Deep Oral (Oropharyngeal) Suctioning

Definition

Indications

• Inability to clear secretions by coughing
• Pooling of saliva, blood, or vomitus in the oropharynx
• Airway obstruction by secretions or particulate matter
• Impaired consciousness or swallowing reflex
• Pre- and post-airway procedure (e.g., intubation attempts)
• Respiratory distress with audible secretions (coarse rales, rhonchi)
• Decreased SpO2 related to secretion accumulation

Equipment

• Yankauer (tonsil tip) suction device - rounded tip, less traumatic to soft tissues; effective for hemorrhage and secretions, but not large enough for thick vomitus
• Large-bore dental-type tip (e.g., HI-D Big Stick, SSCOR Inc.) - preferred for clearing vomitus and blood rapidly; less likely to clog with particulate matter

• Soft catheter, size in French (Fr) selected based on airway size
• Coude (directional) tip catheters available for selective lower airway suctioning
• Closed-system catheters (in-line) for ventilated patients

Procedure / Technique

1. Preoxygenate the patient for 30-60 seconds before suctioning:
   • For mechanically ventilated patients: increase FiO2 to 100%
   • For non-ventilated patients: deliver 10-15 L/min high-flow oxygen
2. Positioning:
   • Awake patients: sitting upright, head neutral
   • Ventilated patients: head of bed elevated 30 degrees
3. Set up monitoring: continuous pulse oximetry, cardiac monitor, capnography if available
4. Insert catheter under direct vision when possible - do not force the suction tip blindly into the posterior pharynx, as this risks tissue injury or converting a partial obstruction to a complete one
5. Apply suction intermittently, not continuously during insertion
6. Advance to desired depth:
   • Oral/oropharyngeal: suction the visible oral cavity and oropharynx
   • Deep/tracheal: advance until resistance is met (carina), then withdraw 1-2 cm before applying suction
7. Apply suction while slowly withdrawing the catheter - rotate gently during withdrawal to maximize secretion removal
8. Duration per pass: no more than 10-15 seconds - this is a firm safety limit to prevent hypoxia
9. Re-oxygenate between passes; do not perform more than 3 passes per session
10. Aseptic technique throughout to prevent introducing bacteria into the lower airway

Suction Pressure Settings

Depths of Suctioning

Note: Deep suctioning has not been shown to be more beneficial than shallow suctioning and should not be performed routinely. It is reserved for cases with excess lower airway secretions.

Contraindications

• Absolute: None for emergency oropharyngeal suctioning
• Relative:
  • Severe bronchospasm (may worsen with suctioning; consider bronchodilators first)
  • Persistently elevated intracranial pressure (ICP) - suctioning increases ICP
  • Cardiovascular instability (risk of dysrhythmias)
  • Coagulopathy / mucosal fragility (nasopharyngeal route especially)
  • Suspected basal skull fracture (avoid nasal route)

Complications

Special Considerations

• Saline instillation before suctioning was once common practice to loosen secretions, but current evidence does not support routine instillation - it may contaminate the lower airway without consistent benefit
• Nasal suction is seldom required in adults (most upper airway obstruction is oral/oropharyngeal), but is more commonly used in infants
• In infants and neonates: suction should be performed to clear meconium-stained secretions before stimulation, though it should not delay definitive endotracheal suctioning in a non-vigorous newborn
• Humidification of inspired air before and during suctioning helps reduce secretion viscosity

Monitoring and When to Stop

• Cardiac dysrhythmia
• SpO2 drop / hypoxia
• Rise in end-tidal CO2
• Marked hemodynamic instability