Airway suctioning refers to the collective measures that are used for clearing the airway of a patient. It involves suctioning, clearing secretions, and maintaining the patency of the airway. It is of particular importance for patients with mechanical ventilators, endotracheal tube (ET) intubations, tracheostomies, or other airway adjuncts. Clearance of airway secretions is a normal process and is critical to the prevention of respiratory infections, atelectasis, and preservation of airway patency. Patients on mechanical ventilation and intubated patients are at risk of increased secretions as they are sedated, supine, and have mechanical adjuncts that prevent spontaneous clearance of secretions. Suctioning can help maintain and establish the gas exchange, adequate oxygenation, and alveolar ventilation. Suctioning can be performed through an endotracheal tube, a tracheostomy tube, the mouth, or the nose.
There are two separate suctioning techniques, namely the closed and open system. Basic principles of suctioning are the same, and care should be incorporated during suctioning. Closed suctioning includes an inline suctioning system.
There is no consensus on the time interval for suctioning airways. It depends on the clinical picture; such as the age of the patient, the associated risk factors, and the ease of obtaining adjunct airway equipment in case of disruption or loss of the airway. Studies of newborns did not show increased risks between 6- or 12-hour intervals. 
Airway anatomy can be divided into two parts: (1) Upper airway anatomy, including the nasal cavity, nasopharynx, oropharynx, laryngopharynx and the larynx, and (2) Lower airway anatomy, including the trachea, bronchi, bronchioles, and the alveoli.
Extra care should be taken while suctioning the airway in children because they have narrow airway calibers, difficult accessibility, and relative deleterious effects from small changes in pressure, oxygen saturations, and lung volumes.
There is no absolute contraindication to suctioning of the airway. Risks are associated with suctioning and should be weighed as per individual patient specific needs. Care should be taken if patients have bradycardia, hypoxia, or other similar complaints or concerns. Risks and benefits have to be calculated for the benefit of the patient.
An oxygen source, vacuum source, sterile gloves, stethoscope, calibrated, adjustable regulator, collecting bottle and tubing, normal saline, and or sterile water for irrigation should be prepared and ready prior to suction. Personal protective equipment should always be used and includes a gown, mask, and preferably goggles. Use of sterile gloves is recommended. Sterile lubricant should be used for nasal suctioning.
The monitoring device, SPO2, end tidal CO2 monitors and cardiorespiratory monitor should be available prior to suction.
It is important to use adequate caliber tubes or suction catheters to prevent injuries, dislodgement, or perforation.
Personnel equipped with knowledge on suctioning and airway anatomy should be performing airway suctioning. Detailed knowledge about the apparatus, respiratory adjuncts, and adequate bag and mask ventilation are some of the skills with which personnel involved with airway suctioning should be comfortable.
Suctioning of the airway requires meticulous preparation by personnel. All supplies should be gathered and prepared in a sterile environment. A verbal or written consent should be obtained depending on the patient's condition. The suction catheter should be connected to a vacuum source.
Preparation for suctioning also depends on an emergent versus a non-emergent need for suctioning. In cases of acute respiratory distress, where obstruction of the airway or the airway adjunct is suspected, suctioning must be performed emergently with even minimal preparation. Care should be taken to maintain sterility while suctioning the endotracheal/tracheostomy tubes. Suctioning of the oropharynx or the nasopharynx does not require complete sterility.
In non-emergent suctioning, all equipment and personnel should be thoroughly prepared.
Preparation should be involved prior to suctioning the airway. Suctioning should only be started only after all supplies and necessary personnel are gathered and consent is obtained.
Preoxygenation with 100% oxygen should be initiated prior to suctioning. This is in preparation for the hypoxia that is precipitated by suctioning, both from mechanical interruption and cessation of oxygen flow briefly. Lubrication of the ends of the catheter with petroleum jelly is recommended if suctioning through the nose. The suction catheter should be introduced slowly down the nose and mouth. It is recommended to stop if there is increased resistance and reintroduce after a brief period of oxygenation and interruption. The catheter should be introduced to the desired depth, and then suctioning should be started. Brief, 10-second suction duration is usually recommended to avoid mucosal damage and prolonged hypoxia.
On withdrawing the catheter, slow spiral motions should be performed to minimize mucosal trauma. If there is a need for repeated suctioning, care should be taken to maintain and normalize vital signs in between suction episodes with special attention to the heart rate and oxygen saturation levels.
Suctioning via the ET tube is usually in two forms: open suction and closed suction. Many recent studies do not recommend the use of normal saline instillation prior to the suctioning episode. There are studies supporting the increased risk of hypoxia, bradycardia, and vagal stimulation/aspiration with normal saline used for suctioning.
Rarely patients may need to be sedated or given analgesia prior to suctioning their airways.
The adequacy of suctioning can be assessed by the clearance of secretions, improved breath sounds, improved air entry, good pulse oximetry readings, and improvement in respiratory distress in a patient.
Complications from airway suctioning are relatively uncommon if performed with care and adequate pre-oxygenation.
Suctioning is a lifesaving procedure requiring timely and precise methodology. If done appropriately with caution, it decreases the risk of infection, pooling of secretions, and prolonged hypoxia.
Suctioning of the airways should be performed by skilled personnel with appropriate preparation. Suctioning has both therapeutic and diagnostic benefits. It is important to gather appropriate equipment prior to suctioning and have adequate knowledge of the airway anatomy, the airway adjuncts in use, and the equipment available.
Suctioning of the airway should be performed with adequate care to avoid injuries, trauma, bleeding, prolonged hypoxia, and bradycardia. Preparation is the key, and the personnel should be aware of the complications and corrective measures. Suction, oxygen, pharmacy, equipment, and adequate medications are absolute prerequisites to obtaining and maintaining a successful patent airway. 
An evidence-based approach to airway suctioning
The two key professionals intimately involved in the care of the airways are the respiratory therapist and the nurse. While the respiratory therapist will suction patients at set times, the nurse will usually suction the airways more frequently as he or she is always at the bedside. The importance of suctioning of both ventilated and non-ventilated patients cannot be overstated. Presence of thick viscous secretions can lead to atelectasis, a decrease in oxygenation and even collapse of the lung lobe(s). Besides suctioning, these professionals also auscultate the lungs, monitor the pulse oximetry, check the secretions for odor and color to rule out an infection, recommend an arterial blood gas or even a change in the ventilator settings. Suctioning is often ordered by the physician but both the nurses and respiratory therapist frequently assess the patient for more suctioning if needed. Also intimately involved in patients who need suctioning of the airways is the radiologist. When atelectasis or a lung pathological process is suspected, x-rays are frequently ordered. In patients who are heavily sedated, the pharmacist also plays a vital role in adjusting the pain medications, so that the patient can breathe and cough up the secretions. (Level III)
When suctioning is done correctly, the majority of patients have a good outcome. Complications are rare with suctioning but too frequent and aggressive suctioning can lead to hypoxia and iatrogenic injuries to the airways. (Level V)