Endotracheal suctioning in intubated newborns: an integrative literature review

Gonçalves, Roberta Lins; Tsuzuki, Lucila Midori; Carvalho, Marcos Giovanni Santos

doi:10.5935/0103-507X.20150048

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Revista Brasileira de Terapia Intensiva

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REVIEW ARTICLES • Rev Bras Ter Intensiva 27 (3) • Sept 2015 • https://doi.org/10.5935/0103-507X.20150048 copy

Endotracheal suctioning in intubated newborns: an integrative literature review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Evidence-based practices search for the best available scientific evidence to support problem solving and decision making. Because of the complexity and amount of information related to health care, the results of methodologically sound scientific papers must be integrated by performing literature reviews. Although endotracheal suctioning is the most frequently performed invasive procedure in intubated newborns in neonatal intensive care units, few Brazilian studies of good methodological quality have examined this practice, and a national consensus or standardization of this technique is lacking. Therefore, the purpose of this study was to review secondary studies on the subject to establish recommendations for endotracheal suctioning in intubated newborns and promote the adoption of best-practice concepts when conducting this procedure. An integrative literature review was performed, and the recommendations of this study are to only perform endotracheal suctioning in newborns when there are signs of tracheal secretions and to avoid routinely performing the procedure. In addition, endotracheal suctioning should be conducted by at least two people, the suctioning time should be less than 15 seconds, the negative suction pressure should be below 100 mmHg, and hyperoxygenation should not be used on a routine basis. If indicated, oxygenation is recommended with an inspired oxygen fraction value that is 10 to 20% greater than the value of the previous fraction, and it should be performed 30 to 60 seconds before, during and 1 minute after the procedure. Saline instillation should not be performed routinely, and the standards for invasive procedures must be respected.

Keywords:
Suction/methods; Respiration; artificial; Infant, newborn

Clinical issue	Recommendation	Articles in agreement (%)	Evidence level
Hyperoxygenation	Hyperoxygenation should not be incorporated into the suctioning routine. If there is a drop in SpO₂ with suctioning, hyperoxygenation should be established by increasing the FIO₂value 10 to 20% above that prior to suctioning 30 to 60 seconds before, during and 1 minute after the procedure	50	2B
Suctioning probe diameter	Probe diameter must not exceed 50% of ETT diameter	50	2C
Suctioning duration	Must not exceed 15 seconds	100	2C
Negative suction pressure	Must be between 50 and 100mmHg	75	3C
Saline instillation	Must not be performed routinely	75	2C
Number of repetitions	Must not exceed 3 repetitions. The NB should be connected to the ventilator between suctions	25	-
Suctioning time	Suctioning must not be performed routinely and should only be performed where clinically indicated. Clinical indications primarily include lung auscultation (coughing, coarse or reduced breathing) or visible secretions in the ETT, audible secretions, drop in SpO₂decreased chest excursion, changes in blood gas values, changes in respiratory rate and/or breathing pattern, bradycardia/tachycardia and/or agitation without other cause, and increased peak pressure on the ventilator	100	1C
Biosafety standards	CDC guidelines should be respected, including the following: protection of the professional's eye, nose and mouth protection with the use of face mask and goggles, use of apron and sterile gloves, and performance of hand hygiene before and after performing the procedure. To increase safety, the procedure must be performed by at least two people	50	-
Monitoring	The following variables should be monitored before, during and after the procedure: SpO₂ skin coloring, respiratory frequency; respiratory pattern; hemodynamic variables (if monitored), such as heart rate, blood pressure, heart rhythm and ICP; suctioned secretion characteristics, such as color, volume, consistency and odor; cough characteristics; ventilatory parameters, such as peak inspiratory pressure and plateau pressure; current volume; flow; exhaled volume; and FiO₂	100	-

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[1] Corresponding author: Roberta Lins Gonçalves, Faculdade de Educação Física e Fisioterapia da Universidade Federal do Amazonas, Avenida General Rodrigo Octávio Jordão Ramos, 3.000, Campus Universitário - Coroado I, Zip code: 69077-000 - Manaus (AM), Brazil. E-mail: betalinsfisio@yahoo.com.br

Title, year of publication and source	Nasotracheal Suctioning - 2004 Revision & Update, 2004, RespiratoryCare⁽¹⁰10 AARC Clinical Practice Guidelines. Nasotracheal Suctioning-2004 Revision & Update. Respir Care. 2004; 49(9):1080-4.⁾	ERNBG Guideline - Suction February 2006. Review: February 2006 Eastern Regional Neonatal Benchmarking Group Suctioning Guideline⁽⁹9 ERNBG Guideline - Suction February 2006 Review due: February 200 6 Eastern Regional Neonatal Benchmarking Group Suctioning Guideline. [cited 2013 Nov 27]. Available http://guideline1.com/e/endotrachealsuctioning-guidelines-s83/. http://guideline1.com/e/endotrachealsuct... ⁾	Evidence-based guideline for suctioning the intubated neonate and infant, 2009, Neonatal Network⁽²2 Gardner DL, Shirland L. Evidence-based guideline for suctioning the intubated neonate and infant. Neonatal Netw. 2009;28(5):281-302. Review.⁾	Endotracheal suctioning of mechanically ventilated patients with artificial airways, 2010, Respiratory Care⁽ ⁶6 American Association for Respiratory Care. AARC Clinical Practice Guidelines. Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respir Care. 2010;55(6):758-64.⁾
Hyperoxygenation before, during and after the procedure	Not stated	Pre-oxygenation should not be performed unless SpO₂ has dropped	Data regarding hyperoxygenation in NB are limited. Therefore, care must be taken when using oxygenation on this population	Pre-oxygenation is suggested if the patient presents a clinically relevant reduction in SpO₂ with suctioning
				Evidence level 2B
				In NB a 10% increase in FiO₂ is recommended before suctioning, especially in hypoxemic NB
				Hyperoxygenation should be maintained for at least 1 minute after suctioning, especially in hypoxemic patients
Characteristics of the suctioning probe	The probe should be sterile, flexible, with various lateral orifices and one frontal one	The probe must be measured prior to the procedure to ensure that the probe does not overshoot the end of the ETT	The diameter of the probe should be less than 50% of the ETT diameter	The probe diameter should not occlude more than 70% of the light in the ETT in small children
			Evidence level V	Evidence level 2C
		The diameter of the probe should not exceed 50% of the internal diameter of the ETT	Probes bigger than 6 F should not be used for suctioning in a 2.5 ETT
			Evidence level V
Suctioning time	Must be limited to 15 sees.	Must be limited to 10 - 15 secs.	Must be limited to 15 secs.	Must be limited to 15 secs.
			Evidence level V	Evidence level 2C
Negative suction pressure	60 - 80 mmHg	50 - 100mmHg	Must not exceed 100 mmHg	80 - 100mmHg.
			Evidence level V
			Suctioning should be applied only when removing the probe
			Evidence level 3
Saline instillation	Not stated	Use limited to NB whose secretions may obstruct airways	Should not be performed routinely	Should not be performed routinely
			Evidence level IV	Evidence level 2C
Number of repetitions	There is controversy regarding the excessive use of this procedure	Normally, one or two attempts are sufficient for cleaning secretions	Should not exceed three repetitions when suctioning	Not stated
Suctioning time	When clinically indicated	When the need for the procedure is identified	When the need for the procedure is identified	Only when there is secretion and not routinely
			Evidence level I	Evidence level 1C
Absolute contraindication	Not stated for intubated NB	Not stated	Not stated	There is no absolute contraindication
Biosafety standards	CDC guidelines for standard precautions should be respected	Not stated	Not stated	CDC guidelines for standard precautions should be respected