Tracheal Suctioning in Children Over 2 Years for Bronchial Secretion Clearance
Yes, tracheal suctioning can and should be performed in children over 2 years of age to clear bronchial secretions, but only when clinically indicated by the presence of secretions, not routinely. 1, 2
When to Perform Suctioning
Suctioning should be performed based on clinical assessment rather than on a fixed schedule. 1, 2 The specific indicators that warrant suctioning include:
- Audible breath sounds indicating secretions 2
- Visual secretions in the artificial airway 2
- A sawtooth pattern on the ventilator waveform (in mechanically ventilated patients) 2
- High-pitched wheezing over the trachea suggesting mucus plugging 3
In children without evidence of secretions, perform suctioning minimally—at morning and bedtime—solely to check tube patency. 1 This is critical because tubes can become obstructed without clinical symptoms. 1
Proper Suctioning Technique
Catheter Size Selection
Use the largest size catheter that will fit inside the tracheostomy tube because a large-bore catheter removes secretions more efficiently than smaller catheters. 1 Specifically:
- In children over 2 years: Use a catheter that occludes less than 50% of the endotracheal tube lumen 4, 2
- The larger catheter allows for rapid secretion removal, minimizing the risk of atelectasis when using the rapid technique 1
Suction Application Method
Apply suction both while inserting AND removing the catheter. 1, 5 This technique, recommended by the American Thoracic Society, results in significantly more secretions obtained compared to traditional methods that only apply suction during withdrawal. 5
- Use a pre-measured catheter and twirl it between fingertips during suctioning 3
- Ensure the catheter passes easily beyond the tracheostomy tube tip into the trachea 3
Duration and Pressure
Complete the suctioning procedure in less than 5 seconds. 1 This rapid technique is vital when using a large suction catheter to prevent atelectasis. 1
Keep suction pressure below -120 mm Hg in pediatric patients. 2 The suction should be adequate to efficiently remove secretions with a rapid pass of the catheter. 1
Critical Technique Considerations
Pre-oxygenation
Consider pre-oxygenation if the patient has clinically important oxygen desaturation with suctioning. 4, 2 However, in stable children with a tracheostomy who are not on additional respiratory support (ventilator, CPAP, or high-level oxygen), pre-oxygenation is typically not necessary. 1
Secretion Management Sequence
If secretions are present, make an initial pass of the catheter first to quickly clear the tube of any visible or audible secretions BEFORE delivering any hyperinflation or hyperoxygenation breaths. 1 Delivering a manual breath when secretions are bubbling in the tube only forces these secretions into more distal airways. 1
Saline Instillation
Do NOT routinely instill normal saline before suctioning. 1, 4, 2 Studies demonstrate that:
- Normal saline does not effectively thin mucus 1
- Routine saline instillation may cause oxygen desaturation 1
- It can contaminate lower airways with unsterile saline 1
- Proper humidification is more successful in maintaining thin mucus than saline instillation 1
Prevention of Secretion Problems
Maintain proper humidification with inspired gas containing a minimum of 30 mg H₂O per liter at 30°C. 3 This prevents secretion thickening and reduces the need for frequent suctioning. 3
Use Heat Moisture Exchanger (HME) devices rather than open flow humidified air systems when possible. 3 This is particularly important in preventing the thick, tenacious secretions that can lead to tube obstruction. 3
Emergency Situations
If suctioning fails to clear an obstruction, perform an immediate emergency tracheostomy tube change. 3 This is a life-saving intervention that cannot be delayed. 3
- Always have emergency equipment at bedside, including smaller tube sizes 3
- Mucus plugging causing tube obstruction represents an immediately life-threatening emergency 3