Endotracheal Tube Closed Suctioning (Neonatal)
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Limit negative pressure for suctioning to −60 mm Hg to −80 mm Hg of negative pressure.undefined#ref3">3
Limit the duration of each suction pass to no longer than 5 to 10 seconds of applied suction.3 A longer duration is associated with increased risk of hypoxemia and bradycardia.3
Do not perform routine suctioning in neonates.3 Suction only when a clinical assessment of the patient indicates that secretions are obstructing the airway.3
When suctioning a patient on a high-frequency jet ventilator (HFJV) with nitric oxide, the jet must be put in standby mode to minimize bolus delivery of nitric oxide.4
When a neonate suffers from respiratory distress or failure, supporting respiratory function may require the insertion of an endotracheal (ET) tube and ventilator support. Having an ET tube in the trachea can increase the production of mucus and impairs airway clearance of secretions by preventing the cough reflex and interfering with the normal mucociliary clearance mechanism.4 The purpose of suctioning the ET tube is to remove secretions that may accumulate and to maintain a patent airway. Successful removal of secretions helps promote oxygenation and ventilation. Of note, the amount of secretions produced can be disease related as there is increased mucus production in infants with respiratory distress syndrome, patent ductus arteriosus, bronchopulmonary dysplasia, and pneumonia.2 The frequency of suctioning is determined according to each patient’s needs.
Suctioning can be performed with either the closed suctioning technique, which involves a sterile, closed, inline suction catheter attached to the ventilator circuit, or the open suctioning technique, which involves disconnection from the ventilator circuit or oxygen source. The closed suctioning technique allows passage of the suction catheter into the airway without disconnection from the ventilator. Advantages of the closed suctioning technique include:3,5
ET tube suctioning is a noxious procedure that may stress vulnerable neonates and should not be a routinely scheduled intervention. Suctioning is appropriate when a clinical assessment of the patient indicates that secretions are obstructing the airway.
Indications for suctioning include:1,2,3
An exception to suctioning when secretions are visible in the ET tube or breath sounds are coarse is the length of time following the instillation of artificial surfactant. To ensure maximal benefit from the artificial surfactant, tracheal suctioning is avoided immediately following surfactant administration if ventilation is adequately maintained. Avoiding suctioning for 1 to 2 hours following surfactant delivery is preferable unless ventilation or oxygenation is compromised.2
One strategy to minimize the risks associated with suctioning is to control the depth of catheter insertion. With deep suctioning, the catheter is inserted until resistance is met. Current evidence suggests that deep suctioning can damage the carina; therefore, shallow suctioning is recommended.3 With shallow suctioning, the catheter is inserted no farther than the sum of the ET tube length and adapter.
Suctioning may result in hypoxia or hyperoxia. No available evidence suggests that preoxygenation is a safe practice with premature neonates.2,3 Hyperoxia in the preterm neonate can result in retinopathy of prematurity and chronic lung disease. Current evidence suggests that increasing the inspired oxygen concentration before suctioning must be individualized based on the patient’s response. To prevent hyperoxia, avoid increasing the fraction of inspired oxygen (FIO2) more than 10% to 20%3 above baseline. For the extremely low-birth-weight neonate, avoid increasing the FIO2 more than 2% to 5%.3 Monitoring oxygen saturation levels is essential to protect the neonate from hypoxia and hyperoxia.
Risks associated with ET tube suctioning include:3
Recommendations and parameters for suctioning the neonate:
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Rationale: The decision to suction a patient should be made on the basis of individual assessment and clinical signs.
Suction only as needed.
Rationale: This allows air to continue to enter the lungs during suctioning and limits mucosal trauma.
Use the minimum negative pressure necessary to remove secretions.2
Do not instill sterile 0.9% sodium chloride solution as a routine procedure to facilitate suctioning of secretions since this may lead to impaired oxygenation and contribute to bacterial colonization of the lower airway.2 Sterile 0.9% sodium chloride solution is only for rinsing the catheter.
Rationale: Sterile gloves are not required because the catheter is enclosed in a sterile covering throughout the procedure.
Rationale: Increasing FIO2 by 10% when clinically indicated may offset hypoxemia related to disruption of ventilation.3
Rationale: If the suction catheter is advanced beyond the end of the ET tube, damage to the carina may result.
Rationale: If the jet or oscillator is on, applying suction during both insertion and withdrawal of the catheter prevents overpressurization of the circuit and alveolar rupture.2
Rationale: The midline position prevents increased ICP, particularly in preterm neonates. There is no evidence indicating that intermittent application of negative pressure, rotation of the catheter, or turning the patient’s head from side to side is beneficial. These interventions may increase the negative effects associated with suctioning, such as desaturation and bradycardia.
Do not apply suction for longer than 5 to 10 seconds.1,3
Rationale: Assessing breath sounds evaluates the effectiveness of suctioning and helps determine if additional passes are needed.
Rationale: Allowing recovery time helps prevent long-term complications associated with hypoxemia.
Rationale: Either extreme in oxygen levels may be detrimental to the patient.
Clinical Review: Justin J. Milici, MSN, RN, CEN, CPEN, CPN, TCRN, CCRN, FAEN
Published: February 2024
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