Artificial Airway Suctioning Procedure Note

Procedure: Artificial Airway Suctioning

Date/Time of procedure: [Date and time of procedure]

Location: [Location / unit]

Operator: [Name and credentials of person performing suctioning]

Urgency: [routine / urgent / emergent]

Clinical Indication

[Precipitating event and reason suctioning was initiated, including specific trigger such as acute desaturation, rising airway pressures, audible secretions, suspected plug, or inability to clear secretions] (Describe in 2–4 sentences.)

[Objective indicators supporting decision, such as abnormal breath sounds, visible secretions, ventilator waveform changes, increased PIP or airway resistance, ventilator alarms, or increased work of breathing] (If a mucus plug is suspected but not confirmed, document as "suspected" with supporting evidence; use "confirmed" only when a plug is removed or directly visualized.)

Baseline Assessment

• Artificial airway: [ETT / tracheostomy]; [size]; [ETT depth at lips or nare / trach type]; [cuff status: inflated / deflated]; [inner cannula type if tracheostomy]
• Ventilation/Oxygen support: [Ventilator mode and settings including FiO2 and PEEP if ventilated / oxygen device and flow rate if not ventilated]
• Pre-procedure vitals: [Timestamp]; SpO2 [value] on FiO2 [value]; HR [value]; BP or MAP [value]; RR [value] (If a value was not obtainable, state "not obtained" with brief reason.)
• Baseline airway mechanics: [PIP / plateau / compliance / airway resistance] (Include only if ventilated and relevant to the event.)

Procedure

• Technique: [closed/in-line / open]; [ventilator remained connected / ventilator disconnected]
• Catheter: [size in Fr]; [number of passes]; [maximum suction duration per pass in seconds]
• Suction pressure: [setting with units]
• Preoxygenation: [performed / not performed]; [method if performed]
• Reoxygenation between passes: [provided / not provided]; [method if provided]
• Saline instillation: [no saline instillation / volume instilled with rationale] (Document as exception to standard practice if used.)
• Specimen obtained: [none / tracheal aspirate sent to microbiology / cytology / other]
• Inner cannula: [removed / changed / not applicable] (For tracheostomy patients.)

Findings

• Secretions: Amount [none / scant / small / moderate / copious]; Color [clear / white / yellow / green / tan / brown / blood-tinged / frank blood]; Consistency [thin / thick / tenacious / frothy] (If no secretions returned, explicitly state and reconcile with the indication.)
• Mucus plug or material: [none / plug removed / airway cast / particulate material]; [size and appearance if present]
• Catheter passage: [easy / difficult / resistance noted]; [brief details if abnormal]
• Airway patency after suctioning: [improved / unchanged / worsened]

Patient Response

• SpO2 trajectory: Pre [value] at [time]; Nadir [value] at [time]; Post [value] at [time]
• Hemodynamics: HR [pre / post values with times]; BP or MAP [pre / post values with times] (Include intra-procedure values if unstable.)
• Ventilator response: [airway pressures improved / unchanged / worsened]; [specific values if relevant] (Include only if ventilated.)
• Tolerance: [tolerated well / coughing / bronchospasm / agitation / other]; [interventions if distress occurred] (Use "tolerated well" only when paired with objective stability or improvement.)

Complications

• Complications: [No immediate complications / hypoxemia / bradycardia / arrhythmia / hypotension / bronchospasm / bleeding / increased ICP / airway dislodgement / other] (This field is required.)
• Interventions: [None required / stopped suction / increased FiO2 / manual ventilation / bronchodilator / recruitment maneuver / airway repositioning / other]; [response and current status] (Include only if complications occurred.)
• Escalation: [None / rapid response called / code called / provider notified]; [time and recipient] (Include only if escalation occurred.)

Plan

• Current support: [Ventilator settings or oxygen device and flow after procedure]
• Monitoring: [Ongoing plan such as observe SpO2, clinical reassessment, repeat suction PRN]
• Follow-up actions: [ABG / chest radiograph / bronchoscopy consideration / culture results pending / none] (Include only if applicable.)
• Notifications: [Provider notified with time and recipient / none]