ICU Suctioning Protocol

Suctioning System Selection

Open suctioning systems are recommended for most mechanically ventilated ICU patients, as closed suctioning systems offer no advantage in preventing ventilator-associated pneumonia, mortality, or ICU length of stay, while significantly increasing costs 1, 2, 3
The Society of Critical Care Medicine recommends open system suctioning as the standard approach for the majority of mechanically ventilated ICU patients 2, 3, 4
Closed suctioning systems do not reduce the incidence of ventilator-associated pneumonia, duration of mechanical ventilation, ICU length of stay, or mortality compared to open systems, and increase costs approximately 25-fold without providing universal clinical benefit 1, 2, 3, 4, 5

Provide reassurance, sedation, and pre-oxygenation to minimize detrimental effects of airway suctioning, with a strength of evidence level of moderate to high 2, 3, 4, 7
Ensure adequate sedation to prevent coughing and cardiovascular instability 2, 3

Do not routinely instill normal saline during airway suctioning, as it has potential adverse effects on oxygen saturation and cardiovascular stability with variable results in sputum yield, based on evidence from the American Thoracic Society 2, 3, 4
Chest wall compression prior to endotracheal suctioning does not improve secretion removal, oxygenation, or ventilation, according to the European Respiratory Society 2, 3

Manual or ventilator hyperinflation combined with suctioning is indicated for airway secretion clearance, with a recommendation from the American Association for Respiratory Care 2, 3, 4, 7
Use manual hyperinflation judiciously in patients at risk of barotrauma, volutrauma, or hemodynamic instability, as advised by the Society of Critical Care Medicine 2, 3, 4
Maintain airway pressures within safe limits (≤40 cm H₂O) by incorporating a pressure manometer into the circuit, as recommended by the American Society of Anesthesiologists 2, 3, 4, 7

Exercise caution with suctioning and hyperinflation techniques in patients with brain injury, as they can increase intracranial pressure and mean arterial pressure, according to the Neurocritical Care Society 2, 3, 4, 7
Monitor cerebral perfusion pressure, which typically remains stable despite these transient increases, as advised by the American Heart Association 2, 3, 4, 7
A closed airway suction system is recommended to reduce viral aerosol production in confirmed or suspected COVID-19 patients, based on guidelines from the Centers for Disease Control and Prevention 6

Do not use closed suctioning systems routinely as a VAP prevention strategy, as they provide no benefit and significantly increase costs, according to the American College of Chest Physicians 1, 5
Avoid routine saline instillation, which can worsen oxygenation and hemodynamic stability, as recommended by the Society of Critical Care Medicine 2, 3, 4