International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 179
Tracheal suctioning is one of the critical nursing
interventions to keep the airway patent by removing
secretion via suctioning. This critical skill requires
expertise with the knowledge to perform and facilitate
a patient’s effortless breathing pattern through
effective secretion management. But this aspect of care
is associated with the risk of injury therefore, the role
of competent health care professionals (HCP) is vital
in performing tracheal suctioning.
The literature reviewed was obtained through
different databases that includes: Cumulative Index
to Nursing and Allied Health Literature (CINAHL),
Medical Literature Analysis and Retrieval System
Online (MEDLINE), PubMed, Science Direct,
SpringerLink, and Google Scholar.
Pre suctioning phase
Prior to suctioning, patient assessment; monitoring
the vital signs and chest auscultation is important 1, 2, 3.
The reommended period for assessment is in each shift,
before each suctioning, or depending on the patient’s
Practices of Tracheal Suctioning Technique among Health
Care Professionals: Literature Review
Rozina Khimani1, Fauziya Ali2, Salma Rattani3, Sohai Awan4
Clinical Nurse Instructor, Aga Khan University Hospital,
Assistant Professor and Director,
Aga Khan University School of Nursing and Midwifery,
Associate Professor and Section Head, Otolaryngology
Department of Surgery, Aga Khan University, Karachi Pakistan
The current study aims to assess tracheal suctioning practices among health care practitioners; nurses,
critical care technicians and physiotherapist. Employing literature review as the methodology, multiple
databases were searched focusing on three phases of tracheal suctioning (a) the pre suctioning phase,
(b) the suctioning phase, (c) the post suctioning phase and complications related to tracheal suctioning.
It was concluded that to provide quality care it is important that the evidence based practice guidelines
should be followed.
Keywords: Tracheal Suctioning, Tracheostomy, Evidence Based Practice, Nursing Skills, Health Care
Aga Khan University Hospital, School of Nursing and
Midwifery, Stadium Road, Karachi 74800, Pakistan
Phone: +92 21 34930051
need 1, 2, 4. Through evidence-based practices it is
revealed that nurse are using their clinical judgment,
nurses perform tracheal suctioning without using
normal saline and they screen patients’
cardiopulmonary position before, during, and after the
suctioning phase 5. Similarly an observational study
conducted to assess the nurses’ practices of tracheal
suctioning in the cardiac intensive care unit (CICU)
and the general intensive care unit (GICU) in Ireland,
it was revealed that among the CICU nurses (n=17)
only two nurses, i.e. 12% out of 34, from CICU and
four nurses, i.e. 14%, from GICU performed chest
auscultation to assess the need of suctioning 7.
While looking the entire pool as health care
practitioners it was revealed that the patients with
respiratory distress were monitored for occurance of
tachypnea and deoxygenation throughout the
suctioning process and based on patient’s need, the
HCPs selected a suitable sized of suctioning catheter6.
Along with assessment, informing the patient and
taking consent prior to the suctioning have been
identified as strategies for reducing the anxiety and
distress of patients as they help in gaining maximum
outcomes from suctioning 1, 2. It has been found that
informing a client about the details of the procedure
always ensures its smooth execution. Whereas, one
study explicated that, out of 53, 28% of the nurses
from the GICU were unable to communicate and
explain procedures to the patients 7.
DOI Number: 10.5958/0974-9357.2015.00037.9
37. Rozina Pak--179--183.pmd 1/16/2015, 10:07 AM179
180 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1
Hypoxemia is one of the complications related to
tracheal suctioning2, 8. Hypoxemia is associated
with cardiac arrhythmias, hypotension, cardiac arrest,
and death, therefore, hyperventilation and
hyperoxygenation are essential aspects of treatment 1.
Hyperoxygenation is the administration of oxygen
in greater amount than what the patient is receiving
or requires 9. Hyperoxygenation and hyperinflation is
found to be an effective intervention prior to suctioning
in order to prevent suction induced hypoxia in adult
patients10. However, the careful oxygen administration
is required in patients with chronic obstructive
pulmonary diseases (COPD), as these patients cannot
tolerate high oxygen flow 11. Tracheal suctioning and
tracheostomy care are high-risk processes. To avoid
adverse consequences, HCPs who execute these,
whether they are experts or beginners, must follow
the evidence based guidelines. It is also suggested that,
patients should be hyperoxygenated and encouraged
deep breathing, then manage four to six compressions
with a manual ventilator bag or trigger the ventilator
Another point to note during this phase is that,
normal saline instillation is not recommended prior
to or during suction. It is usually a misconception that
it helps in liquifying secretions 9, 4, 8. The potential
hazards of normal saline instillation include a fall in
PaO2, lower respiratory track infection, and failure to
remove all saline during suctioning 9, 12. Despite
available evidences against the use of saline in tracheal
suctioning, a survey found that 33% of nurses and
therapists still use saline before and during suctioning4.
In fact, another survey, on 1665 nurses and respiratory
therapists from 27 different sites in the United States,
regarding saline instillation protocol, reported that 74%
centers had a protocol which recommended saline
instillation during suctioning 13.
A quasi experimental study was conducted to
assess the level of dyspnea with the use of saline during
suctioning in which dyspnea was graded immediately
after the suctioning, and at 10, 20, and 30-minute
intervals. The findings indicated no beneficial use of
saline; whereas, age variation highlighted that older
patients, above 60years of age had decreased levels of
dyspnea when suctioning was done without saline
instillation. The study validated that saline instillation
might precipitate a considerable increase in the level
of dyspnea for up to 10 minutes after suctioning in
patients older than 60 years of age 14. Similarly, the
findings of another study reported that the use of
saline instillation during tracheal suctioning decreased
the mix venous saturation as compared to the patients,
suctioning without saline instillation 5.
The use of saline during suctioning also varies
among health care professionals, such as nurses,
doctors, and physiotherapists. Survey on saline
instillation protocol and related practices of HCPs
indicated that 79% hospitals use saline during
suctioning, among which 58% physiotherapists use
saline in their practices, while saline use by nurses and
other medical staff was 42% 15.
Pain is also one of the frequently associated
complaint during tracheal suctioning 16. Tracheal
suctioning was specifically an identified discomforting
factor among 30% of the ICU ventilated patients. On a
0-10 scale, pain intensity during suctioning among
patients with tracheostomy was reported to be at 7 or
Tracheal suctioning is an invasive and sterile
procedure, therefore, all aseptic protocols, such as,
hand washing before and after the procedure, gloves,
apron, protectors and use of sterile catheter for each
episode of suction should be followed to prevent
patients from getting an infection 2, 4. Several diseases
can occur during suctioning treatment due to
noncompliance of standard precautions. The sterile
procedure is essentially followed to avoid
contamination of the airway. The tube must never be
reused once it is opened and a new sterile catheter must
be used for each session of suctioning 18.
Compliance of infection control practices among
HCPs needs to be emphasized to prevent
complications related to the suctioning procedure and
equipment. A study conducted in Ireland identified
that, out of 53, only 30% of the nurses in GICU and
65% nurses, from 34 nurses, in CICU performed
handing washing prior to suctioning. Moreover, 59%
CICU and 29% of GICU nurses failed to maintain the
sterility of the suction catheter till its insertion into the
airway, which indicates an alarming situation 7.
Another study was conducted on Infection
Prevention (Werkgroep Infectiepreventie [WIP]) to
find out whether some policies on tracheal suctioning
(open and closed tracheal suctioning systems) are
superior to others, in terms of anticipation of ventilator-
associated pneumonia (VAP). They found that there
was no significant difference in the use of both open
and closed tracheal suction systems in decreasing the
rate of VAP. The study, however, clarifies that the
37. Rozina Pak--179--183.pmd 1/16/2015, 10:07 AM180
International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 181
quality of the evidence is substantive. Investigations
other than the anticipation of VAP should regulate the
choice of the suction system 6, 19.
The suctioning phase
The suctioning phase is an active period for the
removal of secretions. It is widely accepted that during
tracheal suctioning, the catheter diameter should be
one and a half times of the tracheotomy tube in
diameter 1, 4. The tracheostomy suction catheter size
can be easily calculated. The size of tracheotomy tube
divided by 2 and multiplied by 3 will give the
appropriate catheter size according to the
tracheostomy tube ((14, 4). However, a study in two
critical care areas in Ireland documented that 40% of
the CICU nurses and 28% of the GICU nurses selected
a larger sized suction catheter in comparison to the
size of tracheotomy tube 7. Large catheter obstructs
the airway resulting in hypoxemia during suctioning
as well as trauma to the mucosal lining of the
Negative pressure is needed to remove tracheal
secretions. Most of the literature recommends that the
pressure range during tracheal suctioning should be
from 70 to 150mmHg1, 9, 2. However, it has been
suggested that a pressure range between 70 to
120mmHg 20, 4. Furthermore, a pressure of 200 mm Hg
can cause mucosal lining damage, alveolar collapse,
and could also lead to bacterial colonization 2, 9.
The whole procedure of tracheal suctioning should
not take too long as it could cause hypoxia,
bradycardia, and mucosal damage 11, 1, 9, 2. The
recommended duration of tracheal suctioning is 10 to
15 seconds with 20 to 30 seconds intervals between
passes 1, 4, 8. Each session of suctioning should comprise
of three suction catheter passes at the most 11, 1, 9, 2.
Furthermore, suction vacuum should always be
applied during catheter withdrawal 2. Moreover, the
suction catheter should not be inserted deeply into the
trachea as it causes cough and vagal nerve stimulation
at the bifurcation of the trachea (Carina). Where
catheter encounter resistance, withdraw the catheter
1cm and then applies suction 1, 2.
Tracheal suctioning can easily cause airway
mucosal trauma when inappropriate suctioning
methods are used. Suction can only be useful for
extracting secretion from the airway. Unnecessary high
vacuum pressure and extensive suction exercises
should be avoided. It is important to pay special
consideration to the possibility of complexity in
patients who might be predominantly susceptible to
mucosal injury, i.e., very young patients, or patients
with thrombocytopenia or on general anticoagulant
A randomized control trial study was conducted
to relate and distinguish the alterations in endotracheal
suction consequences in patients who routinely
received 2 hourly suctioning and those who received
it following an evaluation. The results verified a clear
rise in nurses’ knowledge regarding endotracheal
suctioning and indicated the effectiveness of
procedures with minimal complications 3.
Suctioning is a high risk process, which can cause
hypoxemia, bleeding, cardiovascular instability,
infection, atelectasis, elevated intracranial pressure,
and can also create lesions in the tracheal mucosa.
These complications can be avoided with the use of
best practices 21.
Post suctioning phase
The patient’s condition needs to be assessed
following suctioning to evaluate the effectiveness of
the procedure, which includes respiratory rate, oxygen
saturation, and chest auscultation for the presence of
secretions and bilateral air entry to the lungs 1, 2, 4, 8, 9.
Oxygen therapy needs to be reconnected immediately
after suctioning, ideally, within 10 seconds to prevent
the patient from hypoxia 1, 2.
Moreover, post suctioning documentation is
essential which includes patient physiological and
psychological response, color, odor, consistency and
amount (COCA) of secretion 4, 9.
Complications related to tracheal suctioning
Endotracheal suctioning is, thus, imperative in
order to decrease the danger of atelectasis and
consolidation that might lead to insufficient
ventilation. A number of risk and complications are
related to the suction process. These include atelectasis,
bleeding, cardiovascular instability, infection,
hypoxemia, elevated intracranial pressure, and grazes
in the tracheal mucosa. The key recommendations use
evidence based guidelines to prevent and minimize
these complications 21.
A conducted a study with the objective of
determining the impact of suction tube insertion and
tracheal stimulation on the cerebrovascular and
systemic vascular status in adults with severe
37. Rozina Pak--179--183.pmd 1/16/2015, 10:07 AM181
182 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1
traumatic brain injury. They tested thirty intubated and
mechanically ventilated adults with brain injury. The
participants’ average age was 31 +/- 15 years. The
results showed that suction tube inclusion and tracheal
stimulation, inaccessible from other constituents of the
suctioning process, meaningfully enlarged cerebral
perfusion pressure (CPP), mean arterial pressure
(MAP), and mean intracranial pressure (MICP) 22.
Moreover, a tracheostomy team approach can
minimize the risk of complications pertinent to tracheal
suctioning for which a study examined the
mechanisms of tracheostomy through an inter
professional team approach which consist of divers
health cre professional possess expertise to care
patients with tracheostomy. The findings indicated
that tracheotomy teams increased the regularity of care
through the expansion and application of inter
professional protocol. These findings provided new
ways of understanding the role of tracheostomy teams
in effectively implementing complex protocols and
mechanisms through which inter professional teams
might produce positive consequences for tracheotomy
Tracheal suctioning is an important aspect of
airway management however, this aspect of care is
associated with many rist factors therefore, its is
important for health care professionals to follow
evidence based guidelines to prevent complications
and promote safety. Moever, the knowledge and
competence of health care professionals play an
important role in enhancing safety of the patient.
Acknowledgement: I (Rozina Khimani, principal
investigator) would like to acknowledge Division of
Nursing Services, Aga Khan University, Hospital,
Conflict of Interest: The authors declare having no
conflict of interest.
Source of Funding: No separate funding was received
for this study as the current study was done during
1. Day, T., Farnell, S., Haynes, S., Wainwright, S., &
Wilson-Barnett, J. (2002). Tracheal suctioning: an
exploration of nurses’ knowledgeand
competence in acute and high dependency ward
areas. Journal of Advanced Nursing, 39 (1), 35-45.
2. Freeman, S. (2011). Care of adult patients with a
temporary trachesotomy. Nursing Standard,26 (2),
3. Nance-Floyd, B. (2011). Tracheostomy care: An
evidence-based guide to suctioning and dressing
change. Journal of American Nurse Today , 6 (7),
4. Wood, C. J. (1998). Endotracheal suctioning: a
literature review. Journal of Intensive and Critical
Care Nursing, 14, 124-136.
5. Kuriakose, S. A. (2008). Using the synergy model
as best practice in endotracheal tube suctioning
of critically ill patients. Journal of Dimensions of
Critical Care Nursing, 27(1), 10-15.
6. Niel-Weise, B. S., Snoeren, R. L., & Broek, P. J.
(2007). Policies for Endotracheal Suctioning of
Patients Receiving Mechanical Ventilation: A
Systematic Review of Randomized Controlled
Trials. Journal of Infection Control and Hospital
Epidemiology, 28(5), 529-536.
7. Kelleher, S., & Andrews, T. (2006). An
observational study on the open-system
endotracheal suctioning practices of critical care
nurses. Journal of Clinical Nursing, 17, 360-369.
8. Russell, C. (2005). Providing the nurse with a
guide totracheostomy care and mangement.
British Journal of Nursing , 14 (8), 428-433.
9. Day, T., Wainwright, S. P., & Wilson-Barnett, J.
(2001). An evaluation of teaching Intervention to
improve the practice of endotracheal suctioning
in intensive care unit. Journal of Clinical Nursing,
10. Atta, J. M., & Beck, S. L. (1992). Preventing
hypoxemia and hemodynamic compromise
related to endotracheal suctioning. American
Journal of Critical Care, 1 (3), 62-79.
11. Barnett, M. (2005). Tracheostomy Management
and care. Journan of Community Nursing, 19 (1),
12. Halm, M. A., & Krisko-Hagel, K. (2008). Instilling
Normal Saline with suctioning: Benificial
technique or potencially harmful sacred cow?
American Journal of Critical Care, 17(5), 469-472.
13. Sole, M. L., Byers, J. F., Zhang, Y., Banta, C. M., &
Brummel, K. (2003). A Multisite Survey of
Suctioning Techniques and Airway Management
Practices. American Journal of Critical Care, 12(3),
14. O’Neal, P. V., Grap, M. J., Thompson, C., &
Dudley, W. (2001). Level of dyspnoea
experienced in mechanically ventilated adults
37. Rozina Pak--179--183.pmd 1/16/2015, 10:07 AM182
International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 183
with and without saline instillation prior to
endotracheal suctioning. Journal of Intensive and
Critical Care Nursing, 17, 356-363.
15. Reeve, J. C., Davies, N., Freeman, J., & Donovan,
B. (2007). The use of normal saline instillation in
the intensive care unit by physiotherapists: a
survey of practice in New Zealand. Journal of
Physiotherapy, 35(3), 119-125.
16. Arroyo-Novoa, C. M., Figueroa-Ramos, M. I.,
Puntillo, K. A., Stanik-Hutt, J., Thompson, C.
L., White, C., et al. (1998). Pain related to tracheal
suctioningin awake acutely and critically ill adult:
A descriptive study. Journal of Intensive and Crtical
CareNursing, 24, 20-27.
17. Stotts, N. A., Puntillo, K., Stanik-Hutt, J.,
Thompson, C. L., White, C., & Wild, L. R. (2007).
Does age make a difference in procedural pain
perceptions and responses in hospitalized adults?
Journal of Acute Pain, 9, 125-134.
18. Florentini, A. (1992). Potential hazards of
tracheobronchial suctioning. Intensive and Critical
Care Nursing, 8(4), 217-226.
19. Jansson, M., Ala-Kokko, T., Ylipalosaari, P., &
Kyngas, H. (2013). Evaluation of endotracheal-
suctioning practices of critical-care nurses – An
observational correlation study. Journal of Nursing
Education and Practice, 3(7), 99-105.
20. Bond, et al. (2003). Best practice in the care of
patients with tracheostomy. Nursing Times, 99
21. Pedersen, C. M., Rosendahl-Nielsen, M.,
Hjermind, J., & Egerod, I. (2009). Endotracheal
suctioning of the adult intubated patient-What
is the evidence? Journal of Intensive and Critical
Care Nursing, 25, 21-30.
22. Brucia, J., & Rudy, E. (1996). The effect of suction
catheter insertion and tracheal stimulation in
adults with severe brain injury. Journal of Heart
and Lung, 25(4), 295-303.
23. Mitchell, R., Parker, V., & Giles, M. (2013). An
interprofessional team approach to tracheostomy
care: A mixed-method investigation into the
mechanisms explaining tracheostomy team
effectiveness. International Journal of Nursing
Studies, 50, 536–542.
37. Rozina Pak--179--183.pmd 1/16/2015, 10:07 AM183