Airway Suctioning: ETT & Tracheostomy — Open vs Closed Nursing Guide
On a ventilated ICU bay, suction is often the difference between stable gas exchange and a preventable desaturation—this guide covers when to suction, how to protect PEEP and oxygenation, and how open and closed systems change your bedside choices, linked to respiratory assessment, mechanical ventilation monitoring, and hypoxia symptoms.
Contents
Quick Facts
Key Takeaway
Suction only when secretion retention is clinically evident—and treat each pass as a brief interruption to gas exchange. Use the lowest effective pressure, apply suction only while withdrawing, avoid routine saline instillation into the airway, and stop immediately if hypoxia or haemodynamic instability appears.
Quick procedure summary
| Procedure | Airway suctioning (artificial airway) |
| Also known as | Tracheal suctioning, endotracheal suctioning, Yankauer/oral suctioning (oropharyngeal) |
| Category | Respiratory / critical care airway management |
| Purpose | Remove retained secretions to improve ventilation, oxygenation, and airway patency |
| Who performs | Registered nurses and respiratory therapists per scope; physicians for advanced airway decisions |
| Typical time | 5–15 minutes including assessment and recovery between passes |
| Settings | ICU, HDU, emergency department, respiratory wards, theatre recovery |
What is airway suctioning?
Airway suctioning removes secretions from an artificial airway—most often an endotracheal tube (ETT) or tracheostomy—to restore airflow and reduce work of breathing. It is not a benign comfort measure: each pass can cause hypoxemia, mucosal trauma, bleeding, bronchospasm, and vagally mediated bradycardia.
This page focuses on lower-airway suction via ETT or tracheostomy (open sterile catheter or closed inline system). Oropharyngeal Yankauer suction clears pooled secretions at the mouth and is a related but distinct skill—still important before mask ventilation or oral care, and often paired with the VAP bundle.
Indications & when not to suction
- Visible secretions in tube or stoma; gurgling or coarse wheezing with reduced air entry
- Rising peak pressures, falling tidal volumes, or obstruction-type ventilator alarms
- Drop in SpO2 or increased work of breathing when secretions are the likely driver—confirm with pulse oximetry and lung assessment
- Ineffective cough or inability to clear secretions (common with sedation or neuromuscular weakness)
- Do not suction “by the clock” without clinical signs
- Do not pass the catheter deeper than needed or force past resistance
- Do not routinely instill saline into the airway to “loosen” secretions
- Severe desaturation, cyanosis, or acute shortness of breath
- Bradycardia, arrhythmia, or hypotension during or after suction
- Frank bleeding, sudden high resistance, or suspected tube displacement
- Suspected mucus plugging with no improvement after one careful pass—consider chest X-ray and medical review
Circuit-break decision: open vs closed before you start
The first clinical judgment is not catheter size—it is whether you can afford to break the ventilator circuit. Patients with high PEEP or FiO2 (for example acute respiratory distress syndrome) derecruit quickly when disconnected.
| Patient context | Favour | Nursing focus |
|---|---|---|
| High PEEP / high FiO2 / unstable oxygenation | Closed inline suction when available | Pre-oxygenate per policy; minimise passes; watch SpO2 and pressures on ventilator monitoring |
| Stable low PEEP, brief disconnect tolerated | Open suction may be appropriate | Disconnect only at suction moment; reconnect rapidly |
| Thick tenacious plug not cleared with inline device | Medical/RT-led plan—may need open suction or bronchoscopy per orders | Do not force; escalate |
Equipment
Use the smallest effective catheter. Many policies target external diameter ≤ half the internal diameter of the airway. Institutional protocols and manufacturer instructions may vary.
Safety essentials
| Check | Action | Why |
|---|---|---|
| Indication | Confirm secretion retention; review recent changes | Avoids unnecessary trauma |
| Pressure | Lowest effective suction per policy/manufacturer | Reduces mucosal injury and atelectasis |
| Asepsis | Hand hygiene; sterile open technique | Limits cross-infection |
| Duration | Brief passes; recovery time between passes | Limits hypoxemia and vagal events |
| Technique | Insert without suction; suction on withdrawal | Reduces mucosal drag and hypoxemia |
Extra caution with severe asthma/bronchospasm, raised intracranial pressure, recent airway surgery, or cardiovascular instability. Align with closed suction and rapid escalation pathways when available.
Pre-oxygenation & pass timing
Suction-induced hypoxemia is common because suction removes gas as well as secretions. For at-risk patients, follow policy for hyperoxygenation or pre-oxygenation (ventilator FiO2 boost or BVM) immediately before and after open suction or between closed passes.
- Limit each pass to a few seconds; allow full recovery before repeating
- Watch for vagal bradycardia—especially in infants and ICU patients with high vagal tone
- Reassess difficulty breathing and ventilator data after every pass
Procedure steps
Verify patient, airway type, and indication
Confirm identity, ETT vs trach, orders, SpO2/HR/BP, and ventilator settings. Complete a focused respiratory assessment.
Prepare equipment and PPE
Set suction pressure per policy. Test the circuit. For open suction, open sterile supplies only when ready to minimise disconnect time.
Pre-oxygenate if indicated
Optimise oxygenation before the first pass when policy or patient risk requires it.
Advance catheter with circuit connected
Unlock inline device; advance gently to recommended depth or slight resistance—withdraw slightly if met. Do not force.
Suction only while withdrawing
Brief controlled pass; stop if coughing, bradycardia, or desaturation occurs.
Flush inline system and reassess
Flush catheter per IFU (into system, not routine airway instillation). Reassess breath sounds, SpO2, and pressures; repeat only if still indicated.
Sterile setup; disconnect only when ready
Don sterile gloves. Disconnect ventilator at the moment of suction to limit derecruitment.
Insert without suction; withdraw with suction
One controlled pass; re-oxygenate if the patient deteriorates.
Reconnect promptly and reassess
Restore circuit, confirm ventilation, dispose of single-use equipment, hand hygiene.
Document and communicate
Record indication, method, passes, secretions, response, and escalation. Notify if suction is frequent, purulent, or bloody.
Closed vs open suction comparison
Both are widely used. Closed systems often preserve PEEP and reduce aerosol spread; open suction allows a fresh sterile catheter each time. Evidence on ventilator-associated pneumonia prevention is mixed—individualise to the patient and unit policy.
- Circuit stays connected—less derecruitment
- Often better for high PEEP/FiO2
- Lower splash exposure; follow catheter change policy
- Single-use sterile catheter each time
- May suit stable patients or when inline device unavailable
- Requires strict asepsis and rapid reconnection
ETT vs tracheostomy specifics
- Minimise time off ventilator during open suction
- Watch biting, kinking, cuff leak, tube migration
- Pair with oral care and subglottic suction if device has a port (per orders)
- Check inner cannula patency—plug may be cannula not lungs
- Humidification is critical; thick secretions often reflect drying
- Do not tug ties; know tracheostomy emergency algorithm
VAP bundle alignment when suctioning ventilated patients
Suctioning sits inside broader ventilator-associated infection prevention. Coordinate with the VAP bundle: head-of-bed elevation, scheduled mouth care, sedation targets, and circuit management per policy—not ad hoc circuit breaks.
- Prefer closed suction when supplied to reduce disconnections
- Perform hand hygiene and PPE for splash/aerosol risk
- Escalate purulent secretions with fever or worsening oxygenation as possible pneumonia—cultures per orders
Complications & troubleshooting
| Problem | Signs | Action |
|---|---|---|
| Hypoxemia | SpO2 drop, distress, alarms | Stop; re-oxygenate; consider closed suction next time; escalate if persistent |
| Bradycardia | HR fall, hypotension | Stop suction; oxygenate; urgent review if unstable |
| Bleeding | Blood-streaked or frank blood | Lower pressure; fewer passes; notify for significant bleeding |
| Mucus plug | High pressures, low volumes, resistance | Stop; assess patency/position; escalate immediately |
Documentation pitfalls: weak vs safer notes
“Suction done. Patient OK.”
“Closed inline suction for coarse breath sounds and peak pressure 38→32 cmH2O. One 8 s pass; thick yellow secretions moderate volume. SpO2 91→94% on FiO2 0.60. No bleeding. RT notified re frequent suction.”
Documentation
- Indication and pre-suction assessment findings
- Airway type; open vs closed; catheter size; pressure setting per policy
- Number of passes, secretion description, patient tolerance
- Pre/post SpO2, HR, ventilator pressures; complications and notifications
If someone with a tracheostomy develops sudden breathing difficulty, noisy breathing, bluish lips, heavy bleeding, or the tube looks displaced, seek urgent help and follow your emergency tracheostomy plan.
NCLEX practice questions
When peak pressures climb and SpO2 drifts down between suction passes, circuit breaks and catheter technique decide oxygenation—rehearse NCLEX-style clinical judgment practice for airway suctioning on high PEEP: priority action, select-all-that-apply cues, post-suction trend interpretation, matrix escalation, documentation cloze, and ordered open-suction steps (recognise cues → analyse → prioritise → act → evaluate outcomes).
Unfolding case — ICU. Ms. Rivera, 58, is intubated day 4 for pneumonia progressing to ARDS. PEEP 12 cmH2O, FiO2 0.60. After open suction with circuit disconnect, SpO2 fell from 94% to 86%, peak pressure rose from 34 to 40 cmH2O, and coarse secretions remain audible. Inline closed suction is available.
Answer key & rationale
Frequently asked questions
Should suctioning be scheduled every two hours?
Generally no—suction when assessment shows retention. Scheduled suction without indications increases complications.
Can saline loosen secretions?
Routine instillation is discouraged; it may worsen oxygenation. Use only when policy or a specific order supports it.
What if the catheter will not pass?
Do not force. Reassess catheter size, biting, kinking, mucus plug, or displacement. For tracheostomy, consider inner cannula obstruction. Escalate promptly.
When is closed suction preferred?
When maintaining PEEP/FiO2 matters—common in ARDS, high oxygen requirements, or when limiting aerosol exposure is a priority.
How does tracheostomy suction differ from ETT suction day to day?
Tracheostomy adds humidification and cannula/stoma considerations; ETT emphasises circuit integrity and oral fixation. See our tracheostomy care and endotracheal tube care guides.
References
Authoritative sources used to develop this guide. Royal Marsden procedure principles are attributed to official RMM Online pages; proprietary step text and illustrations are not reproduced. Each citation lists the source first; the URL is the page used for content alignment.
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American Association for Respiratory Care. Clinical Practice Guideline: Endotracheal Suctioning of Mechanically Ventilated Patients With Artificial Airways (2022).https://www.aarc.org/wp-content/uploads/2022/10/cpg-artificial-airway-suctioning.pdf
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National Tracheostomy Safety Project (NTSP). Tracheostomy care and emergency resources (UK).https://tracheostomy.org.uk/
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NTSP. Cuff management and airway care considerations.https://tracheostomy.org.uk/storage/files/Cuff%20management.pdf
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Centers for Disease Control and Prevention. Guideline for preventing health care-associated pneumonia — HCP hub.https://www.cdc.gov/infection-control/hcp/pneumonia-prevention/index.html
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Royal Marsden Manual — Tracheostomy: suctioning a patient (single-use suction catheter) (Chapter 12).https://www.rmmonline.co.uk/manual/c12-fea-0018
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The Royal Marsden Manual of Clinical Nursing Procedures — Procedures (RMM Online hub).https://www.rmmonline.co.uk/contents/procedures
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Cochrane Review: Closed tracheal suction systems versus open tracheal suction systems for mechanically ventilated adult patients.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004473.pub3/full
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OpenStax. Clinical Nursing Skills — artificial airway and suctioning fundamentals.https://openstax.org/details/books/clinical-nursing-skills
This page summarises evidence-based nursing principles aligned with licensed Marsden Nursing Procedure materials in the project library; it does not reproduce proprietary manual text. Use your institutional subscription for verbatim steps.
Editorial standards & medical review
About the author: Sid A. Abdala Balal, RN, writes evidence-based nursing education focused on practical bedside skills, patient safety, and clinical decision support for nurses.
Medical review: This guide is reviewed by Dr. Adam Sayedi, MD, for clinical accuracy, clarity, and alignment with current artificial-airway suctioning and infection prevention standards.
Policies: Medical Review Process · Editorial Policy · Correction Policy