SUCTIONING THE TRACHEOSTOMY: OPEN SYSTEM

Suctioning through a tracheostomy is indicated to maintain a patent airway. Tracheal suctioning

can lead to hypoxemia, cardiac dysrhythmias, trauma, atelectasis, infection, bleeding, and pain. It
is imperative to be diligent in maintaining aseptic technique and following facility guidelines and
procedures to prevent potential hazards. Suctioning frequency is based on clinical assessment to
determine the need for suctioning.
The purpose of suctioning is to remove secretions that are not accessible to bypassed
cilia, so the recommendation is to insert the catheter only as far as the end of the tracheostomy
tube. Catheter contact and suction cause tracheal mucosal damage, loss of cilia, edema, and
fibrosis, and increase the risk of infection and bleeding for the patient. Insertion of the suction
catheter to a predetermined distance, no more than 1 cm past the length of the tracheostomy
tube, avoids contact with the trachea and carina, reducing the effects of tracheal mucosal
damage (Ireton, 2007; Pate, 2004; Pate & Zapata, 2002). Box 14-1 in Skill 14-8 shows several
methods for nurses to use to determine appropriate suction catheter depth.
Note: In-line, closed suction systems are available to suction mechanically ventilated
patients. The use of closed suction catheter systems may avoid some of the infection control
issues and other complications associated with open suction techniques. The closed suctioning
procedure is the same for patients with tracheostomy tubes and endotracheal tubes connected
to mechanical ventilation. See Skill 14-9.

EQUIPMENT:
• Portable or wall suction unit with tubing
• A commercially prepared suction kit with an appropriate-size catheter (See General
Considerations) or
• Sterile suction catheter with Y-port in the appropriate size
• Sterile, disposable container
• Sterile gloves
• Towel or waterproof pad
• Goggles and mask or face shield
• Additional PPE, as indicated
• Disposable, clean gloves
• Resuscitation bag connected to 100% oxygen

ASSESSMENT:
Assess lung sounds. Patients who need to be suctioned may have wheezes, crackles, or gurgling
present. Assess oxygenation saturation level. Oxygen saturation usually decreases when a
patient needs to be suctioned. Assess respiratory status, including respiratory rate and depth.
Patients may become tachypneic when they need to be suctioned. Additional indications for
suctioning via a tracheostomy tube include secretions in the tube, acute respiratory distress,
and frequent or sustained coughing. Also assess for pain and the potential to cause pain during
the intervention. Perform individualized pain management in response to the patient’s needs
(Arroyo-Novoa, et al., 2007). If the patient has had abdominal surgery or other procedures,
administer pain medication before suctioning. Assess appropriate suction catheter depth.
(Refer to Box 14-1 in Skill 14-8.)

NURSING DIAGNOSIS:
Determine the related factors for the nursing diagnosis based on the patient’s current status.
Appropriate nursing diagnoses may include:
• Ineffective Airway Clearance • Impaired Gas Exchange
• Risk for Aspiration • Ineffective Breathing Pattern

IMPLEMENTATION

NURSING ACTION RATIONALE 0 1 2

1. Bring necessary equipment to the Bringing everything to the bedside
bedside stand or overbed table. conserves time and energy. Arranging
items nearby is convenient, saves
time, and avoids unnecessary
stretching and twisting of muscles on
the part of the nurse.
2. Perform hand hygiene and put on PPE, if Hand hygiene and PPE prevent the
indicated. spread of microorganisms. PPE is
required based on transmission
precautions.
3. Identify the patient. Identifying the patient ensures the
right patient receives the intervention
and helps prevent errors.
4. Close curtains around bed and close the This ensures the patient’s privacy.
door to the room, if possible.
5. Determine the need for suctioning. To minimize trauma to airway
Verify the suction order in the patient’s mucosa, suctioning should be done
chart. Assess for pain or the potential to only when secretions have
cause pain. Administer pain medication, as accumulated or adventitious breath
prescribed, before suctioning. sounds are audible. Suctioning can
cause moderate to severe
pain for patients. Individualized pain
management is imperative (Arroyo-
Novoa, et al., 2007). Suctioning
stimulates coughing, which is painful
for patients with surgical incisions.
6. Explain to the patient what you are Explanation alleviates fears. Even if
going to do and the reason or doing it, the patient appears unconscious, the
even if the patient does not appear to be nurse should explain what is
alert. happening. Any procedure that
Reassure the patient you will interrupt the compromises respiration is
procedure if he or she indicates respiratory frightening for the patient
difficulty.
7. Adjust bed to comfortable working Having the bed at the proper height
position, usually elbow height of the prevents back and muscle strain. A
caregiver (VISN 8 Patient Safety Center, sitting position helps the patient to
2009). Lower side rail closest to you. If cough and makes breathing easier.
patient is conscious, place him or her in a Gravity also facilitates catheter
semi-Fowler’s position (Figure 1). If patient insertion. The lateral position prevents
is unconscious, place him or her in the the airway from becoming obstructed
lateral position, facing you. Move the and promotes drainage of secretions.
overbed table close to your work area and The overbed table provides work
raise to waist height. surface and maintains sterility of
objects on work surface
8. Place towel or waterproof pad across This protects bed linens and the
patient’s chest. patient.
9. Turn suction to appropriate pressure Higher pressures can cause excessive
(Figure 2). For a wall unit for an adult: 100– trauma, hypoxemia, and atelectasis.
120 mm Hg (Roman, 2005); neonates: 60– Glove prevents contact with blood
80 mm Hg; infants: 80–100 mm Hg; and body fluids. Checking pressure
children: 80–100 mm Hg; adolescents: 80– ensures equipment is working
120 mm Hg (Ireton, 2007). properly.
For a portable unit for an adult: 10–15 cm Allows for an organized approach to
Hg; neonates: 6–8 cm Hg; infants 8–10 cm procedure.
Hg; children 8–10 cm Hg; adolescents: 8-
10 cm Hg.
Put on a disposable, clean glove and
occlude the end of the connecting tubing to
check suction pressure. Place the
connecting tubing in a convenient location.
If using, place resuscitation bag connected
to oxygen within convenient reach.
10. Open sterile suction package using Sterile normal saline or water is used
aseptic technique. The open wrapper or to lubricate the outside of the
container becomes a sterile field to hold catheter, minimizing irritation of
other supplies. Carefully remove the sterile mucosa during introduction. It is also
container, touching only the outside used to clear the catheter between
surface. Set it up on the work surface and suction attempts.
pour sterile saline into it.
 FIGURE 2. Turning suction device to the appropriate
FIGURE 1. Patient in semi-Fowler’s position
11. Put on face shield or goggles and mask Handling the sterile catheter using a
(Figure 3). Put on sterile gloves. The sterile glove helps prevent
dominant hand will manipulate the introducing organisms into the
catheter and must remain sterile. The respiratory tract; the clean glove
nondominant hand is considered clean protects the nurse from
rather than sterile and will control the microorganisms.
suction valve (Y-port) on the catheter.

FIGURE 3. Putting on goggles and mask.

12. With dominant gloved hand, pick up Sterility of the suction catheter is
sterile catheter. Pick up the connecting maintained.
tubing with the nondominant hand and
connect the tubing and suction catheter
(Figure 4).
FIGURE 4. Connecting suction catheter to the suction
tubing
13. Moisten the catheter by dipping it into Lubricating the inside of the catheter
the container of sterile saline, unless it is a with saline helps move secretions in
silicone catheter (Figure 5). Occlude Y-tube the catheter. Silicone catheters do not
to check suction (Figure 6). require lubrication. Checking ensures
equipment is working properly.

FIGURE 5. Moistening catheter in saline solution

FIGURE 6. Occluding Y-port to check for proper
suction
14. Using your nondominant hand and a Hyperoxygenation and
manual resuscitation bag, hyperventilate hyperventilation aid in preventing
the patient, delivering three to six breaths hypoxemia during suctioning.
or use the sigh mechanism on a
mechanical ventilator.
15. Open the adapter on the mechanical This exposes the tracheostomy tube
ventilator tubing or remove oxygen without contaminating sterile gloved
delivery setup with your nondominant hand.
hand.
16. Using your dominant hand, gently and Catheter contact and suction cause
quickly insert catheter into trachea. tracheal mucosal damage, loss of cilia,
Advance the catheter to the redetermined edema, and fibrosis, and increase the
length. Do not occlude Y-port when risk of infection and bleeding for the
inserting catheter. patient. Insertion of the suction
catheter to a predetermined distance,
no more than 1 cm past the length of
the endotracheal tube, avoids contact
with the trachea and carina, reducing
 the effects of tracheal mucosal
damage (Ireton, 2007; Pate, 2004;
Pate & Zapata, 2002). If resistance is
met, the carina or tracheal mucosa
has been hit. Withdraw the catheter at
least 1⁄2 inch before applying suction.
Suctioning when inserting catheter
increases the risk for trauma to airway
mucosa and increases risk of
hypoxemia.
17. Apply suction by intermittently Turning the catheter as it is
occluding the Y-port on the catheter with withdrawn minimizes trauma to the
the thumb of your nondominant hand, and mucosa. Suctioning for longer than 10
gently rotate the catheter as it is being to 15 seconds robs the respiratory
withdrawn (Figure 7). Do not suction for tract of oxygen, which may result in
more than 10 to 15 seconds at a time. hypoxemia. Suctioning too quickly
may be ineffective at clearing all
secretions.

FIGURE 7. Applying intermittent suction while withdrawing

catheter.
18. Hyperventilate the patient using your Suctioning removes air from the
nondominant hand and a manual patient’s airway and can cause
resuscitation bag, delivering three to six hypoxemia. Hyperventilation can help
breaths. Replace the oxygen delivery prevent suction-induced hypoxemia
device, if applicable, using your
nondominant hand and have the patient
take several deep breaths. If the patient is
mechanically ventilated, close the adapter
on the mechanical ventilator tubing and
use the sigh mechanism on a mechanical
ventilator
19. Flush catheter with saline. Assess the Flushing clears the catheter and
effectiveness of suctioning and repeat, as lubricates it for next insertion.
needed, and according to patient’s Reassessment determines need for
tolerance. Wrap the suction catheter additional suctioning. Prevents
around your dominant hand between inadvertent contamination of the
attempts. catheter.
20. Allow at least a 30-second to 1-minute The interval allows for reventilation
interval if additional suctioning is needed. and reoxygenation of airways.
No more than three suction passes should Excessive suction passes contribute to
be made per suctioning episode. Encourage complications. Alternating nares
the patient to cough and deep breathe reduces trauma. Clears the mouth of
between suctionings. secretions. More microorganisms are
Suction the oropharynx after suctioning usually present in the mouth, so it is
the trachea. Do not reinsert in the suctioned last to prevent transmission
tracheostomy after suctioning the mouth. of contaminants.
21. When suctioning is completed, remove This technique reduces transmission
gloves from dominant hand over the of microorganisms. Ensures patient
coiled catheter, pulling it off inside out comfort. Proper positioning with
(Figure 8). Remove glove from raised side rails and proper bed
nondominant hand and dispose of gloves, height provide for patient comfort
catheter, and container with solution in the and safety.
appropriate receptacle. Assist patient to a
comfortable position. Raise bed rail and
place bed in the lowest position.

FIGURE 8. Removing gloves while keeping catheter inside.

22. Turn off suction. Remove supplemental Removing PPE properly reduces the
oxygen placed for suctioning, if risk for infection transmission and
appropriate. Remove face shield or contamination of other items. Hand
goggles and mask. Perform hand hygiene. hygiene prevents transmission of
microorganisms.
23. Offer oral hygiene after suctioning. Respiratory secretions that are
allowed to accumulate in the mouth
are irritating to mucous membranes
and unpleasant for the patient
24. Reassess patient’s respiratory status, These assess effectiveness of
including respiratory rate, effort, oxygen suctioning and the presence of
 saturation, and lung sounds. complications.
25. Remove additional PPE, if used. Removing PPE properly reduces the
Perform hand hygiene. risk for infection transmission and
contamination of other items. Hand
hygiene prevents the spread of
microorganisms.
DOCUMENTATION Document the time of suctioning,
your before and after intervention
assessments, reason for suctioning,
and the characteristics and amount of
secretions.

Computation of Grades:
Step 1: Get the sum of all the points for the entire procedure.
Step 2: Use the formula below to get the final grade for the particular competency checklist.
Formula: RAW SCORE/PERFECT SCORE x 75 +25 = FINAL GRADE

Evaluated by: Conforme:

_______________________________ ________________________________
Signature over printed name Signature over printed name
(Clinical Instructor) (Student)

Date:_____________________ Date:_____________________

SUCTIONING THE NASOPHARYNGEAL AND OROPHARYNGEAL AIRWAYS

Suctioning of the pharynx is indicated to maintain a patent airway and to remove saliva,
pulmonary secretions, blood, vomitus, or foreign material from the pharynx. Suctioning helps a
patient who cannot successfully clear his or her airway by coughing and expectorating. When
performing suctioning, position yourself on the appropriate side of the patient. If you are right-
handed, stand on the patient’s right side; if left-handed, stand on the patient’s left side. This
allows for comfortable use of the dominant hand to manipulate the suction catheter.

EQUIPMENT
• Portable or wall suction unit with tubing
• A commercially prepared suction kit with an appropriate size catheter or
• Sterile suction catheter with Y-port in the appropriate size (Adult: 10F to 16F)
• Sterile disposable container
• Sterile gloves
• Sterile water or saline
• Towel or waterproof pad
• Goggles and mask or face shield
• Disposable, clean gloves
• Water-soluble lubricant
• Additional PPE, as indicated

ASSESSMENT
Assess lung sounds. Patients who need to be suctioned may have wheezes, crackles, or gurgling
present. Assess oxygenation saturation level. Oxygen saturation usually decreases when a
patient needs to be suctioned. Assess respiratory status, including respiratory rate and depth.
Patients may become tachypneic when they need to be suctioned. Assess the patient for signs
of respiratory distress, such as nasal flaring, retractions, or grunting. Assess effectiveness of
coughing and expectoration. Patients with an ineffective cough and who are unable to
expectorate secretions may need to be suctioned. Assess for history of deviated septum, nasal
polyps, nasal obstruction, nasal injury, epistaxis (nasal bleeding), or nasal swelling.

NURSING DIAGNOSIS
Determine the related factors for the nursing diagnosis based on the patient’s current status.
Appropriate nursing diagnoses may include:
• Ineffective Airway Clearance • Ineffective Breathing Pattern
• Impaired Gas Exchange • Risk for Aspiration

IMPLEMENTATION
NURSING ACTION RATIONALE 0 1 2
1. Bring necessary equipment to the Bringing everything to the bedside
bedside stand or overbed table. conserves time and energy.
Arranging items nearby is
convenient, saves time, and avoids
unnecessary stretching and twisting
of muscles on the part of the nurse.
2. Perform hand hygiene and put on Hand hygiene and PPE prevent the
PPE, if indicated. spread of microorganisms.
PPE is required based on
transmission precautions.
3. Identify the patient. Identifying the patient ensures the
right patient receives the intervention
and helps prevent errors.
4. Close curtains around bed and This ensures the patient’s privacy.
close the door to the room, if
possible.
5. Determine the need for suctioning. To minimize trauma to airway
Verify the suction order in the mucosa, suctioning should be done
patient’s chart, if necessary. For a only when secretions have
postoperative patient, administer pain accumulated or adventitious breath
medication before suctioning. sounds are audible. Some facilities
require an order for naso and
oropharyngeal suctioning. Suctioning
stimulates coughing,
which is painful for patients with
surgical incisions.
6. Explain what you are going to do Explanation alleviates fears. Even if
and the reason for suctioning to the the patient appears unconscious,
patient, even if the patient does not explain what is happening. Any
appear to be alert. Reassure the procedure that compromises
patient you will interrupt procedure if respiration is frightening for the
he or she indicates respiratory patient.
difficulty.
7. Adjust bed to comfortable working Having the bed at the proper height
height, usually elbow height of the prevents back and muscle
caregiver (VISN 8 Patient Safety strain. A sitting position helps the
Center, 2009). Lower side rail closest patient to cough and makes
to you. If patient is conscious, place breathing easier. Gravity also
him or her in a semi-Fowler’s position. facilitates catheter insertion. The
If patient is unconscious, place him or lateral position prevents the airway
her in the lateral position, facing you. from becoming obstructed
Move the bedside table close to your and promotes drainage of secretions.
work area and raise it to The bedside table provides a work
waist height. surface and helps maintain sterility of
objects on the
work surface.
8. Place towel or waterproof pad This protects bed linens.
across the patient’s chest.
9. Adjust suction to appropriate Higher pressures can cause excessive
pressure (Figure 1). trauma, hypoxemia, and
For a wall unit for an adult: 100–120 atelectasis.
mm Hg (Roman, 2005); neonates: 60–
80 mm Hg; infants: 80–100 mm Hg;
children: 80–100 mm Hg; adolescents:
80–120 mm Hg (Ireton, 2007).
For a portable unit for an adult: 10–15
cm Hg; neonates: 6–8 cm Hg; infants:
8–10 cm Hg; children: 8–10 cm Hg;
adolescents: 8–10 cm Hg.
Put on a disposable, clean glove and
occlude the end of the connecting
tubing to check suction pressure. Place
the connecting
tubing in a convenient location.

FIGURE 1. Adjusting wall suction.

10. Open sterile suction package Sterile normal saline or water is used
using aseptic technique. The open to lubricate the outside of the
wrapper or container becomes a catheter, minimizing irritation of
sterile field to hold other supplies. mucosa during introduction. It
Carefully remove the sterile container, is also used to clear the catheter
touching only the outside surface. Set between suction attempts.
it up on the work surface and pour
sterile saline into it.
11. Place a small amount of water- Lubricant facilitates passage of the
soluble lubricant on the sterile catheter and reduces trauma to
field, taking care to avoid touching mucous membranes.
the sterile field with the lubricant
package.
12. Increase the patient’s Suctioning removes air from the
supplemental oxygen level or apply patient’s airway and can cause
supplemental oxygen per facility hypoxemia. Hyperoxygenation can
policy or primary care provider help prevent suction induced
order. hypoxemia.
13. Put on face shield or goggles and Handling the sterile catheter using a
mask. Put on sterile gloves. sterile glove helps prevent
The dominant hand will manipulate introducing organisms into the
the catheter and must remain sterile. respiratory tract; the clean glove
The nondominant hand is considered protects the nurse from
clean rather than sterile and will microorganisms.
control the suction valve
(Y-port) on the catheter.
14. With dominant gloved hand, pick Sterility of the suction catheter is
up sterile catheter. Pick up the maintained.
connecting tubing with the
nondominant hand and connect
the tubing and suction catheter
(Figure 2).

FIGURE 2. Connecting catheter to tubing.

15. Moisten the catheter by dipping it Lubricating the inside of the catheter
into the container of sterile with saline helps move secretions in
saline (Figure 3). Occlude Y-tube to the catheter. Checking suction
check suction. ensures equipment is working
properly.

FIGURE 3. Dipping catheter into sterile saline.

16. Encourage the patient to take Suctioning removes air from the
several deep breaths patient’s airway and can cause
hypoxemia. Hyperventilation can help
prevent suction-induced
hypoxemia.
17. Apply lubricant to the first 2 to 3 Lubricant facilitates passage of the
inches of the catheter, using the catheter and reduces trauma to
lubricant that was placed on the mucous membranes.
sterile field.
18. Remove the oxygen delivery Using suction while inserting the
device, if appropriate. Do not catheter can cause trauma to the
apply suction as the catheter is mucosa and remove oxygen from the
inserted. Hold the catheter respiratory tract. Correct
between your thumb and forefinger. distance for insertion ensures proper
placement of the catheter.

19. Insert the catheter:

a. For nasopharyngeal suctioning,
gently insert catheter through the The general guideline for
naris and along the floor of the nostril determining insertion distance for
toward the trachea (Figure 4). Roll the nasopharyngeal suctioning for an
catheter between your fingers to help individual patient is to estimate
advance it. Advance the catheter the distance from the patient’s
approximately 5” to 6” to reach the earlobe to the nose.
pharynx.

FIGURE 4. Inserting catheter into naris.

b. For oropharyngeal suctioning,

insert catheter through the
mouth, along the side of the mouth
toward the trachea.
Advance the catheter 3”to 4” to reach
the pharynx.

20. Apply suction by intermittently Turning the catheter as it is

occluding the Y-port on the catheter withdrawn minimizes trauma to the
with the thumb of your nondominant mucosa. Suctioning for longer than
hand and gently rotating the catheter 10 to 15 seconds robs the
as it is being withdrawn (Figure 5). Do respiratory tract of oxygen, which
not suction for more than 10 to 15 may result in hypoxemia.
seconds at a time. Suctioning too quickly may be
ineffective at clearing all
secretions

FIGURE 5. Suctioning nasopharynx

21. Replace the oxygen delivery Suctioning removes air from the
device using your nondominant patient’s airway and can cause
hand, if appropriate, and have the hypoxemia. Hyperventilation can help
patient take several deep prevent suction-induced hypoxemia
breaths.
22. Flush catheter with saline (Figure Flushing clears catheter and
6). Assess effectiveness of suctioning lubricates it for next insertion.
and repeat, as needed, and according Reassessment determines the need
to patient’s tolerance. Wrap the for additional suctioning.
suction catheter around your Wrapping prevents inadvertent
dominant hand between attempts. contamination of catheter.

FIGURE 6. Rinsing catheter.

23. Allow at least a 30-second to 1- The interval allows for reventilation
minute interval if additional and reoxygenation of airways.
suctioning is needed. No more than Excessive suction passes contribute
three suction passes should be made to complications. Alternating nares
per suctioning episode. Alternate the reduces trauma. Suctioning the
nares, unless contraindicated, if oropharynx after the nasopharynx
repeated suctioning is required. clears the mouth of secretions. More
Do not force the catheter through the microorganisms are usually present
nares. Encourage the patient to cough in the mouth, so it is suctioned
and deep breathe between last to prevent transmission of
suctioning. Suction the oropharynx contaminants.
after suctioning the nasopharynx.
24. When suctioning is completed, This technique reduces transmission
remove gloves from dominant of microorganisms. Proper
hand over the coiled catheter, pulling positioning with raised side rails and
them off inside out. Remove glove proper bed height provide
from nondominant hand and dispose for patient comfort and safety.
of gloves, catheter, and container with
solution in the appropriate receptacle.
Assist patient to a comfortable
position. Raise bed rail and place bed
in the lowest position.
25. Turn off suction. Remove Proper removal of PPE and hand
supplemental oxygen placed for hygiene reduces risk of transmission
suctioning, if appropriate. Remove of microorganisms.
face shield or goggles and mask.
Perform hand hygiene.
26. Offer oral hygiene after Respiratory secretions that are
 suctioning. allowed to accumulate in the mouth
are irritating to mucous membranes
and unpleasant for the patient.
27. Reassess patient’s respiratory This assesses effectiveness of
status, including respiratory rate, suctioning and the presence of
effort, oxygen saturation, and lung complications
sounds.
28. Remove additional PPE, if used. Removing PPE properly reduces the
Perform hand hygiene. risk for infection transmission and
contamination of other items. Hand
hygiene prevents the spread of
microorganisms
DOCUMENTATION Document the time of suctioning,
your before and after intervention
assessments, reason for suctioning,
route used, and the characteristics
and amount of secretions.

EVALUATION
The expected outcome is met when the patient exhibits improved breath sounds and a clear and
patent airway. In addition, the oxygen saturation level is within acceptable parameters, and the
patient does not exhibit signs or symptoms of respiratory distress or complications.

Computation of Grades:
Step 1: Get the sum of all the points for the entire procedure.
Step 2: Use the formula below to get the final grade for the particular competency checklist.
Formula: RAW SCORE/PERFECT SCORE x 75 +25 = FINAL GRADE

Evaluated by: Conforme:

_______________________________ ________________________________
Signature over printed name Signature over printed name
(Clinical Instructor) (Student)

Date:_____________________ Date:_____________________