Complications of Frequent Suctioning

Major Structural Complications

Stenosis and granuloma formation occur in 1.2 to 36% of infants with chronic lung disease who undergo frequent suctioning 1, 2, 3
Endoscopic findings reveal airway narrowing or occlusion by thickened respiratory mucosa with circumferential nodular or polypoid granulations in the distal trachea, often extending into main bronchi 1, 2, 3, 4
Histologically, these lesions show squamous metaplasia, ulceration of overlying epithelium, and fibrosis in the mucosa and submucosa 1, 2, 3
Acute mucosal injury to the carina and main bronchi occurs from unrestricted or "deep" suctioning 1, 2, 3, 4
Central airway collapse has been documented in 45% with tracheomalacia and 34% with bronchomalacia among infants with chronic lung disease undergoing bronchoscopy 1, 3, 4

The possibility of catastrophic bleeding from tracheal erosion into a major artery exists with tracheostomy 5, 6
Minor endotracheal bleeding is common during routine tracheal suctioning and results from tracheal epithelial abrasions 7, 8
In COVID-19 patients on anticoagulation, bleeding risks are substantially amplified, with mortality risks approaching 10% 9, 10

Recurrent infection (tracheitis and/or bronchitis) is a common complication of frequent suctioning 5, 6
Tracheostomies rapidly become colonized, making cultures of tracheostomy secretions not always helpful 5, 6
Concomitant infection in the setting of mucosal injury has been proposed as a risk factor for subglottic stenosis 1, 4

The most important preventative measure is to restrict passage of the suction catheter to the distal tip of the artificial airway, protecting the airway mucosa from injury 1, 2, 3, 4
Use a suction catheter that occludes less than half the lumen of the endotracheal tube (usually 5-6F in newborns) 1, 2, 3, 4
Use negative pressures no greater than 50-80 cm H₂O—higher pressures increase mucosal damage without improving secretion removal 1, 2, 3, 4
Catheters with multiple side holes on several planes are less likely to cause invagination of airway mucosa than those with single side or end holes 1, 2, 3, 4

The most common error is performing "deep" or unrestricted suctioning that extends beyond the artificial airway tip, directly causing distal tracheal and bronchial injuries that lead to stenosis and granuloma formation 1, 2, 3, 4