Continuous Suctioning Doesn’t Hasten Hypoxemia

Written by Anand Swaminathan
REBEL Crit, REBEL EM
Medical Category: Resuscitation
acute hypoxemia, Airway, Airway Management, DuCanto, hypoxemia, RSI, SALAD, suction catheter, Suctioning, yankauer

February 9, 2026

📌 Key Points

🙅🏽‍♂️Continuous suctioning during RSI did not cause more rapid deoxygenation when compared to a standard approach of “as needed suctioning.”
📉Limitations in the study size and design make these results inconclusive and larger studies are needed to further elucidate the issue.

📝 Introduction

Airway contamination with vomit, blood or secretions poses a serious threat to first pass intubation success and subsequent hypoxemia and hemodynamic collapse. The Suction Assisted Laryngoscopy for Airway Decontamination (SALAD) technique, created by Dr. Jim DuCanto, addresses the issue of airway decontamination (video link). This technique relies on application of continuous suctioning. Prior research has shown that deep tracheal suctioning can result in more rapid development of hypoxemia. It is unclear if continuous suctioning during intubation poses a similar risk.

🧾 Paper

Strayer RJ et al. The Impact of Suctioning on Oxygenation During Rapid Sequence Intubation in the Emergency Department: A Multi-Center Pilot Randomized Controlled Trial. J Emerg Med. 2025. PMID: 40533376

🔙Previously Covered and Related Content:

REBEL EM: The DuCanto Catheter: It Sucks!
REBEL EM: Core Cast 4.0 – RSI Cheat Codes

⚙️ What They Did

CLINICAL QUESTION

Does the application of continuous suctioning during rapid sequence intubation (RSI) result in more rapid deoxygenation?

STUDY DESIGN

Multicenter, pilot randomized controlled trial at three tertiary academic emergency departments.
Investigators, patients and outcome assessors were non-blinded to intervention.
Beyond the specific intervention of suctioning, all clinical care was at the discretion of the clinical team.

POPULATION

Inclusion Criteria:

Patients ≥18 years of age
Need for emergent airway management
RSI and laryngoscopy as the planned approach

Exclusion Criteria:

Cardiac arrest
Known or predicted heavily soiled airway (defined as significant blood or emesis in mouth)
Unreliable pulse oximetry

INTERVENTION & COMPARATOR

Intervention:

Constant suctioning: the suction catheter was inserted at the start of laryngoscopy and left in the oropharynx until the ETT was delivered.

Comparator:

As needed suction: the suction catheter was applied as needed to clear secretions.

OUTCOMES

Primary Outcome:

Absolute decrease to final O2 saturation (defined as SpO2 at the time of ETT confirmation subtracted from SpO2 at the time of laryngoscope insertion

Secondary Outcomes:

Absolute decrease to lowest saturation (defined as the lowest SpO2 recorded during laryngoscopy subtracted from the SpO2 at the time of initiation of laryngoscopy)
Duration of laryngoscopy
Number of laryngoscopy attempts
Procedural complications

📈Results

💥 Critical Results

💪🏽 Strengths

The study asks a clinically important question that has not previously been researched.
Multicenter nature increases external validity
Exclusion criteria were limited increasing external validity
Randomization was performed using a computer-generated random number sequence
Data available on all patients randomized to the study

⚠️ Limitations

This is a small study and no power calculation was performed prior to enrollment
All of the departments within the study operate under one hospital system which decreases external validity.
This was a convenience sample of patients thus introducing sampling bias as all patients requiring intubation were not included.
There was no standardization of care beyond the suctioning approach which decreases internal validity.
Investigators and outcome assessors were not blinded to intervention.
Only 25% of intubations were performed with large bore suction catheters (eg DuCanto catheters).

🗣️ Discussion

The sickest subset of patients were not included in the study
- Patients requiring immediate intubation may have been intubated prior to availability of a research assistant
- This biases the study towards patients who are less likely to desaturate
Most patients were not suctioned using a large bore suction catheter
- In many departments, these have become ubiquitous
- It is unclear if widespread use of large bore suction catheters would have a greater effect on deoxygenation with constant suctioning
Would have been interesting to evaluate the impact on the duration of suctioning with use of either a small bore or large bore catheter on overall hypoxia and how this may or may not have played a role in first pass success

📘 Author's Conclusion

“The study found that constant suctioning during Emergency Department laryngoscopy facilitated by RSI does not cause more rapid desaturation compared to as needed suctioning. However, the reliability of these results is limited by the small sample size and convenience sampling which likely skewed the cohort to patients less likely to develop hypoxia. Further studies are needed to confirm these findings and their impli- cations for emergency airway management.”

💬 Our Conclusion

Continuous airway suctioning in order to relieve or prevent airway contamination is a reasonable approach to airway management in the ED based on the available limited data.

🚨 Clinical Bottom Line

Stick with current benzodiazepine protocols as first-line treatment, as midazolam remains the mainstay of treatment. Ensure adequate initial dosing as underdosing is common and delays seizure control. If considering ketamine, reserve it for true refractory cases after standard benzodiazepines have failed and other second-line options (like levetiracetam or fosphenytoin) are unavailable or delayed.

📚 References

Strayer RJ et al.
The Impact of Suctioning on Oxygenation During Rapid Sequence Intubation in the Emergency Department: A Multi-Center Pilot Randomized Controlled Trial. J Emerg Med. 2025.
PMID: 40533376

Post Peer Reviewed By: Mark Ramzy, DO (X: @MRamzyDO), and Anand Swaminathan (X: @EMSwam)

👤Associate Author

Anand Swaminathan

MD, MPH

All Things REBEL EM

Meet The Team

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Cite this article as: Anand Swaminathan, "Continuous Suctioning Doesn’t Hasten Hypoxemia", REBEL EM blog, February 9, 2026. Available at: https://rebelem.com/continuous-suctioning/.