Endotracheal Tube: Closed Suctioning (Neonatal) - CE/NCPD

ALERT

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

OVERVIEW

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

• Ventilator settings can be maintained, especially positive end-expiratory pressure (PEEP)
• Continued oxygen delivery
• Fewer episodes and severity of hypoxia
• Lowered risk of ventilator-associated pneumonia
• Lowered risk of exposure to secretions by the health care team

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

• Audible or visible secretions in the ET tube
• Coarse breath sounds
• Coughing
• Increased work of breathing
• Oxygen desaturation
• Bradycardia or tachycardia
• Increased end-tidal carbon dioxide (ETCO₂) or transcutaneous carbon dioxide
• Agitation and restlessness
• Apnea
• Changes in blood gas values
• Decreased breath sounds
• Color changes (pale, dusky, or cyanotic)
• Decreased chest wiggle for neonates on high-frequency ventilators³
• Increasing oxygen requirements
• Loss of or poor chest wall excursion with ventilator breaths
• Pattern change in ventilator graphics such as saw tooth pattern⁴
• Increased peak inspiratory pressure (PIP) during volume-controlled mechanical ventilation or decreased tidal volume during pressure-controlled ventilation⁴

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

• Alterations in cerebral blood flow
• Atelectasis
• Barotrauma
• Bradycardia
• Bronchospasms
• Changes in blood pressure
• Hypoxemia
• Increased intracranial pressure (ICP)
• Infection
• Intraventricular hemorrhage
• Pneumothorax
• Tachycardia
• Tracheal damage
• Tissue trauma

Recommendations and parameters for suctioning the neonate:

• Instilling sterile 0.9% sodium chloride solution to facilitate suctioning of secretions is not recommended and may, in fact, contribute to bacterial colonization of the lower airway and impaired oxygenation.^3,4
• Negative pressure exerted on the ET tube should be the minimum that removes the secretions.³ Suction should not exceed −60 mm Hg to −80 mm Hg.^1,3
• There is no evidence that intermittent application of negative pressure, rotation of the catheter, or turning the neonate’s head from side to side is beneficial.³ The neonate’s head should be maintained in the midline position to prevent increased ICP, particularly in a preterm neonate.³
• To reduce the risk of hypoxemia, a duration of no more than 5 to 10 seconds per suction pass is recommended.^1,3 Longer duration is associated with hypoxia and bradycardia.^3,4
• The size of the suction catheter should not exceed 50% of the internal diameter of the ET tube size. This allows air to continue to enter the lungs during suctioning and limits mucosal trauma.¹
• Safe suction depth should be limited to the length of the ET tube including the adapter.¹
• Catheter passes should be limited to only the number of times required to remove secretions. If more than one catheter pass is required, then the patient must be allowed recovery time between passes.
• Suction should be applied only as the catheter is removed (unless the patient is ventilated with an HFJV or high-frequency oscillatory ventilator [HFOV]). Suction applied while inserting the suction catheter does not aid in removal of secretions and may increase the negative effects associated with suctioning (i.e., desaturation and bradycardia).
• With HFOV, stop oscillations while maintaining mean airway pressure during suction passes.⁴
• With HFJV with nitric oxide, put the jet in standby mode when suctioning to minimize bolus delivery of nitric oxide.⁴
• With HFOV and HFJV, follow the inline suction procedure and apply suction during both insertion and withdrawal of the suction catheter. Withdraw the catheter in a slow rotating manner (5 to 10 seconds) to minimize the effects of negative pressures caused by suctioning.⁴

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• As time permits, explain the procedure and what to expect, including the purpose, steps, and rationale.
• Explain to the family that suctioning may be uncomfortable and may cause coughing or shortness of breath for a brief time.
• Explain the plan for pain assessment and management.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the family.
3. Verify the correct patient using two identifiers.
4. Assess the family’s understanding of the reasons for and risks and benefits of the procedure.
5. Assess the patient for signs of airway secretions and inadequate oxygenation and ventilation.

   Rationale: The decision to suction a patient should be made on the basis of individual assessment and clinical signs.

   Suction only as needed.

   1. Visible secretions in the airway
   2. Inspiratory wheezes
   3. Expiratory crackles
   4. Restlessness
   5. Diminished breath sounds
   6. Tachypnea
   7. Tachycardia or bradycardia
   8. Cyanosis
   9. Hypertension or hypotension
   10. Shallow respirations
   11. Oxygen desaturation
   12. Coughing
6. Check the integrity of the tape or securement device to ensure that the ET tube is secure and movement is minimal.
7. Determine the family’s desire to be present during the procedure.

Preparation

1. Ensure that an appropriate-size bag and mask are connected to an oxygen source at the bedside.
2. Ensure that the oxygen source has the capability of being blended to provide a sufficient variety of oxygen concentrations to meet the patient’s needs.
3. Confirm that the inline catheter is the appropriate size or, if placing a new one, choose the proper catheter size.
   1. Select a recommended suction catheter size:¹
      1. 5 Fr or 6 Fr for 2.5 mm ET tube
      2. 6 Fr or 8 Fr for 3.0 mm ET tube
      3. 8 Fr for 3.5 mm ET tube
      4. 8 Fr for 4.0 mm ET tube
   2. Alternatively, calculate the proper size suction catheter by determining the catheter size occludes no more than 50% of the internal diameter of the tracheostomy tube.³ (e.g., 3.0 mm tracheostomy tube × 2 = 6 Fr suction catheter)

      Rationale: This allows air to continue to enter the lungs during suctioning and limits mucosal trauma.

4. Set the suction control at −60 to −80 mm Hg for suction.^3,5

   Use the minimum negative pressure necessary to remove secretions.²

5. Prepare sterile 0.9% sodium chloride solution for rinsing the catheter.

   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.

PROCEDURE

1. Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.

   Rationale: Sterile gloves are not required because the catheter is enclosed in a sterile covering throughout the procedure.

2. Verify the correct patient using two identifiers.
3. Explain the procedure to the family and ensure that they agree to treatment.
4. Provide developmentally appropriate containment (e.g., swaddling) for comfort during the procedure.
5. Increase the FIO₂ by a maximum of 10%, if needed, to maintain target oxygen saturation levels.³

   Rationale: Increasing FIO₂ by 10% when clinically indicated may offset hypoxemia related to disruption of ventilation.³

6. Secure the suction tubing from the suction source to the closed system suction port per the manufacturer’s directions (Figure 1). At this time, if obtaining a tracheal specimen, attach sterile specimen trap to suction catheter and suction tubing for specimen before suctioning.
7. Remove the cap and attach the sterile 0.9% sodium chloride solution to the irrigation port.
8. Determine the safe suction depth for suctioning by measuring the length of the ET tube, including the adapter.
9. Document the safe suction depth and, when suctioning, do not advance the catheter beyond the point where this measurement can be seen in the catheter window.³ Post the safe suction depth at the bedside.

   Rationale: If the suction catheter is advanced beyond the end of the ET tube, damage to the carina may result.

10. Unlock the suction control valve on the suction catheter by lifting and turning the valve to the open position.
11. Stabilize the ET tube with one hand while advancing the catheter with the other to the predetermined distance (Figure 2A).
12. If the patient is ventilated with an HFOV or HFJV, suction with the ventilator either on or off. If suctioning with the HVOV or HFJV on, apply suction while inserting and when withdrawing the catheter.²

    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

13. Maintain the patient’s head in the midline position.³

    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.

14. Suction secretions by depressing the control valve while withdrawing the catheter from the ET tube (Figure 2B). Continue to stabilize the tube.

    Do not apply suction for longer than 5 to 10 seconds.^1,3

15. Withdraw the black tip of the catheter into the middle of the cleaning chamber.
16. Depress suction first and then gently squeeze sterile 0.9% sodium chloride solution into the chamber to clear secretions from the suction tubing.¹
17. Monitor for dysrhythmia, change in heart rate, or peripheral oxygen saturation (SpO₂) while suctioning.
18. Reassess breath sounds.

    Rationale: Assessing breath sounds evaluates the effectiveness of suctioning and helps determine if additional passes are needed.

19. After each pass, monitor the patient’s tolerance of the procedure and allow time for recovery (i.e., oximetry and cardiopulmonary status returned to baseline) by providing positive pressure ventilatory support, as needed.²

    Rationale: Allowing recovery time helps prevent long-term complications associated with hypoxemia.

20. Note the color, quantity, and consistency of secretions removed.
21. Rinse the suction catheter with sterile 0.9% sodium chloride solution at the completion of the suctioning procedure.
22. Reconfirm the security and position of the ET tube.
23. Remove the 0.9% sodium chloride solution from the irrigation port and recap the port. Lock the control mechanism by lifting and turning to closed position.
24. Wean oxygen to preprocedure level as tolerated.
25. Change in-line (closed system) suction device per manufacturer’s recommendation or per organization’s practice.¹
26. Discard supplies, remove PPE, and perform hand hygiene.
27. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Monitor oxygenation levels before, during, and after suctioning and adjust support to prevent extremes of oxygenation.

   Rationale: Either extreme in oxygen levels may be detrimental to the patient.

2. Assess breath sounds and chest excursion before, during, and after each suctioning pass.
3. Assess, treat, and reassess pain.
4. Notify practitioner if there is a change in quality or color of secretions.

EXPECTED OUTCOMES

• Adequate removal of secretions from ET tube
• Comfort for the patient
• Decreased work of breathing
• Secure ET tube
• Hemodynamic stability
• Improved gas exchange
• Improvement in the symptoms that indicated the need to suction
• No evidence of increased ICP

UNEXPECTED OUTCOMES

• Bradycardia
• Bronchospasm
• Hemodynamic instability
• Hypoxia
• Inability to clear secretions
• Inadvertent/unplanned extubation
• Evidence of increased ICP
• Intracranial hemorrhage
• Respiratory instability
• Unmanaged agitation and irritability
• Ventilator-associated pneumonia

DOCUMENTATION

• Date and time of the procedure
• Physical assessment findings, including vital signs, breath sounds, and indicators of respiratory distress before and after the procedure
• Interventions necessary before, during, and after suctioning, including any changes to FIO₂
• Color, quantity, and consistency of secretions
• ET tube size and position
• Suction catheter size
• Patient’s response to suctioning and care
• Education
• Unexpected outcomes and related interventions

REFERENCES

1. Bailey, T., Maltsberger, H.L. (2021). Chapter 15: Common invasive procedures. In M.T. Verklan, M. Walden, S. Forest (Eds.), Core curriculum for neonatal intensive care nursing (6th ed., pp. 244-269). St. Louis: Elsevier.
2. Fraser, D., Diehl-Jones, W. (2021). Chapter 26: Assisted ventilation. In M.T. Verklan, M. Walden, S. Forest (Eds.), Core curriculum for neonatal intensive care nursing (6th ed., pp. 425-445). St. Louis: Elsevier.
3. Gardner, S.L., Enzman-Hines, M., Nyp, M. (2021). Chapter 23: Respiratory diseases. In S.L. Gardner and others (Eds.), Merenstein & Gardner's handbook of neonatal intensive care nursing: An interprofessional approach (9th ed., pp. 729-835). St. Louis: Elsevier.
4. Manikoth, P., Muhib Khan, J., Lakshminrusimha, S. (2019). Chapter 33: Nursing care and endotracheal suction. In P.K. Rajiv, D. Vidyasagar, S. Lakshminrusimha (Eds.), Essentials of neonatal ventilation (pp. 722-746). St. Louis: Elsevier.
5. Stein, M.I., Mancuso, T., Watters, K. (2023). Chapter 36: Airway management. In B.K. Walsh (Ed.), Neonatal and pediatric respiratory care (6th ed., pp. 609-631). Philadelphia: Elsevier.

Clinical Review: Justin J. Milici, MSN, RN, CEN, CPEN, CPN, TCRN, CCRN, FAEN

Published: February 2024