What are the guidelines for managing suction orders in patients with respiratory secretions?

Management of Suction Orders in Patients with Respiratory Secretions

Endotracheal suctioning should be performed only when clinically indicated by the presence of secretions—not on a routine schedule—using sterile technique with appropriate catheter sizing and suction pressure limits. 1, 2, 3

Indications for Suctioning

Suctioning should be performed based on clinical assessment, not routine scheduling:

• Audible or visible secretions in the artificial airway are primary indicators for suctioning in pediatric and adult patients 2
• Adventitious breath sounds (coarse crackles, rhonchi) indicate the need for secretion clearance 2, 3
• Sawtooth pattern on ventilator waveforms suggests secretion accumulation requiring intervention 2
• Acute increase in airway resistance may indicate need for suctioning, particularly in neonates 2
• As-needed suctioning is superior to scheduled routine suctioning for neonatal and pediatric patients 2, 3

The evidence strongly supports abandoning routine scheduled suctioning in favor of clinically-driven intervention, as routine suctioning increases unnecessary procedures without improving outcomes 2, 4, 3.

Infection Control and Technique

Hand Hygiene and Barrier Precautions

• Decontaminate hands before and after contact with the patient's respiratory tract or any respiratory device, using either antimicrobial soap and water or alcohol-based hand rub 1
• Wear gloves when handling respiratory secretions or contaminated objects 1
• Change gloves between patients and after handling secretions before touching other surfaces 1
• Wear a gown when soiling with respiratory secretions is anticipated, changing it before caring for another patient 1

Sterile vs. Clean Technique

• Use sterile technique during open-system suctioning in hospitalized patients 2, 5
• For open-system suction, use a sterile, single-use catheter 1
• Clean technique is appropriate for home care with thorough handwashing before and after each procedure 6
• The evidence remains unresolved regarding sterile versus clean gloves for endotracheal suctioning 1

Open vs. Closed Suction Systems

Both open and closed suction systems can safely and effectively remove secretions, but specific clinical scenarios favor one approach:

• Closed suction systems are suggested for adults with high FiO₂, high PEEP, or at risk for lung de-recruitment 2, 3
• Closed systems are recommended for neonates to avoid disconnection from ventilation 2, 3
• Open suctioning may be more effective than closed suctioning for secretion clearance during pressure-support ventilation 1
• Closed systems do not reduce ventilator-associated pneumonia incidence, duration of mechanical ventilation, ICU length of stay, or mortality, but do increase costs 1
• For mechanically-ventilated patients, closed-circuit suctioning decreases aerosolization risk 6

The CDC guidelines note this remains an unresolved issue for pneumonia prevention, giving clinicians flexibility based on patient-specific factors 1.

Technical Parameters

Catheter Sizing

• Suction catheters should occlude less than 50% of the endotracheal tube lumen in pediatric and adult patients 2, 3
• In neonates, catheters should occlude less than 70% of the tube lumen 2, 3
• In infants, catheters should occlude less than 70% of the tube lumen 3

However, for chronic tracheostomy patients at home, the American Thoracic Society recommends using the largest catheter that fits inside the tracheostomy tube because larger-bore catheters remove secretions more efficiently and provide better tactile feedback for detecting partial obstruction 1.

Suction Pressure

• Keep suction pressure below -120 mm Hg in neonatal and pediatric patients 2
• Keep suction pressure below -200 mm Hg in adult patients 2
• Use the lowest possible suction pressure that effectively removes secretions 5

Suctioning Duration and Depth

• Limit suction application to a maximum of 15 seconds per suctioning procedure 2, 5, 3
• Perform continuous rather than intermittent suctioning during catheter withdrawal 5
• Shallow suctioning is preferred over deep suctioning based on evidence from infant and pediatric studies 2, 3
• Deep suctioning should only be used when shallow suctioning is ineffective 2
• For routine suctioning, use the "premeasured technique" inserting the catheter to a predetermined depth with distal side holes just exiting the tube tip 6
• Do not insert the catheter beyond the carina 5

Preoxygenation and Hyperinflation

• Preoxygenation should be performed before suctioning in pediatric and adult patients, particularly if clinically important oxygen desaturation occurs with suctioning 2, 3
• Reassurance, sedation, and pre-oxygenation minimize detrimental effects of airway suctioning 1
• Hyperinflation combined with hyperoxygenation should be provided on a non-routine basis 5
• Manual hyperinflation (MHI) should be used judiciously in patients at risk of barotrauma, volutrauma, or hemodynamic instability 1
• Airway pressures must be maintained within safe limits (e.g., below 40 cmH₂O) by incorporating a pressure manometer into the MHI circuit 1

Normal Saline Instillation

The routine instillation of normal saline should be avoided during suctioning. 1, 2, 5, 3

The evidence consistently demonstrates that normal saline instillation:

• Has potential adverse effects on oxygen saturation and cardiovascular stability 1
• Does not effectively thin or mix with mucus 1
• May contaminate lower airways with unsterile saline 1
• Shows variable results in increasing sputum yield 1

Proper humidification is more effective than saline instillation for maintaining thin secretions 1.

Sterile Fluid for Catheter Cleaning

• Use only sterile fluid to remove secretions from the suction catheter if it will be re-entered into the patient's lower respiratory tract 1, 6
• For home care, flush the catheter with tap water until secretions are cleared, wipe the outside with alcohol, and allow to air dry 6

Equipment Maintenance

• Change the entire length of suction-collection tubing between uses on different patients 1
• Change suction-collection canisters between uses on different patients except in short-term-care units 1
• No recommendation exists for the frequency of changing in-line suction catheters in closed-suction systems used on one patient 1

Special Considerations

Tracheostomy Care

• Perform tracheostomy under aseptic conditions 1
• When changing a tracheostomy tube, use aseptic technique and replace with a tube that has undergone sterilization or high-level disinfection 1
• Maintain cuff pressure between 20-30 cmH₂O for air-filled cuffs to prevent tracheal injury while maintaining circuit integrity 7, 6

Patients at Risk for Complications

• Avoid disconnection from the ventilator during suctioning when possible 3
• Use lung recruitment maneuvers if suctioning-induced lung de-recruitment occurs in patients with ARDS 3
• MHI can increase intracranial pressure and mean arterial pressure, though cerebral perfusion pressure usually remains stable 1

Mucolytic Agents

When acetylcysteine is administered to facilitate secretion clearance, the airway must be maintained open by mechanical suction if cough is inadequate, as an increased volume of liquified secretions may occur 8. If bronchospasm progresses during acetylcysteine treatment, discontinue the medication immediately 8.

Common Pitfalls to Avoid

• Do not perform routine scheduled suctioning—this increases unnecessary procedures without benefit 2, 4, 3
• Do not instill normal saline routinely—it does not thin secretions and may cause harm 1, 2, 5, 3
• Do not use excessively large catheters—they increase risk of trauma and hypoxemia 2, 5, 3
• Do not apply suction for longer than 15 seconds—prolonged suctioning causes hypoxemia 2, 5, 3
• Do not perform deep suctioning routinely—use shallow technique unless ineffective 2, 3
• Do not use routine bronchoscopy for secretion removal—it is not recommended 2