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 

• 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. 
• Conventional Ventilation Modes: The primary mode of invasive ventilation used to provide respiratory support to infants.
• Derecruitment:  Refers to the collapse of alveoli, in this case following a suction procedure.
• EndotrachealTube (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, 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.
• ET CO₂: End Tidal Carbon Dioxide monitoring is the level of carbon dioxide in exhaled air which gives an assessment of ventilation.
• HFOV: High Frequency Oscillation Ventilation
• HFJV: High Frequency Jet Ventilation
• Inhaled Nitric oxide (iNO): An inhaled selective pulmonary vasodilator that is used alongside mechanical ventilation and sometimes CPAP as a treatment for hypoxic respiratory failure, associated with pulmonary hypertension.
• Nasopharyngeal Suction: A suction catheter is passed through the nose to clear secretions.
  
• Neopuff: T-piece resuscitator device where peak inspiratory pressure and positive end expiratory pressures can be set.
  
• Oropharyngeal Suction: A suction catheter through the mouth to clear secretions.
• 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.
• PPE: Personal Protective Equipment.  For an aerosol generating procedure, such as open suctioning, this will entail mask, eyewear and gloves. 
• PIP: Peak Inspiratory Pressure
• Recruitment: Refers to manoeuvres that aid the opening of collapsed alveoli. 
• Transcutaneous Carbon dioxide (TcO₂): Measures the skin surface partial pressure of carbon dioxide to be able to assess, as an alternative to regular arterial blood sampling 
• 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. 

Assessment

 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:

• Oxygen saturation
• Heart rate
  
• Respiratory rate
  
• Blood pressure (where possible)
  
• ETT CO₂ or TCO₂ 
  
• 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 wall movement
  
• Visible secretions in ETT
  
• Increased ET CO₂ or TCO₂
• "Sawtooth" pattern on ventilator waveform
• 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, TCO₂, heart rate, blood pressure, respiratory rate
• Decreased work of breathing, improved chest movement
  

Measurement of Length to Suction

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.

Equipment

• Functioning wall suction unit with suction tubing connected (checked as part of the safety checks at the start of each 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 -120 cmH₂O.  The likelihood of needing a higher pressure increases with smaller sized closed suction catheter.
• Non-sterile gloves
• Normal saline ampoule and 1ml syringe and blunt needle (if normal saline lavage required)
• Neopuff set to appropriate settings (checked at shift commencement)
• Suction catheter for open suction (see table below for appropriate sizes)

Table 1: Suction catheter size relating to ETT size in infants

•  An adapter (Y adapter closed suction system for neonates/paediatrics) needs to be added into the circuit at the ETT when closed suctioning is required. Remove original adaptor and attach new appropriately 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. Refer to (procedure link).

 Table 2: Suction Catheter Size for Closed Suction of ETT 

Management

Procedure for open suction technique on Butterfly

• Assess patient’s clinical indication for suctioning (see assessment)
• Where possible, this procedure requires two clinicians.  If clinician deems it safe, or in an emergency, the procedure can be performed without assistance however, in this situation, nearby staff members should be alerted that ETT suction is occurring.
  
• Explain to parents what is about to occur.
  
• Determine suction catheter size and suction depth (see equipment).
  
• Check the suction pressure (see equipment).
  
• Consider pre oxygenation (see Oxygenation Pre and post oxygenation).
  
• Pre-silence alarm and observe pre-suction physiological parameters. 
  
• Both clinicians perform hand hygiene and dons PPE (gloves on both hands, mask and eyewear).
  
• Protecting key parts, the primary clinician attaches appropriately sized suction catheter to suction tubing. Ensure that the suction catheter does not touch anything that could contaminate it e.g. bed linen.
  
• To prevent accidental extubation, assistant gently holds infant’s head in steady position and holds ETT steady. 
  
• 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.
    
• 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 and auscultate chest to determine effectiveness of procedure.
  
• 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.
  
• Adjust ventilator settings to pre-suctioning baseline (if settings have been adjusted) when indicated by stabilisation of infant’s oxygen saturations and heart rate.
  
• 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.
  

Open vs Closed suction

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

• Hypoxaemia
  
• Atelectasis
  
• Bradycardia
  
• Tachycardia
  
• Increased ETT CO₂ and TCO₂
  
• 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

Other considerations

Normal Saline Lavage with ETT 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:

• 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.
  

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 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.

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. 

Documentation

Document clearly in EMR:

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

Oral and nasopharyngeal suction will need to be documented separately in the ventilation flowsheet.

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

Special Considerations

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.

Open Suction vs closed suctioning on HFOV and HFJV

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. 

HFOV

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 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. 

iNO

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

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.

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

• https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Neonatal_Pain_Assessment/
• https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Neonatal_Pain_Management_in_the_NICU/
• https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Assisting_with_elective_intubation_of_the_neonate_on_the_Butterfly_Ward/
• https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Extubation_(elective)_of_the_neonate_on_butterfly_ward/
• https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Oxygen_Saturation_SpO2_Level_Targeting_Premature_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 November 2023.