Suctioning an adult ICU patient: hyperinflation

Recommendations for practice





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


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

The adverse effects of hyperinflation including significant increases/decreases in mean arterial pressure, cardiac output, pulmonary artery pressure and pulmonary airway pressure have been well described in the literature (1). Recent evidence contained in two systematic reviews (2, 3) and one literature review (4) consistently supports the 2007 (5) recommendation that hyperinflation should not be performed on a routine basis prior to suctioning.

Hyperinflation using a manual resuscitator bag or the ventilator has been used as a method of both hyper oxygenation and as a lung recruitment manoeuvre. It has been recognised that there may be occasions where hyperinflation during suctioning is clinically warranted, for example sputum plug, excessive secretions or volume loss as evidenced on a chest X-ray due to lobar or lung collapse. In this instance, hyperinflation is used by clinicians as a therapeutic intervention. This can be performed either manually or via a ventilator depending on level of positive end expiratory pressure (PEEP). Manual (MHI) or ventilator hyperinflation (VHI) results in increased lung compliance in patients on mechanical ventilation and decreased airway resistance in patients with ventilator associated pneumonia (3, 4, 6).

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 (7)


  1. Thompson L. Suctioning adults with an artificial airway. Adelaide, South Australia: The Joanna Briggs Institute for evidence based nursing and midwifery, 2000.
  2. (AARC) AAfRC. AARC Clinical Practice Guidelines.  Endotracheal suctioning of mechanically ventilated patients with artificial airways. Respiratory Care. 2010;Jun; 55(6):758-64.
  3. Overend TJ, Anderson CM, Brooks D, Cicutto L, Kein M, McAuslan D, et al. Updating the evidence base for suctioning adult patients: a systematic review. Canadian Respiratory Journal. 2009;16(3):e6-e17.
  4. Pederson CM, Rosendahl-Nielsen M, Hjermind J, Egerod I. Endotracheal suctioning of the adult intubated patient - What is the evidence? Intensive and Critical Care Nursing. 2009;25:21-30.
  5. Rolls K, Smith K, Jones P, Tuipulotu M, Butcher R, A/Prof Kent B, et al. Suctioning an Adult with a Tracheal Tube. Penrith: Intensive Care Coordination & Monitoring Unit (ICCMU) & NSW Health, 2007.
  6. Dennis D, Jacob W, Budgeon C. Ventilator versus manual hyperinflation in clearing sputum in ventilated intensive care unit patients. Anaesthesia and Intensive Care. 2012;40(1):142-9.
  7. NHMRC. NHMRC additional levels of evidence and grades for recommendations for developers of guidelines. 2009.


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.