7 Tips For Successful Endotracheal (ET) Suctioning

7 Tips For Successful Endotracheal (ET) Suctioning

Endotracheal suctioning is often necessary for ventilated patients, but it comes with significant risks ranging from respiratory distress to cardiac arrhythmias to hypertension, according to a 2009 study in Pediatric Critical Care Medicine.(1). Endotracheal tubes (ET) can irritate the airways and cause an increase in secretions. (1) However, suctioning is used frequently in pediatric intensive care units (PICUs) because intubated patients can’t clear secretions very well due to glottis closure blockages, and impairment of normal mucus production (1).

While studies in the medical literature do not always agree on best practices to balance benefits over risks, respiratory therapists and researchers make the following recommendations:

  1. Suction only as needed: The literature does not agree on an appropriate frequency of suctioning, but one 2009 study in Intensive and Critical Care Nursingsuggested it should be performed only when necessary due to its risks and adverse effects. (2), including that patients often describe it as “painful and uncomfortable, and may result in a choking sensation.” Despite the discomfort, it is often a necessary procedure that can improve breathing. (2)
  2. Increase oxygen in different amounts for adults and children: While pre-oxygenation at 100% is the typical practice with adults before, during and after intubation, that same level of oxygen can cause hyperoxia—over oxygenation—in preterm infants according to a 2010 article in Respiratory Therapist. (3) However, some oxygen is necessary in infants to prevent bradycardia—a slowing of the heart rate—and apnea so, many NICUs recommend oxygen at 10 to 20 percent before intubation.(3)
  3. Use low vacuum pressure unless otherwise necessary: A number of studies recommend using the lowest vacuum pressure to reduce risks of hypoxia—a lack of oxygen—atelectasis, and tracheal mucosa injury. (2)However, the pressure has to be strong enough to remove the secretion. So researchers suggest nurses and respiratory therapists don’t rely on the manometer dial of the suctioning equipment alone. “[I]t depends on the suction catheter-ET-tube ration, the duration of the procedure and the volume and viscosity of the secretions.” (2)  Ultimately, they recommend the lowest possible suction pressure—usually between 80 and 120 mmHg, unless the secretion is not responding. (2)
  4. Choose the right suction catheter size: If a suction catheter is too large for the ET or there is too much vacuum pressure, atelectasis can occur (3). Ideally, the general recommendation is to use a suction catheter “that has an external diameter less than 50% of the size of the [endotracheal tube (ETT)] inner diameter,” according to Respiratory Therapist. Or, put another way, a suction catheter that “occludes less than one-half the internal diameter of the ETT lumen,” and to always use the smallest suction catheter possible that will still allow for effective aspiration. (3)
  5. Weigh the pros and cons of open or closed suctioning systems: While the literature is inconclusive as to whether open trachea or closed tracheal suctioning systems cause greater infections or trauma to tissues, many health care professionals have come to prefer closed suctioning systems (CSS or CTSS) for their convenience and speed. According to a study in the Egyptian Journal of Chest Diseases and Tuberculosis(4), CTSS had the following advantages over OTSS: “improved oxygenation; decreased clinical signs of hypoxemia; maintenance of positive end-expiratory pressure; limited environmental, personnel and patient contamination; and smaller loss of lung volume.”
  6. Use continuous suction: Both continuous and intermittent suctioning can cause some damage to the trachea (2), however, when using the CTSS system, researchers recommend using continuous suctioning, otherwise there is a risk of alveolar collapse.
  7. Use shallow suction depth when possible: While studies in neonates found no major differences in heart rate and oxygen saturation between deep or shallow suctioning, deeper suctioning can cause mucosal injury, bleeding, and even vagal stimulation and bradycardia. (3) However, sometimes deep suctioning is needed, particularly when there are larger amounts of mucus in the lower airways. In lieu of more conclusive studies, the general recommendation is to “minimize the use of deep suctioning.” (3)


  1. Morrow BM, Argent AC. Pediatr Crit Care Med. 2008 Sep; 9(5):465-77. doi: 10.1097/PCC.0b013e31818499cc.A comprehensive review of pediatric endotracheal suctioning: Effects, indications, and clinical practice.
  2. Pedersen, Carsten M. Intensive and Critical Care Nursing. 2009. 25, 21-30. Endotracheal suctioning of the adult intubated patient—What is the evidence? doi: 10.1016/j.iccn.2008.05.004
  3. Hahn, Michael, RPFT, RRT-NPS. Respiratory Therapist. July, 2010. “10 Considerations for Endotracheal Suctioning.” http://www.rtmagazine.com/2010/07/10-considerations-for-endotracheal-suctioning/
  4. Elmansoury, Ahmed. Egyptian Journal of Chest Diseases and Tuberculosis. Closed suction system versus open suction. 2017. 509-515. http://dx.doi.org/10.1016/j.ejcdt.2016.08.001