Ambulance lights | suction and intubation best practices

When you think of intubation, you should automatically be thinking "suction." The two treatments go hand in hand; you cannot safely intubate without the aid of suction, which is why you must include the portable suction unit anytime there is the possibility of intubating.


Suction plays several important roles in securing an advanced airway. They include:


  • Maintaining patency in the tenuous airway while you assemble your equipment
  • Clearing mucus, vomit, and blood prior to inserting the blade
  • Visualizing the cords prior to inserting the tube
  • Clearing the tube of froth and blood, once the patient is intubated


Include the portable emergency suction unit in your ALS assemblage or stow a suction unit in your airway bag so that it is always available.

New: Ultimate Guide To Purchasing A Portable Emergency Suction Device

Deciding When to Intubate

Deciding when a patient needs an advanced airway is a crucial step in treatment. The key is to differentiate between a patient in respiratory distress and a patient in failure.

Respiratory distress is characterized by: 

  • Mild anxiety
  • Normal level of consciousness
  • Cyanosis may be present but should be minimal
  • Tachycardia
  • Chest tightness is a possibility
  • Breath sounds may be altered
  • Decreased O2 saturation


A patient in respiratory failure needs immediate intervention, preferably with an advanced airway. He or she will exhibit the following signs:

  • Altered mental status
  • Use of accessory muscles or retraction
  • Tachycardia typically >130 bpm
  • Decreased O2 saturation, even with oxygen therapy
  • Dyspnea that interferes with speech
  • Absent breath sounds and abnormal respiratory patterns
  • Cyanosis
  • Pale skin and diaphoresis


Assembling Your Equipment

Once you decide that intubation is needed, the next step is to assemble your equipment. Have someone maintain airway patency while this important step is accomplished. Have suction at the ready, to keep the airway clear. Your intubation equipment will include:

  • PPE – gloves, mask, and goggles
  • Appropriately sized tube (most adults accept a size 7.0 to 8.0)
  • Appropriately sized laryngoscope handle and blade (either Miller or Macintosh, depending on personal preference)
  • 10 mL syringe
  • Water-soluble lubricant (especially for nasal intubation)
  • Commercial tube-holding device
  • Bag mask with reservoir
  • Supplemental oxygen
  • Stethoscope
  • ETCO2 detector

COVID-19 requires some extra precautions. Be sure to wear a fit-tested N95 respirator, face protector such as a shield, gown, and gloves. Plan what you will be doing carefully, and do it as quickly as possible.

Suctioning the Endotracheal Tube

Once you have the endotracheal tube in place, your patient may still require suction. If the patient has chest or airway trauma, or a history of COPD, he or she may have bloody froth enter the tube from the lungs. In such situations, it may be necessary to suction the tube.  


The main tool you'll need is your portable suction unit, which should already be in place during intubation. Next, you will need to:

  • Choose an appropriate suction catheter—a small, flexible French catheter
  • Check, prepare, and assemble your equipment
  • Maintain universal precautions—use a sterile technique throughout the procedure
  • Lubricate the suction catheter
  • Preoxygenate the patient for at least one minute with 100 percent oxygen
  • Measure the suction catheter tip from the corner of the mouth to the angle of the jaw or insert into the endotracheal tube until the patient coughs
  • Apply suction as you remove the suction catheter using a twisting motion
  • Suction for no longer than five to 10 seconds at a time
  • Monitor the patient via pulse oximetry, capnography, and vital signs
  • Continually reassess the airway, endotracheal tube, and lung sounds
  • Preoxygenate your patient in between each suction procedure


Possible Complications of Endotracheal Suctioning

As with any airway procedure, you may experience complications. Be alert for the following:

  • Hypoxemia
  • Cardiac arrhythmias
  • Signs of airway trauma
  • Increased intracranial pressure
  • Buildup of mucus plugs


Be sure to keep the portable suction unit nearby should the tube become dislodged or the patient vomits. Even with an endotracheal tube in place, the patient may still vomit, necessitating rapid suction.


Your best practices for both suction and intubation are to think of them as inseparable: Never attempt intubation without the portable suction unit and always have suction at the ready during any respiratory emergency.


Editor's Note: This blog was originally posted on Nov 2017 and has recently been updated with new content. 


2011, Pollak, A., Ed.

Critical Care Transport, American College of Emergency Physicians, Jones and Bartlett.