Neonatal/pediatric endotracheal suctioning: general characteristics of the procedure

By Cristiano Antonino On Mar 8, 2023

Endotracheal suctioning is one of the most commonly performed interventions in the neonatal/pediatric intensive care unit and other emergency situations, but this practice requires special attention to the neonatal and paediatric airway

Endotracheal suctioning is a common intervention in the Neonatal Intensive Care Unit (NICU) and Paediatric Intensive Care Unit (PICU), but the practice requires special attention for the much smaller and more sensitive airways

Although endotracheal suctioning is an effective method of clearing airway secretions and an essential procedure for intubated babies, this practice is still often poorly understood, with research limited to adults and preterm infants1.

However, there are many ways in which respiratory therapists and other healthcare professionals can minimise potential harm.

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By working carefully on the delicate airways of these patients, clinicians can prevent vagal nerve stimulation that can occur during endotracheal suctioning

If the tube is positioned incorrectly, nerve stimulation can lead to a cascade of negative consequences downstream, including bradycardia, arrhythmia and hypoxaemia.

An experienced physician can avoid these outcomes if he takes the right precautions in the management of paediatric and neonatal patients.

In some cases, doctors can avoid endotracheal tube aspiration by using other methods to clear the airway, including chest physiotherapy techniques that use vibration or move secretions out of the airway.

Small, portable, non-invasive devices can supplement this process to clear the upper airway.

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When to perform endotracheal suctioning

The first step is to know when to suction, because you do not want to over-aspirate the patient.

The latest guidelines of the American Association for Respiratory Care (AARC), published in February 2022, recommend suctioning as needed, instead of performing suctioning on a fixed schedule.

First, the AARC indicates to listen for breath sounds.2

Are there crackles or rales when the patient inhales? Are there any other indications of audible secretions? Is the sound different only on the right or left side of the chest?

Then note any visual evidence of mucus.

Do secretions ascend the endotracheal tube?

Visual secretions in the artificial airway and a sawtooth pattern on the ventilator waveform are indicators for aspiration of paediatric and adult patients, according to AARC guidelines.

These factors are all important to consider when deciding whether or not to proceed.

Pay close attention to catheter size and suction pressure

If there is reason to proceed with endotracheal tube aspiration, research has indicated that catheter size and suction pressure should be considered in relation to each other, according to a review article published in the Journal of Paediatric Intensive Care.3

It is necessary to have a suction catheter of the correct size.

You do not want the suction catheter to be too narrow, as this creates a stronger suction that can cause parts of the lungs to collapse, so care must be taken not to have a catheter that is too large.

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Getting to know catheters

In general, to minimise patient discomfort, it is useful to familiarise oneself with the catheters available.

Specific scenarios may require different types of catheters.

For example, when working with an infant with a tracheal tube, most physicians may find that an elbow connector works best for these patients.

The reason it is important to talk about this is that if we do not know what the physical characteristics of the different types of catheters are, we are guessing about how much to insert.

In short, we often don’t know if we have inserted a catheter too far until we have stimulated a vagal response, which has caused hypertension, a bradycardic episode, a rapid change in oxygen level; avoiding this problem before it becomes a problem is very important and I think it starts with understanding the physical characteristics of the type of catheter you are using.

References

Tume LN, Copnell B. Endotracheal Suctioning of the Critically Ill Child. J Pediatr Intensive Care. 2015 Jun;4(2):56-63.
Blakeman TC, et al. AARC Clinical Practice Guidelines: Artificial Airway Suctioning. Respir Care. 2022 Feb;67(2):258-271.
Tume LN, Copnell B. Endotracheal Suctioning of the Critically Ill Child. J Pediatr Intensive Care. 2015 Jun;4(2):56-63.

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