Oral / Nasopharyngeal Suctioning
and Tracheostomy Care
By Prof. Unn Hidle
Updated Spring 2010
Video: Respiratory: Concepts and Techniques
– Part 4: “Chest Therapy – Suctioning”
Professor Hidle’s Skills
– Tracheostomy Care
– Oro-pharyngeal Suctioning
Suctioning = aspiration of secretions through a
catheter connected to a suction machine or wall
Rational for suctioning include:
– to remove secretions that obstruct the airway
– to facilitate ventilation (either via nasopharynx,
oropharynx, tracheostomy or endotracheal tube)
– to obtain secretions for diagnostic purposes
– to prevent infection that may result from accumulated
Although the upper airways (oropharynx and
nasopharynx) are not sterile, sterile technique is
recommended for all suctioning to avoid
introducing pathogens into the airways
Suction catheters may be either open tipped or
whistle tipped. The whistle-tipped catheter may
be more effective for removing thick mucous
plugs. Most suction catheters have a thumb port
on the side to control the suction.
Open tip suction catheter
Whistle tip suction catheter
The openings on the tip of the catheter
distributes negative pressure over a
wide area. This prevents irritation to
any one area of the mucous
An oral suction tube (Yankauer
device) is used to suction the oral
Measure the depth for insertion (tip of nose
to earlobe) which usually measures
approximately 5” or 13 cm.
Rotate the catheter when suctioning (not
when inserting the catheter)
Encourage deep breathing and coughing
Always use the least amount of pressure
necessary when suctioning (use appropriate
Assessing the need for suctioning
Oropharyngeal and nasopharyngeal suctioning
removes secretions from the upper respiratory
Endotracheal suctioning is used to remove
secretions from the trachea and bronchi.
The nurse should auscultate the lung fields and
note any adventitious sounds (crackles, rhonchi,
rales, wheezing), NOT “coarse” breath sounds.
Also, upper airway needs to be adequately
assessed for any obstruction by secretions
Other clinical signs indicating the need for
suctioning may include:
– gurgling sounds during respiration
– skin color (pallor, cyanosis)
– rate and pattern of respirations (retractions, use of
accessory muscles, flaring, grunting, etc.)
– pulse rate and rhythm
– decreased SaO2 levels (O2 saturation)
– change in mental status
Too frequent suctioning may cause irritation of
mucous membranes and increase secretions.
A suction attempt should last =< 10 seconds.
There should be 20-30 second intervals between
each suction (non-respiratory or O2 dependent)
Limit suctioning to 5 minutes in total
Applying suction for too long may cause
increased secretions &/or decrease the client’s
Complications of suctioning
Trauma to the airway
Cardiac dysrhythmia (related to the
Preventing complications with
Pressure on the suction gauge (used in LaGCC lab):
** Note: different institutions may use different settings
– Adult 100-120 mmHg
– Child 95-110 mmHg
– Infant 50-95 mmHg (*same for ET/Tracheostomy suctioning)
– Adult 10-15 inchesHg
– Child 5-10 inchesHg
– Infant 2-5 inchesHg
Oro / nasopharyngeal suctioning
Perform vital signs pre-suctioning (baseline) and
– Conscious person (+ gag reflex):
• Oropharyngeal suctioning: in semi-Fowler’s position with
head turned to one side
• Nasopharyngeal suctioning: with the neck hyper-extended
(nasopharyngeal suctioning). This will facilitate insertion of
the catheter and help prevent aspiration.
– Unconscious client should be placed in a lateral
position, facing you (risk for vomiting).
Suctioning Endotracheal or
– Semi-Fowler’s position to promote deep breathing,
maximum lung expansion, and productive coughing.
– Deep breathing oxygenates the lungs, counteracts the
hypoxic effects of suctioning, and may induce
coughing which helps to loosen and move secretions
Assess for need of analgesia
Oxygen flow via bag-valve-mask (Ambu) should
be set at 100%
“Lubricate” with sterile NS (to be used for
Unless contraindicated, hyperventilate the lungs
prior to suctioning.
Oxygen should be set to 12-15L/min (FiO2
Suctioning should last no longer than 10 sec in
order to minimize oxygen loss
Hyperventilate between suctioning
attempts and allow 2-3 minutes between
Monitor O2 saturations of pt which should
be maintained between 95-100%
Clients with ET or trach tubes should
receive mouth care Q3-4 hours.
Sources of oxygenation
Ambu (bag-valve-mask): 100%
Respirator (different FiO2 settings)
CPAP / BiPAP
– Simple face mask (varies in % of O2 delivery)
– Partial face-tent (varies in % of O2 delivery)
– Non-rebreather (close to 100% oxygen delivery)
Nasal Cannuli (delivery of O2 in liters)
Preventing complications of
suctioning with ETT or trach.
– Giving the client breaths that are 1-1.5 times the tidal
volume (TV) set on the ventilator through the
ventilator circuit or via a manual resuscitation bag
(Ambu bag). Three to five breaths are delivered before
and after each pass of the suction catheter
– This can be done with a manual resuscitation bag;
bag-valve-mask (Ambu bag) or through the ventilator.
It is performed by increasing the oxygen flow (usually
to 100%) before suctioning and between suction
For ET and Trach suctioning, the diameter of the
suction catheter should be about half the inside
diameter of the Trach or ET tube so that
hypoxia can be prevented.
To determine suction catheter size, multiply the
artificial airway’s diameter X 2 (i.e. # 8 ET tube,
use #16 French suction catheter)
Cuffed versus uncuffed ET tube. Does it matter?
Sterile technique is again used
Endotracheal tubes - uncuffed
Endotracheal tube - uncuffed
Endotracheal tube - cuffed
Closed suction system
– Disconnecting the client from the ventilator, suction and
reconnect. Drawbacks include extensive protective gear for the
nurse in order to avoid exposure to the client’s sputum. Also,
increased cost as disposable, one-time catheters are used
Closed airway/tracheal suction system, also called in-
– The suction catheter attaches to the ventilator tubing and the
client does not need to be disconnected from the ventilator. The
nurse does not need protective gear and the suction catheter be
reused as it is enclosed in a plastic sheath. This method is
becoming more popular.
Deep breathing and coughing:
– The nurse can facilitate respiratory functioning by encouraging deep
breathing exercises and coughing to remove secretions from the airways.
– When coughing raises secretions high enough, the client may either
expectorate = spit out, or swallow them (not harmful but does not allow
for viewing secretions for documentation purposes or obtain sputum
– Splinting = using counter-pressure with i.e. a pillow decreases the pain
– Abdominal (diaphragmatic) breathing permits deep full breaths with
– Pursed-lip breathing helps the client develop control over breathing by
creating resistance to the air flowing out (prolonging exhalation) and
preventing airway collapse by maintaining positive airway pressure.
Incentive spirometer: or sustained maximal
inspiration devices (SMIs) = measures the flow
of air inhaled through the mouthpiece.
It is used to:
– 1) Improve pulmonary ventilation
– 2) Counteract the effects of anesthesia or
– 3) Loosen respiratory secretions
– 4) Facilitate respiratory gaseous exchange
– 5) Expand collapsed alveoli
They offer an incentive to improve inhalation
If the child is too young to use incentive
spirometry, deep breathe & cough, etc.,
what should be used????
vibration, and postural drainage
Percussion = “clapping”
– a forceful striking of the skin with cupped hands.
– Mechanical percussion cups and vibrators are also
available (see demonstration).
– Percussion over congested lung areas can
mechanically dislodge tenacious secretions from the
– Cupped hands trap the air against the chest and the
trapped air sets up vibrations through the chest wall to
Postural drainage (PVD):
– drainage by gravity of secretions from various lung segments.
– Secretions that remain in the lungs or respiratory airways
promote bacterial growth and subsequent infections.
– They can obstruct the smaller airways and cause atelectasis.
– Careful assessment of the client’s tolerance for PVD is necessary
prior to the procedure.
– The usual sequence for PVD is usually:
• 1) Positioning (usually Trendelenburg)
• 2) Percussion
• 3) Vibration
• 4) Removal of secretions: coughing or suctioning
Will be covered in SG#11 in lecture
– bronchodilator (MDI, nebulizer, or liquid form
– Usually first line of treatment with
asthma/wheezing/reactive airway disease
bronchodilator (MDI, nebulizer, or nasal
Fluticason (Flonase; Flovent)
• The above corticosteroids have potent
Cromolyn sodium (Intal)
• Different forms of the drug are used to manage bronchial
asthma, to prevent asthma attacks, and to prevent and treat
seasonal and chronic allergies. NOT USED IN ACUTE
• The drug works by preventing certain cells in the body from
releasing substances that can cause allergic reactions or
prompt too much bronchial activity. It also helps prevent
bronchial constriction caused by exercise, aspirin, cold air,
and certain environmental pollutants such as sulfur dioxide.
Indicated for clients with long-term airway
A surgical incision in the trachea just
below the larynx; curved tracheostomy
tube (excellent tracheostomy teaching site)
inserted to extend through the stoma into
Tracheostomy tubes consist of an outer cannula
(inserted into the trachea) and a flange that rests
against the neck and allows the tube to be secured
in place with trach-ties. All tubes also have an
obturator (used to insert the outer cannula and
then is removed) which is kept at the clinet’s
bedside in case the tube becomes dislodged and
needs to be reinserted. Some tracheostomy tubes
have an inner cannula that can be removed for
Pediatric Tracheostomy Tube
Cuffed tracheostomy tube: has an inflatable cuff that
produces an airtight seal between the tube and the trachea.
The seal prevents aspiration of oropharyngeal secreations
and air leakage between the tube and the trachea. Cuffed
tubes are usually used in adults
Uncuffed tracheostomy tube: no cuff present; used in
children < 5 years of age (general rule, however, depends
on their size). Due to the anatomical difference in
childrens’ airway, their trachea s are resilient enough to
seal the airspace around the tracheostomy tube.
Low-pressure cuffs: commonly used to distribute a low,
even pressure against the trachea. This decreases the risk
of tracheal tissue necrosis (do not need to be deflated)
Checking the pressure cuff
In cuffed tracheostomy tubes, the cuff
pressure needs to be periodically
The pressure should never exceed 25
To maintain airway patency
To maintain cleanliness and prevent
infection at the tracheostomy site
To facilitate healing and prevent skin
excoriation around the tracheostomy
To promote comfort
Hints during tracheostomy care
Semi-Fowler or Fowler’s position whenever possible to
promote lung expansion
Suction before starting tracheostomy care
Using Hydrogen peroxide solution (half-strength), will
loosen secretions when soaking inner cannula. However,
always rinse thoroughly
Always use 4X4 gauze and not cotton lint for dressing
Always leave the old trach-ties in place when applying
the new ones to maintain security of the trach
You should be able to place 2 fingers between trach-ties
and the client’s neck
Peak Flow Meter
A peak flow meter is a small, easy-to-use instrument that measures
your peak expiratory flow (how fast you or your child can blow out
air after a maximum inhalation).
It reveals how well your or your child's lungs are working ("looks" at
how narrow your airways are before you have an asthma attack).
Used by adults and children (over 5 years of age) who require
medication for asthma on a daily or near-daily basis
Personal Best = The highest number regularly blown is your
personal best. This is done by recording the peak flow values for two
weeks first thing in the morning before taking any medications and
late afternoon when your asthma is under control.
Treatment "zones“ = based on personal best.
– Zones will help you decide what to do when you have changes with your
– The zone system can be compared to the colors of a traffic light.
How do I use a peak flow meter?
Stand up or sit up straight.
Slide indicator to base of meter.
Take in deep breath.
Place mouthpiece in mouth and seal lips around it.
Blow out as hard and fast as you can (one quick blow).
Repeat process 2 more times.
Select highest number of the 3 efforts.
Record this number on your peak flow diary or on a
Peak flow meters
Peak Flow Meter Chart