Intensive care – suction for intubated and non-intubated patients, including saline instillation

AARC Clinical Practice Guideline: Nasotracheal suctioning and endotracheal suctioning of mechanically ventilated patients with artificial airways (2004) Respir Care, 49, 9, 1080

AARC Clinical Practice Guideline: Suctioning of the patient in the home (1999) Respir Care, 44, 1, 99,

Bell L (2015) Using endotracheal suctioning for patients. Am J Crit Care; 24:326; doi:10.4037/ajcc2015597

Bodenham AR (2002) Removal of obstructing blood clot from the lower airway: an alternative suction technique. Anaesthesia, 57, 40-3

Branson RD, Gomaa D, Rodriquez D Jr. (2014) Management of the artificial airway. Respir Care; 59(6):974-89; discussion 989-90. doi: 10.4187/respcare.03246

Brown SE (1983) Prevention of suction-related arterial oxygen desaturation. Chest, 83, 621-8
• intermittent suction reduces effectiveness by reducing flow from 18-20 L/min to 8-9 L/min

Caruso P et al (2009) Saline instillation before tracheal suctioning decreases the incidence of ventilator-associated pneumonia. Crit Care Med, 37(1):32-8
• instillation of isotonic saline before tracheal suctioning decreases the incidence of ventilator-associated pneumonia

Corley A, Sharpe N, Caruana LR et al (2014) Lung volume changes during cleaning of closed endotracheal suction catheters: a randomized crossover study using electrical impedance tomography. Respir Care; 59(4):497-503. doi: 10.4187/respcare.02601

Chung F-F, Lin HL, Liu H-E et al (2015) Aerosol distribution during open suctioning and long-term surveillance of air quality in a respiratory care center within a medical center. Respir Care; 60(1):30-37

Czarnik RE, Stone KS et al (1991) Differential effects of continuous versus intermittent suction on tracheal tissue. Heart Lung, 20, 144-51.

Day T (2000) Tracheal suctioning: when, why and how. Nurs Times, 96, 20, 13-15.

Day T, Farnell S, Wilson-Barnett J (2002) Suctioning: a review of current research recommendations. Int Crit Care Nurs, 18, 2, 79-89

Donald KJ (2000) Setting safe and effective suction pressure: the effect of using a manometer in the suction circuit. Int Care Med, 26, 15-19

Dyhr T (2002) Lung recruitment manoeuvres are effective in regaining lung volume and oxygenation after open endotracheal suctioning in ARDS. Crit Care, 7, 55-62
• catheters, technique, complications

Fernαndez M (2004) Changes in lung volume with three systems of endotracheal suctioning with and without pre-oxygenation. Int Care Med, 30, 12, 2210-15,10,29;journal,21,297;browsepublicationsresults,615,1574

Grigoriadis KF, Angouras DC, Flevari A et al (2015) Comparison of the feasibility and safety of nasotracheal suctioning with curved edge catheter versus conventional suction catheter in critically 111 subjects: a prospective randomized crossover trial. Respir Care; 60(12):1826-1833

Guglielminotti J (2000) Bedside detection of retained tracheobronchial secretions in patients receiving mechanical ventilation. Chest, 118,1095-9
• sawtooth pattern on flow-volume loop indicates secretions

Halm MA, Krisko-Hagel K (2008) Instilling normal saline with suctioning: beneficial technique or potentially harmful sacred cow? Am J Crit Care, 17, 5, 469-72
• argument against routine use of saline instillation.
• best interventions for thick secretions are hydration, humidification and mobilization

Heinze H et al (2011) Functional residual capacity-guided alveolar recruitment strategy after endotracheal suctioning in cardiac surgery patients. Crit Care Med, 39, 5, 1042-9
• benefit from a post-suction recruitment manoeuvre can be identified by measuring FRC

Henley C, Draper A (2002) Endotracheal suction of mechanically ventilated patients: a brief review of the literature. ACPRC Journal, 35, 29-31
• overview including saline, open vs. closed catheters

Hicky J (2006) Manually ventilating and suctioning in-line with a SensorMedics 3100B high frequency oscillatory ventilator bench test. AARC Conference, Texas
• method for manual hyperinflation and suction without losing airway pressure with HFO

Jenkin A (1996) The nasopharyngeal airway. Acc Emerg.Nurs, 4, 16-20
• technique of insertion and use

Jevon P (2001) Insertion of an oropharyngeal airway. Nurs Times, 97, 43, 39-40

Jones CH, Kluayhomthong S, Chaisuksant S et al (2013) Breathing exercise using a new breathing device increases airway secretion clearance in mechanically ventilated patients. Heart Lung; 42(1):177-182

Jongerden IP, Rovers MM, Grypdonck MH et al (2007) Open and closed endotracheal suction systems in mechanically ventilated intensive care patients: a meta-analysis. Crit Care Med; 35(1):260–270

Knipper (1986) Minimizing complications of tracheal suctioning. Focus Crit.Care, 13, 4, 23-6
• debunks myth of safety of boxed gloves

Leur JP, Zwaveling JH, Loef BG et al (2003) Endotracheal suctioning versus minimally invasive airway suctioning in intubated patients. Int Care Med, 29, 426-32
• shallow suctioning is less damaging than deep suctioning

Leur JP, Zwaveling JH, Loef BG, Schans CP (2003) Patient recollection of airway suctioning in the ICU: routine versus a minimally invasive procedure. Int Care Med, 29, 433-6.
Lewis RM (2002) Airway clearance techniques for the patient with an artificial airway. Resp Care, 47, 808-17
• review of current research, including prevention of infection

Lindgren S, Almgren B, Hogman M et al (2004) Effectiveness and side effects of closed and open suctioning. Int Care Med, 30, 1630-7

Lorente L (2006) Tracheal suction by closed system without daily change versus open system. Int Care Med, 32, 4, 538-44,9,37;journal,4,297;browsepublicationsresults,615,1574
• closed suction without daily change is optimal if suction is required for < 4 days

Lv J (2013) Laboratory test of a visual sputum suctioning system. Respir Care; 58(10):1637-42

Maggiore SM (2003) Prevention of endotracheal suctioning-induced alveolar derecruitment in acute lung injury. Am J Resp Crit Care Med, 167, 1215-24.
• suction-induced atelectasis in acute lung injury can be prevented by a recruitment manoeuvre (pressure support at 40 cmH2O) during suction, and minimized by avoiding disconnection

Maggiore SM, Lellouche F, Pignataro C et al (2013) Decreasing the adverse effects of endotracheal suctioning during mechanical ventilation by changing practice. Respir Care; 58(10):1588–97

Ntoumenopoulos G (2013) Endotracheal suctioning may or may not have an impact, but it does depend on what you measure! Respir Care; 58(10):1707-10

Ntoumenopoulos GM, Shannon H, Main E (2013) Do commonly used ventilator settings for mechanically ventilated adults have the potential to embed secretions or promote clearance? Respir Care; 58(10):1887-92

O’Neal PV, Grap MJ, Thompson C et al (2001) Level of dyspnoea experienced in mechanically ventilated adults with and without saline instillation prior to endotracheal suctioning. Int Crit Care Nurs, 17, 356-63

Palazzo SGC, Soni B (2013) Pressure changes during tracheal suctioning – a laboratory study. Anaesthesia, 68:576–584. doi: 10.1111/anae.12218
• suction pressure should be less than −20 kPa (−150 mmHg)

Paulus J, Roquilly A, Beloeil H et al (2013) Pupillary reflex measurement predicts insufficient analgesia before endotracheal suctioning in critically ill patients. Crit Care, 17:R161. doi:10.1186/cc12840

Rahu MA, Grap MJ, Cohn JF (2013) Facial expression as an indicator of pain in critically ill intubated adults during endotracheal suctioning. Am J Crit Care; 22(5):412-22. doi: 10.4037/ajcc2013705.

Rodrigues FVJ, Pires DL, Valιria A et al (2017) Comparing the effects of two different levels of hyperoxygenation on gas exchange during open endotracheal suctioning: a randomized crossover study. Respir Care; 62(1): 92-101

Rossoff LJ (1995) Is handwashing really needed in an intensive care unit? Crit.Care Med, 23, 1211-6
• half of boxed gloves are contaminated

Schreuder FM, Jones UF (2004) The effect of saline instillation on sputum yield and oxygen saturation measurement in adult intubated patients (abstract). Physiotherapy, 90, 108-9
• single study design showing increased sputum yield with saline instillation

Seymour CW, Cross BJ, Cooke CR (2009) Physiologic impact of closed-system endotracheal suctioning in spontaneously breathing patients receiving mechanical ventilation. Respir Care, 54, 3, 367-74
• pre-oxygenation maintains oxygenation during and after suction
• adverse effects of suction last longer in sedated and paralysed patients than in weaning patients.

Siempos II, Vardakas KZ, Falagas ME (2008) Closed tracheal suction systems for prevention of ventilator-associated pneumonia. Br J Anaesth, 100, 3, 299-306.
• meta-analysis showing no benefit of closed over open suction: no difference in mortality or length of stay; closed system showed longer time on IPPV and higher colonisation rates.

Sole ML, Bennett M, Ashworth S (2015) Clinical indicators for endotracheal suctioning in adult patients receiving mechanical ventilation. Am J Crit Care; 24:318-324; doi:10.4037/ajcc2015794

Unoki T (2004) Effects of expiratory rib cage compression combined with endotracheal suctioning on gas exchange in mechanically ventilated rabbits with induced atelectasis. Resp Care, 49, 896-901
• rib cage compression probably exacerbates atelectasis

Vianna, J.R., Pires, V.A., Simυes, M.M., et al. 2017. Comparing the effects of two different levels of hyperoxygenation on gas exchange during open endotracheal suctioning: a randomized crossover study. Respir Care. 62(1),92-101. doi: 10.4187/respcare.04665.

Young-Ra J, Hee-Seung K, Park J-H (2002) Instillation of normal saline before suctioning in patients with pneumonia. Yonsei Med J, 43, 5, 607-12
• saline instillation can cause desaturation if used routinely

AARC = American Association for Respiratory Care
ACPRC = Association of Chartered Physiotherapists in Respiratory Care
ARDS = acute respiratory distress syndrome
FRC = functional residual capacity
HME = heat moisture exchanger
HFO = high frequency oscillation
SaO2 = saturation of haemoglobin with oxygen in arterial blood
PC = pressure control
PEEP = positive end-expiratory pressure
VC = volume control