When is suction indicated in clinical practice?

When is Suction Indicated in Clinical Practice?

Suction should be performed only when clinically indicated by assessment findings—not routinely—to avoid complications including hypoxemia, cardiovascular instability, mucosal trauma, and infection. 1, 2

Clinical Indications for Suctioning

Airway Obstruction

• Perform suctioning when there is visible or audible evidence of secretions obstructing the airway, including coarse breath sounds on auscultation, visible secretions in the airway, or increased work of breathing. 2, 3
• Suction immediately if airway obstruction is suspected in any patient unable to clear secretions independently. 4

Mechanically Ventilated Patients

• Suction when assessment reveals secretions, indicated by: 3, 5

  • Coarse crackles or rhonchi on auscultation
  • Increased peak airway pressures
  • Visible secretions in the endotracheal tube
  • Decreased oxygen saturation not explained by other causes
  • Patient restlessness or ventilator dyssynchrony suggesting secretion accumulation

• Do not suction on a fixed schedule (e.g., every 2 hours), as assessment-based suctioning produces significantly better outcomes with fewer complications compared to routine time-based protocols. 3

Patients with Tracheostomy

• Suction based on clinical assessment rather than a predetermined schedule, with frequency varying by secretion volume, viscosity, and the patient's ability to generate effective cough. 4
• Perform minimum suctioning at morning and bedtime to assess tube patency, even in patients without evidence of secretions, as tubes can become obstructed without clinical symptoms. 4

Specific Clinical Scenarios Where Suction is NOT Indicated

Neonatal Resuscitation

• Do not perform routine oropharyngeal or nasopharyngeal suctioning in newborns with clear amniotic fluid, as it causes vagal-induced bradycardia, lower oxygen saturation, and delays resuscitation without providing benefit. 4
• Do not perform routine tracheal intubation and suctioning for meconium-stained amniotic fluid, even in nonvigorous infants, as this delays ventilation without improving survival (RR 0.99,95% CI 0.93-1.06) or reducing meconium aspiration syndrome (RR 0.94,95% CI 0.67-1.33). 6, 7
• Reserve suctioning only for suspected airway obstruction in neonates; otherwise, proceed immediately with positive-pressure ventilation if needed. 4, 6

Chest Tube Management

Pneumothorax

• Apply suction after 48 hours if the pneumothorax is slow to re-expand, using high-volume, low-pressure systems (−10 to −20 cm H₂O). 4
• Refer for surgical consultation at 5-7 days for persistent air leak in patients without pre-existing lung disease, or earlier (2-4 days) in those with underlying disease or large persistent air leak. 4
• Never clamp a bubbling chest drain, as this may cause tension pneumothorax. 4

Pleural Infection (Empyema)

• Use suction at 5-10 cm H₂O pressure via underwater seal to improve drainage, though evidence for this practice is limited. 4
• Clamp the drain for 4 hours only after intrapleural fibrinolytic instillation, with standing orders to unclamp immediately if the patient develops breathlessness or chest pain. 4
• Initially remove only 10 ml/kg of pleural fluid, then clamp for 1 hour to prevent re-expansion pulmonary edema. 4

Safe Suctioning Technique (When Indicated)

Pre-Suctioning

• Hyperoxygenate before suctioning to prevent hypoxemia, using 100% oxygen for 30-60 seconds in mechanically ventilated patients. 1, 2
• Assess the patient for heart rate, blood pressure, oxygen saturation, and respiratory pattern before beginning. 2

During Suctioning

• Use a catheter that occludes less than half the endotracheal tube lumen to maintain adequate airflow and prevent atelectasis. 1
• Apply the lowest effective suction pressure: 80-100 mm Hg for pediatric patients, 100-120 mm Hg for adults. 4, 1
• Insert the catheter to premeasured depth only—to the tip of the tracheostomy tube or just above the carina—never deeper, to avoid mucosal trauma. 4
• Apply continuous suction while withdrawing (not intermittent), with total suctioning time less than 15 seconds in adults and less than 5 seconds in children with tracheostomy. 4, 1
• Twirl the catheter between fingers during withdrawal to suction all areas of the tube wall. 4

Post-Suctioning

• Reconnect oxygen immediately and reassess the patient for heart rate, blood pressure, oxygen saturation, and respiratory status. 2
• Return oxygen concentration to baseline once the patient stabilizes. 2

Critical Pitfalls to Avoid

• Delaying positive-pressure ventilation to perform suctioning in nonbreathing neonates prolongs hypoxia and worsens outcomes. 6, 7
• Routine suctioning without assessment exposes patients to unnecessary complications including hypoxemia, cardiovascular instability, elevated intracranial pressure, and mucosal trauma. 1, 2, 3
• Using excessive suction pressure or prolonged suctioning causes atelectasis, hypoxemia, and airway trauma. 4, 1
• Applying suction too early after chest tube insertion for pneumothorax (before 48 hours) may precipitate re-expansion pulmonary edema. 4
• Clamping a bubbling chest drain can cause fatal tension pneumothorax. 4