Airway suctioning: a guide for nursing students

Airway suctioning is a high-stakes skill that nursing students will use across nearly every acute care setting. When a patient cannot clear secretions independently — because of altered consciousness, intubation, neuromuscular weakness, or pain-limited respiratory effort — secretions accumulate in the airway and impair gas exchange. Left uncleared, they cause atelectasis, hypoxemia, and pneumonia. Suctioning removes those secretions mechanically, but performed incorrectly it causes exactly the complications it is meant to prevent: hypoxia, mucosal trauma, arrhythmias, and ventilator-associated pneumonia. Understanding the indications, technique, equipment, and complications of each suctioning type is not optional knowledge for NCLEX — it is tested extensively because it is a direct-harm skill where mistakes injure patients in real time.

This guide covers all four suctioning types, suction pressure settings, the sterile vs clean technique distinction, pre-oxygenation requirements, closed vs open systems, and the NCLEX-focused points most likely to appear on licensing exams.

Types of airway suctioning

There are four distinct suctioning approaches, each targeting a different airway region, using different equipment, and requiring different levels of sterility. Selecting the wrong type — or applying the wrong technique — can introduce infection or cause trauma in an airway that has no protective defenses.

Indications and contraindications

When to suction

Suctioning should be performed based on clinical assessment — not on a fixed time schedule. The presence of secretions requiring removal is determined by:

• Visible secretions in the mouth, pharynx, or endotracheal tube
• Audible secretions — gurgling, rattling, or wet breath sounds heard at the bedside
• SpO₂ decline without another identified cause
• Decreased or absent breath sounds on auscultation, suggesting airway obstruction
• Increased peak airway pressures on the ventilator with no other explanation
• Patient inability to clear secretions by coughing — due to weakness, pain, altered mental status, or intubation
• Restlessness or respiratory distress in a patient known to accumulate secretions

Do not suction on a routine schedule in the absence of these signs. Unnecessary suctioning increases mucosal trauma, hypoxia, and arrhythmia risk without benefit.

Contraindications and precautions

• Nasopharyngeal suctioning is absolutely contraindicated in patients with a suspected or confirmed basilar skull fracture — inserting a catheter through the nasal passage risks intracranial placement through a fractured cribriform plate.
• Nasopharyngeal suctioning requires caution with severe thrombocytopenia, anticoagulation, and known esophageal varices.
• Oropharyngeal suctioning may trigger vomiting in patients with an intact gag reflex — have suction immediately available and position the patient on their side if aspiration risk is high.
• Endotracheal suctioning carries a risk of inducing bronchospasm in patients with reactive airway disease. Pre-treat with bronchodilators per order if clinically indicated.

Equipment and supplies

Assemble all supplies before beginning. Interrupting a suction procedure to retrieve missing equipment increases contamination risk and prolongs patient distress.

For endotracheal (open) suctioning — sterile field required:

• Sterile suction catheter (appropriate French size — see catheter sizing below)
• Sterile gloves (at minimum, the dominant hand must be sterile)
• Sterile water or normal saline for catheter flushing
• Sterile basin
• Non-sterile glove for the non-dominant hand
• Suction canister with connecting tubing
• Suction source (wall suction or portable unit) set to correct pressure
• Supplemental oxygen source (manual resuscitation bag or ventilator hyperoxygenation function)
• Personal protective equipment: mask, eye protection, gown if splash risk

For oropharyngeal or nasopharyngeal suctioning — clean technique:

• Yankauer suction tip (oropharyngeal) or flexible whistle-tip catheter (nasopharyngeal)
• Clean (non-sterile) gloves
• Suction canister with connecting tubing
• Suction source set to correct pressure
• Nasal airway (nasopharyngeal trumpet) and water-soluble lubricant for nasal route

Suction catheter sizing for endotracheal suctioning

The suction catheter must be small enough not to completely occlude the endotracheal tube lumen during suctioning — total obstruction eliminates the patient’s ability to breathe around the catheter and dramatically worsens hypoxia. The standard rule:

Catheter French (Fr) size = no more than half the inner diameter of the ET tube.

Practical calculation: ET tube inner diameter (in mm) × 2 = maximum French size. Use the catheter size at or below that value.

When in doubt, use a smaller catheter. A catheter that is too small will suction less efficiently; a catheter that is too large will occlude the tube and cause acute hypoxia.

Suction pressure settings

Suction pressure must be set before contacting the patient’s airway. Pressure that is too low fails to remove secretions; pressure that is too high traumatizes mucosa and causes bleeding. Pressure is expressed in millimeters of mercury (mmHg) and adjusted at the wall regulator or suction unit before beginning.

Verify pressure by occluding the catheter tubing against your gloved finger before entering the airway — watch the pressure gauge confirm the target setting.

Endotracheal suctioning: step-by-step procedure

Endotracheal suctioning is the highest-risk suctioning type and requires strict adherence to sterile technique. These steps apply to open (circuit-disconnect) suctioning of an intubated patient.

Step 1: Assess and prepare

Confirm the indication for suctioning: assess breath sounds, SpO₂, ventilator waveforms, and patient status. Identify the ET tube size and calculate the appropriate catheter French size. Gather all supplies.

Explain the procedure to the patient. Even sedated patients should be spoken to — level of sedation does not guarantee level of hearing. Patients who are aware often report distress from unexplained procedures.

Step 2: Set suction pressure

Turn on the suction source. Set pressure to 80–120 mmHg for adults. Occlude the catheter tubing to verify pressure on the gauge before approaching the airway.

Step 3: Pre-oxygenate

Pre-oxygenation is mandatory before every ET suction pass. Set the ventilator or deliver manual breaths at 100% FiO₂ (FiO₂ 1.0) for 30–60 seconds before disconnecting the circuit. Most modern ventilators have a “suction” or “hyperoxygenation” button that delivers 100% O₂ for 2 minutes without manual circuit adjustment — use this whenever available.

The reason: suctioning removes not only secretions but also the oxygen-enriched gas in the airway. Without pre-oxygenation, SpO₂ can fall sharply during the brief period of apnea required for suctioning.

Step 4: Open sterile field and don gloves

Open the sterile catheter package without contaminating the catheter. Don your non-dominant hand glove (clean) first. Don your dominant hand glove (sterile) last, using aseptic technique. Pick up the catheter with your sterile dominant hand only. Attach the catheter to the connecting tubing using your clean non-dominant hand to hold the tubing.

Step 5: Disconnect the ventilator circuit (open suctioning)

With your clean hand, disconnect the ventilator circuit from the ET tube adapter. Move the circuit tubing aside without placing it on a contaminated surface.

Step 6: Insert the catheter without suction applied

Insert the suction catheter gently into the ET tube using your sterile hand. Do not apply suction during insertion — applying suction while advancing the catheter removes oxygen, traumatizes mucosa, and does not improve secretion removal. Advance the catheter to the appropriate depth: until you feel slight resistance at the carina, then withdraw 1 cm. Do not force the catheter past resistance.

Catheter insertion depth equals approximately the length of the ET tube. The catheter tip should sit at the distal end of the tube or just beyond — not deep into the bronchi. Passing the catheter to the carina and then withdrawing 1 cm prevents contact trauma to the carina, which is highly sensitive and a trigger for bronchospasm and coughing.

Step 7: Apply suction and withdraw

Occlude the catheter thumb port (or activate suction) and withdraw the catheter in a continuous, gentle, rotating motion. The entire withdrawal with suction applied should take no more than 10–15 seconds. Set a timer if needed — most clinicians significantly underestimate this duration.

Do not apply suction during insertion. Do not move the catheter in and out repeatedly with suction applied — a single smooth withdrawal is the technique.

Step 8: Reconnect and reoxygenate

Reconnect the ventilator circuit immediately. Allow the patient to ventilate for at least 30–60 seconds (or until SpO₂ recovers to baseline) between passes.

Repeat pre-oxygenation before each additional pass. Limit to a maximum of 3 suction passes per episode. After 3 passes, allow the patient to rest and recover regardless of whether secretions remain. Returning more than 3 times per episode compounds hypoxia and mucosal trauma without evidence of additional benefit.

Step 9: Post-suction assessment

Auscultate bilateral breath sounds after the suctioning episode. Compare to baseline. Reassess SpO₂. If breath sounds are now clear and SpO₂ has returned to or exceeded baseline, the episode was successful. If secretions remain audible, allow the patient to rest before repeating.

Flush the connecting tubing (not the airway) with sterile water after each use to clear secretions from the tubing and prevent colonization of the catheter exterior.

Step 10: Document

Document: the amount, color, and consistency of secretions; patient tolerance; pre- and post-SpO₂; number of passes; any complications; and the time.

Oropharyngeal and nasopharyngeal suctioning

Oropharyngeal suctioning (Yankauer)

The Yankauer is a large-bore, rigid-tip suction catheter designed for the mouth and oropharynx. It is not used for the deeper airway. It uses clean technique — non-sterile gloves are appropriate because the oropharynx is not sterile.

Indications: visible oral secretions, vomitus, blood pooling in the pharynx, or a patient who cannot clear the mouth independently.

Procedure:

1. Don clean gloves. Apply mask and eye protection.
2. Position the patient: sitting upright if tolerated, or lateral position if unconscious (reduces aspiration risk if vomiting occurs).
3. Set suction to 80–120 mmHg.
4. Insert the Yankauer along the inside of the cheek, directing the tip toward the pharynx. Do not insert blindly into the back of the throat and do not contact the posterior pharyngeal wall aggressively — this stimulates gagging and vomiting.
5. Apply suction and move the tip in smooth sweeping motions through the oral cavity.
6. Duration: 10–15 seconds per pass; allow recovery between passes.
7. Clear tubing with water between passes.

Nasopharyngeal suctioning

Nasopharyngeal suctioning uses a soft flexible catheter inserted through the nostril into the posterior nasopharynx. It is used for patients who have secretions posterior to what the Yankauer can reach, or who cannot tolerate oral suctioning because of an intact and sensitive gag reflex. It uses clean technique — not sterile.

Measuring insertion depth: The standard landmark is the distance from the tip of the nose to the earlobe, plus 1 inch (approximately 2.5 cm). This estimates the distance to the posterior nasopharynx without advancing into the larynx.

Procedure:

1. Insert a nasopharyngeal airway (nasal trumpet) into the selected nostril if performing repeated passes — the trumpet protects the nasal mucosa from repeated catheter trauma. Lubricate with water-soluble lubricant.
2. Measure and note insertion depth.
3. Gently advance the catheter to the measured depth without applying suction.
4. Apply suction and withdraw in a rotating motion over 10–15 seconds.
5. Allow recovery between passes; limit to 3 passes per episode.

Absolute contraindication: known or suspected basilar skull fracture. The cribriform plate sits at the roof of the nasal cavity; a fracture at the base of the skull creates a pathway through which a catheter can enter the cranial vault. This is a high-mortality complication. Any patient with significant facial trauma, periorbital ecchymosis (raccoon eyes), Battle’s sign (mastoid ecchymosis), or CSF leak from the nose should not have nasal suctioning performed until a skull fracture has been excluded.

Infant and neonatal bulb suctioning

Infants, particularly newborns, cannot blow their nose or cough effectively. When secretions or amniotic fluid are present in the upper airway, bulb syringe suctioning is used.

The critical sequence for infant bulb suctioning is mouth before nose:

1. Compress the bulb syringe before insertion.
2. Suction the mouth first, then the nose.
3. Clean the bulb between each insertion.

The reason for mouth-first sequencing: infants are obligate nasal breathers in the neonatal period. When the nose is suctioned first, stimulation of the nasal passages can trigger a gasp reflex. If the mouth is not yet clear, the infant gasps secretions into the lower airway. Clearing the mouth first removes that material before stimulating the nasal gasp.

Closed vs open suction systems

Ventilated patients can be suctioned via open technique (circuit disconnect) or via an inline closed suction system (which keeps the circuit intact throughout). The choice between systems has significant implications for PEEP maintenance, infection risk, and nursing workload.

For patients on mechanical ventilation — especially those with ARDS on high PEEP settings — closed suction systems are strongly preferred. Opening the circuit on a patient requiring 14–18 cmH₂O of PEEP causes immediate alveolar collapse; the patient may not re-recruit for minutes even after reconnection. This directly worsens hypoxemia and can precipitate hemodynamic instability. The mechanical ventilation nursing guide covers PEEP management and lung-protective strategies in detail.

Normal saline instillation: why it is no longer recommended

For decades, clinical practice included instilling a small bolus of normal saline (3–10 mL) into the ET tube before suctioning, on the theory that it thinned secretions and improved removal. Current evidence does not support this practice.

Saline instillation does not effectively dilute lower airway secretions — the saline does not mix with the thick mucus plugs in the bronchi. What it does instead is dislodge biofilm and bacteria that have colonized the ET tube and proximal airways, driving them deeper into the lung. Multiple studies demonstrate a measurable increase in lower airway bacterial burden and a higher rate of ventilator-associated pneumonia (VAP) in patients who receive routine saline instillation.

The American Association for Respiratory Care (AARC) Clinical Practice Guidelines and most current nursing standards explicitly recommend against routine saline instillation before ET suctioning. Adequate humidification of the ventilator circuit — which prevents secretion desiccation in the first place — is the evidence-based alternative. Patients with genuinely thick, inspissated secretions require humidification optimization and, in some cases, mucolytic agents ordered by the physician — not saline pushed into an already-compromised airway.

Complications and prevention

Airway suctioning causes predictable complications when technique deviates from standard practice. Most are preventable. Recognizing early warning signs allows the nurse to intervene before the complication becomes serious.

Patients at highest risk for complications include those with ARDS, acute respiratory failure, elevated ICP, severe reactive airway disease, and coagulopathy. Tailor suctioning frequency and technique accordingly.

NCLEX high-yield tips

These are the points most consistently tested on NCLEX regarding airway suctioning. Each represents a concept where the plausible-sounding wrong answer is the one most students select.

1. Pre-oxygenate before every ET suction pass — 100% FiO₂ for 30–60 seconds. This is non-negotiable for endotracheal suctioning. The question may ask what to do “first” before suctioning — the answer is hyperoxygenation, not gathering equipment or donning gloves (those come before you reach the patient).

2. Each suction pass is 10–15 seconds maximum. No more. The timer starts when you apply suction. After 10–15 seconds, remove the catheter, reconnect oxygen, and allow recovery. Longer passes cause hypoxia, arrhythmias, and mucosal damage simultaneously.

3. Maximum 3 passes per suctioning episode. After 3 passes, stop regardless of residual secretions. The cumulative hypoxia and trauma of repeated passes outweighs the marginal secretion clearance.

4. Do NOT apply suction during catheter insertion — only during withdrawal. Applying suction while inserting the catheter depletes airway oxygen and traumatizes mucosa. Insert first, then apply suction on the way out.

5. Catheter size = no more than half the ET tube lumen. The classic NCLEX calculation: ET tube inner diameter × 2 = maximum French size. A catheter that fills more than half the lumen causes complete airway occlusion during suctioning.

6. Normal saline instillation is NOT recommended. This is a high-frequency NCLEX trap. The practice is outdated; current evidence shows it increases VAP risk by mobilizing biofilm into the lower airways. Select the answer that does NOT include saline instillation.

7. Nasopharyngeal suctioning is contraindicated with basilar skull fracture. Any patient with raccoon eyes, Battle’s sign, hemotympanum, or CSF rhinorrhea should not have a catheter inserted through the nasal passage. This is an absolute contraindication.

8. Oropharyngeal (Yankauer) suctioning uses clean technique — NOT sterile. The oropharynx is not sterile. Non-sterile gloves are appropriate. Endotracheal suctioning requires sterile technique because it enters the lower airway.

9. Closed inline suction is preferred for ventilated patients, especially on high PEEP. Open suction disconnects the circuit, loses PEEP, and risks lung derecruitment. For ARDS patients on high PEEP, circuit disconnect can produce severe, difficult-to-reverse hypoxemia.

10. Suction pressure: 80–120 mmHg adults, 60–100 mmHg children, 40–60 mmHg neonates. Pressure too high = mucosal trauma; too low = ineffective removal. Know the ranges by patient category.

11. Infant bulb suctioning: mouth before nose. The order prevents aspiration when nasal stimulation triggers a gasp reflex in a patient whose mouth has not yet been cleared.

12. Nasopharyngeal insertion depth: tip of nose to earlobe + 1 inch. This is the NCLEX-tested landmark for nasal catheter depth. Inserting further risks laryngeal entry; inserting less may not reach posterior secretions.

13. Stop suctioning immediately if the patient develops bradycardia. Vagal stimulation from catheter contact with the carina causes bradycardia. Remove the catheter, administer oxygen, and notify the provider. Do not continue suctioning through an arrhythmia.

14. Assess breath sounds before and after suctioning. This frames the clinical indication (decreased sounds before = rationale for suctioning) and confirms effectiveness (improved or clearing sounds after). It is the cornerstone of the nursing assessment around this procedure.

Related skills

Airway suctioning is inseparable from a broader set of respiratory skills. The tracheostomy nursing guide covers suctioning via tracheostomy tube in detail, including the specific technique for fenestrated tubes and the emergency response to tube obstruction. The mechanical ventilation nursing guide explains how PEEP settings and ventilator modes affect suctioning decisions and why circuit disconnection is particularly high-risk in certain ventilator-dependent patients. For patients whose secretion burden is driven by pulmonary infection, the pneumonia nursing guide and the acute respiratory failure nursing guide provide context for how suctioning fits into the broader management picture. Understanding the oxygen delivery devices used for pre-oxygenation before suctioning is covered in the oxygen therapy nursing guide. For patients receiving non-invasive ventilatory support where suctioning decisions are different, the noninvasive ventilation nursing guide covers BiPAP and CPAP management. When suctioning uncovers signs of worsening respiratory failure, ABG interpretation provides the framework for evaluating oxygenation and ventilation status from arterial blood gases.

Clinical references: American Association for Respiratory Care (AARC) Clinical Practice Guidelines — Endotracheal Suctioning of Mechanically Ventilated Patients with Artificial Airways (2010); Perry, Potter & Ostendorf — Clinical Nursing Skills and Techniques, 10th edition; Wiegand DL (ed.) — AACN Procedure Manual for Progressive and Critical Care, 7th edition; StatPearls — Tracheal Suctioning (Shen et al., 2023); Sole ML et al. — “Bacterial colonization of endotracheal tubes” (American Journal of Critical Care); Centers for Disease Control and Prevention (CDC) — Guidelines for Preventing Healthcare-Associated Pneumonia (2004).