 In this module, we will discuss sectioning of the artificial airway. Endotracheal and tracheostomy tube sectioning is a frequently performed procedure for patients that require mechanical ventilation. The purpose of sectioning is to remove excess secretions in the airway that cannot be removed via the normal physiologic mechanisms, although uncommon complications of airway sectioning can be severe if proper care is not taken. Some hazards include hypoxia, hypoxemia, or low oxygen levels, tissue trauma to the airways or mucosa layers, cardiac arrests or dysrhythmias, respiratory arrest, collapsed lung, airway irritation, infection, bleeding, excessively high or low blood pressure, elevated intracranial pressure, or pressure in the brain. Several signs may be present that help the caregiver determine the need for sectioning. The needs of section secretions may be evident by one or more of the following. Excess breath sounds or rumbling in the chest and in the tubing often described as noisy breathing. Increased peak pressures during mechanical ventilation, visible secretions in the airway, the need to maintain the patency of the artificial airway, suspected aspiration of gastric or upper airway secretions, apparent increased work of breathing or excessive coughing. Once the caregiver has determined the need for endotracheal tube sectioning, careful steps in preparation must be observed. Gathering appropriate equipment and adequately preparing for this procedure will help ensure its success. The following equipment is essential before endotracheal tube sectioning is attempted. Vacuum source from the wall or equivalent portable device, calibrated suction regulator for an adult's pressure of negative 100 to 120 millimeters of mercury is considered as safe and adequate. suction bottle and connecting tubing, sterile suction catheter of appropriate caliber, for most adults a 12 or 14 French catheter can be used. Diameter of the suction catheter should not exceed more than one half of the internal diameter of the artificial airway, goggles, mask, and other appropriate equipment for standard precautions, oxygen source, manual resuscitation bag. Once equipment is assembled and proper function is determined, the patient should be prepared for the procedure. Once again, proper preparation is essential to ensure patient safety and successful outcomes of the procedure. To prepare the patient for sectioning, the following steps should occur. Discuss procedure with patient and or family member for reassurance. Provide 100% oxygen for at least 30 seconds. This is known as hyperoxygenation by one of the following methods. Increasing oxygen on mechanical ventilator, this is the preferred method, or if the previous recommendation is not an option, hyperoxygenation can be accomplished by manual resuscitation as discussed earlier. When possible, the patient may be placed on a pulse oximeter to assess oxygenation during and following the procedure. Oxygen levels should be maintained at or greater than 90%. The sectioning procedure is accomplished by first obtaining suction catheter and related equipment while employing sterile technique. To do so, follow these steps. Open suction catheter package or packages without touching the contents. Expose cuff of glove and lift only the inside portion of the first glove by grasping the cuff. Insert dominant hand into the glove without touching out a portion. Once first glove is on, use gloved hand to assist with donning other glove by sliding gloved hand under the cuff of second glove. Being careful to not touch anything but packaged contents, lift suction catheter with dominant hand about 2 inches from the tip. Wrap catheter around hand and grip the control port. Use non-dominant hand to lift and attach suction catheter to suction tubing. Remember now that you have touched the connection tubing, your non-dominant hand is no longer sterile. Do not attempt to touch or grab the suction catheter with that hand any longer. Using the now non-sterile hand, disconnect ventilator or open suction adapter port for insertion of catheter. Use catheter with sterile hand into the endotracheal tube slowly and gently until the patient coughs or the slightest amount of the resistance is felt, whichever is first. Occlude suction control port with non-sterile hand and remove catheter steadily back out of the airway. The last three steps can be repeated as necessary, however each event should last no longer than 10 to 15 seconds and sufficient time should be allowed in between events. Given the potentially cumbersome nature of this procedure, it is recommended that these steps be practiced before performing on patients. It is also recommended that appropriate help of an experienced clinician is available to manage potentially adverse events if needed. When complete, the patient should once again be hyperoxygenated for at least one minute following the sectioning procedure. Careful monitoring of adverse events and hazards should occur for an appropriate amount of time following the procedure. Once the procedure is complete, disconnect catheter from suction tubing, avoiding contact with the patient and other surfaces to prevent contamination. Next carefully remove gloves and wrap catheter in gloves then wrap gloves in packaging for disposal.