How to manage thin suction in a patient with a tracheostomy?

Management of Thin Secretions in Tracheostomy Patients

For thin secretions in tracheostomy patients, use rapid suctioning technique with adequate vacuum pressure and proper humidification—avoid routine saline instillation as it worsens outcomes without benefit. 1

Suctioning Technique for Thin Secretions

The key principle is rapid, efficient removal rather than attempting to thin already-thin secretions. 1

Catheter Selection and Pressure

• Use the largest catheter that fits inside the tracheostomy tube to maximize efficiency 1
• Apply 80-100 mm Hg suction pressure for pediatric patients 1
• Apply up to 200 mm Hg for adult patients 1
• Pass a soft suction catheter beyond the tracheostomy tube tip to establish patency and perform therapeutic suctioning 2, 3

Rapid Suctioning Protocol

• Complete the entire suctioning procedure in less than 5 seconds to minimize complications like atelectasis 1
• Apply suction both while inserting AND removing the catheter to maximize efficiency 1
• Use pre-measured catheters and twirl the catheter between fingertips during suctioning 2
• Make an initial pass to quickly clear visible or audible secretions BEFORE delivering any hyperinflation or hyperoxygenation breaths 2, 1

Critical pitfall to avoid: Never deliver manual breaths when secretions are bubbling in the tube—this only forces secretions distally into smaller airways 2, 1

What NOT to Do: Avoid Routine Saline Instillation

The American Thoracic Society explicitly recommends AGAINST routine normal saline instillation for thin secretions. 2, 1, 3 This practice:

• Decreases oxygen saturation 2, 1
• Does not actually mix with or thin mucus effectively 2, 1
• Contaminates lower airways with unsterile saline 2, 1
• Increases coughing and aerosolization 1, 3
• Has potential adverse cardiovascular effects 1

Maintaining Thin Secretion Consistency: Humidification Priority

Proper humidification is far more effective than saline instillation for maintaining optimal secretion consistency. 1

• For non-ventilated tracheostomy patients, use heat moisture exchange (HME) devices with viral filters 1
• Heated and humidified oxygen delivery systems provide superior comfort and secretion management 1
• Ensure humidification equipment is functioning properly to prevent secretions from thickening 2, 1

Frequency of Suctioning

Base suctioning frequency on clinical assessment rather than a rigid schedule. 2

• Suction when you observe or hear secretions, increased work of breathing, or decreased oxygen saturation 2
• For children without evidence of secretions, perform minimum suctioning at morning and bedtime to check tube patency 2
• Frequency varies based on age, neurological status, cough effectiveness, and secretion quantity 2

Pre-Suctioning Preparation

• Pre-oxygenate with FiO₂ 1.0 before suctioning to maximize oxygen stores 1
• Provide reassurance and adequate sedation to minimize cardiovascular effects 1
• Position patient appropriately (head-up or semi-recumbent for obese patients) 1
• Remove any obstructing devices (caps, obturators, speaking valves, humidifying devices) in emergency situations 2

Post-Suctioning Management

For patients prone to atelectasis, deliver bag hyperinflation AFTER the initial cleaning passes of the suction catheter. 2

• Limit inflation pressures to ≤40 cm H₂O to avoid barotrauma 1
• Patients receiving supplemental oxygen should be evaluated for need of hyperoxygenation when delivering artificial breaths 2
• Use end-tidal CO₂ measurement and oxygen saturations to guide decision-making 2

Infection Control Considerations

Use clean technique for home/chronic care settings; sterile technique is not required. 2

• Clean technique uses a clean catheter and nonsterile disposable gloves or freshly washed hands 2
• For hospital settings, modified clean technique (nonsterile gloves with sterile catheters) is acceptable 2
• Catheters can be cleaned and reused at home: wash with hot soapy water, disinfect with vinegar solution, rinse with clean water, and air dry 2

Special Populations Requiring Caution

Brain injury patients: Suctioning and hyperinflation can increase intracranial pressure and mean arterial pressure, though cerebral perfusion pressure typically remains stable 1. Monitor closely and use minimal necessary interventions 1.

Pediatric patients: Use lower suction pressures (80-100 mm Hg) and ensure suction catheters occlude <70% of endotracheal tube lumen in neonates and <50% in pediatric patients 1.

Essential Bedside Equipment

Every tracheostomy patient requires immediate access to: 4, 5

• Functional suction source with appropriate catheters 4, 5
• Manual resuscitation bag of appropriate size 2, 4
• Two spare tracheostomy tubes (current size and one size smaller) with ties in place 2, 4
• Oxygen source and delivery devices 4
• Scissors and emergency phone numbers 2, 4