Endotracheal Tube Closed Suctioning (Neonatal)
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Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions.
Limit negative pressure for suctioning to −60 mm Hg to −80 mm Hg of negative pressure.undefined#ref2">2
Limit the duration of each suction pass to no more than 10 seconds with 5 seconds of applied suction.1 A longer duration is associated with increased risk of hypoxemia and bradycardia.3
Do not perform routine suctioning in neonatal patients.3 Suction only when a clinical assessment of the patient indicates that secretions are obstructing the airway.3
When a neonatal patient suffers from respiratory distress, supporting respiratory function may require the insertion of an ET tube and ventilator support. Intubation causes an increase in the production of secretions, which neonates are unable to clear. 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. 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:3,4
ET suctioning is a noxious procedure that may stress vulnerable neonatal patients 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 audible or visible secretions in the ET tube, coarse breath sounds, coughing, increased work of breathing, oxygen desaturation, and bradycardia.3
In addition to the listed indications, the nurse should assess for suctioning needs with these findings:1
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 neonatal patients.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 neonatal patient:
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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 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 neonatal patients. 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 seconds.1,3
Rationale: Assessing breath sounds evaluates the effectiveness of suctioning and helps determine if additional passes are needed.
Rationale: Either extreme in oxygen levels may be detrimental to the patient.
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