Emergency room sign - when to perform nasotracheal suctioning


We all know what an important role suctioning plays in airway management. Imagine treating a respiratory, trauma, or cardiac arrest patient without the aid of suction. Impossible, right? Effective nasotracheal suctioning can mean the difference between a patent and a non-patent airway. It can also mean the difference between life and death for your patient. 


The main goal of effective suctioning is to prevent hypoxia. Whether the hypoxia stems from a fluid (vomit, blood, or mucus) or a physical obstruction (tissue, foreign body, or teeth), your main goal in managing the airway is to keep the patient oxygenated.


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Signs and Symptoms of Hypoxia

Recognizing the early signs of hypoxia is the first step in airway management. This will also help you determine whether your patient needs an advanced airway (endotracheal or nasotracheal intubation). Signs and symptoms of hypoxia include:


  • Dyspnea – one of the first signs of respiratory distress
  • Tachypnea – rapid rate of breathing
  • Use of accessory muscles – indicates increased work of breathing
  • Noisy breathing – such as crackles, wheezes, or fluid
  • Flaring of nostrils – another form of work of breathing
  • Changes in skin color – pale or bluish/grey (cyanotic)
  • Inability to speak – due to respiratory difficulty
  • Positioning – patient will be unable to lie flat
  • Decreased oxygen saturation – be sure to monitor O2 saturation and note changes
  • Restlessness or anxiety – usually seen in early hypoxia
  • Decreased level of consciousness (LOC) – occurs in the late stages of hypoxia


If your patient is exhibiting signs of hypoxia, it is time to consider your airway options. Although endotracheal intubation remains the airway of choice, there may be times when nasotracheal intubation is the preferred method. The main criteria in choosing nasotracheal intubation are for patients who are breathing spontaneously yet who cannot maintain a patent airway. This can include:


Contraindications for nasotracheal intubation include:

  • Suspected epiglottitis
  • Midface instability
  • Coagulopathy
  • Suspected basilar skull fractures
  • Apnea or impending respiratory arrest


Nasotracheal Intubation: A Brief Review

Once you've determined to nasally intubate your patient, here are the general steps:


  • Premedicate the patient, when possible, with nasal spray or hurricane spray.
  • Select the larger and less obstructed nostril.
  • Insert a lubricated nasal pharyngeal airway (NPA) to help dilate the nasal passage.
  • Preoxygenate the patient.
  • Lubricate the tube for ease of insertion.
  • Remove the nasal airway.
  • Gently insert the tube with the bevel facing toward the septum.
  • Listen for air movement as you pass the tube.
  • Look for vapor condensation in the tube.
  • Air movement will become more audible as you approach the trachea.
  • As the patient inhales, gently advance the tube through the glottic opening, minimizing trauma to the vocal cords.
  • The patient may cough, buck, strain, or gag—a normal response (be sure to maintain cervical spine immobilization in patients with suspected trauma).
  • Be alert for vomiting—KEEP SUCTION HANDY!
  • Auscultate for bilaterally equal breath sounds and absence of sounds of the epigastrium.
  • Observe for symmetrical chest expansion.
  • Inflate the cuff with 5–10 ccs of air.
  • Confirm tube placement.
  • Secure the tube.
  • Reassess breath sounds and 02 saturation continually.


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Suctioning the Nasotracheal Tube

As with endotracheal intubation, patients who have been nasally intubated may still require suction. Here are some reminders:


  • Have the suction unit nearby ANY TIME you are placing an advanced airway.
  • Maintain your suction unit so that it is fully functional on every call.
  • Have an assortment of suction catheters available—you will need small, flexible catheters for naso- or endotracheal suctioning.
  • Use a sterile technique whenever you are suctioning an advanced airway.
  • Insert the catheter until the patient coughs and then remove it, using a twisting motion while applying suction.
  • Have a rigid catheter at the ready, should the patient produce froth or sputum through the tube.


No matter which form of advanced airway you choose for your patient, you MUST have suction available, to ensure ease of placement and continued patency and, most importantly, to prevent hypoxia.


Editor's Note: This blog was originally published in December 2017. It has been re-published with additional up-to-date content.