When to Use Endotracheal Suctioning in Field Intubations

The call is going smoothly. The elderly woman had gone into cardiac arrest just minutes before you arrived, but immediate CPR and rapid defibrillation were rewarded with a weak return of pulses. Your IV is flowing and the patient is intubated. But just because you have secured an endotracheal tube does not mean the airway is completely protected.

First, let’s review the basics

Patients usually require intubation for one of two reasons: either the patient is unable to maintain a patent airway or you are impeded from adequately ventilating or oxygenating the patient.

The primary indications for endotracheal intubation are:

• A diminished level of consciousness accompanied by loss of airway control
  • Inadequate gag reflex
  • Glasgow Coma score of 8 or less (the adage, “Less than 8, intubate!”)
  •  Potential for aspiration

• Respiratory failure

• Cardiac arrest 

But in some situations, despite an airway adjunct, your patient may still be at risk for obstruction. And the simplest remedy is also one of the most vital: suctioning. 

Many adjunct airway procedures begin by suctioning the airway, especially if you intend to use an endotracheal tube. To pass the ET tube through the vocal cords, you must first be able to see the cords, and blood, mucous, and vomit can make visualization difficult, if not impossible. These impediments are also detrimental to the patient, especially if the patient is unresponsive and unable to protect their airway.

But even if you’ve achieved intubation, the need for suctioning remains. Here are the indications for suctioning in a patient who has an ET tube in place:

• Dyspnea
• Obstruction
• Excessive Secretions

Suctioning the Endotracheal Tube

If your patient is in need of ET tube suctioning, the first step is to have a reliable and effective suction unit on hand. Once your unit is ready, here are the steps to follow:

• Choose an appropriate suction adjunct – small, flexible tips for use in artificial airways
• Check, prepare, and assemble your equipment

• Maintain universal precautions – use a sterile technique throughout the procedure
• Lubricate the suction catheter
• Preoxygenate the patient for 1-2 minutes with 100% oxygen
• Measure the suction catheter tip from the corner of the mouth to the angle of the jaw or you can simply insert it through the ET tube until the patient coughs
• Suction for no longer than 5-10 seconds as you remove the suction catheter using a twisting motion
• Be sure to monitor the patient’s response through observation and vital signs
• Assess the airway, ET tube, and lungs for effectiveness and then continue ventilating the patient 

If the patient needs repeated suctioning, be sure to oxygenate and ventilate them in between each procedure. 

Possible Complications

With every medical procedure, complications may arise. Such is the case with suctioning the endotracheal tube, so be alert for these problems:

• Hypoxemia
• Cardiac arrhythmias
• Mechanical trauma
• Increased intracranial pressure
• Inability to remove the material due to a mucous plug or dried crusting 

Suctioning the endotracheal tube is a vital step in maintaining a secure airway, so choose the right equipment, maintain that equipment, and follow proper procedures to ensure your patient receives the best possible care.