Airway Suction & Postural Drainage

Maintaining a clear airway is one of the most critical aspects of prehospital emergency care. Airway obstructions, whether caused by secretions, vomit, blood, or other substances, can lead to life-threatening conditions such as hypoxia.

In prehospital settings, airway suction & postural drainage techniques are invaluable in keeping patients’ airways patent, particularly for those unable to protect their own airway. This article explores the indications, techniques, equipment, and best practices surrounding airway suction and drainage in prehospital environments.

Indications for Airway Suctioning/Drainage

Airway suctioning/drainage is indicated when a patient’s airway is compromised due to the accumulation of fluids or foreign materials. Common scenarios include:

Decreased Level of Consciousness: Unconscious or semi-conscious patients are unable to clear their airway independently, increasing the risk of aspiration and obstruction.

Trauma Patients: Blood, vomit, or foreign objects from trauma, particularly facial injuries, can obstruct the airway.

Excessive Secretions: Patients with respiratory conditions or those who are intubated often require suction to clear mucus and other fluids that can obstruct airflow.

In all of these cases, the goal of suctioning is to remove obstructions and allow for unobstructed ventilation and oxygenation.

Airway Drainage

Postural drainage is a simple yet highly effective technique used in airway management to assist in the removal of fluids from the airway by leveraging gravity. It involves positioning the patient in such a way that fluid drains naturally from the respiratory passages, which can be particularly beneficial when mechanical suction is not readily available or when excessive fluids are present.

In postural drainage, gravity becomes a key tool to aid in the clearance of fluids, secretions, or vomit from the airway. By positioning the patient in specific ways, it can facilitate the movement of these substances from the airway into the mouth or nose, where they can be expelled or easily removed.

One of the most common and simple forms of postural drainage is placing the patient in the lateral, or side-lying, position. This position allows secretions or vomit to drain out of the mouth instead of pooling at the back of the throat, which can lead to aspiration.

In more advanced cases, the patient may be placed in a head-down position, where the lower body is elevated above the chest. This position can promote the drainage of secretions from the deeper parts of the lungs into the larger airways, where they can be expelled more easily.

When to Use Postural Drainage?

Postural drainage is particularly useful in the following scenarios:

Patients with Excessive Secretions: In patients with conditions such as pneumonia, chronic bronchitis, or other respiratory illnesses where mucus production is excessive, postural drainage can help clear secretions from the lungs and airways, improving oxygenation and reducing the risk of airway obstruction.

Actively Vomiting Patients: In cases where patients are actively vomiting or have the potential for regurgitation, postural drainage is a quick, non-invasive way to prevent the risk of aspiration. By positioning the patient on their side, any vomit is naturally drained away from the airway, reducing the chance of it being inhaled into the lungs.

During Suctioning: Even in situations where suctioning is being performed, postural drainage can complement the process. For instance, positioning the patient laterally while suctioning the oropharynx can enhance the clearance of secretions.

Why Postural Drainage is Effective?

Ease of Use: One of the primary benefits of postural drainage is that it requires no additional equipment, making it an ideal method in prehospital environments where time and resources may be limited. Whether on-scene or during transport, it is a straightforward technique that can be applied quickly by paramedics or first responders.

Non-Invasive: Since postural drainage simply involves adjusting the patient’s body position, it is completely non-invasive and can be performed on patients who are awake, semi-conscious, or unconscious.

Accessible for All Levels of Providers: The simplicity of postural drainage means that even those with basic first aid training can apply the technique effectively, making it a universally applicable skill in prehospital and emergency care.

Types Of Airway Suctioning

Suctioning methods vary depending on the location and nature of the obstruction:

This involves clearing the mouth and pharynx, typically using a rigid suction catheter like a Yankauer. It is commonly used when secretions or obstructions are visible in the upper airway.

In cases where the patient’s mouth is inaccessible (e.g., due to trauma) or for those who are semi-conscious, a flexible catheter can be inserted through the nose to suction the nasopharyngeal area. This technique is gentler and can be used in patients with an intact gag reflex.

For intubated or patients with an advanced airway, a soft suction catheter is passed through the endotracheal tube to clear secretions from the lower airway. This method is essential for mechanically ventilated patients who are unable to clear their airways independently.

Equipment For Airway Suction

Having the right equipment readily available is essential for efficient airway suction in the prehospital setting. The main components include:

Portable Suction Device: Portable, battery-powered suction units are standard in ambulances and other emergency response vehicles. These devices provide the mobility required in unpredictable environments.

Suction Tubing and Canisters: Properly functioning tubing and canisters are critical for effective suction, as they transport fluids away from the patient.

Yankauer Suction Tip: This rigid, curved instrument is ideal for clearing larger obstructions in the mouth and oropharynx.

Flexible Suction Catheters: These are used for deeper suctioning, such as nasopharyngeal or endotracheal suctioning, and come in various sizes to accommodate different patient needs.

Oropharyngeal Suctioning

1. Assess the Need for Suctioning

Evaluate the patient’s airway by looking for signs of obstruction, such as gurgling sounds, visible secretions, or respiratory distress. In unconscious patients, be vigilant for any signs of compromised airway clearance.

Check the patient’s oxygen saturation levels (SpO2) and respiratory effort.

2. Prepare the Equipment

Ensure that the suction unit is functioning properly and has adequate battery life.

Attach the Yankauer suction catheter to the suction tubing, then connect the tubing to the suction unit.

Set the suction pressure to the recommended level, typically between 80–120 mmHg for adults (lower for paediatric patients).

3. Position the Patient

If the patient is conscious, encourage them to sit up. If unconscious or semi-conscious, place the patient in the lateral (recovery) position to allow fluids to drain naturally from the mouth and prevent aspiration.

In trauma cases, ensure spinal precautions are maintained if necessary.

4. Insert the Suction Catheter

Using the Yankauer suction catheter, carefully insert it into the patient’s mouth. Begin with the catheter tip at the back of the oropharynx (just behind the tongue), avoiding stimulation of the gag reflex in semi-conscious patients. You should only advance the catheter as far as you can see.

Avoid forcefully pushing the catheter, as this could cause trauma to the oral tissues.

5. Apply Suction

Apply suction by covering the suction control valve or button. Suction should only be applied while withdrawing the catheter to prevent tissue injury.

Withdraw the catheter slowly while rotating (figure of 8) to clear secretions effectively from all areas of the mouth and pharynx.

Limit suctioning to no more than 10 seconds at a time to prevent hypoxia, especially in critically ill patients.

6. Monitor the Patient’s Condition

Continuously monitor the patient’s respiratory status during and after suctioning. Look for improvements in oxygen saturation, decreased respiratory distress, and clearer breath sounds.

Reassess the airway and repeat suctioning if necessary, ensuring that the patient receives adequate oxygen between suction attempts.

7. Post-Suction Care

After completing suctioning, recheck the patient’s airway for patency. Administer supplemental oxygen if needed and continue monitoring their vital signs.

Dispose of used equipment and ensure that the suction canister is properly emptied and disinfected.

Document the procedure, including the patient’s condition before and after suctioning, the amount and type of secretions removed, and any complications that occurred.

Maintain Proper Suction Pressure: Using suction that is too high can cause mucosal damage, while suction that is too low may not effectively clear obstructions.

Use Intermittent Suction: Continuous suctioning can cause a drop in oxygen levels. Always suction intermittently and only while withdrawing the catheter.

Observe for Complications: Be mindful of potential complications such as trauma to the mouth or airway, hypoxia due to prolonged suctioning, or stimulation of the vagus nerve leading to bradycardia.

Limited Access: In some situations, such as trauma with facial injuries, access to the oropharynx can be restricted. Use the available space and position the patient to optimise airway clearance.

Gag Reflex: In semi-conscious patients, stimulation of the gag reflex can cause vomiting or laryngospasm. Be gentle, and if possible, use an alternative method like nasopharyngeal suctioning in these cases.

Foreign Bodies: If a large foreign body is lodged in the airway, suctioning may be insufficient. In these cases, more advanced airway manoeuvres or devices like Magill forceps may be required to remove the obstruction.

Nasopharyngeal Suctioning

1. Assess the Need for Suctioning

Assess the patient for signs of upper airway obstruction or respiratory distress, such as nasal congestion, gurgling sounds, decreased oxygen saturation, or visible secretions in the nasal passages.

2. Prepare the Equipment

Set up the portable suction unit and connect the tubing to the soft suction catheter.

Lubricate the catheter with water-soluble gel to ensure it can be smoothly inserted into the nasal passage without causing trauma.

Adjust the suction pressure to a safe level, typically 80–120 mmHg for adults, and lower pressures for paediatric patients.

3. Position the Patient

Have the patient sit upright if possible, which helps to open the airway and makes the procedure more comfortable.

If the patient is unconscious, place them in the lateral or semi-recumbent position, ensuring that their head is slightly elevated to allow for easier suctioning and drainage.

4. Insert the Suction Catheter

Gently insert the lubricated suction catheter into one of the nostrils, directing it towards the nasopharynx. Advance the catheter slowly and carefully, without applying suction at this point, to avoid causing trauma.

Once resistance is felt or the catheter reaches the desired depth (around the level of the ear lobe), stop advancing the catheter.

5. Apply Suction

Once the catheter is in position, apply suction by covering the suction control valve or button.

Gently withdraw the catheter while rotating it to maximise the removal of secretions from all areas of the nasopharynx.

Limit suctioning to no more than 10-15 seconds at a time to avoid hypoxia and prevent excessive trauma to the nasal mucosa.

6. Monitor the Patient’s Condition

Monitor the patient closely during the procedure. Ensure they remain comfortable and watch for signs of distress, such as bradycardia or hypoxia.

Reassess the patient’s airway and respiratory status after each suction attempt. Look for improvements in breath sounds and oxygen saturation.

7. Post-Suction Care

After the suctioning is complete, assess the patient’s airway patency and check their respiratory effort.

Administer supplemental oxygen if required and continue to monitor the patient’s vital signs.

Dispose of used equipment according to local infection control protocols and ensure the suction canister is emptied and cleaned.

Lubricate the Catheter: Always use a water-soluble lubricant to minimise discomfort and reduce the risk of damaging the nasal mucosa during insertion.

Choose the Right Catheter Size: Selecting the appropriate catheter size is critical, as a catheter that is too large can cause trauma, while one that is too small may be ineffective at clearing secretions.

Be Gentle and Slow: Inserting the catheter too quickly or forcefully can cause nasal trauma or bleeding. Always insert the catheter gently and at a slow, controlled pace.

Limit Suction Time: Avoid prolonged suctioning to prevent hypoxia. Suction for a maximum of 10-15 seconds at a time, then allow the patient to recover and reoxygenate between attempts.

Observe for Signs of Distress: During suctioning, watch for complications such as a drop in oxygen saturation, increased heart rate, or patient discomfort. If any of these occur, stop suctioning immediately.

Nasal Trauma: The nasal passages are sensitive, and improper technique can lead to trauma or bleeding (epistaxis). Careful insertion and appropriate catheter selection can minimise this risk.

Hypoxia: As with other forms of suctioning, hypoxia can occur if suction is applied for too long. Ensure suction is applied intermittently and for no longer than 15 seconds at a time.

Vagal Stimulation: In some patients, suctioning can stimulate the vagus nerve, leading to bradycardia or hypotension. If this occurs, stop the procedure and provide supportive care.

Endotracheal Suctioning

1. Assess the Need for Suctioning

Evaluate the patient’s respiratory status, looking for signs of airway obstruction such as gurgling breath sounds, decreased tidal volume, poor oxygenation (low SpO2), or difficulty ventilating. Listen to lung sounds with a stethoscope and observe the patient’s chest rise to identify possible obstructions.

2. Prepare the Equipment

Set up the portable suction unit and connect the suction tubing to the unit and the catheter. Lubricate the soft suction catheter with water-soluble gel if required for smoother insertion. Adjust the suction pressure to an appropriate level (80–120 mmHg for adults, lower for paediatric patients).

3. Oxygenate the Patient

Prior to suctioning, preoxygenate the patient with 100% oxygen for 30 seconds if possible to reduce the risk of hypoxia during suctioning.

4. Insert the Suction Catheter

For iGel Suctioning: Carefully pass the soft suction catheter down the drainage port (if available) of the iGel device. If an iGel lacks a drainage port, remove it briefly if necessary for oropharyngeal suctioning, then reinsert.

For Endotracheal Tube Suctioning: Gently insert the catheter into the endotracheal tube until resistance is felt (typically at the level of the carina). Avoid applying suction during insertion to prevent damage to the tracheal mucosa.

5. Apply Suction

Once the catheter is in place, apply suction by covering the control valve on the catheter. Withdraw the catheter slowly while rotating it to ensure the removal of secretions from all areas of the airway. Limit each suction attempt to 10 seconds to avoid causing hypoxia or trauma to the airway.

6. Monitor the Patient’s Condition

Monitor the patient’s oxygen saturation levels and observe for improvements in respiratory effort and ventilation. Listen for clearer breath sounds and easier ventilation. If necessary, repeat suctioning after reoxygenating the patient.

7. Post-Suction Care

After suctioning, ensure the airway remains clear, ventilations are effective, and the patient’s oxygen levels stabilise. Administer supplemental oxygen or continue ventilating the patient, as necessary, to maintain appropriate oxygenation. Dispose of used catheters and equipment according to infection control protocols.

Preoxygenate: Always provide supplemental oxygen before suctioning to avoid causing desaturation or hypoxia.

Use the Correct Catheter Size: Ensure the suction catheter is appropriately sized for the airway device. A catheter that is too large can occlude the endotracheal tube or iGel, while one that is too small may not be effective in clearing secretions.

Be Gentle: Avoid excessive force during insertion and suctioning to prevent trauma to the delicate tissues of the trachea and bronchi.

Suction Intermittently: Continuous suctioning can lead to mucosal damage and hypoxia. Always apply suction intermittently and only while withdrawing the catheter.

Hypoxia: If suctioning is prolonged or if the patient is not adequately oxygenated beforehand, suctioning can cause oxygen levels to drop dangerously. To mitigate this, limit suction attempts to 10 seconds and preoxygenate.

Trauma to the Airway: Inserting the catheter too deeply or forcefully can cause damage to the airway tissues, including the trachea and bronchi. It is essential to advance the catheter gently and stop at the appropriate depth.

Infection: Repeated suctioning can introduce bacteria into the airway, increasing the risk of infection, especially in ventilated patients. Proper technique and equipment hygiene are vital to preventing this complication.

Bradycardia: Stimulation of the vagus nerve during suctioning can lead to a decrease in heart rate (bradycardia). If this occurs, stop suctioning and monitor the patient’s vitals closely.

Key Points

Bibliography

Joint Royal Colleges Ambulance Liaison Committee, & Association of Ambulance Chief Executives. (2022). JRCALC Clinical Guidelines 2022. Class Professional Publishing

Resuscitation Council UK (2021). 2021 Resuscitation Guidelines. Resuscitation Council UK. Available at: https://www.resus.org.uk/library/2021-resuscitation-guidelines

www.sciencedirect.com. (2008). Postural Drainage – an overview | ScienceDirect Topics. Available at: https://www.sciencedirect.com/topics/medicine-and-dentistry/postural-drainage