Airway Suctioning

Suctioning the airways prevents airway and breathing issues in all types of patients. Blood, pus, vomit, and saliva can directly compromise the airway in some patients. In others, excess of these fluids in the mouth can lead to aspiration and resulting lung infections at a later date. This section will review suctioning of the upper airway and the lower airway. 

 

Upper Airway Suctioning

Suctioning is necessary whenever obstructions or secretions threaten the airway above the larynx/vocal cords. While suction is a simple mechanical intervention to remove an obstruction, there are some details to remember that are specific to the upper airway.

PEDIATRICS: The anatomy of young patients increases the risk of airway obstruction. The pediatric tonsils, adenoids, tongue, and epiglottis are all large relative to the size of the airway and can compromise your visualization of the airway. Children have a strong response to stimulation of the vagal nerve in the back of the throat. Stimulation of this nerve can lead to bradycardia in young children.

TECHNIQUE: If the obstruction is partial and the patient is still respiring, it is appropriate to pre-oxygenate the patient prior to suctioning to relieve symptoms. When suctioning, use caution with the tip of the suction device, aggressive use can lead to bleeding or vomiting in patients. 

Suctioning deprives a patient of oxygen and stimulates vagal changes in breathing and heart rate.

According to the AHA, Suction for a max of 10 seconds at a time for an adult

 

Lower Airway Suctioning

Suctioning of the lower airways is more complex as passing a suction catheter past the larynx effectively requires the patient to have been previously intubated. In fact, ET suctioning is required in intubated patients, as secretions naturally build up in the artificial airway. AEMTs and above are permitted to perform this procedure if local protocols allow and they have been properly trained/certified in the procedure. There are two types of suctioning: invasive and non-invasive. Invasive suctioning goes past the tip of the ET tube, this will be reviewed in further detail below.

CONTRAINDICATION OF ET SUCTIONING: A lack of training is the only contraindication for ET suctioning. Suctioning is a necessary procedure for all patients who are intubated; Not performing it when indicated out of fear of a negative reaction may be fatal.

INDICATIONS FOR ET SUCTIONING: Suctioning is usually performed for two reasons: it has become difficult for the rescuer or ventilator to deliver a breath, or a specified time interval has passed since the patient was last suctioned (this depends on local protocols).

The listed indications for non-invasive suctioning are:

• Difficulty providing sufficient ventilation
• To remove secretions that have accumulated in the ET tube
• Visualization of material in the ET tube

The listed indications for invasive suctioning are:

• Difficulty providing sufficient ventilation after non-invasive suctioning has failed.
• Suspected aspiration
• Crackles on lung auscultation that were not present before intubation
• Unexplained decreases in blood oxygenation or end-tidal CO2

COMPLICATIONS OF ET SUCTIONING: There are an insane number of complications to lower airway suctioning; concern for these complications is never a reason to avoid suctioning if it is indicated. Prepare for these side effects and be ready to treat them if indicated.

• Hypoxia or respiratory arrest
• Bronchoconstriction or bronchospasm
• Cardiac arrhythmia or arrest
• Bleeding due to tissue trauma
• Infection
• Increases in intracranial pressure
• Hypertension or hypotension

 

The Procedure of ET Suctioning

PREPARATION: To prepare for ET suctioning, the patient should be pre-oxygenated by delivering 100% oxygen for at least 30 seconds before the suctioning event. The patient should be under continuous SPO2, ETCO2, and cardiac monitoring to assess for complications during the procedure.

There are two types of suctioning: deep suctioning and shallow suctioning.

DEEP SUCTIONING: Deep ET suctioning suctions past the tip of the ET tube into the trachea and potentially just past the carina. It is an invasive procedure and can result in tissue injury at multiple sites (carina, bronchioles, trachea). This is done when an obstruction past the level of the ET tube is suspected. Generally, the ET tube is inserted at a distance that matches the sternal notch. This is the approximate location of the carina.

SHALLOW SUCTIONING: Shallow suctioning is a non-invasive procedure and only suctions the length of the ET tube. For this procedure, you must know the length of the inserted ET tube and ensure that you do not exceed that marked distance on the suction catheter.

STEPWISE PROCEDURE:

A suction catheter has several key parts. A sterile sheath that the catheter comes in, an eyelet to control suction, and markings that denote the length of the catheter. Some catheters will have a valve that allows you to toggle suction on and off.

1. Select the largest diameter suction catheter that will fit down the patient's airways.
2. Ensure the patient is on monitoring for SPO2, ETCO2, Heart rate, Respiratory rate, and, if available, ECG.
3. Connect the catheter to the suction source.
4. Unless emergent, and if available, prep a sterile area and don sterile gloves.
5. Pre-oxygenate the patient with 100% O2 for at least 30 seconds unless the patient is suspected of having a complete obstruction.
6. Insert the catheter with the eyelet unobstructed until you reach the predetermined depth.
7. After reaching the desired depth, occlude the eyelet and watch for secretions to enter the catheter; if they become stuck, rapidly tap the eyelet to help break up the thick secretions. 
8. Withdraw the catheter while keeping the eyelet obstructed, ensuring that this step takes no more than 10 seconds in an adult and 5 seconds in a child.
9. Reconnect the patient to oxygen-rich ventilation before the next pass of the catheter.

LIMITATIONS TO ET SUCTIONING: ET sectioning can be ineffective in patients with extremely thick secretions. In these cases, advanced hospital treatment is promptly required. Suction also does not clear the more distal bronchi and bronchioles. If the patient's lungs are fully filled with fluid, suction will only be marginally effective.