Surgical Airway Suctioning

Anatomy and Physiology

Airway anatomy is divided into the upper and lower airways. The upper airway includes the nasal cavity, nasopharynx, oropharynx, laryngopharynx, and larynx, whereas the lower airway comprises the trachea, bronchi, bronchioles, and alveoli. The pharynx and larynx connect the oral and nasal cavities to the trachea and bronchi. The pharynx consists of the nasopharynx, oropharynx, and hypopharynx, serving as the pathway connecting the posterior nasal and oral cavities to the larynx, esophagus, and lower airways.

The trachea is composed of smooth muscle, connective tissue, and C-shaped cartilaginous rings. The trachea contains the mucociliary escalator, which helps clear particulates by transporting them upward with the aid of mucus-secreting goblet cells. The tracheal smooth muscle is innervated by both sympathetic and parasympathetic nerves. Beta-2 adrenergic receptors, activated by the sympathetic nervous system, promote airway dilation, while muscarinic receptors, stimulated by the parasympathetic system, cause airway constriction.[6]

Gas exchange is a passive, involuntary process in which oxygen enters the bloodstream and carbon dioxide is expelled across the alveolar-capillary membrane. This process relies on adequate ventilation, which allows oxygen to diffuse effectively across the alveoli. The efficiency of gas exchange is influenced by lung tidal volumes, minute ventilation, and cardiac output. Any disruption in the distribution of air or blood can lead to a V/Q mismatch. Pulmonary pathology may impair gas exchange by affecting the lung parenchyma, alveoli, or capillaries, while reduced perfusion can limit tissue oxygenation. In response to V/Q mismatch, the body may compensate through increased oxygen extraction, enhanced ventilation, or elevated cardiac output.[7]

An inability to protect the airway due to chronic or acute illness, or an induced state of diminished consciousness, can lead to the accumulation of excess secretions, hypoventilation, or shunting, as atelectasis develops and alveoli become filled with fluid or other matter. Artificial airway devices disrupt normal coughing and mucociliary clearance, which are essential for clearing secretions. Suctioning is required to maintain oxygen saturation but carries potential physiological effects, such as sympathetic or parasympathetic stimulation, and increases in blood pressure and heart rate.[1] Airway suctioning can alter ventilatory mechanics and disrupt gas exchange, potentially causing alveolar collapse and reduced oxygenation. While hyperoxygenation before suctioning can mitigate these effects, it may also contribute to a proinflammatory response and cause hyperoxic damage.[8] 

Pediatric patients have unique anatomical and physiological characteristics that require special consideration and care during suctioning. Pediatric airways are narrower and may be more challenging to access. Children are also more susceptible to harmful effects from even small changes in pressure, oxygen saturation, and lung volumes.[1] In pediatric patients, using controlled pressures during suctioning can help prevent collapse of the right upper lobe.[9] Additionally, children with brain injuries may experience increased intracranial pressure during suctioning due to tracheal stimulation.[10]

Indications

Airway suctioning is indicated in various clinical situations where patients are unable to effectively clear airway secretions, thereby risking ventilation, oxygenation, or airway protection.[11] These situations include:

• Individuals with temporary or long-term artificial airways (eg, endotracheal or tracheostomy tubes) where normal mucociliary clearance is impaired.
• Patients with altered mental status or those under the effects of sedatives or hypnotics, leading to reduced cough reflex or airway protection.
• Individuals with neuromuscular diseases, atonia, or hypotonia, where muscle weakness impairs effective airway clearance.
• Patients with copious respiratory secretions who are unable to clear them independently, leading to respiratory distress or an increased risk of infection.
• Infants and children with respiratory conditions or ventilatory difficulties complicated by excessive secretions.
• Cases where airway secretions need to be collected for culture, laboratory analysis, or research purposes.
• Patients with visible or audible secretions who are unable to clear them despite coughing or repositioning.
• Individuals who have visibly aspirated, requiring suctioning to remove aspirated material and prevent aspiration pneumonitis or obstruction.[11]

These indications guide the timely and appropriate use of suctioning to maintain airway patency, prevent complications, and support respiratory function.

Contraindications

Suctioning is crucial for maintaining adequate ventilation in patients with compromised respiratory mechanics, particularly those who are unable to clear secretions independently. While there are no absolute contraindications to suctioning, the procedure carries inherent risks that require careful clinical judgment. Patients with preexisting trauma to the upper airway should undergo suctioning with caution, as further manipulation may worsen the injury.

Additionally, conditions such as bradycardia, arrhythmias, or hypoxia may be aggravated by suction-induced vagal stimulation or transient desaturation. Continuous monitoring of physiological parameters and vigilant clinician oversight are essential to ensure safety and promptly address any adverse reactions that may occur during the suctioning process.[11]

Equipment

The equipment required for airway suctioning includes essential tools for the procedure, as well as supportive monitoring devices to ensure patient safety. Core components include a negative pressure source (either wall-mounted or portable suction), connected to tubing and a collection canister, as well as suction catheters or tips. For oropharyngeal suctioning, a Yankauer tip is commonly used, while flexible catheters are appropriate for nasopharyngeal or tracheal suctioning. Normal saline or sterile water is used for flushing, and sterile lubricant is applied when suctioning via the nasal route. The selection of catheter size should be tailored to the patient’s age and the size of the artificial airway. The catheter diameter should not exceed half the diameter of the artificial airway.[12]

Clinicians must use personal protective equipment (PPE), including gloves, gowns, eye protection, and masks, to maintain infection control and prevent the spread of pathogens. Sterile gloves are recommended during suctioning. Additional useful items include a basin, towels, and collection containers. Before the procedure, patient safety must be ensured by confirming access to oxygen with a regulator, as well as having a stethoscope and monitoring equipment available, including a pulse oximeter, continuous electrocardiogram (ECG), and an end-tidal CO₂ monitor. These tools allow for real-time assessment of oxygenation, ventilation, and cardiac status throughout the procedure.[11]

Personnel

Airway suctioning may be performed by experienced nurses, respiratory therapists, and other medically trained providers who are properly trained in the procedure.

Preparation

Preparation for airway suctioning includes a comprehensive baseline assessment of the patient’s respiratory and cardiovascular status, including ventilator settings, oxygenation levels, heart rate, and rhythm. Lung and heart auscultation is essential, and continuous monitoring tools—such as pulse oximetry, capnography, and ECG—should be readily available and operational. Preoxygenation before suctioning helps stabilize systolic blood pressure and heart rate.[1]

Proper preparation for airway suctioning is essential and includes selecting suction settings and equipment sizes appropriate to the clinical scenario. Suction pressure should be adjusted based on the patient’s age to ensure safety and effectiveness:

• Adults: 100 to 150 mm Hg
• Children: 100 to 120 mm Hg
• Infants: 80 to 100 mm Hg
• Newborns: 60 to 80 mm Hg

All emergency airway and resuscitation equipment should be readily available.[13][14] All equipment, including suction and oxygen sources, must undergo a functional check.[15] In emergent cases of acute airway obstruction, suctioning may proceed even if full preparation is not complete.[16][17][18]

Airway suctioning should be performed with care and precision to avoid trauma, prolonged hypoxia, and bradycardia. Selecting an appropriately sized suction catheter is essential to minimize the adverse effects of excessive negative pressure.

Technique or Treatment

Airway suctioning in ventilated patients can be performed using either the open or closed technique. Open suctioning requires disconnecting the patient from the ventilator to insert a suction catheter, whereas closed suctioning utilizes a catheter system integrated into the ventilator circuit, allowing for uninterrupted ventilation. Closed suctioning systems may vary by manufacturer, and clinicians must review and adhere to specific instructions for their attachment, irrigation, and maintenance.[19][20] Closed suctioning systems are not automatically included in standard ventilator setups and must be added based on clinical need. Open suctioning is typically reserved for non-ventilated patients or those without a closed suction system in place.

Before suctioning, ventilated patients should be preoxygenated using bag-mask ventilation or through the ventilator to prevent hypoxia. The appropriate suction catheter and related equipment must be selected based on the patient’s age, size, and the dimensions of any artificial airway. In non-ventilated patients, deep breathing should be encouraged before suctioning begins. Once the suction tubing is connected and the system has been tested for proper functioning, the catheter should be lubricated and gently inserted into the appropriate airway—nasopharynx, oropharynx, or tracheostomy.

The catheter should never be advanced past the point of resistance or deep enough to cause trauma.[1] Specific guidelines recommend advancing the catheter 5 to 6 inches for nasopharyngeal suction and 3 to 4 inches for oropharyngeal suction, stopping earlier if a cough is elicited.[1] For tracheostomy suctioning, the procedure must be performed through a non-fenestrated inner cannula to prevent injury to the tracheal wall.

During suctioning, the catheter should be gently rolled and rotated as it is withdrawn, with suction applied only during the withdrawal by covering the suction port. Each suction event should be limited to 10 to 15 seconds to prevent mucosal injury and hypoxia. Patients should be reoxygenated for at least 60 seconds between passes to restore adequate oxygenation. The catheter should be flushed with sterile saline after each use, and the vital signs of patients should be closely monitored.[18] Analgesia or sedation may be necessary for some patients to tolerate the suctioning procedure. Indicators of effective suctioning include improved respiratory mechanics, clearer breath sounds, and stable or improved oxygen saturation.[1]

Saline irrigation of the airways, once a common practice, is now discouraged due to its association with arrhythmias, oxygen desaturation, airway trauma, and increased patient discomfort, without demonstrating measurable clinical benefit.[21] Comparisons between open and closed suctioning techniques yield mixed results. Closed systems are generally associated with better oxygenation and preserved lung compliance, whereas open systems may transiently disrupt ventilation.[22][23] However, some studies have found no significant physiological differences between the 2 methods.[1] Additionally, routine scheduled suctioning is discouraged, as evidence shows no advantage over as-needed suctioning in terms of ventilator days, ICU length of stay, mortality, or pneumonia rates. In non-ventilated patients, unnecessary suctioning may increase the risk of aspiration, gastrointestinal ulceration, and hospital-acquired pneumonia.[24]

Suctioning must be performed with precision and caution to minimize the risk of complications such as mucosal trauma, hypoxia, vagally induced bradycardia, and inadvertent decannulation. Careful selection of catheter size is crucial to minimize airway trauma and mitigate the effects of excessive negative pressure.

Complications

Airway suctioning can result in a range of mechanical, infectious, and physiological complications. Direct contact and the negative pressure from suction equipment may cause trauma to the airway mucosa, leading to hemorrhage or structural injury. The chemomechanical stimulation during suctioning can provoke bronchospasm, laryngospasm, coughing, gagging, or vomiting, and may also induce pain and anxiety. Vagal stimulation may lead to bradycardia, while desaturation during the procedure can cause clinically significant hypoxia. Additionally, there is a risk of introducing pathogens into the airway, which could potentially result in infection. In some cases, inadvertent decannulation of endotracheal or tracheostomy tubes may occur.[1]

Suctioning can also disturb cardiorespiratory physiology, especially in pediatric and critically ill patients. Saline lavage, once commonly used as an adjunct, is now discouraged due to its association with arrhythmias, oxygen desaturation, elevated systolic blood pressure, airway trauma, and impaired recall of the event, without any proven clinical benefit. In neonates and children, suctioning may lead to increased heart rate, mean arterial pressure, and intracranial pressure, likely due to tracheal stimulation rather than elevated CO₂ levels. Research has shown that suctioning can affect lung compliance, minute ventilation, respiratory rate, and tidal volume in pediatric patients. Carefully regulating suction pressure is crucial to prevent complications, such as lobar collapse.[1]

Clinical Significance

Surgical airway suctioning is crucial for maintaining airway patency in patients with artificial airways, including those with tracheostomy or endotracheal tubes. The clinical significance of the procedure lies in preventing life-threatening airway obstruction from retained secretions, reducing the risk of aspiration, and supporting effective oxygenation and ventilation. Proper suctioning decreases the work of breathing, promotes pulmonary hygiene, and helps prevent complications such as atelectasis, ventilator-associated pneumonia, and mucus plugging, particularly in patients who are unable to clear secretions on their own due to neurologic impairment, sedation, or neuromuscular conditions.

In the critical care setting, precise and appropriate suctioning is vital for maintaining airway integrity, ensuring effective gas exchange, and stabilizing cardiorespiratory function. Suctioning directly affects outcomes in both acutely ill and chronically ventilated patients. The technique, timing, and equipment used can impact the immediate effectiveness of secretion clearance and long-term safety. Improper suctioning may lead to mucosal injury, hemorrhage, desaturation, bradycardia, or infection. Therefore, surgical airway suctioning is both a therapeutic and diagnostic procedure that requires skilled execution, vigilant monitoring, and coordinated interprofessional care to optimize patient safety and respiratory outcomes.

Enhancing Healthcare Team Outcomes

Surgical airway suctioning requires a coordinated, interprofessional approach to ensure patient-centered care, safety, and optimal outcomes. Physicians and advanced practice providers assess the clinical need for suctioning, determine appropriate suction pressures, and identify potential complications such as mucosal trauma or hypoxia. Nurses play a vital role in monitoring vital signs, administering pre-oxygenation, performing suctioning procedures, and recognizing changes in respiratory status. Respiratory therapists ensure the proper functioning of equipment, adjust ventilation parameters as needed, and implement strategies to manage secretions. Pharmacists contribute by recommending appropriate sedatives or analgesics to enhance patient comfort before suctioning, particularly in pediatric or ventilated patients.

Effective interprofessional communication and care coordination among healthcare providers are critical in the surgical airway suctioning setting. A shared understanding of suctioning protocols, emergency responses to complications such as desaturation or bradycardia, and adherence to infection control practices enhances team cohesion and performance. Consistent documentation, standardized handoffs, and regular team huddles support situational awareness and reduce the risk of adverse events. By combining technical proficiency with a collaborative care model, healthcare teams can ensure safer and more effective suctioning practices, thereby minimizing procedural risks and optimizing respiratory function and overall patient outcomes.