Suctioning in Critical Care 

Types of Suctioning

1. Oropharyngeal Suctioning

Devices

  • Yankauer sucker (tonsil tip)
  • Flexible catheter

2. Nasopharyngeal Suctioning

Catheter passed through nostril into nasopharynx.

Contraindications

  • Basilar skull fracture
  • Severe coagulopathy
  • Nasal trauma

3. Endotracheal/Tracheal Suctioning

Most important ICU suctioning technique.

Catheter inserted through:

  • Endotracheal tube
  • Tracheostomy tube

Types

Open Suction System (OSS)

Ventilator disconnected.

Closed Suction System (CSS)

In-line catheter without ventilator disconnection.

4. Deep Suctioning

Catheter advanced into lower tracheobronchial tree.

Used for:

  • Copious secretions
  • Mucus plugging

5. Subglottic Suctioning

Removal of secretions above ETT cuff.

Special ETT with subglottic port.

Purpose

Prevent aspiration and VAP.

Indications for Endotracheal Suctioning

Suctioning should NOT be routine..Perform only when clinically indicated.

Relative Contraindications

  • Severe bronchospasm
  • Raised ICP
  • Severe hypoxemia
  • Hemodynamic instability
  • Recent airway surgery
  • Coagulopathy
  • Arrhythmias

Suction Catheters

Types

Flexible Catheter

Most common.

Yankauer Catheter

Rigid oral suction.

Whistle-tip Catheter

Less mucosal trauma.

Catheter Sizing

Rule:Catheter external diameter should be <50% of ETT internal diameter.

Formula French size = (ETT size − 2) × 2

Example: ETT 8.0 mm → catheter ≈ 12 Fr

Suction Pressure

Patient

Pressure

Neonates

60–80 mmHg

Infants

80–100 mmHg

Children

100–120 mmHg

Adults

100–150 mmHg

Avoid >200 mmHg.

Open vs Closed Suction System

Feature

Open System

Closed System

Ventilator disconnection

Yes

No

Loss of PEEP

Yes

Minimal

Hypoxemia

More

Less

Infection risk

Higher

Lower

Cost

Lower

Higher

Aerosol generation

More

Less

Preferred in ARDS

No

Yes

Closed Suction System (CSS)

Advantages

  • Maintains oxygenation
  • Preserves PEEP
  • Reduced derecruitment
  • Less aerosolization
  • Better for severe hypoxemia

Preferred In

  • ARDS
  • High PEEP
  • COVID
  • Hemodynamic instability
  • ECMO

Preoxygenation

Important to prevent hypoxemia.

Increase FiO₂ to 100% for:

  • 30–60 seconds  OR. 3–5 breaths

Especially important in:

  • ARDS
  • Critically ill patients
  • Children

Hyperinflation

Used selectively.

Methods

  • Ventilator hyperinflation
  • Manual bagging

Purpose

  • Mobilize secretions
  • Recruit alveoli

Risks

  • Barotrauma
  • Hemodynamic compromise

Routine manual hyperinflation is NOT universally recommended.

Normal Saline Instillation

Routine saline instillation is NOT recommended.

Why?

Can cause:

  • Desaturation
  • Infection spread
  • Bronchospasm
  • Increased ICP

May occasionally help in:

  • Extremely thick secretions,Occasionally,secretions can become quite viscous. Instillation of 5 to 10 mL of sterile normal saline can aid removal.

Suctioning Procedure (Open System)

1. Hand Hygiene(This is a sterile

procedure necessitating appropriate care in handling the catheter.

Gloves and hand washing are necessary unless a closed system is

employed. )

2. PPE

3. Explain Procedure

4. Monitoring

5. Preoxygenate

6. Sterile Technique

7. Insert Catheter WITHOUT suction

Advance until:

  • Resistance OR Predetermined depth

8. Withdraw while rotating and applying suction

Duration:≤10–15 seconds

9. Reoxygenate

10. Reassess

Depth of Suctioning

Deep Suctioning

Advance until resistance then withdraw slightly.

Risks

  • Trauma
  • Bradycardia

Shallow Suctioning

Only to end of ETT.

Safer and often preferred.

Duration and Number of Passes

Recommended

  • Each pass ≤10–15 sec
  • Usually ≤3 passes/session

Allow recovery between passes.

Complications of Suctioning

  • Hypoxemia—Most common.
  • AtelectasisEspecially with:Large catheter,High suction pressure
  • Bronchospasm
  • Mucosal Trauma
  • PneumothoraxRare.
  • Bradycardia Due to vagal stimulation.
  • Tachycardia
  • Arrhythmias
  • Hypotension/Hypertension
  • Raised ICP Mechanisms:Hypoxemia–Hypercarbia–Coughing
  • Ventilator-Associated Pneumonia (VAP). Risk factors:Nonsterile technique,Frequent unnecessary suctioning

SALAD Technique

Suction Assisted Laryngoscopy and Airway Decontamination.

Used during:

  • Massive vomiting
  • GI bleed
  • Aspiration

Continuous suction during laryngoscopy.

Documentation

Document:

  • Indication
  • Type of secretions
  • Patient response
  • Complications
  • Oxygen requirement
  • Number of passes