Chief among a health care provider’s worst nightmares, apart from losing a patient, is unintentionally doing harm to one. In addition to a feeling of failure or shame, a poor outcome carries the risk of a malpractice allegation.


Human error and negligence are unfortunate but not uncommon in medicine, particularly emergency care, where providers may be working quickly, patients may be in a distressed state that makes treatment difficult, or the environment itself is working against all earnest efforts to manage a situation. 


During a delicate procedure, such as airway suction or intubation, an error can cause serious complications that compound the original issue. The following are complications and issues that can occur during suctioning that can lead to errors — and how to avoid them.


Causing physical trauma


Physical trauma to the airway often occurs when a suctioning or intubation procedure goes poorly. Bad technique, incorrect equipment or environmental circumstances can cause airway bruising, abrasions or bleeding in soft tissue areas, or more serious long-term injuries.


Misjudging the size of the tubing or catheter used in suctioning and intubation is an easy way to cause an injury. Too large of a tube, and it may damage the airway; too small, and the suction or intubation may not be effective. In most cases, a suction catheter should have an external diameter that is less than half the internal diameter of the endotracheal tube. Keeping multiple sizes on hand is a must for emergency teams.


Additionally, children have smaller airways and geriatric patients generally have more delicate, weaker tissues, so size, as well as suctioning power, play a role in mitigating injury in those patient groups. For children, specifically, a small suctioning tip should be used, and a soft tip with French sizing for infants and neonates.


Even when doing everything correctly, an airway can simply be difficult to suction or intubate and more susceptible to injury, as a result. The 3-3-2 rule is a relatively simple assessment for predicting difficult airways. Perform it like this:


  • 3: You should be able to fit three fingers between the upper and lower teeth of a patient with an open mouth.  If this is not the case, the narrow space may make it more difficult to visualize the glottis or insert the laryngoscope. 


  • 3: An additional three fingers that fit between the tip of the mandible and the anterior neck helps estimate the size of the submandibular region. A distance of less than three fingers suggests a narrower angle, which will make it more difficult to insert a tube. It also suggests that there is less space for the tongue next to the throat, potentially occluding the pharynx further. 


  • 2: Two fingers should fit between the base of the mandible and the thyroid notch on the anterior portion of the neck. A larynx positioned too highly in the neck makes laryngoscopy more challenging because of the acute angle between the larynx and base of the tongue. It will also be more difficult, and maybe impossible, to see the larynx.


Additionally, trauma is also more common if the person performing the suctioning is rushing, or if a patient is moving or in distress. Balancing urgency with control of a situation is difficult in an emergency, and a more experienced health care provider may be better prepared to handle such a scenario.


Suctioning for too long


From blood to vomitus, food particles, foreign objects, hazardous materials and much more, the number of things that can block an airway is nearly endless. During suctioning, the intent is to clear the airway of obstructions, but there can be, so to speak, too much of a good thing.


Timing is important when suctioning. Performing the procedure for too long is not only uncomfortable, but it leaves the airway at risk for trauma and potentially serious side effects. For example, bradycardia is a sudden slowing of a person’s heart rate (below 60 beats per minute). It, along with related symptoms like fainting or lightheadedness, can be triggered if the suctioning equipment stimulates the vagus nerve. Patients with other conditions, such as cardiovascular issues, can have more serious reactions to bradycardia. Hypoxia, the absence of oxygen in bodily tissues, can also be risked with improper suctioning, particularly if the equipment is blocking the airway or the suctioning continues for too long.


Therefore, EMTs must be aware that they are suctioning at the appropriate cadence. Never suction longer than 15 seconds — and normally, suctioning should be performed at just a few seconds per attempt.


Improper positioning


Poor positioning prior to or during suctioning is another way to cause trauma, or it can lead to ineffectual suctioning that can cause bigger problems for a patient.


Patients in distress will attempt to assume a position of comfort, when possible, usually sitting up straight to maximize airflow and lung expansion. They may also use accessory muscles, appear agitated or frightened and, in extreme cases, be cyanotic (show blue or purple discoloration due to deficient oxygenation of the blood).


Before suctioning, EMTs can allow patients to assume the position of comfort, as long as there is no suspected trauma. For trauma patients, consider elevating or turning the backboard to assist respiratory efforts and protect the airway. And if the patient is unresponsive, position the airway using:


  • Head tilt-chin lift: Most common means of opening the airway in trauma patients.
  • Tongue-jaw lift: Effective means of opening the airway and checking for foreign body obstruction; not used during artificial ventilation.
    Jaw thrust: Used to open the airway in suspected trauma.




The goal of suctioning is to clear the airway, but sometimes it can introduce other dangers, such as harmful bacteria or viruses. This is most likely to occur if first responders or hospital personnel reuse equipment, fail to properly sterilize reusable equipment or do not wear protective gear. Additionally, airway trauma increases the risk of infection because open wounds are susceptible to dangerous microbes, especially when a patient already has an infection or aspirated.


Follow these steps following each shift to properly disinfect a suction unit and related equipment:


  • Disconnect the unit from its power source.
  • Disconnect the battery from the PC board when cleaning the interior chassis.
  • Discard all disposable parts, including the canister, tubing and catheters.
  • Dispose biohazardous materials appropriately.
  • Use a mild detergent or a mixture of bleach and water (1 part bleach/10 parts water) and rinse thoroughly.
  • Follow the instruction manual when disinfecting the mechanics of the unit.
  • Never submerge the suction unit.
  • Use disinfectant wipes to clean all outer surfaces, including control knobs, screens and handles.


Additionally, keep equipment in a clean and safe environment when not in use. For example, stay away from wet or high moisture areas, keep the unit free of dust and debris, and secure it within the rig to prevent damage (if using it as part of an ambulance).


Stay safe


Sometimes, a mistake cannot be avoided, and an accident is just that. For health care providers, however, those platitudes won’t suffice following a poor patient outcome. That’s why all those who work in emergency medicine, including those who regularly perform airway suctioning and maintenance, must take care to follow proper procedures, stay current on advances in their field and keep a calm, focused demeanor during crises. Medical errors will never be totally eliminated, but we can all do our part to reduce them.