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

Management of Suction Orders in Patients with Respiratory Secretions

Suction 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 pressure limits to minimize complications while maintaining airway patency. 1, 2, 3

Indications for Suctioning

Suction only when secretions are present, based on clinical assessment rather than scheduled intervals 2, 3:

• Audible breath sounds indicating secretion accumulation 2
• Visual secretions in the artificial airway 2
• Sawtooth pattern on ventilator flow-volume waveforms 2
• Acute increase in airway resistance (particularly relevant in neonates) 2
• Clinical deterioration with evidence of secretion retention 4

As-needed suctioning is superior to scheduled routine suctioning in neonatal and pediatric patients, and this principle extends to adult care 2. Routine scheduled suctioning increases unnecessary procedures and associated complications 4, 5.

Infection Control and Technique

Hand Hygiene and Barrier Precautions

Decontaminate hands before and after any contact with the patient's respiratory tract or respiratory devices, regardless of glove use 1:

• Use antimicrobial soap and water, or alcohol-based hand rub if hands are not visibly soiled 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 if soiling with respiratory secretions is anticipated, changing it before caring for another patient 1

Sterile Technique

Use sterile technique during open suctioning procedures 2:

• For open-system suction, use a sterile single-use catheter 1
• Use only sterile fluid to clear secretions from the suction catheter if it will re-enter the lower respiratory tract 1
• Clean technique is acceptable for home care with thorough handwashing 1, 6

Suction System Selection

Open vs. Closed Systems

No definitive recommendation exists for preferential use of closed versus open suction systems for pneumonia prevention, as evidence remains unresolved 1:

• Both systems can safely and effectively remove secretions in adult patients 2
• Closed suction is suggested for specific populations: adults requiring high FiO₂ or PEEP, patients at risk for lung de-recruitment, and neonates 3
• Closed systems do not reduce ventilator-associated pneumonia incidence, duration of mechanical ventilation, ICU length of stay, or mortality, but increase costs 1
• Open suctioning may be more effective during pressure-support ventilation 1

For mechanically ventilated patients, closed-circuit suctioning systems with inline catheters decrease aerosolization risk 6, which is particularly important for infection control 1.

Equipment Changes

Change suction collection tubing and canisters between different patients 1:

• No recommendation exists for routine changing frequency of inline suction catheters in closed systems used on a single patient 1

Catheter Selection and Suction Pressure

Catheter Sizing

Use the largest catheter that fits inside the tracheostomy tube for efficient secretion removal 1:

• For endotracheal suctioning: catheter should occlude <50% of tube lumen in pediatric and adult patients 2, 3
• For neonates: catheter should occlude <70% of tube lumen 2, 3
• Larger catheters provide better tactile feedback for detecting partial obstructions and remove secretions more quickly 1

Suction Pressure Limits

Maintain suction pressure within safe limits to prevent mucosal trauma 2, 3:

• Neonatal and pediatric patients: <-120 mm Hg 2
• Adult patients: <-200 mm Hg 2
• A pressure of 40 cmH₂O has been recommended as an upper limit for manual hyperinflation 1

Suctioning Procedure

Pre-Suctioning Preparation

Preoxygenation should be performed before suctioning in pediatric and adult patients if clinically important oxygen desaturation occurs 2, 3:

• Reassurance, sedation, and pre-oxygenation minimize detrimental effects of airway suctioning 1
• Hyperoxygenation combined with hyperinflation may be used on a non-routine basis 5

Catheter Insertion Depth

Use the premeasured technique for routine suctioning 1, 6:

• Insert catheter to predetermined depth with distal side holes just exiting the tracheostomy tube tip 1, 6
• Shallow suctioning is suggested instead of deep suctioning based on infant and pediatric evidence 2, 3
• Deep suctioning should only be used when shallow suctioning is ineffective 2
• Use premarked catheters to ensure proper depth and avoid epithelial damage 1, 6

Suctioning Duration and Technique

Apply suction for a maximum of 15 seconds per suctioning procedure 2, 5, 3:

• Perform continuous rather than intermittent suctioning during catheter withdrawal 5
• Twirl or rotate the catheter between fingers during insertion to reduce friction and clear secretions from all tube wall areas 1, 6
• Be careful when removing bougies or stylets to avoid spraying secretions on the team 1

Saline Instillation

Routine instillation of normal saline should generally be avoided 1, 2, 3:

• Normal saline does not effectively thin mucus and cannot mix with secretions 1
• Saline instillation has potential adverse effects on oxygen saturation and cardiovascular stability 1
• Variable and inconsistent results for increasing sputum yield 1
• Proper humidification is more effective than saline for maintaining thin secretions 1

Special Considerations for Tracheostomy Patients

Routine Tracheostomy Care

For routine nursing care of tracheostomy patients, instill 1-2 mL of 10-20% acetylcysteine solution every 1-4 hours if needed for thick secretions 7:

• When acetylcysteine is administered, increased volume of liquified secretions may occur; maintain airway patency with mechanical suction if cough is inadequate 7
• Watch asthmatics carefully during acetylcysteine treatment; most bronchospasm responds to nebulized bronchodilators, but discontinue if bronchospasm progresses 7

Nocturnal Management

For patients using T-piece at night, specific protocols apply 8:

• Use T-piece with expiratory filter for spontaneously breathing patients 8
• Maintain cuff pressure between 20-30 cmH₂O for air-filled cuffs 8, 6
• Use heat moisture exchangers (HMEs) over large-volume humidifiers 8, 6
• Use closed-circuit suctioning systems to decrease aerosolization 8, 6

Common Pitfalls to Avoid

Do not perform suctioning routinely or on a fixed schedule—this increases unnecessary procedures and complications without clinical benefit 2, 4, 3.

Avoid disconnecting ventilated patients during suctioning when possible, as this causes lung de-recruitment 3. If disconnection occurs in patients with ARDS, use lung recruitment maneuvers 3.

Do not use excessively small catheters in an attempt to minimize trauma, as this prolongs suctioning time and increases hypoxemia risk while failing to adequately remove secretions 1, 5.

Never auscultate the chest when wearing airborne precaution PPE during COVID-19 or similar situations, as this risks contamination; instead watch for bilateral chest wall expansion 1.