1. Airway suctioning is used to clear secretions from intubated or mechanically ventilated patients who cannot cough effectively. It requires specialized equipment like suction pumps, tubing, catheters and connections. 2. Suction can be performed through the nose, mouth or an endotracheal/tracheostomy tube. The catheter is inserted until resistance is felt and suction is applied intermittently while withdrawing the catheter. 3. Risks of suctioning include infection, trauma, hypoxia, arrhythmias and atelectasis, so a sterile technique and careful application of suction is important to minimize complications.

1. CENTER FOR PHYSIOTHERAPY AND REHABILITATION
SCIENCE
JAMIA MILLIA ISLAMIA
Submitted to: Dr. Jamal Moiz
Submitted by: Sumaiya Shams
Mpt (cardio)

2. Airway suctioning in mechanically ventilated
patient in ICU

3. • suctioning refers to the method of clearing secretions from the
airways of patients who can not mobilize and expectorate them
without assistance.
• it is given in-
1. patients incapable of coughing at voluntary or reflex level.
2. ineffective coughing due to weakness and exhaustion in very
sick patients.
3. patients who are breathing spontaneously but are unwilling or
unable to cough effectively due to confusion, pain or fear
4. deeply unconscious or, patients with respiratory muscle paralysis
5. all intubated patients

4. Suction Equipments
1. Suction Pumps- it produces the vacuum or suction force needed to aspirate
substances.
a) Suction apparatus designed to work from a vacuum point close to the patient’s
bed. It is most commonly found in hospitals in ICU and wards. It has an on/off
switch, control dial, and a manometer.
b) Electrical suction apparatus is powered from the mains. It has its own small
motor, on/off switch and control dial.

6. b) portable suction apparatus is available powered by rechargeable
batteries.
c) foot pump: power is provided by the operator. These pumps were used
earlier, however modern versions are available and are suitable to be used
in community or for an emergency.
- All suction pumps have at least one suction bottle (partially filled with
antiseptic solution)

8. 2. Suction Tubing-
▪ this leads from the suction bottle to the connection for the suction
catheter.
▪ usually made from clear plastic and is disposable (rubber tubing
is less used)
3. Connections-
▪ made up of clear or semitransparent plastic
▪ have 3 holes or 3 arms (Y connector)
▪ the catheter and tubing fit on to opposite ends and the third hole
is used by operator as control port.
▪ to apply suction force to the catheter the operator places a
finger or thumb over the opening.

9. 4. Catheters-
• made from soft, clear plastic and are disposable
• commonly used sizes for the adult patients are 10,12,14 and 16 FG and
are colour coded for size. (6, 8 FG in paediatric, neonates)
• the size of catheter should not exceed half the diameter of the
endotracheal or tracheostomy tube.
• rubber catheter must be sterilized after use.
• sputum trap- used when bronchial secretions need to be sent for
laboratory investigation

11. 5. Suction Trolley- all the equipments needed for airway suction
should be set out on a trolley for ease of access.
▪ sterile plastic gloves (disposable)
▪ suction catheters of appropriate size
▪ lubricating jelly
▪ sterile gauze swabs
▪ sterile water
▪ plastic bags

12. Suction Technique
• There is a high risk of introducing infection into the respiratory tract
by suctioning. Therefore, a sterile suction technique should always
be preferred using sterile plastic gloves or forceps to introduce the
catheter.
• Prior to application of suctioning, all the equipment should be
checked such as - leads of bottle, sealing washers, tube connections
etc
• Appropriate vacuum pressure is selected (probably between -100 to -
120 mmHg)
• Physiotherapist should wash the hands properly and explain the
entire procedure to the patient. Select appropriate size of the
catheter

13. Mode of Entry
• A suction catheter can be introduced into the respiratory tract through the nose, mouth or a tube
Nasopharyngeal Suction
• The nasopharyngeal airway is a simple airway adjunct that can be used to facilitate ventilation and
removal of secretions. It is also called a nasal trumpet or nasal horn (White, 2013). A
nasopharyngeal airway has advantages over the oropharyngeal airway as this nasal airway can be
used in patients with an intact gag reflex. Other indications include patients with unstable
fractures of the mandible, trimus (lockjaw), or oral trauma (Roberts et al., 2005).
Selection of Nasopharyngeal Airway
• The appropriate size of nasopharyngeal airway for average females is a size 6. For average males,
the size should be a size 7. The final selection should be based on the patient’s height and clinical
condition. The methods of using the width of the patient’s nares or size of the little finger are based
on anecdotal teaching rather than clinical evidence (Roberts et al., 2003).
• Proper sizing for the patient is important. If the nasopharyngeal airway is too short, the airway
would not separate the soft palate from the posterior wall of the pharynx. If the airway is too long, it
would enter either the larynx and aggravate laryngeal reflexes or enter the space between the
epiglottis and the vallecula leading to potential obstruction of the airway.
• The ideal length of the nasopharyngeal airway should have the distal end of the airway within 1 cm
of the epiglottis (Stoneham, 1993). Table 5-2 shows the size chart for nasopharyngeal airways.

15. Insertion of Nasopharyngeal Airway
• Prior to insertion of a nasopharyngeal airway, the nares should be inspected
for obstruction. A local anesthetic spray may be applied to the posterior
nares for patient comfort. Prior to insertion, the patient should be in a sitting
or semi- Fowler position and the nares are lifted to reveal the nasal airway.
• Placement of the airway should be parallel to the nasal floor, rather than
upwards toward the cribriform plate of the ethmoid bone. Lubrication with a
water-soluble lubricant and gentle rotation should facilitate the insertion
(Roberts et al., 2005).
• Body fluid or isolation precautions must be observed throughout the
procedure. A nasopharyngeal airway and its correct placement are shown in
Figure.

16. Complications of Nasopharyngeal Airway
The nasopharyngeal airway is unstable and it should be inspected for
inadvertent movements. Outward movement is more common. Inward
migration may be prevented by using a safety pin on the distal end of the
airway to prevent it from going into the nares. Other common complications
include soft tissue damage of the nasal mucosa and bleeding. There are two
reported cases that involved basilar skull fracture with use of nasopharyngeal
airway (Roberts et al., 2005).

17. Oropharyngeal Suction
• An oropharyngeal airway is used to relieve upper airway obstruction if
airway maneuvers (e.g., head tilt-chin lift, jaw thrust) fail to open an
unobstructed airway (White, 2004). During bag-mask ventilation, an
oropharyngeal airway may facilitate effective ventilation. It may also be
used as a bite block in intubated patients. An oropharyngeal airway should
be used in patients who are sedated or unconscious.
• For conscious patients, insertion of this airway may trigger the gag reflex
and cause vomiting, and aspiration of stomach contents into the lungs.

19. Selection of Oropharyngeal Airway
• The appropriate size (from flange to distal tip) of an oropharyngeal airway
may be estimated based on the length in millimeters from the center of the
mouth to the angle of the jaw. Alternatively, the length in millimeters from
the corner of the mouth to the earlobe may be used. The third method is to
measure the distance from the central incisors to the angle of the jaw. To
evaluate the size using this method, place the airway next to the patient’s
face.
• Proper sizing for the patient is important. If the airway is too large, it may
push the epiglottis against the larynx leading to airway obstruction. If the
airway is too small, the tongue may not be sufficiently moved away from
the soft palate leading to airway obstruction by the tongue

20. Insertion of Oropharyngeal Airway
• Prior to insertion of an oropharyngeal airway, ensure that the patient is
sedated or unconscious. If the patient begins to gag or retch during the
procedure, remove the airway immediately and reassess the necessity of an
oropharyngeal airway. Sometimes the airway may be opened and
maintained by repositioning of the head (e.g., head tilt-chin lift, jaw thrust).
• Body fluid or isolation precautions must be observed throughout the
procedure. The patient should be in a supine position, and the mouth is
opened using the scissors (crosses fingers) technique. If a tongue blade is
available, the tongue is depressed and the oropharyngeal airway may be
inserted with the pharyngeal curvature.
• Some practitioners prefer to insert the airway into the patient’s mouth upside
down so that the distal end of the airway is facing the hard palate (roof of
the patient’s mouth). As the airway is inserted fully, it is turned 180° until
the flange (proximal end) rests on the patient’s lips or teeth (White, 2004).
The correct placement of an oropharyngeal airway is shown in Figure

21. Suction Procedure
1. Whatever the mode of entry the physiotherapist must ensure that no suction
pressure is applied while the catheter is being introduced. It can lead to severe
trauma in the mucus layer.
2. The catheter is inserted until a cough reflex is elicited or some resistance is met
in the trachea (Carina)
3. Suction is then applied by occluding the open hole of control port with the help
of thumb.
4. Simultaneously the catheter is withdrawn while gently rolling the catheter
between finger and thumb to ensure a continuous rotation to minimise tracheal
trauma.
5. Interrupted suction should always be used to avoid a maximum build up of
negative pressure
6. Under no circumstances tromboning method should be used, that is, a vigorous up
and down movement of the catheter.

22. 7. At all times during the procedure observe the patient for signs of hypoxia
and if needed administer oxygen or ventilation immediately
8. Pre-suction oxygenation and Manual hyperinflation can be applied in
patients who are at risk of suffering from hypoxia
9. No longer than 15 seconds should elapse between the disconnection and
reconnection of the patient will the ventilator
10. If possible patient should be suctioned in side lying or with head rotated
to one side to avoid aspiration of gastric contents in case of vomiting
11. After suctioning patient must be connected to the ventilator or oxygen
supply immediately
12. The therapist should flush the catheter through sterile water, remove the
gloves over the catheter and discard both. Suction pump should be switched off.

23. Hazards of Airway Suctioning
• Risk of infection which can be avoided by a good sterile technique
• Trauma which can be minimised by correct size of catheter and correct
application of negative pressure with good technique
• Hypoxia which can occur during nasopharyngeal as well as endotracheal
suctioning. Accurate use of applied negative pressure and timing can be helpful
in minimising hypoxia, that is, not too powerful or not too long
• Cardiac arrhythmia may occur as a secondary response to hypoxia. Bradycardia
is usually noted but breathing higher concentrations of oxygen prior to
suctioning can help to counteract this problem.
• Atelectasis may be caused by too powerful and prolonged suction.
• Airways may be obstructed by repeated, traumatic suction techniques resulting
in bleeding, crusting and eventually fibrosis of mucous membrane.