Contents

1.0 Aim of guideline
2.0 Scope of guideline
3.0 Guideline summary
4.0 Practice Guidelines and basic steps in suctioning
4.1 Purpose of Suction
4.2 Assessment of the Need for Suctioning
4.3 Developmental Care Considerations
4.4 Equipment
4.5 Liquefying Secretions
4.6 Preparation / Physiological Stability
4.7 Reassess / Evaluation
4.8 Documentation
4.9 The Medically Fragile Infant
4.10 Parents
4.11 Training
4.12 Oropharyngeal (OP) and Nasopharyngeal (NP) Suction
4.13 Endo Tracheal Tube Suction (in line / closed or open)
Appendix 1 – 10 Controversies of Suctioning: The Evidence Base
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1.0 Aim of Guideline

• To provide a framework to ensure that all infants receiving suctioning are optimally cared for.
• Suctioning is a high risk procedure. To avoid poor outcomes, nurses who perform suctioning must adhere to evidence based guidelines. This guideline describes evidence based best practice for suctioning neonates in the hospital setting.
• Not included within this guideline are the specialised practices of suctioning nasal stents, tracheostomies, naso-pharyngeal airways or infants with replogle tubes insitu.

2.0 Scope of Guideline

The guideline applies to all infants requiring suctioning within Thames Valley and Wessex Neonatal Network Operational Delivery Network.

3.0 Guideline Summary

• All individuals performing suctioning should receive formal training and documented assessment of competence, before suctioning independently.
• Suctioning should be tailored to respond to the infant’s behavioural cues and consider their sleep wake cycles wherever possible.
• If a need for suctioning is anticipated, all equipment should be available and in safe working order at the bedside.
• When preparing suction equipment, the suction pressure should be set to 60-120 mmHg / 8-16 kPa (GOS.).
• For all suctioning episodes the lowest negative pressure should be used for suctioning, with the smallest catheter and the shortest suctioning time- that effectively clears secretions.
• Suction pressure may be lowered if the baby is small or unstable, or increased if required to remove thick or tenacious secretions.

ETT suction:

• Where possible ETT suction is a 2 person procedure – especially for the inexperienced practitioner. This will also enable containment and support to be offered to the infant during the procedure.
• The catheter size should not exceed ½ the internal diameter of the ETT tube. For example – Ett of 2.5mm- use a suction catheter size of 5FG.
• Pre-measure the suction catheter to the tip of the ETT and only suction to this depth.
• The time taken to pass and withdraw a suction catheter from the ETT should ideally be 5 – 8 seconds or less for neonates.
• Continuous suction should be used, rather than intermittent suction.
• Do not rotate or twist the suction catheter during withdrawal.
• Normal saline instillation should not be routinely used.
• Closed suction is preferable to open suction in ventilated patients.
• It is important that manufacturer’s guidelines are referred to for the use of closed suction systems.

NP suction:

• The catheter needs to pass to a depth approximately the distance from the nose to the ear. This should be sufficient to pass the pharynx and stimulate a cough. It is inadvisable to go further and pass through the larynx.
• Catheter size
  • Preterm baby size 4-5 Fr
  • Neonate- birth- 28 days 6Fr
  • Infant 1month-1 year 8Fr

OP suction:

• Aim to insert the catheter when the baby is inspiring, as this will decrease the chance of the catheter being swallowed and entering the stomach.
• The catheter should glide easily through the mouth or oropharynx- never force its passage.
• Catheter size
  • Preterm baby size 4-6 Fr
  • Neonate- birth- 28 days 6-8 Fr
  • Infant 1month-1 year 8-10 Fr
  • Yankauer Sucker- only for the term infant and upwards with large volumes of secretions or very tenacious secretions

4.0 Practice Guidelines

Suctioning is a procedure that needs to be taught and learnt in the clinical setting. Nursing staff should not consider themselves competent to suction as a result of having read this guideline. The guideline is intended as a source of evidence based information and practical guidance that should be used in conjunction with hands on clinical training, to ensure safe, effective and competent suctioning practice.

Every nurse taking on the role of suctioning neonates needs to ensure that they make themselves familiar with both the clinical skills and knowledge base behind each of the 14 steps outlined above.

4.1 Purpose of Suction

• Suction is used to clear retained or excessive lower respiratory tract secretions in patients who are unable to do so effectively for themselves. This could be due to the presence of an artificial airway, such as an endotracheal tube or tracheostomy tube, or in patients who have a poor cough due to a variety of reasons such as excessive sedation or neurological impairment’. (GOSH, 2014)
• In self-ventilating patients the upper respiratory tract may need to be suctioned, via the oro or nasopharynx, to enable a child to breathe comfortably, particularly in the presence of increased secretions during a respiratory infection.
• In the intubated patient removing secretions will prevent obstruction, atelectasis and increase lung compliance, whilst optimising oxygenation and ventilation. However there are many potential complications of ETT suction, these include;
  • predispose to bacteraerimia
  • hypoxaemia
  • tachycardia
  • bradycardia
  • atelectasis
  • systemic hypertension
  • decreased tidal volume
  • airway mucosal trauma
  • fluctuations in intracranial pressure and cerebral blood flow velocity
  • pneumonia
  • pnuemomediastinum
  • Increased TcCO2
• Although every care should be taken to minimize the occurrence of the above side effects, it is of paramount importance that the objective, the maintenance of a patent airway is achieved. When suctioning in indicated, the decision to withhold suction to avoid potential adverse effects may result in a blocked airway and the risk associated with an emergency reintubation. (GOS 2014)

4.2 Assessment of the need for Suctioning

• Clinical Indications / Findings, that suggest the need for suction;
  • Increased work of breathing (recession, nasal flaring, chin tug, grunting)
  • Changes in respiratory rate
  • Decreased oxygen saturation
  • Decreased heart rate
  • Increased oxygen requirement
  • Rise in transcutaneous Co2 (TcCO₂) reading
  • Fall in transcutaneous oxygen (TcO₂) reading
  • Change in ventilation flow pattern- show on ventilator LED display
  • Reduced tidal / minute volume values – show on ventilator LED display
  • Infant may be making unsuccessful attempts to clear secretions i.e. coughing
  • Copious secretions which may be visible in an opaque et tube, spilling out of an infant’s mouth, visible collection / plugs of mucous at infants lips
  • Audible secretion sounds with each breath (i.e. rattling or swinging in tube, wet sucking in and out at tip of tracheostomy)
  • Blood pressure fluctuations
  • Irritability / agitation of the infant
  • Cyanosis / pale or mottled appearance
  • Recent history of large amounts of thick / tenacious secretions
  • Examination of the chest x-ray
  • A change in the blood gas values
  • A baby that has just been repositioned will often require suctioning, as the secretions can be ‘loosened’ by the movement, and obstruct the airway totally or partly.
• Auscultate with a stethoscope before, during and after the procedure in order to evaluate the necessity of and effectiveness of the procedure.
• Remember that it is possible that causes for respiratory destress may be other than a need for suctioning. For example a pneumothorax, fluid overloads or misplaced artificial airway.
• It has been standard practice to avoid suctioning for up to 8-12 hours after endo-tracheal surfactant administration. This is to allow the surfactant as much time as possible to remain in the lungs and achieve its purpose. However, more recent scientific literature indicates that surfactant absorption/ utilisation has actually occurred within 1-2 hours after surfactant administration- and safe suctioning can occur, if required.

4.3 Developmental Care Considerations

• Time procedures to infant’s sleep wake cycles wherever possible.
• Whenever possible provide containment and support to the infant during the procedure. This can be done by a parent or other helper when available, but appropriate use of nesting and bedding can also help.
• Tailor the pace of the procedure to respond to the infants behavioural cues and allowing space for the infant to reorganise to a calm state.
• Where possible aim to provide 20-30 minutes of rest post procedure to recover before the next activity.

4.4 Equipment

• Functioning wall suction or a mobile suction unit should be available by every patient who may require suctioning. There should be suction tubing connected to the device (checked at beginning of shift) and appropriately sized suction catheters and / or Yankauer suction catheter available, which connect into this system.
• The suction system should be checked at the beginning of each shift to ensure it is working, and also to ensure that the pressure level is set correctly.
• When preparing suction equipment in case it is required, the suction pressure should be set to 60-120 mmHg / 8-16 kPa (GOS.)
• A Neopuff, Ambubag or similar should be available next to every patient who may require suctioning (checked at the beginning of the shift).
• Suction catheters for suctioning artificial airways should be available (open or closed system) as appropriate for the size of the airway, ideally less than half the diameter of the artificial airway, so there is still leeway for air flow around the catheter during the suction procedure. See table below.

• Suction catheters used for oropharyngeal suction will vary, dependent on the size of the infant, but should be available from FG size 5 to FG size 12 to cover the range of infants cared for on neonatal units.
• The suction catheters should be of a type that is graduated, with two lateral side holes smaller than the end hole. This allows secretions to be collected distally and from the sides of the tube.
• Ensure a new suction catheter is used for each pass, and that the tip of the suction catheter remains clean and untouched during the preparations before suctioning. In particular a suction catheter used for tracheal suctioning should never have first been used for oral or nasal suctioning, as it will be contaminated with bacterial flora.
• Yankauer Suction catheters can be are a more rigid suction device, designed specifically for oro-pharyngeal suction. They can be useful for infants with large volumes of secretions or very tenacious secretions. If used, the appropriate size should be selected, to avoid damage or discomfort to the infant’s mouth.
• Normal saline and a small volume syringe should be available if normal saline lavage is required, (although this should never be done routinely) or the suction system requires flushing after use.
• Change suction extension and collection pot at least every 24 hours – date and time pot and tubing to facilitate this process.
• Change inline suction system at least 24 hourly – date and time to facilitate this process.

4.5 Liquefying Secretions

• When secretions are liquefied they will come more readily up the suction catheter during suction.
• The best way to ensure liquefied secretions is for the infant to be receiving humidified respiratory gases if requiring ventilator support (i.e. high flow therapy, or nasal CPAP / DuoPAP/ BiPAP).
• A Swedish nose humidifier will do the equivalent job for infants with a tracheostomy who are breathing independently.
• A well hydrated infant will naturally have more loose/ liquefied secretions.
• Using saline routinely to liquefy secretions is not recommended, as this practice can;
  • Lead to decreased post suctioning oxygen saturations.
  • Increases bacterial colonisation.
  • Damage bronchial surfactant.
• If saline is instilled via an artificial airway, it will be done with the purpose of;
  • Loosening or mobilising tenacious secretions.
  • Making the infant cough, which may loosen and dislodge secretions.
  • Hoping it may lubricate the ETT.
• This practice should be done only by an experienced practitioner, and with caution. (GOS)
• If saline is used, it should be 0.9% normal saline, and in the volume of 0.1-0.2ml/kg.
• A new plastic saline ampoule should be used for each episode of suction.

4.6 Preparation / Physiological Stability

• Where possible ETT suction is a 2 person procedure – especially for the inexperienced practitioner. If an assistant is not available, then at the very least someone must be available to assist if a complication arises, such as the baby exhibits a profound negative response, accidental extubation or it becomes necessary to adjust the ventilator settings.
• The timing of suction should be tailored to each infant, rather than performed to a set schedule. This will ensure that a patient is not suctioned more than necessary, but conversely should also ensure that the patient is suctioned when needed, so reducing the risk of secretion build up, and increasing the patients discomfort or work of breathing.
• An exception to this rule is the patient with a new tracheostomy where in the first 12-24 hours the patient must be suctioned every 30 minutes and then regularly (as required) until the first tube change. GOS (2014)
• If the patient is on continuous feeds turn the feed off prior to suctioning, to reduce the risk of vomiting.
• Proceed to suction with caution if the patient has recently had a bolus feed, due to the risk of vomiting and subsequent aspiration. If a baby is at high risk, or known to vomit during suction then consider aspirating their total stomach contents before the suctioning episode, and then returning the stomach contents afterwards.
• In the intubated patient, ensure they are adequately sedated.
• For the awake non-ventilated baby, it may be advisable to wrap them securely in a sheet and place in the side lying position, if there is no parent or colleague free to support them.
• In general it should be possible to suction an infant so that they remain physiologically stable throughout the procedure. This may require some skill, planning and careful handling by the infant’s nurse. Before commencing suctioning consider carefully;
  • Whether you need the help of one or even two colleagues, to make the process smoother or quicker.
  • Is suctioning really required now? It should not be done routinely – although there is a safe minimum frequency of suctioning required for infants with a tracheostomy or ett in situ.
  • Is the infant in the best position to tolerate suctioning? If not, position the patient to enable easy access to the airway.
  • Has the infant just received a lot of handling? Could suctioning be delayed to allow the infant time to recover?
  • If the infant will be receiving more care that just suctioning, could the suctioning be done first when the baby is best able to manage?
  • Would the infant benefit from a parent or colleague providing comfort/ reassurance during suctioning? To assist them in their ability to tolerate the procedure.
• For some infants it may be necessary to anticipate the infants need for increased respiratory support during a suctioning procedure. See section 4.9 on the medically fragile infant.

4.7 Reassess / Evaluation

• Effectiveness of every suction episode should be assessed after the procedure by observing and documenting;
  • Physiologic response to the procedure.
  • Secretions gained- describing colour, consistency and volume.
  • Improvement in breath sounds.
  • Improved oxygen saturations, TcCo2, heart rate, blood pressure, respiratory rate.
  • Decreased work of breathing, improved chest movements.

4.8 Documentation

• • Amount, consistency and colour of secretions.
  • Degree of tcCO2 changes and amount of time to return to baseline.
  • Degree of bradycardia and amount of time to return to baseline.
  • Other physiological or behavioural changes.
  • Infant’s tolerance of the procedure and what technique / equipment worked best for them (i.e. side lying, pre-oxygenation, parental presence).

4.9 The Medically Fragile Infant

• For some infants it may be necessary to anticipate the infants need for increased respiratory support during a suctioning procedure. This is most likely when;
  • They are requiring high levels of respiratory support and only just maintaining acceptable stability already e.g. babies receiving Nitric Oxide, babies receiving high ventilation pressures, babies with chest drains in situ, babies in 100% oxygen.
  • Often particular individual babies are known to tolerate suctioning poorly- and this information is passed on by a colleague who has cared for the baby on the previous shift.

• Additional support may also include;
  • Pre oxygenating – this may be simply increasing the FiO2 by 2-3% in anticipation of a slight drop in oxygen saturations during suctioning; to counterbalance the slight decrease in oxygen saturation that otherwise occurs.
    • Increasing the infant’s oxygen prior to the procedure, bringing their saturations up to the top end of the acceptable range, so that they tolerate the procedure as well as possible, and the resulting desaturation is minimised.
    • Pre oxygenation can significantly reduce the adverse effects of hypoxaemia related to ETT suction, however it can also contribute to long-term adverse effects on the infant. These include retinopathy of prematurity, parenchymal lung damage and oxygen free radical damage and should therefore be done, only when clinically necessary. E Of E 2020.
    • It is important that nursing staff caring for an infant are familiar with the pathophysiology of their patient before administering oxygen. Some infants with certain congenital heart defects will be develop severe cardiac instability if high levels of oxygen are administered.

• Hyperinflating – this can be carried out for intubated, ventilated infants and consists of electively increasing the PIP or MAP for a brief time around the episode of suction, enabling the procedure to be tolerated. Guidance on this practice suggests;
  • Increasing PIP by 10-20% above baseline for approximately 2 minutes prior to suction and continuing after suction until the baby has returned to its pre-suction oxygen saturation level.
  • For infants on HFOV usually MAP is increased by 1-2cmH2O above baseline for 1-2 minutes prior to suction and continues after suction until pre-suction oxygen saturation levels are achieved.
  • Guidance on which value to change and by how much is often passed on by the nurse caring for the baby on the previous shift, who may also be able to advise how long the baby is likely to take to recover.
  • Care should be taken to ensure that the setting is reduced to the pre-suction level as soon as possible after ETT suction.

• Hyperventilation– this can be carried out for intubated ventilated infants any may reduce hypoxaemia and shorten stabilisation and recovery times. It is performed by increasing the ventilator rate setting by 5-10 breaths a minute, above the baseline immediately prior to suction. This elevated rate continues during and after suction, until the infant returns to the pre suction oxygen saturation and TcCo2 level –if monitored.
  • This technique is not usually performed for infants on HVO ventilation, as other options are more appropriate.

These three practices are something that would be discussed and agreed with the medical team and senior nursing staff, and notcarried out as a decision made independently by one nurse.

4.10 Parents

• It is the carer’s responsibility to ensure the baby’s parents understand the rationale for the procedure, as well as the potential complications.
• Parents who are present during suction episodes should be offered the opportunity to provide comfort and support to their baby during the suctioning.

4.11 Training

• All individuals performing suctioning- which may be nursing staff, medical staff, physiotherapist or other members of the MDT or the baby’s parent(s) or guardian, should receive training in;
  1. Respiratory assessment.
  2. Indications for suction.
  3. Suction technique.
  4. Potential side effects.
  5. Signs of clinical deterioration.
  6. Basic life support.
  7. How to document the procedure.

4.12 Oropharyngeal (OP) and Nasopharyngeal (NP) Suction

• Infants will usually keep their oropharynx and nasopharynx clear by coughing, sneezing and by the protective mechanisms of the gag/cough reflex. NP and OP suction is therefore an invasive procedure and may be traumatic to the infant.
• NP and /or OP suction is most commonly performed on the semi- conscious or unconscious infant who is unable to maintain a safe airway. However babies receiving respiratory support may gather secretions in their oro and/ or naso-pharynx that they cannot effectively clear themselves. Both due to drying of secretions by the continual flow of respiratory gases, or due to physical obstruction of swallowing and cough mechanisms, by an ET tube.
• OP/ NP suction can also be required to remove vomit, blood or other foreign material.
• NP suction can stimulate the vagal nerve, causing bradycardia and more rarely arrhythmia or cardiorespiratory arrest. The risk of this occurring can be minimised by not suctioning aggressively, but using a gentle pressure and steady speed. Should this vaso-vagal response occur, cease suctioning and support the baby to recover, before repeating the suction attempt.
• If endotracheal and oropharyngeal suction are both required, experienced staff identify that by preference they would suction oropharyngeally first, before going on to do endotracheal suction. In their experience ett secretions are more effectively cleared if the op is cleared of secretions first.
• It is regularly noted in practice that babies being nursed on CPAP can build up collections of dry white secretions deep in their oro-pharynx. It is not recommended to routinely suction deep into the oropharynx, however if baby becomes less stable on CPAP, (for example having an increased oxygen requirement or increased work of breathing) it would be appropriate to attempt deeper suction, in case such secretions are the cause of the problem.

4.13 Endo Tracheal Tube Suction (in line / closed or open)

Open suction

• For ETT suction, set the suction pressure to 60-120 mmHg / 8-16 kPa (GOS).
• Suction pressure may be lowered if the baby is small or unstable, or higher if required to remove thick or tenacious secretions.
• The lowest negative pressure with the smallest catheter and the shortest suctioning time- that effectively clears secretions– should be used.
• Measurement of length to suction should be predetermined at the beginning of a shift, by adding the length of the ETT and any additional length of the ETT adaptor(s).
• The catheter size should not exceed ½ the internal diameter of the ETT tube – see the table below.

• Use a clean catheter for each pass, and never use the same catheter just used for oral suction as the mouth/ nose are considered contaminated with normal bacterial flora.
• Normal saline instillation should not be routinely performed for ET suctioning.
• Do not rotate or twist the suction catheter during withdrawal.
• Minimize the time spent disconnected from the ventilator, between 6-10 seconds is acceptable, from insertion to the end of withdrawal.
• Allow 20-30 seconds between passes to enable the infant to recover.
• Only apply suction (negative pressure) when the catheter is being withdrawn.
• The number of suction passes should be kept to a minimum.
• If the suction catheter does not have any centimetre marking on it, the length for suctioning should be documented on a measuring tape that is clearly visible on the cot.

THE SECTION BELOW IN RED IS UNDER REVIEW – DO NOT USE

• A small amount of sterile water can be used to clear secretions from the suction tubing after use (not the suction catheter, which will be disposed of after use). This is done by placing the end of the tubing into a bottle of sterile water designated for the purpose. The suction is turned on for 1-2 seconds allowing a larger volume of water to be sucked up the tubing. Flushing away any secretions sticking to the sides of the tubing.

Closed Suction

• Closed suction is preferred to open suction in ventilated patients because closed suction benefits the infant by maintaining positive pressure ventilation, ensuring a stabilised PEEP, allowing a continuous oxygen supply, reducing levels of hypoxia, minimising blood pressure variation, gives less atelectasis and a shorter length of time to return to baseline physiological parameters.
• It is compatible with all modes of ventilation, and particularly beneficial when used on infants receiving High Frequency Oscillatory Ventilation, or Nitric Oxide therapy as there is no interruption to.
• Set the suction pressure to 60-120 mmHg / 8-16 kPa, however, staff should be aware that closed suction is identified in the literature as often requiring suction pressures at the higher end of the recommended range, to ensure effective removal of secretions occurs.
• The suction is equally as effective with closed suction, as when using open suction. However, the noise of the suctioning is muted by the closed system and may give the impression it is less effective.
• Normal saline instillation should not be routinely performed for ET suctioning.
• There are a range of different inline circuits for suctioning infants. All the systems are similar in principle, but do vary between manufacturers. It is important that manufacturer’s guidelines are referred to for instruction for use and that all staff receive training in the clinical setting and assessment of competence.
• The suction catheter within the closed suction system is marked with bands of colour at different lengths along the catheter. It will be necessary to identify before suctioning, which colour band will be the ‘reference colour’ during the suction episode.
• The reference colour is determined by the size of the ETT and its length within the baby’s trachea. When suctioning the infant, the pre-determined reference colour will be used to guide how far in the suction catheter is passed, as the colour band will be viewed in an observation window.
• When setting up the system for the first time, it is usually necessary to place a special Y adaptor on the end of the ETT, to enable the suction system to be attached. The original connector from the end of the ETT tube should be retained, as if the suctioning system is removed, the ETT tube cannot be ventilated without this connector in place.
• Ensure the visible presence of the black tip of the closed circuit suction catheter within the dome component, following suction. Otherwise air can leak out from the catheter tip and cause the plastic sheath around the catheter will swell up with air. If this occurs, remove the catheter briefly from the Y adaptor, and squeeze the air out of the sheath, then replace immediately.
• Closed suction catheters must be flushed with normal saline after each episode of suctioning.
• If secretions plugs can be seen on the tip of the catheter, despite flushing after use, then the catheter can be disconnected briefly and the tip wiped with a sterile wipe. If this is ineffective the catheter should be changed.
• The control valve is lockable and is usually kept locked between episodes of suctioning, to prevent accidental depression of the valve.
• In line suction should be changed a minimum of every 24hours.
• If the ventilator indicates air leak, following suctioning- check that all the suction connections are tightly in place and secure.
• If collecting a specimen to send to the laboratory for microscopy, culture and sensitisation then use a new in-line suction catheter to do the procedure- this can then be left in place afterwards.

Appendix 1 – 10 Controversies of Suctioning: The Evidence Base

1. Suctioning should never be performed routinely, only as indicated by individual patient assessment and following the clinical signs.
2. Hyper-oxygentaion before suction has been found in adult studies to prevent hypoxia, however due to concerns about the effect of high oxygen levels on preterm infants, it is not recommended to be performed routinely for neonates.
3. Whenever possible use a suction catheter with an external diameter that is a maximum of 50% of the internal diameter of the ETT.
4. The lowest effective suction pressures are considered the best choice, for minimizing iatrogenic effects of suctioning.
5. Studies have shown better physiological stability for infants receiving closed suctioning. However, the financial cost of the closed and open systems is comparable.
6. When drawing back the suction catheter during ETT suction, continuous suction should be used, rather than intermittent suction as it minimizes the risk of tracheal damage and alveolar collapse.
7. A long duration of suctioning is not best practice, ideally 5 – 8 seconds or less for neonates.
8. Pre-measured suctioning to the approximate tip of the ETT is considered the best practice for normal suctioning, as current available evidence suggests that deep suctioning could be harmful.
9. There is no recent evidence to support the routine instillation of saline.
10. There is no evidence that lung volume recruitment manoeuvres following suction are beneficial.

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