A variety of conditions render patients unable to clear their own secretions. Aspiration usually occurs when the tone of the lower esophageal sphincter is insufficient to deal with the increased intragastric pressure and the protective laryngeal airway reflexes are depressed. The common iatrogenic causes include BVM ventilation, the presence of nasogastric tubes, and pharmacologic neuromuscular paralysis. Some common predisposing conditions include trauma, bowel obstruction, obesity, overdose, pregnancy, hiatus hernia and seizures.

Aspiration after urgent ET intubation occurs infrequently in ED patients if there is inattention to technique. 18 The intubator should consider using large-diameter suction systems or tubing for the removal of particulate matter or clots that are larger than the standard Yankauer tip can handle. 19 The rigid-tip plastic tonsil suction catheter can remove large quantities of oropharyngeal secretions.

When necessary, place the patient in a left lateral Trendelenburg position. This helps get the tongue out of the laryngoscopist's way and will facilitate immediate endotracheal suctioning.

To suction the nasopharynx and tracheobronchial tree, use a well-lubricated, soft, curved-tip catheter. Straight catheters will usually pass into the right mainstem bronchus. If a curved-tip catheter is available, turning the head to the right in addition to catheter rotation will often facilitate passage into the left bronchus.

A suction catheter of a size no larger than half the diameter of the tube to be suctioned should be selected. This will prevent pulmonic collapse from insufficient ventilation during suctioning. Then oxygenate the patient before and after suctioning to avoid transient desaturation. The catheter is inserted without suctioning and then slowly removed, suctioning with rotation over 10 to 15 s.

Some of the complications of suctioning include hypoxia, cardiac dysrhythmias, hypotension, pulmonic collapse, and direct mucosal injury. The magnitude of the ICP increase during endotracheal suctioning may be related to the increase in intrathoracic pressure with coughing if lidocaine has been omitted.

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