A tracheostomy is a surgically created opening in the neck that leads directly into the windpipe (trachea), kept open by a specialized tube. This tube provides an alternative route for breathing but bypasses the body’s natural filtering mechanisms, leading to a buildup of mucus and secretions. Tracheostomy suctioning uses a specialized catheter connected to a vacuum source to safely remove these secretions and maintain a clear airway. While this procedure is a regular part of tracheostomy care, it requires specific knowledge and training. Caregivers must receive hands-on instruction from a qualified healthcare professional before attempting the procedure to ensure patient safety.
Identifying the Need for Suctioning
Suctioning should only be performed when specific indicators suggest that the airway is obstructed by secretions, not on a fixed schedule. The body’s natural cough is the most effective way to clear the airway, so unnecessary suctioning should be avoided to prevent irritation to the tracheal lining. A primary visual cue is the presence of visible secretions or frothy mucus bubbling at the opening of the tracheostomy tube. These secretions may appear thick, tenacious, or simply excessive in volume, indicating they cannot be cleared by an ordinary cough.
Auditory signs also signal an urgent need for the procedure, such as noisy, wet, or rattling sounds during breathing. These gurgling noises are caused by mucus vibrating in the large airways. The patient may report a feeling of wetness in their chest or an inability to move the secretions despite trying to cough forcefully. These symptoms point toward an accumulation of mucus that is compromising airflow.
Patient-specific changes in respiratory effort are also significant indicators that the airway requires immediate clearance. An increased work of breathing, manifested by rapid respiratory rate (tachypnea) or the use of accessory neck muscles, suggests the patient is struggling to move air past the obstruction. A sudden drop in oxygen saturation, measured by a pulse oximeter, or signs of distress like restlessness and anxiety are serious physiological cues. Furthermore, an increase in the patient’s heart rate (tachycardia) can be a response to reduced oxygen levels, making immediate suctioning necessary.
Essential Equipment and Setup
Performing tracheostomy suctioning safely requires a complete collection of equipment assembled before approaching the patient. The core device is the suction machine, which must be checked to ensure it is functioning correctly and set to the appropriate negative pressure. For adults, the recommended pressure range is typically between 100 and 150 millimeters of mercury (mmHg), not exceeding 150 mmHg to avoid mucosal trauma. High suction pressures can pull oxygen from the lungs and cause injury to the delicate tracheal tissue.
The suction catheter itself must be the correct size to safely and effectively remove secretions without causing complications. A critical guideline is that the external diameter of the suction catheter should be no more than half the internal diameter of the tracheostomy tube. A catheter that is too large can completely block the tube during insertion, causing the patient to suffocate and leading to severe hypoxia. The correct size catheter allows air to continue moving around it during the procedure, mitigating the risk of deoxygenation.
The procedure necessitates the use of a sterile suction kit, which includes a catheter and often a sterile container. Hand hygiene is the first step, followed by setting up a sterile field and donning sterile gloves to maintain a clean technique and prevent introducing bacteria into the lungs. Other necessary supplies include sterile normal saline or water to clear the suction tubing between passes, and a working oxygen source, such as a manual resuscitation bag, immediately available for use in an emergency.
Step-by-Step Suctioning Procedure
Before beginning the procedure, the patient should be placed in a comfortable, semi-Fowler’s position (sitting up at a 30 to 45-degree angle) to promote lung expansion. If the patient is receiving supplemental oxygen, they should be pre-oxygenated with 100% oxygen for at least 30 seconds to a minute. This hyper-oxygenation step helps build an oxygen reserve, counteracting the temporary drop in oxygen saturation that suctioning can cause. The suction machine is turned on, and the catheter is connected to the tubing, checking the pressure setting one final time.
After preparing the patient and the equipment, the caregiver dons sterile gloves and opens the sterile catheter package. The catheter is connected to the suction tubing and tested by briefly suctioning sterile saline from the container. This action lubricates the catheter tip, aiding smooth insertion into the tracheostomy tube. The caregiver then gently and quickly introduces the catheter into the tracheostomy tube without applying suction.
The catheter is inserted until either the patient coughs, resistance is met, or the pre-measured depth is reached. The depth of insertion is typically determined by the length of the tracheostomy tube, as inserting the catheter too far can cause trauma to the sensitive lining of the trachea. Once the catheter is at the correct depth, the caregiver applies suction by placing a thumb over the control port and begins to withdraw the catheter. Suction should only ever be applied while the catheter is being withdrawn from the airway.
As the catheter is being pulled out, it should be gently rotated between the thumb and forefinger to ensure all surfaces of the airway tube are cleared of secretions. This entire suction pass, from the moment suction is applied until the catheter is fully removed, must be limited to a maximum of 10 to 15 seconds. Exceeding this limit significantly increases the risk of hypoxemia. After the catheter is withdrawn, the caregiver should suction a small amount of sterile saline through the connecting tubing to clear the removed secretions and prevent clogging.
The patient must be allowed to rest and recover for at least 30 to 60 seconds between each suction pass to re-oxygenate their lungs. During this recovery period, the patient should be encouraged to take deep breaths, and supplemental oxygen should be administered if needed. The procedure is repeated only if the patient still exhibits signs of distress or if visible or audible secretions remain. If more than two or three passes are required to clear the airway, the procedure should be paused to allow for full recovery before further attempts are made.
Recognizing and Managing Complications
Despite careful technique, several adverse events can occur during or immediately following tracheostomy suctioning. One of the most dangerous complications is hypoxia, often indicated by the patient’s skin or lips turning a bluish color (cyanosis) or an acute decrease in the pulse oximetry reading. If this occurs, the suctioning must be stopped immediately, and the patient should be re-oxygenated with a manual resuscitation bag or supplemental oxygen to restore normal levels.
Another possible reaction is vagal stimulation, where the catheter touches the wall of the trachea, triggering the vagus nerve. This can result in a sudden drop in the heart rate (bradycardia), which may cause the patient to feel faint or dizzy. Should the heart rate drop unexpectedly, the procedure must be terminated immediately, and the patient’s oxygenation status should be assessed and supported. This complication is often more pronounced with deep or aggressive suctioning.
Minor bleeding, visible as streaks of blood in the mucus, is a common sign of mucosal trauma from the catheter tip. This is usually managed by ensuring the catheter size is correct and using a less vigorous suctioning technique in subsequent passes. If the bleeding is persistent, heavy, or does not resolve after a few minutes, the healthcare provider must be contacted for further evaluation. Foul-smelling, yellow, or green secretions, or the development of a fever, can indicate a respiratory infection, requiring contact with a physician for treatment.
If the patient’s distress worsens, they become severely agitated, or the tracheostomy tube appears completely blocked and the catheter cannot pass, this is an emergency. Emergency medical services must be called immediately. The caregiver’s immediate action should be to provide rescue breaths using the manual resuscitation bag connected directly to the tracheostomy tube while awaiting professional help.