Endotracheal Tube Suctioning: Duration and Guidelines
Endotracheal tube suctioning should be completed in less than 15 seconds per pass, using a rapid technique with adequate suction pressure (80-120 mm Hg), and performed only when clinically indicated rather than on a routine schedule. 1, 2
Duration of Suctioning
The critical time limit is 15 seconds or less per suctioning pass. 1, 3, 2
For pediatric patients using the premeasured technique (catheter inserted only to the end of the tube, not beyond), the American Thoracic Society recommends completing the procedure in less than 5 seconds to prevent atelectasis, particularly when using larger bore catheters. 1
In head-injured adults, limit suction duration to 10 seconds to minimize increases in intracranial pressure and reduce risk of cerebral ischemia. 4
The rationale for these time limits is that prolonged suctioning causes hypoxemia, atelectasis, cardiovascular instability, and elevated intracranial pressure. 3, 5
Suction Pressure
Use suction pressure of 80-120 mm Hg for both adults and pediatric patients. 1, 3, 6, 2
Apply suction both while inserting and removing the catheter for efficient secretion removal. 1
Higher pressures may be necessary for particularly thick secretions, but the goal is to use the lowest effective pressure that adequately clears secretions. 1
For head-injured patients specifically, keep negative suction pressure under 120 mm Hg. 4
Catheter Selection
Use the largest catheter that fits inside the endotracheal tube for efficient secretion removal with rapid technique. 1
This represents a shift from older recommendations that suggested smaller catheters (occupying less than 50% of tube lumen in adults, less than 70% in infants). 2
The American Thoracic Society consensus supports larger catheters because atelectasis is less likely when using the rapid, premeasured technique completed in under 5 seconds. 1
For head-injured patients, avoid suction catheters with outer-to-inner diameter ratios greater than 0.50. 4
Catheter Insertion Depth
Insert the catheter only to the end of the endotracheal tube (premeasured technique), not beyond into the trachea. 1, 2
Do not insert the suction catheter beyond the end of the endotracheal tube to avoid injuring the tracheal mucosa. 1
Shallow suctioning is preferred over deep suctioning based on evidence from infant and pediatric studies. 2
Frequency and Indications
Suction only when secretions are present, not on a routine schedule. 3, 2
Clinical indicators for suctioning include: visible secretions, coarse breath sounds on auscultation, increased peak inspiratory pressures, decreased tidal volumes, or oxygen desaturation. 3
Routine scheduled suctioning increases unnecessary complications and should be avoided. 2
Pre-oxygenation and Ventilation Management
Pre-oxygenation should be considered if the patient has clinically important oxygen desaturation with suctioning. 2
Perform suctioning without disconnecting the patient from the ventilator when possible to maintain oxygenation and PEEP. 2
Use closed suction systems for adults with high FiO₂, high PEEP, or those at risk for lung de-recruitment. 2
For neonates, closed suction systems without ventilator disconnection are specifically recommended. 2
Number of Passes
Limit suction passes to 1-2 per suctioning procedure. 4
- Multiple passes increase the risk of complications including hypoxemia, mucosal trauma, and cardiovascular instability. 3
Technique Considerations
Always use aseptic technique to minimize risk of nosocomial infections. 3, 2
Do not routinely instill normal saline prior to suctioning, as evidence does not support this practice and it may increase complications. 3, 2
Provide reassurance and support to conscious patients to minimize discomfort and distress during the procedure. 6
Special Populations
For head-injured patients, additional precautions include: