Suctioning explained: oral, nasopharyngeal and endotracheal suctioning

Nasopharyngeal suctioning, oral suctioning and endotracheal suctioning are the three main ways clinicians clear secretions from an airway that a patient cannot clear by coughing. Oral suction uses a rigid Yankauer tip in the mouth; nasopharyngeal and nasotracheal suction pass a flexible catheter through the nose; artificial-airway suction clears an endotracheal tube or tracheostomy with an open or closed (inline) catheter.

This article explains each type, when it is used, the main risks and the equipment a facility needs. It is educational background for trained staff and equipment buyers, not a substitute for clinical training. Always follow your local protocols and the manufacturers' instructions for use.

What is a suctioning procedure?

A suctioning procedure removes secretions, blood, vomit or other material from the airway using negative pressure. A catheter or tip is connected through tubing and a collection canister to a vacuum source: hospital wall suction or an electric suction machine.

Suctioning is indicated by assessment, not by the clock. Signs that commonly prompt suctioning include:

• Visible or audible secretions in the mouth or airway
• Coarse crackles or rattling breath sounds over the large airways
• Falling oxygen saturation with suspected secretion retention
• On a ventilator, rising peak airway pressures or a sawtooth pattern on the flow waveform
• An ineffective cough in a patient who cannot clear their own airway

The 3 types of suctioning

Each type reaches a different part of the airway and uses different equipment.

Oral suctioning

Oral suctioning clears the mouth and oropharynx, usually with a rigid Yankauer tip. It is the simplest and least invasive form of airway suction, and the one most often needed in emergencies, recovery rooms and wards.

Because the tip stays in the mouth, oral suctioning is generally a clean rather than sterile technique. Staff avoid pushing the tip into the back of the throat, which can trigger gagging and vomiting. Our guide to Yankauer suction tips, canisters and tubing covers the devices themselves.

Nasopharyngeal suctioning

Nasopharyngeal suctioning passes a soft, lubricated catheter through a nostril into the pharynx to remove secretions the patient cannot clear. The catheter is inserted without suction and suction is applied as it is withdrawn.

Key points for practice:

• Caution or avoidance after facial or basal skull trauma, with nasal obstruction, active nosebleeds or bleeding disorders, and following some head and neck surgery.
• Repeated suctioning through the same nostril can injure the mucosa; some protocols use a nasopharyngeal airway to protect the tissue when frequent suctioning is needed.
• Infants. Nasopharyngeal suctioning in infants is common in bronchiolitis. Superficial nasal suction can ease feeding and breathing, but research has associated deep nasopharyngeal suctioning with longer hospital stays in infants with bronchiolitis, so many units prefer gentle nasal suction. Follow your pediatric protocol.

Nasotracheal suction

Nasotracheal suction advances a sterile catheter through the nose, past the larynx and into the trachea, in patients who do not have an artificial airway but cannot cough secretions up. It is more invasive and uncomfortable than nasopharyngeal suctioning.

Risks include hypoxemia, bradycardia and other arrhythmias, laryngospasm, bronchospasm and mucosal bleeding. Nasotracheal suction is typically performed by experienced staff with oxygen and monitoring available, and the need for it should prompt a review of whether the patient's airway plan is adequate.

Endotracheal and tracheostomy suctioning

Suctioning an endotracheal tube or tracheostomy clears secretions from the artificial airway and trachea. The American Association for Respiratory Care (AARC) clinical practice guideline on artificial airway suctioning is the most widely cited reference. Its main recommendations include:

• Suction only when secretions are present, not routinely
• Use the lowest effective suction pressure; the guideline cites about 80–100 mmHg for neonates and less than 150 mmHg for adults
• Limit each suctioning event to less than 15 seconds
• Use a catheter that occludes less than 50% of the tube lumen in children and adults, and less than 70% in infants
• Prefer shallow over deep suctioning
• Do not routinely instill normal saline before suctioning
• Consider preoxygenation if the patient's oxygen saturation drops significantly with suctioning

Shallow vs deep suctioning a trach

In shallow suctioning, the catheter is advanced only to a pre-measured depth, approximately the length of the tube plus its connector. In deep suctioning, the catheter is advanced until resistance is met, then withdrawn slightly before suction is applied. Deep suctioning has not been shown to work better and may cause more mucosal damage, which is why guidelines favor shallow suctioning.

What suctioning a trach involves

At a high level, the steps of suctioning a trach follow the same arc in most protocols: assess the need, explain to the patient, perform hand hygiene and put on protective equipment, check the suction source and pressure, oxygenate if indicated, insert the catheter without suction, apply suction while withdrawing, reassess, and document. The exact sequence, pressures and catheter sizes must come from your facility's procedure and supervised training, especially for home caregivers.

Open suctioning vs closed (inline) suctioning

Open and closed suctioning are two ways to suction a ventilated patient's artificial airway.

The AARC guideline suggests closed suctioning for adults with high oxygen or PEEP requirements or a risk of derecruitment, and for neonates. Rates of ventilator-associated pneumonia have not been shown to differ clearly between the two methods, so the choice usually rests on oxygenation, infection control and cost.

Suctioning a newborn after delivery

Routine suctioning of the mouth and nose is no longer recommended for newborns who are breathing well and have good tone, including when the amniotic fluid is meconium stained. Current neonatal resuscitation guidance reserves suction for babies whose airway appears obstructed or who need positive-pressure ventilation.

When suction is needed in newborns, staff typically use a bulb syringe or a suction catheter at a low, controlled pressure, mouth before nose. An infant suction machine therefore needs fine control at the low end of its vacuum range and a clearly readable gauge.

For parents asking about phlegm in an infant's throat: most babies clear mucus themselves by swallowing, coughing and sneezing, and saline drops with a bulb syringe are usually enough for a blocked nose. Parents should contact their clinician promptly if the baby has difficulty breathing, poor feeding or a change in color, and should not use an infant nasal suction machine unless it has been recommended and they have been shown how.

Complications of airway suctioning

Every type of suctioning has risks, which is why it is done only when needed and with monitoring where appropriate.

Lung suctioning: what suction can and cannot reach

Mucus suction from the lungs is limited to the large airways. A catheter reaches the trachea and, at most, the start of the main bronchi. Secretions in smaller airways are moved upward by coughing, positioning, chest physiotherapy, airway clearance devices and medicines, and are sometimes removed during bronchoscopy. This is why suctioning is combined with an overall airway clearance plan.

Types of suction machine for airway care

Facilities use several types of suction machine, often side by side:

• Hospital wall suction from the pipeline vacuum, with a regulator at the bed head
• Portable electric suction machines for wards, transport and home care
• Mobile high-flow units on castors for operating rooms and emergency departments
• Battery or AC/DC units for ambulances and patient transfers
• Manual suction devices, hand- or foot-powered, as backup where power may fail

For airway care, the essentials are an adjustable vacuum regulator with a readable gauge, an overflow valve and bacterial filter, and suitable flow. Keling's DFX-23A-II Electric Sputum Suction Machine portable sputum suction machine has a vacuum range of 0.013–0.07 MPa (about 100–525 mmHg), a 1,000 ml vessel and a noise level of 55 dB or less. For transport and home tracheostomy care, the DFX-23B-II Portable Electric Suction Machine adds AC/DC power with up to 2 hours of battery supply. ISO 10079-1 is the standard for electrically powered suction equipment; ask for the documents that apply to the model and your country.

Our portable suction machine guide covers choosing a unit for home and hospital use, and the medical suction machine guide explains flow, vacuum and jar sizes.

Next steps

Match the suction method to the patient and airway, follow your local protocol, and make sure every bed space, crash cart and transport bag has working suction with the right catheters. To equip wards, theaters or home-care programs, see the suction machines range or request a quotation.