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Clinical Guidelines (Nursing)

Endotracheal tube suction of ventilated neonates

  • Introduction

    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. 

    Aim

    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.

    Definition of Terms 

    • Endotracheal Tube (ETT):  An airway catheter inserted into the trachea (windpipe) via the mouth or nose in endotracheal intubation.  On Butterfly Ward this is usually un-cuffed
    • Endotracheal Intubation:  The placement of a tube into the trachea in order to maintain an open airway in patients who are unable to breathe on their own or maintain their own airway
    • ETT Suction:  The process of applying a negative pressure to the distal ETT or trachea by introducing a suction catheter to clear excess, or abnormal, secretions
    • Oropharygyl Suction: A suction catheter through the mouth to clear secretions
    • Nasopharygeal Suction: A suction catheter is passed through the nose to clear secretions
    • PIP: Peak Inspiratory Pressure
    • HFOV: High Frequency Oscillation Ventilation
    • HFJV: High Frequency Jet Ventilation
    • Open Suction: Suction is performed by means of disconnecting the patient ETT from the ventilation device during the procedure and then reconnecting it following the procedure.
    • Closed Suction: An in-line suction catheter is connected to the ventilation circuit and ETT suction procedure can be performed without disconnecting the patient from the ventilation circuit. 
    • ET CO2: End Tidal Carbon Dioxide monitoring is the level of carbon dioxide in exhaled air which gives an assessment of ventilation
    • Transcutaneous Co2: Measures the skin surface partial pressure of carbon dioxide to be able to assess, as an alternative to regular arterial blood sampling 
    • Conventional Ventilation Modes: The primary mode of invasive ventilation used to provide respiratory support to neonates.
    • TTV + Mode: Targeted Tidal Volume is a mode of ventilation which is set on the ventilators that are used on Butterfly which aims to reduce the risk of damage to the babies’ lungs. 
    • Neopuff: T-piece resuscitator device where peak inspiratory pressure and positive end expiratory pressures can be set.
    • Nitric oxide: An inhaled selective pulmonary vasodilator that is used alongside mechanical ventilation as a treatment for hypoxic respiratory failure, associated with pulmonary hypertension.
    • Recruitment: Refers maneuvers that aid the opening of collapsed alveoli. 
    • Derecruitment:  Refers to the collapse of alveoli, in this case following a suction procedure. 
    • PPE: Personal Protective Equipment.  For an aerosol generating procedure, such as open suctioning, this will entail mask, eyewear and gloves. 

    Assessment

    ETT suction should be based on a clinical assessment of the infant. The inspired gas is warmed and humidified (therefore decreasing the amount of secretions drying and occluding the airway).

    Auscultate 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:

    • Oxygen saturation
    • Heart rate
    • Respiratory rate
    • Blood pressure (where possible)
    • ETT CO2 or transcutaneous CO
    • Respiratory function monitoring (during conventional modes of ventilation), including flow, pressure, tidal volume and minute volume

    Clinical Indications for ETT suction

    • Desaturations
    • Bradycardia
    • Tachycardia
    • Absent or decreased chest movement
    • Visible secretions in ETT
    • Increased ETT CO2 or transcutaneous CO2
    • Irritability
    • Coarse or decreased breath sounds
    • Increased work of breathing
    • Blood pressure fluctuations
    • Recent history of large amounts of thick / tenacious secretions

    Effectiveness of ETT suction should be assessed after the procedure by observing:

    • Improvement in breath sounds
    • Removal of secretions
    • Improved oxygen saturation, transcutaneous CO2, heart rate, blood pressure, respiratory rate
    • Decreased work of breathing, improved chest movement

    Measurement of Length to Suction

    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). If patient on HFOV or HFJV, allow for different lengths of suction adaptors.

    Equipment

    • Functioning wall suction unit with suction tubing connected
    • This should be checked at shift commencement of each nursing shift and prior to each procedure
    • Suction pressure at -80-100 cmH2O.  Suction pressure may be lower for a small or unstable infant, or higher to remove thick or tenacious secretions. Maximum pressure should not be higher than -200 cmH2O.  The likelihood of needing a higher pressure increases with smaller sized closed suction catheters
    • Neopuff set to appropriate settings (checked at shift commencement)
    • Suction catheter for open suction (see table below for appropriate sizes)
    ETT Size (mm) Suction Catheter Size
    2.5 5 FG
    3.0-3.5 6-7 FG
    4.0-4.5     8 FG


    • Suction unit for closed suction (Halyard closed suction system for neonates/paediatrics) ETT adaptor needs to be added into the circuit. Remove original adaptor and attach new appropriate sized Fr adaptor which comes in the package. Use the chart below to select the correct in-line suction unit size and note the correct depth to insert the catheter to.

    ET tube size Suction Catheter size Distance/ Colour to view
    2.0 5 Fr 18cm (between yellow and green stripes)
    2.5 6 Fr 19cm (between purple and red stripes
    3.0 7 Fr 21.5 (between blue stripes and yellow stripes)
    3.5 8 Fr 23cm (between black stripes and green stripes)
    4.0 8 FR 23cm (between black stripes and green stripes)

    • Non sterile gloves
    • Normal saline ampoule and 1mL syringe and blunt needle (if normal saline lavage required)

    Management

    Procedure for open suction technique on Butterfly

    • Adjust ventilator settings to pre-suctioning baseline (if settings have been adjusted) when indicated by stabilisation of infant’s oxygen saturations and heart rate.
    • Where possible, this procedure requires two clinicians.  If clinician deems it safe, she/he may undertake the procedure without assistance and in this situation should alert other nearby members of staff that ETT suction is occurring.
    • Explain to parents what is about to occur.
    • Determine suction catheter size.
    • Check the suction pressure (see equipment).
    • Pre-silence alarms.
    • Both clinicians perform hand hygiene and dons PPE (gloves on both hands, mask and eyewear).
    • Protecting key parts, the primary clinician attaches appropriate sized suction catheter to suction tubing. Ensuring that the suction catheter does not touch anything that could contaminate it e.g. bed linen.
    • Observe pre-suction physiological parameters.
    • When the primary clinician and assistant are ready, assistant disconnects ETT from ventilator tubing at ETT adaptor. 
    • Primary clinician passes suction catheter to predetermined length, ensuring catheter is only passed the length of the ETT.
    • Applying negative pressure, primary clinician gently rotates suction catheter as it is being withdrawn from the ETT
    • Negative pressure should only be applied when the suction catheter is being withdrawn from the ETT.  
    • Duration of negative pressure should not exceed 6 seconds to prevent hypoxaemia
    • Repetitive catheter passes are not used unless the volume of secretions indicates another pass, or the clinician determines another pass is necessary
    • To prevent accidental extubation, assistant gently holds infant’s head in steady position and holds ETT steady while primary clinician suctions ETT.  
    • Assistant reconnects ventilator tubing to ETT, when ETT suction complete, and continues to provide containment and comfort to the infant.
    • Allow the infant to rest prior to oropharyngeal and nasopharyngeal suction.  The primary clinician suctions infant’s oropharynx and nasopharynx, allowing removal of secretions.  A size 8 or 10 FG tube may be used to suction the oropharynx.
    • Observe infant’s post-suction physiological parameters.
    • Use a small amount of sterile water if needed to clear secretions from suction tubing.
    • Turn off vacuum pressure. Dispose of contaminated catheter, remove gloves and perform hand hygiene.
    • Ensure infant is left in a contained and comfortable position.
    • Document effectiveness of and tolerance to suctioning within the flowsheet in the EMR
    • If the infant requires ETT suction, and it is safe to perform a suction with one clinician, the procedure is as above, however the primary clinician will need to detach the ETT from the ventilator and steady the tube using the same hand. The suction catheter will need to be inserted the catheter using “clean” hand.  Care is especially required to steady the ETT and infant’s head to ensure the infant does not accidentally self-extubate.


    Procedure for closed suction technique on Butterfly

    • Adjust ventilator settings to pre-suctioning baseline (if settings have been adjusted) when indicated by stabilisation of infant’s oxygen saturation and heart rate.
    • This procedure is safe to complete with one clinician.
    • Explain to parents what is about to occur.
    • Determine suction catheter size
    • Check suction pressure (see equipment)
    • Clinician performs hand hygiene and dons gloves. 
    • Remove blue cap from end of suction system and connect to wall suction tubing.
    • Unlock device by lifting white suction control valve and rotating it 180 degrees.
    • If using a saline lavage, instil NaCl 0.9% with a 1mL syringe via the lavage port. Follow with instillation of 0.3mL-0.5mL air to flush the NaCl 0.9% down the tube.
    • Introduce the catheter to required depth, the appropriate colour is seen in the window at the lavage port (this will only work if the ETT hasn’t been trimmed). The numbers on the suction catheter should line up with the appropriate number on the ETT (refer to the below table)
    • Apply suction by depressing suction control valve and withdraw catheter to fully extended length.
    • Repeat as necessary.
    • On completion, to clear secretions from the catheter, depress suction control valve before slowly instilling NaCl via lavage port. Follow with air to completely clear the system of NaCl. Remove syringe and close lavage port.
    • Ensure infant is left in a contained and comfortable position.
    • Document effectiveness of and tolerance to suctioning within the flowsheets in EMR.
    • Change closed suction system weekly and place provided sticker determining next change. 

    Please note, that if you are going to trim an ETT do this prior to attaching closed suction system. If you need to trim ETT once closed suction system in place, please remove from ETT, replace original adaptor and attach neopuff, trim ETT and then insert closed suction system 

    Open vs Closed suction

    There is some evidence that utilizing a closed suction method during mechanical ventilation in neonates 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 appropriate to use this technique when caring for patients with infectious respiratory conditions.


    Complications of ETT suction

    • Hypoxaemia
    • Atelectasis
    • Bradycardia
    • Tachycardia
    • Increased ETT CO2 and transcutaneous CO2
    • Blood pressure fluctuations
    • Decreased tidal volume
    • Airway mucosal trauma
    • ETT dislodgement
    • Pneumothorax
    • Pneumomediastinum
    • Bacteraemia
    • Pneumonia
    • Fluctuations in intracranial pressure and cerebral blood flow velocity

    Complications of oropharyngeal and nasopharyngeal suction:

    • Hypoxia
    • Bradycardia

    Normal Saline Lavage with ETT Suction

    Lavage by instillation of normal saline into the ETT immediately prior to ETT suction:

    • May aid in the removal of thick, tenacious secretions by thinning, loosening and dislodging these secretions
    • Makes the infant cough, which may loosen and dislodge secretions
    • May lubricate the ETT
    • May have detrimental effects on the infant – damages airway mucosa, acts as a foreign body, does not lead to effective cough as the glottis remains closed in an intubated patient, contributes to lower airway colonisation


    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.

    Oxygenation Pre/Post-Suction

    Oxygenation pre/post suction should not be routine but:

    • May reduce the incidence of suction related hypoxaemia and bradycardia
    • May cause hyperoxaemia which is associated with oxygen free-radical damage and retinopathy of prematurity

    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 is 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.

    Recruitment Post-Suction

    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:

    • May reduce atelectasis related to suction and restore functional residual capacity (FRC) after suctioning.  Hyperinflation is achieved by increasing the tidal volume (increasing PIP)
    • May result in pneumothorax due to poor or rapidly changing alveolar compliance

    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. 

    Hyperventilation Pre-Suction

    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:

    • May reduce hypoxaemia related to suction and shorten stabilisation and recovery times

    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.

    Documentation

    Document clearly in EMR:

    • ETT suctioned
    • Airway secretion amount
    • Airway secretion colour
    • Suction tolerance
    • Significant events

    Family Centred Care

    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 potential complications.  Parents can help to support, contain and comfort the neonate while the nurse is carrying out the procedure.

    Special Considerations


    Analgesia/Sedation

    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.    


    Open Suction for HFOV and HFJV

    For HFOV and HFJV use the suction port (closed suction) at the end of the ETT.

    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. 

    HFVO

    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. 

    HFJV

    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 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.

    Nitric Oxide 

    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.

    Infection Control

    Use aseptic technique and personal protective equipment.  Suction catheters should be discarded following each suction event, in order to reduce the risk of introducing infection.   

    Patient Safety

    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. 

    Related guidelines

    Evidence table

    Evidence table for Endotracheal Tube Suction of Ventilated Neonates

    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 May 2020.