Artificial Airway Suctioning

Publication Date: February 1, 2022

Summary of Recommendations

  • Breath sounds, visual secretions in the artificial airway, and a sawtooth pattern on the mechanical ventilation waveform provide the best indications for endotracheal suctioning in the adult andpediatric population (evidence level B).
  • An acute increase in airway resistance may be an indicator for the need for artificial airway suctioning in neonates (evidence level B).
  • Mitigation strategies such as adequate sedation, preoxygenation, and suctioning only if indicated may reduce the incidence and severity of potential complications, including but not limited to increased heart rate, mean arterial pressure, ICP, cardiac arrythmias, and oxygen desaturation (evidence level B).
  • As-needed suctioning is just as effective as routine suctioning and does not increase morbidity or mortality in neonatal and pediatric populations (evidence level B).
  • Either the closed suction system or the open suction system can be used safely and effectively to remove secretions from the adult patient with an artificial airway (evidence level B).
  • Adult and pediatric patients should be preoxygenated before artificial airway suctioning (evidence level B).
  • The routine use of normal saline solution (generally should be avoided) is unnecessary during artificial airway suctioning (evidence level B).
  • The clinician should use a sterile procedure for open suctioning events to protect the patient from potential cross-contamination (evidence level C).
  • Suction catheters should occlude < 70% of the ETT lumen in infants, children, and adults (evidence level C).
  • Suction pressures should be kept below –200 mm Hg in adults and below –120 mm Hg in the neonatal and pediatric population (evidence level C).
  • Efforts to set the suction pressure as low as possible and effectively lear secretions should be made (evidence level C).
  • The clinician should keep the suctioning procedure as brief as possible and no longer than 15 s (evidence level C).
  • A shallow suctioning technique should be used routinely (evidence level B).
  • Deep suctioning should generally be used only when shallow suctioning is ineffective with consideration of the potential for airway trauma and the negative impact on physiologic indices (evidence level B).
  • Routine use of bronchoscopy for secretion removal is not recommended (evidence level C).
  • There is evidence that supports the use of devices use to clear ETTs when an increase in Raw are suspected due to secretion accumulation (evidence level B).

Recommendation Grading




Artificial Airway Suctioning

Authoring Organization

Publication Month/Year

February 1, 2022

Document Type


Country of Publication


Document Objectives

Artificial airway suctioning is a key component of airway management and a core skill for clinicians charged with assuring airway patency. Suctioning of the artificial airway is a common procedure performed worldwide on a daily basis. As such, it is imperative that clinicians are familiar with the most-effective and efficient methods to perform the procedure. We conducted a systematic review to assist in the development of evidence-based recommendations that pertain to the care of patients with artificial airways. From our systematic review, we developed guidelines and recommendations that addressed questions related to the indications, complications, timing, duration, and methods of artificial airway suctioning. By using a modified version of the RAND/UCLA Appropriateness Method, the following recommendations for suctioning were developed for neonatal, pediatric, and adult patients with an artificial airway: (1) breath sounds, visual secretions in the artificial airway, and a sawtooth pattern on the ventilator waveform are indicators for suctioning pediatric and adult patients, and an acute increase in airway resistance may be an indicator for suctioning in neonates; (2) as-needed only, rather than scheduled, suctioning is sufficient for neonatal and pediatric patients; (3) both closed and open suction systems may be used to safely and effectively remove secretions from the artificial airway of adult patients; (4) preoxygenation should be performed before suctioning in pediatric and adult patients; (5) the use of normal saline solution should generally be avoided during suctioning; (6) during open suctioning, sterile technique should be used; (7) suction catheters should occlude < 70% of the endotracheal tube lumen in neonates and < 50% in pediatric and adult patients, and suction pressure should be kept below -120 mm Hg in neonatal and pediatric patients and -200 mm Hg in adult patients; (8) suction should be applied for a maximum of 15 s per suctioning procedure; (9) deep suctioning should only be used when shallow suctioning is ineffective; (10) routine bronchoscopy for secretion removal is not recommended; and (11) devices used to clear endotracheal tubes may be used when airway resistance is increased due to secretion accumulation.

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Infant, Older adult

Health Care Settings

Hospital, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant



Diseases/Conditions (MeSH)

D058109 - Airway Management


airway suctioning

Source Citation

Blakeman TC, Scott JB, Yoder MA, Capellari E, Strickland SL. AARC Clinical Practice Guidelines: Artificial Airway Suctioning. Respir Care. 2022 Feb;67(2):258-271. doi: 10.4187/respcare.09548. PMID: 35078900.

Supplemental Methodology Resources

Data Supplement, Data Supplement, Data Supplement