In this section
Endotracheal intubation prevents the cough reflex and interferes with normal muco-ciliary function, therefore increasing airway secretion production and decreasing the ability to clear secretions
Endotracheal tube (ETT) suction is necessary to clear secretions and to maintain airway patency, and to therefore optimise oxygenation and ventilation in a ventilated patient
ETT suction is a common procedure carried out on intubated infants. The goal of ETT suction should be to maximise the amount of secretions removed with minimal adverse effects associated with the procedure.
The aim of the guideline is to outline the principles of management for infants requiring ETT suction for clinicians on Butterfly Ward at the Royal Children’s Hospital.
The timing of ETT suction should be based on a clinical assessment of the infant. During artificial ventilation, the inspired gas is warmed and humidified, to reduce the drying of secretions and risk of occluding the airway.
Auscultate chest with stethoscope before and after ETT suction to evaluate necessity and effectiveness of the procedure.
Monitor the infant closely before, during and after the procedure to assess baseline, acute physiological changes and recovery. Parameters to observe:
Effectiveness of ETT suction should be assessed after the procedure by observing:
ETT position should be checked at the start of the nursing shift, using a paper measuring tape to ensure it is documented correctly within the LDAs of EMR.
Suction should only be to the tip of the ETT and should never exceed more than 0.5cm beyond the tip of the ETT, to prevent mucosal irritation and injury.
Measurement of length to suction is to be predetermined at shift commencement. Length is determined by using the centimetre markings on the ETT; and by adding the length of additional space of the ETT adapter (usually 1-1.5 cm). For patients on HFOV or HFJV, allow for different lengths of suction adaptors by measuring
prior to procedure using a paper measuring tape.
Table 1: Suction catheter size relating to ETT size in infants
Table 2: Suction Catheter Size for Closed Suction of ETT
The open suction technique is the standard method that is used for conventionally ventilated patients on Butterfly.
There is some evidence that utilizing a closed suction method during mechanical ventilation infants will help to reduce the de-recruitment phase of ventilation.
Closed suctioning reduces the risk for contamination with environmental pathogens, reduces viral and bacterial colonisation within the ventilation circuit and it also safely protects nursing and medical staff from exposure to patient bodily fluids. It therefore a preference to use this technique when caring for patients with infectious respiratory conditions.
Complications of ETT suction
Complications of oropharyngeal and nasopharyngeal suction:
Normal saline should not be routinely instilled prior to ETT suction in infants. It should only be instilled in infants who have thick, tenacious secretions. The amount of normal saline to use is 0.1-0.2 mL/kg.
Lavage by instillation of normal saline into the ETT immediately prior to ETT suction:
Oxygenation pre/post suction should not be routine, but:
Each infant should be assessed individually regarding whether this is necessary. This is determined by the infant’s clinical condition, response to ETT suction, and length of time it takes for the infant to recover post suction.
FiO2 may be increased 10-20% above baseline for approximately two minutes prior to suction and continues after suction is complete until the infant returns to the pre-suction oxygen saturation level. Care should be taken to ensure the infant’s FiO2 is reduced to baseline as soon as possible after ETT suction.
If the infant’s pre-suction oxygenation is hypoxic, or if the infant becomes severely hypoxic and bradycardic with ETT suction, 100% oxygen may be used prior to ETT suction. This should be decreased as soon as possible after suction is complete.
Some infants may require a pre-suction bolus of analgesia or sedation where the need is anticipated, however urgent suction should not be deferred. The need for this intervention is based on clinical assessment. Nursing comfort measures, such as positioning and containment, should also be utilized following the suction procedure.
Document clearly in EMR:
Oral and nasopharyngeal suction will need to be documented separately in the ventilation flowsheet.
It is the responsibility of the clinician caring for the infant requiring ETT suction, to ensure that the parents understand the rationale for the procedure, as well as the potential complications. Parents can help to support, contain and comfort the infant while the nurse is carrying out the procedure.
Each infant should be assessed individually regarding whether this is necessary. This is determined by the infant’s response to ETT suction, and length of time it takes for the infant to recover post suction.
Recruitment post-suction should not be routine, however:
Using the ventilator setting, PIP is increased 10-20% above baseline for approximately two minutes after suction is complete, or until the infant returns to the pre-suction oxygen saturation level. For infants being ventilated in TTV+ mode it may also be necessary to increase the set tidal volume by 1 mL/kg if no change in delivered PIP occurs. Care should be taken to ensure the PIP is reduced to baseline as soon as possible after ETT suction. If the oxygen saturations are not improving in the two minutes after suction increasing the PEEP by 1 cmH2O should be discussed with the Medical Staff.
Each infant should be assessed individually regarding whether hyperventilation pre-suction is necessary. This is determined by the infant’s response to ETT suction, and length of time it takes for the infant to recover post suction.
Hyperventilation pre-suction should not be routine, but:
Using the ventilator setting, rate is increased by 5-10 breaths above baseline immediately prior to suction and continues after suction is complete until the infant returns to the pre-suction oxygen saturation and ETT or transcutaneous CO2 (if monitored) level. Care should be taken to ensure the rate is reduced to baseline as soon as possible after ETT suction.
For HFOV, use the suction port (closed suction) at the end of the ETT. As there is no flow sensor used during HFJV, you can pass the suction catheter where the ventilation tubing attaches to the end of the ETT tube.
Open suction may be indicated for infants on HFOV and HFJV, as this can result in more effective removal of thick secretions. The need for this intervention is not routine, and where appropriate should be ordered by medical staff. This is a two-person procedure. If performing an open suction technique on patients requiring HFOV or HFJV, a post suction recruitment plan should be made in consultation with the medical team.
For infants on HFOV, mean airway pressure is increased 2cmH2O above baseline for approximately two minutes after suction is complete, or until the infant returns to the pre-suction oxygen saturation level. Care should be taken to ensure the mean airway pressure is reduced to baseline as soon as possible after ETT suction.
For infants on HFJV, conventional ventilator rate may be increased by 1-2 breaths above baseline immediately prior to suction and continues after suction is complete until the infant returns to the pre-suction oxygen saturation and transcutaneous CO2 (if monitored) level. Care should be taken to ensure the rate is reduced to baseline as soon as possible after ETT suction.
When caring for patients on HFJV, ideally the jet ventilator should be put on hold while suctioning and then press the enter button when the procedure is complete. This step prevents the jet ventilators alarms from shutting down the ventilator during suction. There are, however, occasions where this may not be possible due to the instability of the patient you are caring for. There is no need to disconnect from the ventilator as you can suction through the port of the ventilator tubing. Ensure that the patient has good chest wiggle following the procedure and the ready light is on, prior to leaving the patient’s bedside.
Disconnection of a ventilation circuit with iNO therapy should be avoided and so the use of an in-line suction port is most suitable. Suction of the ETT should be done swiftly to avoid de-recruitment of the lungs.
Staff are to use standard aseptic technique and don personal protective equipment. Suction catheters should be discarded following each suction event, to reduce the risk of introducing contamination. ETT suction should be performed prior to oral or nasopharyngeal suction. Inline suction catheter sets should be changed every 24 hours or if no longer patent.
Where possible, ETT suction is a two-person procedure. The primary clinician suctions the ETT maintaining infection control precautions. The assistant ensures the infant remains safe from accidental extubation, adjusts ventilator settings if necessary, and provides containment and comfort to the infant.
Please remember to
read the disclaimer.
The development of this nursing guideline was coordinated by Allison Kendrick, Clinical Nurse Educator, Nursing Education, and approved by the Nursing Clinical Effectiveness Committee. Updated November 2023.
Taylor, JE., Hawley, G., Flenady, V & Woodgate, P.G., (December 2011)
Tracheal suctioning without disconnection in intubated ventilated neonates. Cochrane
Database of Systematic Reviews, 11.