1) Suctioning refers to clearing secretions from the airways of patients unable to do so themselves, such as those with artificial airways like endotracheal or tracheostomy tubes. It is indicated for patients who cannot cough effectively. 2) There are various suction equipment including pumps, tubing, connectors, and catheters that are used through different entry modes like nasopharyngeal, oropharyngeal, or through artificial airways. Proper technique and sizing is important to avoid hazards. 3) Hazards of suctioning include infection, mucosal trauma, hypoxia, and increased intracranial pressure, so pre-oxygenation and careful technique

1. JAMIA MILIA ISLAMIA
CENTRE FOR PHYSIOTHERAPY & REHABILITATION SCIENCES
PRESENTATION OF PHYSIOTHERAPY IN CARDIOPULMONARY
CONDITIONS (BPT-402)
TOPIC- SUCTIONING
SUBMITTED TO- DR. JAMAL ALI MOIZ
SUBMITTED BY- TANVEER BHOLA
BPT 4TH YEAR
PRESENTATION DATE-16.02.2021
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2. SUCTIONING
• Suctioning refers to the method of clearing secretions from the airways of
patients who can not mobilize and expectorate them without assistance.
• Suctioning is used to clear retained or excessive lower respiratory tract
secretions in patients who are unable to do so effectively for themselves.
This could be due to the presence of an artificial airway, such as an
endotracheal or tracheostomy tube, or in patients who have a poor cough
due to an array of reasons such as excessive sedation or neurological
involvement.
• INDICATIONS-
• patients incapable of coughing at voluntary or reflex level.
• ineffective coughing due to weakness and exhaustion in very sick
patients.
• patients who are breathing spontaneously but are unwilling or unable to
cough effectively due to confusion, pain.
• deeply unconscious or, patients with respiratory muscle paralysis
• All intubated patients.
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3. CONTRAINDICATIONS-
• Patients with acute head injury or after intracranial surgery
• Frank hemoptysis
• Severe bronchospasm
• Patients with fracture of base of skull or cerebrospinal fluid leak
• Undrained pneumothorax
• Compromised cardiovascular system.
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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.
c) portable suction apparatus is available powered by rechargeable
batteries.
• All suction pumps have at least one suction bottle (partially filled with
antiseptic solution).
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).
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5. 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.
4. Catheters- these are 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.
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6. 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
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7. SUCTION SYSTEMS-
• Closed Suction System-
• Do not disconnect from ventilator. Similar procedure to open
technique but no application of sterile glove
• Enables a clinician to clear the lungs of secretions whilst
maintaining ventilation and minimising contamination with the least
possible disruption to the patient
• Helpful in preventing cross contamination and infection.
• Open Sterile Technique-
Clearing the airways of a mechanically ventilated patient with a suction
catheter inserted into the endotracheal tube after the patient has been
disconnected from the ventilator circuit.
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8. MODES 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.
• The NPA is a robust, supple but kink-resistant tube made of soft rubber. They
are flanged at the proximal (nasal) end. When properly placed, the tip rests
behind the tongue, just above the epiglottis, having separated the soft palate
from the posterior wall of the oropharynx. A suction catheter can be passed
through the tube and into the posterior pharynx and trachea.
• 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.
• 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.
• The ideal length of the nasopharyngeal airway should have the distal end of
the airway within 1 cm of the epiglottis. 8

9. • 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.
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10. • OROPHARYNGEALAIRWAY-
• An OPA is a rigid PVC tube that is flanged at the proximal (mouth)
end and is shaped to conform to the curvature of the palate. When
inserted properly, the flange sits just outside the lips and the tube
keeps the patient's tongue extended and prevents it from opposing
against the posterior pharynx.
• 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.
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11. • 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 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).
• 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.
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12. 1. Sizing
2. Position OPA upside down
3. Insertion of an OPA - rotation through 180 degrees
4. Rotation of an OPA - rotation through 180 degrees until positioned in
airway
5. Suction via an OPA
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13. 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.
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14. 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.
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15. HAZARDS OF AIRWAY SUCTIONING-
• Risk of infection which can be avoided by a good sterile technique.
• Mucosal trauma- Mucosal trauma is reduced by using an atraumatic
catheter, good suctioning technique, and the correct pressures.
• Cardiac arrhythymias- Direct tracheal stimulation causing a vasovagal
reflex can cause arrhythmias. Pre- and post-oxygenation can minimize
this effect.
• Hypoxia- Hypoxia can be caused by the interruption of ventilation,
reflex bronchospasm and the removal of the oxygen supply. Pre- and
post-oxygenation can minimize this effect. This 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.
• Raised intracanial pressure- Suction has been proven to increase ICP
dramatically, therefore suction should be used only when indicated.
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16. REFERENCES-
• Physiotherapy for Respiratory and Cardiac Problems, Edited by Jennifer
A Pryor MBA MSc FNZSP MCSP and Barbara A Webber FCSP
DSc(Hon), SECOND EDITION.
• PRINCIPLES AND PRACTICE OF CARDIOPULMONARY
PHYSICAL THERAPY, THIRD EDITION, Edited by: Donna
Frownfelter, MA, PT and Elizabeth Dean, PhD, PT.
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