risk cases should be
considered separately

67. American Association of Respiratory Care (ARCC) (2010) Endotracheal suctioning of mechanical ventilated
patients with artificial airways 2010. Respiratory Care, 55(6): 758-764
Gillies, D. and Spence, D. (2013) Deep Versus Shallow Suction of Endotracheal Tubes in Ventilated Neonates
and Young Infants. Cochrane Database of systematic Reviews. Available online: www.cochranelibrary.com
(Accessed October 27th 2015)
Guidelines for noncommercial purposes of scientific or educational advancement. AARC and Respiratory Care
Journal.May 1993 issue of RESPIRATORY CARE [Respir Care 1993;38(5):500–504]
Suctioning. http://www.hopkinsmedicine.org/tracheostomy/living/suctioning.html Accessed July 2014
https://www.rch.org.au/uploadedFiles/Main/Content/rchcpg/hospital_clinical_guideline_index/Evidence%20Table%
20ETT%20Suction%20Ventilated%20Neonates.pdf

69. www.drvenu.blogspot.in
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