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.
Hyper-oxygenation Pre-Suction
Hyper-oxygenation pre suction:
- 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
Hyper-oxygenation pre-suction should not be attended routinely. Each infant should be assessed individually by the bedside nurse regarding whether hyper-oxygenation 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. Care should be taken to ensure the infant's FiO2 is reduced to baseline as soon as possible after ETT 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. 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.
Hyperinflation Pre-Suction
Hyper-inflation pre-suction:
- 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
Hyperinflation pre-suction should not be attended routinely. Each infant should be assessed individually by the bedside nurse regarding whether hyper-inflation 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.
Using the ventilator setting, PIP 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 PIP is reduced to baseline as soon as possible after ETT suction.
For infants on HFOV, MAP is increased 2cmH2O 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 MAP is reduced to baseline as soon as possible after ETT suction.
Hyperventilation Pre-Suction
Hyperventilation pre-suction may reduce hypoxaemia related to suction and shorten stabilisation and recovery times. Hyperventilation pre-suction should not be attended routinely. Each infant should be assessed individually by the bedside nurse 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.
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 TcCO2 (if monitored) level. Care should be taken to ensure the rate 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 TcCO2 (if monitored) level. Care should be taken to ensure the rate is reduced to baseline as soon as possible after ETT suction.