Endotracheal tube (ETT) suctioning is a procedure performed on patients with an artificial airway who cannot effectively clear their own respiratory secretions. The primary purpose of this intervention is to maintain a clear and open airway by removing accumulated mucus and foreign material from the trachea and main bronchi. By ensuring airway patency, the procedure helps to optimize gas exchange and reduce airway resistance, ultimately improving the patient’s breathing and oxygenation. The presence of an ETT bypasses the body’s natural defense mechanisms, like the cough reflex and the mucociliary escalator, making this mechanical clearance necessary. Because this is an invasive procedure that can introduce bacteria into the lower airway, it is performed using a sterile technique to minimize the risk of hospital-acquired infections and other complications.
Essential Equipment and Setup
Proper preparation is fundamental to the safety and success of sterile endotracheal suctioning, beginning with the necessary equipment and pressure settings. The procedure requires a functional suction source, which may be a wall-mounted unit or a portable machine, connected to a collection canister and tubing. Suction pressure must be carefully set to effectively remove secretions without causing undue trauma to the tracheal lining; for an adult, the pressure should be maintained below 150 mmHg, while for infants, a lower range of 60 to 80 mmHg is commonly used.
Selecting the correct size of the suction catheter is crucial to ensure adequate airflow around the catheter during the procedure, which helps prevent lung collapse. A common guideline is to choose a catheter size that is no more than half the internal diameter of the ETT. The catheter itself must be sterile and is typically part of a disposable kit that includes a sterile container for flushing solution, usually sterile water or saline.
Personal protective equipment (PPE), including non-sterile gloves, a mask, and eye protection, must be donned to protect the clinician from splashed secretions. Before touching the patient, the clinician must perform meticulous hand hygiene and ensure the sterile field is maintained. The suction apparatus must be checked for proper function by briefly occluding the end of the connecting tube to confirm the pressure is within the desired range. Additionally, an oxygen source and a manual resuscitation bag (BVM) should be readily available at the bedside in case of sudden desaturation or respiratory distress.
Performing the Sterile Suctioning Procedure
The physical act of sterile endotracheal suctioning must follow a precise, sequential order to maximize secretion removal while minimizing physiological strain on the patient. The initial step involves hyperoxygenation, where the patient is given an increased concentration of oxygen for at least 30 seconds before the catheter insertion. This practice helps mitigate the risk of oxygen desaturation during the procedure. For the open-suction technique, the ventilator circuit is briefly disconnected, and the sterile catheter is introduced into the ETT using the dominant hand, maintaining sterility.
The catheter is advanced gently until the tip reaches the predetermined length, typically measured to reach just the end of the ETT or until a slight resistance is felt. Suction is not applied during insertion to prevent mucosal damage and unnecessary oxygen removal. Once the catheter is at the correct depth, the clinician applies intermittent suction while slowly withdrawing the catheter, simultaneously rotating it between the thumb and forefinger to ensure all sides of the airway are cleared.
The entire period of suction application, from insertion to complete withdrawal, must be strictly limited to ten to fifteen seconds to minimize the risk of hypoxia and cardiac instability. After one pass, the patient is reconnected to the ventilation device and allowed to rest and re-oxygenate for one to two minutes before any subsequent passes are considered. Multiple passes are only performed if the patient remains distressed or if copious secretions are still audible or visible, always ensuring the patient’s oxygen saturation and heart rate have returned to baseline before proceeding.
Recognizing and Managing Adverse Reactions
Despite careful technique, endotracheal suctioning can trigger several adverse physiological reactions that require immediate recognition and intervention. Hypoxemia, a decrease in blood oxygen levels, is one of the most common complications because the suctioning process removes air along with secretions. If the pulse oximetry reading drops significantly, the suctioning must be immediately stopped, and the patient should be hyperoxygenated with 100% oxygen until the saturation returns to the pre-procedure baseline.
Vagal nerve stimulation, caused by the catheter touching the tracheal wall, can lead to cardiac arrhythmias, most notably bradycardia or a sudden drop in heart rate. If bradycardia or another significant change in heart rhythm is observed, the clinician must immediately cease the procedure and administer manual breaths with a BVM to improve oxygenation and reverse the vagal response. Furthermore, the mechanical action of the catheter can cause mucosal trauma, which may be indicated by streaks of blood in the aspirated secretions.
Other serious complications include fluctuations in blood pressure, such as hypotension or hypertension, and an increase in intracranial pressure. Continuous monitoring of the patient’s heart rate, blood pressure, and oxygen saturation before, during, and after the procedure is non-negotiable. If any adverse event is sustained or severe, the procedure must be terminated, the patient stabilized with oxygen and ventilation, and the medical team alerted immediately for further assessment and management.