Suctioning an adult ICU patient

The Suctioning an adult ICU patient with an artificial airway: a clinical guideline has been developed to provide clinicians with recommendations to guide the development of local policy/procedures in related to suction through an artificial airway in critically ill adult patients in NSW acute care facilities.

Suctioning of a tracheal tube is a frequent, fundamental and clinically significant practice in adult intensive care which carries the risk of adverse events. The variability of pathophysiology between patients requiring mechanical ventilation and the potential adverse effects of the procedure requires that suctioning be customised to the individual patient. The 2007 ICCMU Guideline: Suctioning an Adult with a Tracheal Tube (1) was updated following a comprehensive literature review and evaluation of current practice. The guideline will assist practitioners to develop local policy regarding tracheal suctioning of an artificial airway.

Suctioning an Adult ICU Patient with an Artificial Airway: A Clinical Practice Guideline


The importance of suctioning a tracheal tube

Tracheal suction through an artificial airway (endotracheal tube, tracheostomy, or nasotracheal) bypasses the normal protective mechanisms such as the cough reflex that the upper airways provide. An artificial airway refers to the plastic tube inserted via the nose, mouth or trachea and located into the trachea of the patient. The major indications for insertion of an artificial airway include:

  • to secure or maintain a patent airway
  • to assist in the delivery of mechanical ventilatory support, and where non-invasive ventilation (NIV) has failed
  • to facilitate the removal of tracheal secretions
  • to aid in the management of multi-organ failure/sepsis
  • to reduce the risk of aspiration where patients are unable to protect their own airway (neurological, unconscious)
  • to deliver high concentrations of oxygen.

Critically ill patients often have an increase in the production of mucous and an impaired ability to clear secretions. If secretions are not cleared effectively then the patient may be at risk of infection, atelectasis and alveolar collapse (6). Appropriate management of the patient with an artificial airway can have an impact on reducing complications (such as the development of ventilator-associated pneumonia (VAP), length ofICU stay, duration of mechanical ventilation and mortality and morbidity) (7, 8).

Tracheal suction is required to maintain a patent airway and assist with preventing hypoxia, infection and atelectasis from retention of sputum. Complications such as hypoxia, cardiac dysrhythmias and mucosal damage have been associated with tracheal suctioning (9). Appropriate and competent suctioning technique is important in minimising risk and adverse events. The guideline is relevant for practitioners who perform tracheal suction on patients with artificial airways. This includes patients who are mechanically ventilated; those being weaned from mechanical ventilation; and patients with an artificial airway in a ward. Although this guideline addresses the suctioning requirements of most intubated patients, it does not address the specific needs of special patient groups such as patients with intra-cranial hypertension, severe lung injury, or on unconventional modes of ventilation such as high frequency oscillating ventilation (HFOV) or extra corporeal membranous oxygenation (ECMO). Consistent high-level evidence exists supporting the practice of subglottic suctioning as an important component for the prevention of VAP (2-5). Recommendations regarding subglottic suctioning technique are now included in this guideline as they were not included in the previous version of this document.

Target clinicians

It is intended that this guideline be used by clinicians responsible for suctioning a critically ill adult with an artificial airway. It is assumed that users of this guideline have knowledge of respiratory anatomy and physiology and the purpose of artificial airways including endotracheal tubes (ETTs), tracheostomy tubes (TTs) and nasotracheal tubes (NTTs).

How the guideline was developed

This guideline was developed by the suction guideline development network (GDN) comprising senior nursing clinicians, senior ICU physiotherapists and academics as part of the NSW ICCMU Best Practice Project. A systematic literature review was undertaken and recommendations for practice were revised at a consensus meeting held in December 2012. Further details can be found within the full guideline document.

Level of evidence taxonomy and how consensus opinion was developed

The Australian NHMRC (10) levels of evidence were used to grade the recommendations (see Table: Recommendations for practice). Where suitable research evidence was not available, the GDN members formulated a recommendation based on their clinical experience and the NSW survey of practice. These recommendations were then voted upon using a 1-9 (Disagree 1-3, Neutral 4-6 and Agree 7-9) Likert scale with consensus agreement set as a median of 7.

Recommendations for practice






Assessment of the patient to identify the need to suction a tracheal tube should be continuous with chest auscultation performed every two hours or more frequently as indicated by clinical signs such as those mentioned in recommendation 2.



The decision to suction a tracheal tube must be made on the basis of the clinical need to maintain the patency of the tracheobronchial tree. A tracheal tube should only be suctioned when clinically indicated by signs which could include:

  1. visible, palpable or audible secretions (such as sputum, gastric or upper airway contents or blood)
  2. respiratory: desaturation, rising peak inspiratory pressure (during volume-controlled mechanical ventilation/modes), decreasing tidal volume (during pressure-controlled ventilation/modes), increased respiratory rate, increased work of breathing or coarse breath sounds on auscultation
  3. cardiovascular: increased heart rate and blood pressure
  4. other: restless/agitated or diaphoretic patient
  5. a saw-tooth pattern on a flow-volume loop or expiratory flow-time waveform as illustrated on the ventilator graphics.



Prior to suctioning, consideration should be given to the potential complications and contraindications in individual patients (see Table: Hazards/complications of suctioning).



To reduce patient anxiety and to promote patient understanding of, and compliance with, the suctioning procedure patients should be given clear information regarding the suction procedure including: the need for suction, the consequences of not suctioning when it is required and the effects of suctioning. Furthermore, this information should be repeated with each suction procedure as some patients may not recall previous instructions.



Patient assessment before, during and post suction should include an evaluation of the effects on the patient’s pre-suction signs and symptoms. This should include monitoring of cardiac rate and rhythm, blood pressure, pulse oximetry, airway reactivity, tidal volumes, peak airway pressures, or intracranial pressure (See Table: Assessment pre/during/post suction/outcome measures).



Some patient groups require constant/continuous monitoring of electrocardiogram (ECG) and pulse oximetry before, during and post suctioning. (See Table: Assessment pre/during/post suction/outcome measures).



Documentation of the assessment and suction procedure must occur.


Clinical practice: the suction catheter


The size of the suction catheter should be less than half the internal diameter of the tracheal tube.



The total suction procedure (from insertion to removal of catheter) should take a maximum of 15 seconds with negative pressure applied continuously as the catheter is being withdrawn from the tracheal tube.



In patients considered at high risk of adverse events, trauma to, and stimulation of, the carina should be minimised to prevent complications. Therefore, the suction catheter should only be inserted down a tracheal tube until it just emerges out of the lumen of the tube .



In patients not considered at high risk of adverse events, the suction catheter may be passed until either a point of resistance is felt or a cough is stimulated, then the catheter should be withdrawn 1-2 cm prior to continuous suction.



The maximum occluded suction pressure should be limited to - 80 to 150 mmHg (20kPa) for open suction system (OSS) and closed suction system (CSS). The wall outlet should have a high pressure gauge attached.


Clinical practice: pre-oxygenation


If a patient has high oxygen and positive end expiratory pressure (PEEP) requirements and/or is known to de-saturate to clinically significant levels, pre-oxygenation should be considered.



If pre-oxygenating, use the ventilator capability to deliver 100% oxygen.


Clinical practice: saline


To prevent the occurrence of adverse events, bolus instillation of normal saline should not be routinely used prior to suctioning.


Open versus closed suction


Closed suction catheter systems should be used as the system of choice for patients with an ETT or tracheostomy who require suction.



Closed suction catheter systems should be changed as per manufacturer’s instructions.



Closed suction systems should be cleaned as per the manufacturers’ instructions to maintain patency and minimise colonisation.




Hyperinflation should not be performed on a routine basis prior to suctioning.


Above cuff or subglottic suction


Tracheal tubes with subglottic suction capability should be used for mechanically ventilated patients who are expected to be ventilated > 72hours.



If a tracheal tube does not have subglottic suction capability, a Y-catheter should be used to remove “above the cuff” secretions.


Infection prevention


Standard precautions require the use of personal protective equipment (PPE) to prevent contamination and mucosal or conjunctival splash injuries, and is mandatory while suctioning a patient. This must include goggles and mask or face shield/gloves and gown/apron as per NSW 2007 Infection Control Policy.

PD 2007_037 page 7


Clinicians must adhere to the Five Moments of Hand Hygiene.



When using OSS technique an aseptic non-touch technique must be used.



Clinicians should perform a risk assessment for specific droplet and airborne precautions prior to suction.




Each local health district (LHD) should use this guideline to develop site-specific procedures to address suction practice.



To ensure optimal patient outcomes, hospitals should periodically evaluate practice against this guideline.



Hospitals should ensure that clinicians who perform this procedure are competent or are directly supervised by a competent clinician.



Individual feedback should be provided to improve development of competency in tracheal suction.



Where possible, tailored performance in a simulated setting could be useful in teaching and assessing practice of this skill.


The evidence review for these recommendations was current to December 2012. Clinicians are advised to check the literature as research may have been published that change these recommendations

Grading of recommendation taxonomy

Grade of recommendation



Body of evidence can be trusted to guide evidence


Body of evidence can be trusted to guide practice in most situations


Body of evidence provides some support for recommendation/s but care should be taken in its application


Body of evidence is weak and recommendation must be applied with caution


Consensus was set as a median of ≥ 7

Grades A–D are based on NHMRC grades (10)


Indications and assessment

Suction catheter

Saline installation


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The information on this page is general in nature and cannot reflect individual patient variation. It reflects Australian intensive care practice, which may differ from that in other countries. It is intended as a supplement to the more specific information provided by the doctors and nurses caring for your loved one. ICNSW attests to the accuracy of the information contained here but takes no responsibility for how it may apply to an individual patient. Please refer to the full disclaimer.