What is the protocol for suctioning in the Intensive Care Unit (ICU)?

ICU Suctioning Protocol

Open suctioning systems should be used for most mechanically ventilated ICU patients, as closed suctioning systems offer no advantage in preventing ventilator-associated pneumonia, mortality, or ICU length of stay, while significantly increasing costs. 1

Suctioning System Selection

Use Open Suctioning for Most Patients

• Open system suctioning is recommended as the standard approach for the majority of mechanically ventilated ICU patients 1
• Closed suctioning systems do not reduce the incidence of ventilator-associated pneumonia (VAP), duration of mechanical ventilation, ICU length of stay, or mortality compared to open systems 1
• Closed systems increase costs approximately 25-fold without providing universal clinical benefit 1

Consider Closed Systems Only in Specific Circumstances

• Closed suctioning may be considered for patients requiring high PEEP (>10 cm H₂O) to prevent loss of lung volume and alveolar derecruitment 1
• Closed systems may help limit environmental contamination in specific infectious disease contexts (e.g., COVID-19 patients) 1
• However, closed suctioning may be less effective than open suctioning for secretion clearance during pressure-support ventilation 1

Pre-Suctioning Preparation

Patient Preparation

• Provide reassurance, sedation, and pre-oxygenation to minimize detrimental effects of airway suctioning 1
• Pre-oxygenate with 100% FiO₂ before and after the suction procedure to prevent hypoxemia 2
• Ensure adequate sedation to prevent coughing and cardiovascular instability 1

Equipment Setup

• Use a suction catheter that occludes less than half the lumen of the endotracheal tube 2
• Set suction pressure to the lowest effective level (typically 80-120 mmHg) 2
• Maintain strict aseptic technique throughout the procedure 2

Suctioning Technique

Catheter Insertion and Suctioning

• Insert the catheter no further than the carina to avoid tracheal mucosal injury 2
• Apply suction for no longer than 15 seconds per pass 2
• Use continuous rather than intermittent suctioning during catheter withdrawal 2
• Perform suctioning only when clinically indicated (visible secretions, coarse breath sounds, increased peak pressures), not on a routine schedule 2

Avoid Routine Adjuncts

• Do not routinely instill normal saline during airway suctioning, as it has potential adverse effects on oxygen saturation and cardiovascular stability with variable results in sputum yield 1, 2
• Chest wall compression prior to endotracheal suctioning does not improve secretion removal, oxygenation, or ventilation 1

Adjunctive Airway Clearance Techniques

Manual or Ventilator Hyperinflation

• Manual hyperinflation (MHI) or ventilator hyperinflation combined with suctioning is indicated for airway secretion clearance 1
• Use MHI judiciously in patients at risk of barotrauma, volutrauma, or hemodynamic instability 1
• Maintain airway pressures within safe limits (≤40 cm H₂O) by incorporating a pressure manometer into the circuit 1
• Be aware that MHI can increase intracranial pressure and mean arterial pressure, though cerebral perfusion pressure usually remains stable 1

Body Positioning

• Body positioning and mobilization can enhance airway secretion clearance 1
• Head-down positioning may enhance the effects of hyperinflation on sputum volume and compliance 1

Special Populations

Patients with Brain Injury

• Exercise caution with suctioning and hyperinflation techniques, as they can increase intracranial pressure and mean arterial pressure 1
• Monitor cerebral perfusion pressure, which typically remains stable despite these transient increases 1

COVID-19 or High-Risk Infectious Patients

• A closed airway suction system is recommended to reduce viral aerosol production in confirmed or suspected COVID-19 patients 1
• If closed systems are unavailable, minimize the number of suctions using open systems 1

Common Pitfalls to Avoid

• Do not use closed suctioning systems routinely as a VAP prevention strategy, as they provide no benefit and significantly increase costs 1
• Avoid deep suctioning beyond the carina, which increases risk of tracheal mucosal injury without improving secretion clearance 2
• Do not perform routine saline instillation, which can worsen oxygenation and hemodynamic stability 1, 2
• Avoid prolonged suctioning (>15 seconds), which increases risk of hypoxemia, atelectasis, and cardiovascular complications 2
• Do not suction on a fixed schedule; suction only when clinically indicated to minimize complications 2