Pulmonary Concepts In Critical Care

Airway Management



  1. HUMIDIFICATION – heated cascade provides 100% humidification of inhaled gases. Ensure systemic hydration is monitored to help keep secretions thin.
  2. AEROSOL THERAPY – nebulizers delivering aerosols increase secretion clearance and liquefy mucus; nebulizers may become a source of bacterial contamination.
  3. CUFF MANAGEMENT – essential for prevention of necrosis and aspiration. Two different cuff-inflation techniques are currently used:
  4. Minimal leak technique (ML) – inject air into cuff until no leak is heard and then withdrawing the air until a small leak is heard on inspiration. (Problems are related to maintaining PEEP, aspiration around the cuff, and increased movement of the tube.)
  5. Minimal occlusive volume technique (MOV) – inject air into cuff until no leak is heard, then withdrawing the air until a small leak is heard on inspiration, and then adding more air until no leak is heard on inspiration. (Problems are related to higher cuff pressures than ML technique.) Use only if patient needs a seal to provide adequate ventilation and/or is at high risk for aspiration.
  6. Monitor cuff pressures at least q. 8 h. Maintain pressure 18 to 22 mm Hg (25 to 30 cm H2O. Greater pressures decrease capillary blood flow in tracheal wall and lesser pressures increase risk of aspiration. Do not routinely deflate cuff.
  7. POSTURAL DRAINAGE & POSITIONING (see respiratory references).
  8. Key Point: Pneumonia = "Good lung down position"
  9. ARDS = prone positioning for improved oxygenation
  10. SUCTIONING – perform as sterile procedure only when patient needs it and not on a routine schedule. Observe for hypoxemia, atelectasis, bronchospasms, cardiac dysrhythmias, hemodynamic alterations, increased intracranial pressure, and airway trauma.



The nurse performs endotracheal and tracheostomy suctioning to:

  1. Maintain a patent airway.
  2. To improve oxygenation and reduce the work of breathing.
  3. To remove accumulated tracheobronchial secretions using sterile technique.
  4. Stimulate the cough reflex.
  5. Prevent pulmonary aspiration of blood and gastric fluids.
  6. Prevent infection and atelectasis.


Sterile normal saline
Suction source
Ambu bag connected to 100% O2
Clear protective goggles/mask or face shield                   
Sterile gloves for open suction        
Clean gloves for (in-line) closed suction
Sterile catheter with intermittent suction control port or In-line suction catheter


1. Wash hands. Reduces transmission of microorganisms.

2. Assess patient’s need for suctioning. Since endotracheal suctioning can be hazardous and causes discomfort, it is not recommended in the absence of apparent need.

Coarse breath sounds
Coughing; increased respirations
Increased PIP on ventilator

3. Don goggles and mask or face shield. Potential for contamination

4. Turn on suction apparatus and set vacuum regulator to appropriate negative pressure. Recommend 80-120 mmHg; adjust lower for children and the elderly. Significant hypoxia and damage to tracheal mucosa can result from excessive negative pressure.

5. Prepares suction apparatus. Secure one end of connecting tube to suction machine, and place other end in a convenient location within reach.

6. Use in-line suction catheter or open sterile package (catheter size not exceeding one-half the inner diameter of the airway) on a clean surface, using the inside of the wrapping as a sterile field.

7. Prepares catheter and prevents transmission of microorganisms. Catheter exceeding one-half the diameter increases possibility of suction-induced hypoxia and atelectasis.

8. Prepare catheter flush solution.With in-line catheter use sterile saline bullets to flush catheter. With regular suctioning set up sterile solution container and being careful not to touch the inside of the container, fill with enough sterile saline or water to flush catheter.

9. With in-line suction catheter use clean gloves. With regular suctioning, done sterile gloves. Maintain sterility. Universal precautions. In regular suctioning the dominant hand must remain sterile throughout the procedure.

10. Pick up suction catheter, being careful to avoid touching nonsterile surfaces. With nondominant hand, pick up connecting tubing. Secure suction catheter to connecting tubing. Maintains catheter sterility. Connects suction catheter and connecting tubing

11. Ensures equipment function. Check equipment for proper functioning by suctioning a small amount of sterile saline from the container. (skip this step in in-line suctioning)

12. Remove or open oxygen or humidity device to the patient with nondominant hand. (skip this step with in-line suctioning). Opens artificial airway for catheter entrance. Have second person assist when indicated to avoid unintentional extubation.

13. Replace O2 delivery device or reconnect patient to the ventilator. Hyperoxygenate and hyperventilate via 3 breaths by giving patient additional manual breaths on the ventilator before suctioning. Hyperoxygenation with 100% O2 is used to offset hypoxemia during interrupted oxygenation and ventilation. Preoxygenation offsets volume and O2 loss with suctioning. Patients with PEEP should be suctioned through an adapter on the closed suction system.

14. Without applying suction, gently but quickly insert catheter with dominant hand during inspiration until resistance is met; then pull back 1-2 cm. Catheter is now in tracheobronchial tree. Application of suction pressure upon insertion increases hypoxia and results in damage to the tracheal mucosa.

15. Apply intermittent suction by placing and releasing dominant thumb over the control vent of the catheter. Rotate the catheter between the dominant thumb and forefinger as you slowly withdraw the catheter. With in-line suction, apply continuous suction by depressing suction valve and pull catheter straight back. Time should not exceed 10-15 seconds. Intermittent suction and catheter rotation prevent tracheal mucosa when using regular suctioning methods. Unable to rotate with closed- suction method.

16. Replace oxygen delivery device. Hyperoxygenate between passes of catheter and following suctioning procedure. Replenishes O2. Recovery to base PaO2 takes 1 to 5 minutes. Reduces incidence of hypoxemia and atelectasis.

17. Rinse catheter and connecting tubing with normal saline until clear. Removes catheter secretions.

18. Monitor patient’s cardiopulmonary status during and between suction passes. Observe for signs of hypoxemia, e.g. dysrhythmias, cyanosis, anxiety, bronchospasms, and changes in mental status.

19. Once the lower airway has been adequately cleared of secretions, perform nasal and oral pharyngeal or upper airway suctioning. Removes upper airway secretions. The catheter is contaminated after nasal and oral pharyngeal suctioning and should not be reinserted into the endotracheal or tracheostomy tube.

20. Upon completion of upper airway suctioning, wrap catheter around dominant hand. Pull glove off inside out. Catheter will remain in glove. Pull off other glove in same fashion and discard. Turn off suction device. Reduces transmission of microorganisms.

21. Reposition patient. Supports ventilatory effort; promotes comfort; communicates caring attitude.

22. Reassess patient’s respiratory status. Indicates patient’s response to suctioning

23. Dispose of suction liners and connecting tubing, sterile saline solution every 24 hours and set up new system. Decreases incidence of organism colonization and subsequent pulmonary contamination. Universal precautions.


1. Minimize suctioned-induced atelectasis and hypoxemia:

a. Avoid using catheters larger than one-half the diameter of the airway.

b. Administer one or more postsuctioning hyperinflations, using manual or sigh breaths on the ventilator or ambu bag if not ventilated.

2. Maintain rigorous sterile technique when suctioning the intubated patient. Impaired pulmonary defense systems and invasive instrumentation of the pulmonary tract predisposes these patients to colonization and infection. Never use same catheter to suction the trachea after it has been used in the nose or the mouth.

3. Limit the frequency of suctioning and avoid, as much as possible, catheter impaction in the bronchial tree when the patient is anticoagulated or when hemorrhage from suction-induced trauma is evident.

4. Minimize the frequency and duration of suctioning when patient is on positive end-expiratory pressure (PEEP) greater than 5 cm or continuous positive airway pressure (CPAP). Small suctioning-induced changes may have profound effects on these marginally oxygenated patients.

5. Maintain awareness of the limitations of ET/tracheal suctioning. Maneuvers and catheter design have been proposed to increase the likelihood of passage into the left bronchus; however, these have been shown to be of limited success. Because the left main stem bronchus emerges from the trachea at the 45-degree angle from the vertical, suction catheters are almost inevitable passed into the right bronchus (when they pass the carina) despite head-turning, etc.

6. The use of saline installations for loosening secretions has been controversial and recent research shows that in fact it is detrimental and poses a greater risk of pneumonia for the patient.


1. Include strategies to move secretions through peripheral airways. These measures are: appropriate hydration and adequate humidification of inspired gases (to keep secretions thin); coughing and deep breathing; frequent position changes (may need rotation bed); chest physiotherapy; and bronchodilating agents as ordered.

2. Monitor the patient carefully during ET/tracheal suctioning for ectopic dysrhythmias aggravated by suction-induced hypoxemia and other dysrhythmias, particularly conduction disturbances, related to catheter irritation of vagal receptors within the respiratory tract (requires immediate cessation of suctioning and hyperoxygenation).





Nosocomial pulmonary tract infection


Mucosal trauma with increase secretions

Cardiac arrest

All comments and questions about content at this site should be sent to Nurse Bob

This page last updated 07/25/10