On the first night after an older adult comes home from hospital, the son often does not know what to do with the suction machine and the collection bottle in the room. His father has come home after a stroke with a tracheostomy. The nurse demonstrated once before discharge, but at the bedside in a public housing flat the son hardly dares to touch anything, not knowing which setting to turn the suction pressure to or how deep to insert the catheter. Therapists who teach suctioning at home meet the same situation almost every day: the family seemed to understand while learning in hospital, but forgot everything once they got home.
Whether suctioning at home is safe depends on whether the carer has learned it correctly. With in-person teaching by a visiting therapist, together with proper infection control and recognition of warning signs, a carer can carry out the existing medical instructions safely and smoothly. Training can only improve the quality of care. It does not change the illness itself, and the overall quality of evidence for this kind of support is generally low. A cross-sectional study of family members of home-ventilated tracheostomy patients found that carers' "caring behaviour" scores were significantly related to first-aid knowledge, readiness to use the equipment and the number of home visits (Kim 2021). In other words, how well care is given depends on whether training and support are enough, and not on the illness itself.
A study that interviewed 27 carers of children with a tracheostomy at home found that they generally felt the training before discharge was "enough", but also wished strongly for teaching better matched to their own situation. Even those who felt ready for discharge still met many difficulties when caring at home (Mai 2020). This shows that the question is not whether the hospital "has taught it", but whether the family has been taught what they can really do in their own home.
How home suction teaching works
Effective home suction training is more than handing out a leaflet or explaining the steps once by word of mouth. Research agrees that carers need teaching that is personalised and can be checked (Mai 2020), and that caring performance is directly linked to the quality of training and support (Kim 2021). A home training session usually runs as follows:
The therapist uses the actual machine in the patient's home and goes round the following cycle step by step, until the carer can complete the whole procedure once in front of the therapist:
- Demonstrate once first—The therapist demonstrates the whole procedure at a slow pace, from checking the equipment, washing hands and setting the suction pressure to inserting and withdrawing the catheter, and explains the reason behind each step along the way.
- Then watch the carer do it once—Next the carer does it with their own hands while the therapist observes and corrects hand movements and timing on the spot, making sure the carer has truly done it and has not just listened.
- Practise repeatedly until steady—The carer practises repeatedly until they can complete the whole suction procedure smoothly and safely alone, without being reminded. Only then is it truly mastered.
- Leave a step card and emergency contacts—The therapist leaves a step card in large print at the bedside, which also says when to call a nurse, so that a carer working alone in the middle of the night still has clear instructions to follow.
This personalised training model of "demonstrate, check, practise repeatedly" matches the carer needs shown by the research, and helps the family truly master safe technique better than a single spoken explanation or a standard leaflet. The interviews in Mai 2020 also show that even when a family feels ready for discharge, the actual transition is still difficult, and home nursing support is hard to arrange but essential. These gaps can only be filled by repeated checking at home. For the safety parameters and oxygen monitoring in each step of suctioning, read the page on safe suctioning steps at home. For the technical detail of pressure, depth and intermittent suction, see safety details of suction technique.
Key points of safe suctioning: pressure, depth, catheter size and saline
Suctioning has a set of clinical practice standards (these are practice guidance and not randomised controlled trial data). Training aims to help the carer remember the safety limits, and the actual values must follow the medical settings for the patient:
Hand washing, aseptic technique and cleaning the equipment
The airway is the gateway to the lungs, and if the suction equipment is not clean enough, bacteria are carried into the lower airway again and again. In suction training, infection control is as important as technique. Suctioning must use an aseptic or clean technique to reduce the risk of lower respiratory tract infection (Ireton 2007; Bott 2009). Knowing how to clean the equipment affects patient safety as much as knowing how to suction. Cleaning also affects how the machine works. If the filter, tubing and collection bottle are not maintained, the suction pressure becomes unstable and suction works much less well. Families can go through the checklist below at home:
- Wash hands thoroughly before and after every suction, and keep an aseptic or clean technique throughout
- Change catheters and tubing regularly as the healthcare team instructs, and never reuse single-use items
- Empty, wash and disinfect the collection bottle regularly, and never leave phlegm in it overnight
- Change the water used for suctioning as instructed, and never use dirty or overnight water
- Clean and maintain the body of the suction machine, the connectors and the filter regularly according to the manual
- Never use the same catheter for both the mouth and the airway, and never reuse a single-use catheter for convenience
When to stop at once and get help
Knowing when to stop and when to call for help is the most important part of the whole training, even more important than knowing how to switch the machine on. Because suctioning briefly removes oxygen from the airway, doing it too quickly or for too long on one pass can make the patient dangerously low in oxygen. Bleeding from the mucosa and being unable to remove phlegm are also common warning signals. If any of the following happens, stop suctioning at once, restore oxygen, and contact the healthcare team or consider going to hospital (Ireton 2007; Bott 2009):
Danger signs to stop at once
- Signs of low oxygen: blue face or lips, a clear fall in the oxygen saturation reading
- Laboured breathing, an abnormal heartbeat, or the patient looking clearly very distressed
- Blood streaks in the phlegm, or bleeding from the mucosa
- Several attempts fail to remove phlegm and the patient has more and more trouble breathing
What to do after stopping
- Withdraw the catheter at once and put the oxygen tubing back, or give oxygen as the healthcare team has instructed
- Let the patient catch their breath, and watch closely whether face colour and oxygen saturation recover
- If this keeps happening, contact the community nurse or the patient's treating healthcare team promptly
- If the situation suddenly becomes very bad, call 999 at once to go to hospital
Clinical markers for suctioning and cough assistance
Suctioning is only one part of airway clearance. Airway clearance techniques fall broadly into proximal (improving the cough) and distal (helping secretions to move) types (Chatwin 2018). In the guideline on airway clearance for hospitalised patients, the only decision with a clear hard threshold is that cough assistance should be considered when the peak cough flow (PCF) of a patient with neuromuscular disease is below 270 L/min (Strickland/AARC 2013). For mechanical insufflation-exsufflation (MI-E) itself, the Cochrane review concluded that the evidence is not enough to support or oppose its use (Morrow 2013). Whether to use it must therefore be assessed by healthcare professionals case by case, and home training does not decide this alone.
- Removes secretions already retained in the stoma or airway
- Used in selected patients with a weak cough and retained secretions
- Has safety limits: pressure, depth, time and infection control
- A supporting measure that does not change the illness itself
- Aimed at a weak cough, helping the patient to cough phlegm up to the large airways
- Hard decision: considered only when PCF is below 270 L/min (AARC 2013)
- For MI-E itself, the evidence is "not enough to support or oppose" (Morrow 2013)
- Must be prescribed after individual assessment by healthcare staff, and not decided alone
How suctioning, cough assistance and chest percussion should work together is a separate topic. To see how a full home respiratory rehabilitation service gives carers technical training and follow-up, see the page on home respiratory rehabilitation training for carers in Hong Kong.
What suction training can and cannot do
The limits of the training have to be stated plainly. What suction training can do is help the carer to carry out the patient's existing medical instructions safely and smoothly and reduce the risks of low oxygen and bleeding from unpractised technique. Training cannot change the illness itself, and suctioning should not be overstated as something that "cures disease or reduces hospital admissions". In fact, the overall research evidence for respiratory physiotherapy is generally of low certainty. For chest physiotherapy used in adult pneumonia, a Cochrane review that included 8 randomised controlled trials with 974 people found that the certainty of evidence was very low for all outcomes, and the effect on outcomes such as mortality is uncertain (Chen 2022). The training therefore aims to improve the quality of care and does not claim a specific treatment effect. Being clear about this difference helps families avoid wrong expectations.
Every setting for home suctioning is tailored to the patient. The suction pressure, the type of tracheostomy tube and whether cough assistance has been prescribed must all follow the patient's existing medical instructions strictly. The responsibility of home training is to teach the carer to follow the original instructions safely, and not to write a new prescription or change the settings. Research shows that how well care is given is closely linked to the quality of training and support (Kim 2021). Keeping to this professional boundary is also the safeguard a family member needs most when working alone in the middle of the night.
Home environment limits in Hong Kong and local sources of support
In Hong Kong, home suction training often has to be adjusted to the actual living space. Many tracheostomy patients live in subdivided flats or very small units, and where the suction machine, sterile gloves and distilled water for cleaning are kept, together with the disinfection routine and how to move around, all have to be arranged to suit the space. If the main daytime carer is a foreign domestic helper, the suction hand movements and machine cleaning also need to be demonstrated step by step in a language the helper knows well, and not just by handing out a Chinese leaflet. Under the current system, families can also consider the following kinds of local support:
If a family member has just come home with a tracheostomy or a suction machine and lacks confidence in the actual procedure, or if low oxygen and blood-stained phlegm keep appearing during suctioning, it is worth arranging a session of home physiotherapy for professional assessment and in-person teaching. The registered physiotherapists at Nova Health demonstrate once on the suction machine in the patient's home, then watch the carer practise once, and finish only when the carer can complete the whole procedure independently and safely. During the session they also check the patient's existing medical instructions (including the suction pressure setting, the tracheostomy tube size and whether a cough assistance prescription exists), and never change clinical parameters themselves. Beyond suctioning, for how manual airway clearance and chest percussion are done, return to the overview page on suctioning at home and secretion management and select the relevant content as needed.