19-3-13-Pediatr-Crit-Care-Med-2008-Vol.-9-No.-5.pdf

Feature Review Articles

A comprehensive review of pediatric endotracheal suctioning:Effects, indications, and clinical practice*

Brenda M. Morrow, PhD; Andrew C. Argent, FCPaed SA

I nfants and children with life-threatening conditions frequentlyrequire admission to the pediatricintensive care unit (PICU), where

they may be intubated and mechanicallyventilated. Globally, respiratory tract in-fections contribute significantly to mor-bidity and mortality in the pediatric pop-ulation (1).

Intubated patients are unable to clearsecretions effectively, as glottic closure is

compromised and normal mucociliaryfunction is impaired (2). Inadequatelyhumidified inspired gas and the presenceof the endotracheal tube (ETT) may causeirritation of the airways and increasedsecretion production (3). In addition,many children with respiratory tract in-fections have increased sputum volumeand altered sputum rheology, which fur-ther impedes secretion clearance. There-fore, all infants and children with an ar-tificial airway require endotracheal (ET)suctioning to remove secretions and pre-vent airway obstruction (4, 5).

ET suctioning is known to have manycomplications. Despite this, the practiceof ET suctioning continues without ade-quate evidence for the different tech-niques used (6). Although recommenda-tions and clinical guidelines have beenmade regarding suction pressures, depthof insertion of the suction catheter, andcatheter size (5, 7–11) few of these havebeen objectively shown to be appropriateor safe. The available guidelines do notaddress any dimensions of the suctioncatheters other than the cross sectionaldiameter, and do not factor in variation in

mucus characteristics; nor do they seem toconsider the relationships between ETTand catheter size (length and diameter) andsuction pressures; and the potential effectsthese may have on the pediatric lung. Sur-veys conducted in clinical settings suggestthat practice guidelines and protocols varywidely and are not, in general, based onsound evidence (12, 13).

This article presents a comprehensivereview of the pediatric ET suctioning liter-ature, including precautions and contrain-dications; effects (clinical and mechanical);frequency of suctioning; open- and closedsystems; preoxygenation; saline instilla-tion; catheter size selection; vacuumpressure; sterility; duration of suction ap-plication; depth of catheter insertion; andpostsuction recruitment maneuvers(RM). Clinical recommendations aremade on the basis of these results.

METHODS

Electronic literature searches for articlespublished between January 1962 and June2007 were conducted using PubMed, Cumu-lative Index of Nursing and Allied HealthLiterature and PEDro (Physiotherapy Evi-

*See also p. 539.From the Division of Paediatric Critical Care and

Children’s Heart Disease (BMM, ACA), School of Childand Adolescent Health, University of Cape Town, CapeTown; and Director of Pediatric Intensive Care Unit(ACA), Red Cross War Memorial Children’s Hospital,Cape Town, South Africa.

Supported, in part, by the grants from the MedicalResearch Council of South Africa (BMM) and the HealthSciences Faculty of the University of Cape Town.

The authors have not disclosed any potential con-flicts of interest.

For information regarding this article, E-mail:[email protected]

Copyright © 2008 by the Society of Critical CareMedicine and the World Federation of Pediatric Inten-sive and Critical Care Societies

DOI: 10.1097/PCC.0b013e31818499cc

Objective: To provide a comprehensive, evidence-based reviewof pediatric endotracheal suctioning: effects, indications, andclinical practice.

Methods: PubMed, Cumulative Index of Nursing and AlliedHealth Literature, and PEDro (Physiotherapy Evidence Database)electronic databases were searched for English language articles,published between 1962 and June 2007. Owing to the paucity ofobjective pediatric data, all reports dealing with this topic wereexamined, including adult and neonatal studies.

Results: One hundred eighteen references were included in thefinal review. Despite the widespread use of endotracheal suction-ing, very little high-level evidence dealing with pediatric endotra-cheal suctioning exists. Studies of mechanically ventilated neo-natal, pediatric, and adult patients have shown that suctioningcauses a range of potentially serious complications. Current prac-tice guidelines are not based on evidence from controlled clinicaltrials. There is no clear evidence that endotracheal suctioningimproves respiratory mechanics, with most studies pointing to thedetrimental effect it has on lung mechanics. Suctioning should beperformed when obstructive secretions are present rather than

routinely. There is no clear evidence for the superiority of closed-or open-system suctioning, nor is there clear evidence for appro-priate vacuum pressures and suction catheter size. Sterility doesnot seem to be necessary when suctioning. Preoxygenation hasshort-term benefits, but the longer-term impact is unknown.Routine saline instillation before suctioning should not be per-formed. Recruitment maneuvers performed after suctioning havenot been shown to be useful as standard practice.

Conclusions: Endotracheal suctioning is a procedure used reg-ularly in the pediatric intensive care unit. Despite this, goodevidence supporting its practice is limited. Further, controlledclinical studies are needed to develop evidence-based protocolsfor endotracheal suctioning of infants and children, and to exam-ine the impact of different suctioning techniques on the durationof ventilatory support, incidence of nosocomial infection, andlength of pediatric intensive care unit and hospital stay. (PediatrCrit Care Med 2008; 9:465–477)

KEY WORDS: endotracheal suction; pediatric; mechanical venti-lation; suction catheter

465Pediatr Crit Care Med 2008 Vol. 9, No. 5

dence Database) databases. The referenceslisted in the publications so identified werealso reviewed. The search terms used weresuctioning, suction, tracheal suction, andendotracheal suction, in various combina-tions with modifiers such as children, pedi-atric, infant, complications, and effects. Thesearch was initially limited to randomizedcontrolled trials (RCTs) and systematic re-views, in the English language, of infantsand children from birth to 18 yrs.

Considering the lack of studies focusing onpediatric ET suctioning, and the small num-ber of controlled clinical trials generally avail-able on the subject, the scope of the reviewwas subsequently extended and all articles in-vestigating or discussing ET suctioning wereconsidered for inclusion; where RCTs specificto the pediatric age group were not identified,studies of lower evidence levels were sourced.Studies pertaining to neonatal care were in-cluded in the data synthesis as these patientsare often managed in PICUs; where insuffi-cient evidence was available on infants andchildren, adult data were considered for inclu-sion. When insufficient human clinical trialswere identified, in vitro and animal studieswere discussed.

The physiologic and anatomical differencesamong the three age groups (neonates, infantsand children, and adults), and the differentdisease spectra were taken into account in thedevelopment of clinical recommendations.

RESULTS

Forty-three clinical trials and system-atic reviews were identified, of which 14were initially excluded as they either didnot evaluate suctioning specifically orthey concerned the adult age group (14–27). A further four studies were excludedas they addressed perinatal suctioning ofmeconium-stained neonates (28–31). Ofthe remaining studies, 17 dealt specifi-cally with neonates (6, 32–47) and eightclinical trials pertained to infants andchildren (48–55). One hundred eighteenarticles were included in the final review.

Data Synthesis

Precautions and Contraindications toET Suctioning. Considering that all intu-bated and ventilated patients may requireET suctioning to maintain a patent air-way, there can be no absolute contrain-dications to the procedure (9).

Special care should be taken with pa-tients who have raised intracranial pres-sure, as this can be exacerbated by ETsuctioning and coughing (23, 54, 56, 57)as can pulmonary hypertension. Patientswith pulmonary edema and pulmonary

hemorrhage should only be suctionedwhen absolutely necessary, as it has beensuggested that these conditions may beexacerbated by suctioning (58, 59).

All patients should be continuouslymonitored to assess clinical and physio-logic changes in response to ET suctioning.

Adverse Clinical Effects. Althoughconsidered essential to prevent airway ob-struction from accumulation of secre-tions, it is recognized that severe adverseevents may result from suctioning.

Respiratory complications include:hypoxia, which has been reported in neo-natal (32, 60–63) and pediatric (54, 55)studies; pneumothorax has been observedin neonates as a result of the suctioncatheter perforating a bronchus (64, 65);deep ET suctioning has been shown tocause mucosal trauma in animal models(2, 66) and in neonates (64, 67, 68); atel-ectasis has been reported in neonatal (69)and pediatric (8, 51, 70) subjects; and lossof ciliary function has been observed inanimal models (2).

Cardiovascular complications includebradycardia (60, 62, 71, 72), other cardiacarrhythmias (62), and increases in sys-temic blood pressure (57, 62), which havebeen reported in neonatal studies. Thepulmonary vasoconstriction, occurringin response to ET suctioning-inducedhypoxia may predispose neonates to per-sistent pulmonary hypertension or patentductus arteriosus (62).

Neurologic sequelae of suctioning in-clude raised intracranial pressure, whichhas been observed in preterm infants (56,57), in pediatric patients (54), and inadult traumatic brain-injured patients(23). Cerebral blood volume has beenshown to increase significantly in me-chanically ventilated preterm neonates(73) during ET suctioning, with the ce-rebral blood volume changes occurringin relation to changes in carbon dioxidetension (61). Marked decreases in cere-bral blood oxygen concentration and,thus, decreased cerebral oxygen avail-ability have been observed in neonates(60, 73). It has been suggested that thehypoxia induced by suctioning in neo-nates may contribute to the develop-ment of intraventricular hemorrhage(60) and hypoxic-ischemic encephalop-athy (74).

ET suctioning has been implicated innosocomial bacteremia, attributed to theintroduction of pathogens by the suctioncatheter (2).

ET suctioning has also been shown tocause behavioral pain responses in low

birth weight infants (75). In a prospectiveobservational study of 151 neonates, itwas shown that patients were subjectedto an average of 14 painful proceduresper day (measured as pain scores �4 ona 10-point scale), of which suctioningaccounted for almost 64%. However,�35% of neonates received preemptiveanalgesia (76). In a randomized, placebo-controlled study of 84 ventilated neo-nates, it was shown that administrationof opioids before ET suctioning signifi-cantly reduced the duration of hypoxemiaand the level of distress, as quantified bya behavioral scoring method (42).

ET suctioning has also been shown tocause pain in critically ill adults (77, 78)and the discomfort caused by suctioningis frequently recalled upon dischargefrom the intensive care unit (79).

Some of the above adverse events maybe due to vagal nerve stimulation (71),coughing, or catheter trauma (2, 65, 74)and others may be directly related to thephysical effects of suctioning on thelungs (68, 80–85). Atelectasis has beenattributed to the aspiration of intrapul-monic gas (81), mucosal edema (8), orbronchial obstruction as a result of mu-cosal trauma (67).

In infants and young children wherefunctional residual capacity is close to theclosing volume, glottic closure on expira-tion is used as a natural mechanism tomaintain lung volume. The ETT preventsglottic closure, predisposing the patientto atelectasis. Therefore, even in intu-bated children with normal lungs, posi-tive end-expiratory pressure may be nec-essary to maintain lung volume.Disconnection from the ventilator resultsin a decrease in airway pressure with lossof lung volume, and further lung volumeloss occurs with the application of a neg-ative suction pressure (70, 84, 86).

The effects ET suctioning have on pa-tient outcome, length of PICU and hospi-tal stay, and patient mortality and mor-bidity are currently not known and thisrequires further investigation.

Effect of Suctioning on Lung Mechan-ics. Main et al. (49) found that overallthere were no significant changes in tidalvolume or respiratory system complianceafter ET suctioning in 100 pediatric pa-tients with variable lung disease. It wasnoted, however, that individual responseswere variable with some patients showinga marked improvement although othersdeteriorated. Patients received differentrepetitions of suctioning; catheter sizeand suction pressures were not reported;

466 Pediatr Crit Care Med 2008 Vol. 9, No. 5

variable amounts of saline were instilledbefore suctioning; and some patients re-ceived hyperinflation maneuvers after theprocedure. The duration, method, andamount of positive pressure applied dur-ing these maneuvers were not docu-mented. The lack of standardization ofthe suctioning technique among patientsresulted in this study having limitationsin interpretation, application, reliability,and reproducibility.

In an observational study prospec-tively investigating the effects of a stan-dardized suctioning procedure in 78 crit-ically ill pediatric patients, ET suctioningwas shown to reproducibly result in adecrease in dynamic compliance and tidalvolume, attributable to a loss of lung vol-ume, which returned to presuction levelsagain within 10 mins of being recon-nected to the ventilator (70). This recur-rent derecruitment and subsequent rere-cruitment on reconnection to theventilator may exacerbate lung injury(84, 86, 87). This study was limited by thelack of a control group. Choong et al. (51)also showed that ET suctioning resulted inloss of lung volume in 14 pediatric patientsreceiving conventional ventilation.

Using inductive plethysmography, itwas shown that open-ET suctioning ofnewborn infants (n � 7) receiving high-frequency oscillatory ventilation caused asignificant loss of lung volume, whichwas in all but one patient rapidly regainedon reconnection to the ventilator withoutfurther intervention (88). Similar studiesrelated to suctioning and high- frequencyoscillatory ventilation have not been con-ducted in older infants and children.

End-expiratory lung volume, mea-sured by inductive plethysmography, de-creased during ET suctioning of adults(n � 9) with acute lung injury (ALI),regardless of the suctioning techniqueperformed: open-suction, through swiveladaptor or through a closed-suction sys-tem (84). This study confirmed that bothloss of airway pressure because of discon-nection and the application of negativepressure were implicated in suction-induced alveolar collapse. This may sug-gest that patients receiving high positiveend-expiratory pressure levels are at in-creased risk of volume loss duringopen-ET suctioning.

Theoretically, removal of secretionsfrom the airways should reduce airwayresistance (63), but this has not beenclinically demonstrated. The reduction inresistance caused by clearing the largeairways could be negated if suctioning-

induced volume loss occurred, with anassociated increase in airway resistance(11). “Routine” suctioning, performed inthe absence of secretions, would not beexpected to drop airways resistance, asdemonstrated clinically in a pediatricstudy (70).

Initial deterioration in resistance as aresult of transient bronchoconstrictionhas been described after suctioning, andit is notable that even after this broncho-constriction had resolved, patients stilldid not show any improvement in airwayresistance (4). Main et al. (49) found thatET suctioning did not affect respiratoryresistance, although chest physiotherapyand suctioning combined caused a de-crease in resistance. This may suggestthat chest physiotherapy combined withET suctioning improves secretion clear-ance more effectively than ET suctioningalone; however, the lack of standardiza-tion of study intervention makes inter-pretation difficult and confirmation is re-quired from further standardizedcontrolled trials.

There is still no clear evidence that ETsuctioning improves respiratory mechan-ics (4). However, many available studiesare limited by small sample sizes, patientheterogeneity, lack of intervention stan-dardization, and the absence of a suitablecontrol group. Although in most studiesthe overall effect was found to be negativeor of no benefit, individual patients haveseemed to improve their lung mechanics.Predictive factors for a positive effectwere unable to be identified statistically.

Frequency of ET Suctioning. It is gen-erally accepted that suctioning shouldnot be performed as a routine interven-tion, but rather as indicated after a thor-ough clinical assessment (89). Observa-tional studies of clinical practice havesuggested that the identification of theneed for ET suctioning is a complex is-sue, involving changes in both clinicalsigns and patient behavior (90).

Previous guidelines based on expertconsensus have suggested that clinicalindications for suctioning include audibleor visible secretions in the ETT, or coarsebreath sounds on auscultation (9);coughing; increased work of breathing(9); arterial desaturation and/or bradycar-dia as a result of secretions; decreasedtidal volume during pressure-controlledventilation (9); the need for a trachealaspirate culture (9); and after chest phys-iotherapy to clear mobilized secretions. Ifventilators are equipped with flow-volume loop displays, changes in graph-

ics (9) or a saw-toothed pattern may in-dicate the presence of secretions in theETT (91). Patients receiving high-fre-quency oscillatory ventilation should beobserved with regard to the amount ofchest wall oscillation; if this changes itmay indicate the presence of secretions.

Many of these indications are verysubjective, and closer monitoring of, forexample, transcutaneous PCO2 levels, mayprovide a more objective indication forsuctioning. This requires investigation.

Open vs. Closed-System Suctioning.Commonly used suctioning systems areopen-ET suctioning (OES) and closed-system suctioning (CSS). OES involvesfirst disconnecting the patient from theventilator and then suctioning the ETTbefore reconnecting the patient to theventilator circuit. CSS allows mechanicalventilation to continue during ET suc-tioning, and may be performed using spe-cial adaptors that allow partial mechani-cal ventilation to continue during theinsertion of the suction catheter (35).However, the method frequently usedclinically is the inline multi-use suctioncatheter system, in which catheters areencased in a plastic sleeve on insertion,providing a seal that maintains a closedsystem (92).

Neonates have been shown to main-tain better physiologic stability duringCSS (33, 93). In a crossover study of 11preterm infants, it was found that themagnitude and duration of desaturationand bradycardia were significantly re-duced with CSS. In addition, OES causeda greater decrease in cerebral blood vol-ume than CSS (94). Rieger et al. (95)found that the suctioning system did notinfluence cerebral blood flow velocity inextremely low birth weight infants.

Use of CSS may prevent ET suction-induced hypoxia and decreases in lungvolume in pediatric (51) and adult (92)patients. CSS may limit aerosolization ofinfectious mucus particles; thereby pre-venting the spread of infection betweenpatients and from patients to staff (96). Ithas been suggested that CSS should re-duce the risk of ventilator-associatedpneumonia by eliminating environmen-tal contamination of the catheter beforeintroduction into the ETT (96).

The drawbacks of CSS include the riskof producing high negative pressures (97)if the amount of air suctioned exceeds thegas flow delivered to the patient by theventilator (98); and reduced efficiency inclearing thick secretions from the air-ways (99). Practically, there is also a risk


of not withdrawing the catheter com-pletely after the suctioning event and,thus, partially occluding the ETT and in-creasing airway resistance.

In a bench test evaluation of a neona-tal closed-suction system, Monaco andMeredith (100) found that CSS did notpreserve continuity of volume or pressuredelivery during suctioning; therefore,this was unlikely to be the reason for thereported reduction in suction-relatedhypoxia (71, 72, 101).

Two randomized crossover studies inadults have compared sputum weightwith OES and CSS. The first study did notfind any difference between the suction-ing systems (102), whereas the secondstudy found that OES was four to fivetimes more effective in removing secre-tions than CSS (103). These studies aredifficult to interpret, as the mass of se-cretions suctioned could have been af-fected by simultaneous aspiration of con-densed water (104).

In an in vitro study using adult-sizedETT and suction catheters (99), it wasfound that OES was significantly moreefficient than CSS during three differentventilation modes. Auto-triggering of theventilator was observed during all CSSprocedures. In addition, during CSS withpositive pressure ventilation, the trig-gered inspiratory gas flow actually forcedsecretions away from the catheter tip. Itseemed that pulmonary secretions couldnot be effectively removed without caus-ing lung collapse and affecting gaseousexchange. OES was presented as the sys-tem of choice, in the presence of clearindications for suctioning. Similarly,Copnell et al. (105) demonstrated in ananimal lung injured model that CSS wasless effective in clearing both thin andthick secretions, regardless of the modeof ventilation.

In 175 low birth weight infants, ran-domized to CSS or OES, CSS did notaffect the rate of bacterial airway coloni-zation, frequency of ET suctioning andreintubation, duration of mechanical ven-tilation, length of hospitalization, incidenceof nosocomial pneumonia or neonatal mor-tality. However, CSS was preferred by mostnurses because of ease of use, time effi-ciency, and the perception that it was bettertolerated by the patients (39).

Freytag et al. (106) showed that notchanging the closed-system catheter for72 hrs in adult patients significantly in-creased microbial growth on the cathe-ters and led to a significant increase in

colonization of the lower respiratorytract.

Three meta-analyses have concludedthat there were no significant differencesbetween OES and CSS on the incidenceof ventilator-associated pneumonia andmortality in adults (107–109). AlthoughCSS was associated with a significant re-duction in fluctuations of heart rate andmean arterial blood pressure, no conclu-sions could be drawn with regard to ox-ygenation or secretion removal, and CSSwas associated with increased coloniza-tion (108). Based on these meta-analyses,there is no evidence to support the use ofCSS over OES, in the adult intensive careunit population.

There is a paucity of evidence relatingto the merits of CSS or OES in the pedi-atric critical care population. Choong etal. (51) found that total lung volume losswas significantly greater with OES thanCSS in pediatric patients aged 6 days to13 yrs. In addition, patients suctionedwith the open method experiencedgreater levels of desaturation. These au-thors suggest that CSS is preferable tothe open technique, especially in patientswith significant lung disease requiringhigh levels of positive end-expiratorypressure, to avoid alveolar derecruitmentand hypoxia during ET suctioning.

ET suctioning provides an abundantopportunity for the spread of infections(110), and this would seem to be more sowith the open technique. Although CSShas not been shown to reduce the inci-dence of ventilator-associated pneumo-nia, the importance of this measure inpreventing patient-to-patient or patient-to-staff transmission of infectious dis-eases has not been adequately studied.

Preoxygenation. Although it is ac-cepted that oxygen should generally beprovided to prevent ET suction-inducedhypoxia, the optimal degree and durationof preoxygenation is currently not known(111).

In preterm neonates, brain oxygen-ation was shown to decrease in parallelwith arterial oxygen saturation (SaO2)during suctioning, but the decreases inboth were ameliorated by increasing thefraction of inspired oxygen (FIO2) by 10%before suctioning (61). In a systematicreview of neonatal trials, Pritchard et al.(34) reported that although preoxygen-ation decreased hypoxemia at the time ofsuctioning, other clinically importantoutcomes, including the adverse effectsof hyperoxia, were not known. Owing tothe poor quality of the one study (46)

qualifying for inclusion in the above re-view, no recommendations for clinicalpractice could be made.

In an observational study of neonates(n � 17), providing 10% FIO2 above base-line for 2 mins before suctioning andmanually ventilating with 100% O2 inbetween suction passes reduced the inci-dence of hypoxemia, bradycardia, and ap-nea associated with suctioning (112). In aprospective, crossover study of 15 venti-lated newborn infants, those who received a10% increase in FIO2 before suctioning, hadsignificantly better postsuctioning SaO2

than those in the control group (32).Kerem et al. (55) examined ways of

preventing hypoxia during ET suctioningin a prospective randomized crossovertrial of 25 hemodynamically stable pedi-atric patients. Patients underwent one offour suctioning approaches: a controlwith no treatment; preoxygenation; hy-perinflation presuction; and hyperinfla-tion postsuction. The significant fall inSaO2 and PaO2 occurring as a result ofsuctioning was completely prevented bydelivering 100% inspired O2 for 1 minbefore the procedure.

A meta-analysis of 15 adult trials (111)showed that the occurrence of hypoxiawas 32% lower when preoxygenation wasapplied. In a crossover study of 30 adultsundergoing CSS (113), it was found thatalthough oxygenation was significantlyhigher in patients who were preoxygen-ated with 100% O2, patients who were notpreoxygenated did not experience signif-icant hypoxia during suctioning. Basedon this data, it was recommended thatthe decision on whether or not to preoxy-genate adults undergoing CSS should bedetermined on an individual basis accord-ing to the patients’ clinical condition.

Branson et al. (9) suggested thatadults and children should receive 100%inspired O2 for �30 secs before suction-ing. Hodge (74) suggested increasing theFIO2 by 10%–20% higher than the FIO2

for about 1 min before suctioning neo-nates. Neither of these recommendationsis supported by high-level evidence.

In all age groups, hyperoxia causesfree-radical damage and absorption atel-ectasis, associated with major morbidity.The issue of what level of oxygenationone should deliver is, however, likely tobe most relevant in the neonatal popula-tion where hyperoxia has been implicatedin the development of periventricular


leukomalacia, retinopathy of prematu-rity, and chronic lung disease, with thepotential for major long-term sequelae(114, 115).

Because of the known risks of hyper-oxia, it is recommended that FIO2 be re-turned to presuctioning levels as soon asthe SaO2 has stabilized.

Use of Saline. Instillation of isotonicsaline (sodium chloride) has been a wide-spread practice in PICUs for many years,under the impression that the fluid aidedin the removal of pulmonary secretionsby lubricating the catheter, eliciting acough, and diluting secretions. This prac-tice may have been necessary historically,before the use of humidifying systems.However, mucus and water in bulk formare immiscible and maintain their sepa-rate phases even after vigorous shaking(116). Thus, the function of saline as asecretion dilutant is doubtful. Instillationof normal saline in conjunction with ETsuctioning may cause additional disper-sion of contaminated adherent materialin the lower respiratory tract, with thesubsequent increased risk of nosocomialinfection (106).

Adult studies have consistently re-ported the adverse effect of saline instil-lation on arterial oxygenation (117–120).

In infants, routine saline instillationbefore suctioning was only found to be ofbenefit in maintaining ETT patency with2.5 mm internal diameter ETT, but nobenefit was found in using saline for a 3.0or a 3.5 mm ETT (43). Shorten et al. (44)randomly assigned 27 clinically stable ne-onates to two orders of suctioning meth-ods, one with and one without saline in-stillation (0.25–0.5 mL). These authorsfound no significant difference in oxygen-ation, heart rate or blood pressure be-tween the groups. Beeram and Dhani-reddy (121) performed suctioning withand without saline in 18 neonates, actingas their own controls. Although there wasno difference in lung compliance or re-sistance, there was a significant, albeittransient, deterioration in SaO2 frombaseline in those infants who receivedsaline before suctioning.

In a randomized controlled trial of 24pediatric patients, for 104 suctioning ep-isodes, it was shown that patients whoreceived between 0.5 and 2 mL of nor-mal saline before or during suctioning,experienced significantly greater oxy-gen desaturation than patients who didnot receive saline instillation. Therewere no cases of ETT occlusion in ei-ther group (52).

Despite the body of knowledge indicat-ing that instillation of saline is unlikely tobe beneficial and may in fact be harmful,there is still limited evidence in the pedi-atric population, and many clinicianscontinue to be concerned about ade-quately clearing thick secretions from thesmall ETTs used for infants and children(52). Hodge (74) suggested that in thecase of tenacious secretions, 0.1– 0.2mL/kg body weight of 0.9% saline couldbe instilled before suctioning. Shorten etal. (44) showed that clinically stable new-born infants tolerated 0.25–0.5 mL salineinstilled before suctioning.

To ensure that pulmonary secretionsare easily manageable with suctioning, itis essential to ensure adequate humidifi-cation of inspired gas (9, 52).

Suction Catheter Size. If a catheterlargely or completely occludes an artifi-cial airway or bronchus, the full suctionpressure may be transmitted to that air-way leading to massive atelectasis (80,122). To avoid this, the recommendationhas been made that the suction cathetersize should be no more than half theinternal diameter of the ETT (8, 11). Thisis not possible when suctioning infantswith small diameter ETTs (�3.5 mm).

The amount of gas that can be re-moved from the thorax through the cath-eter will largely be determined by thecross sectional area of the catheter. Witha partially occluded ETT, gas would beable to flow into the thorax, largely re-placing the gas removed during suction-ing. The amount of gas able to flow intothe thorax through the ETT would de-pend on the available space between theETT and the catheter. Morrow et al. (122)suggested, therefore, that lung volumeloss would be related to the catheter area:area difference ratio (where area differ-ence is the difference between the inter-nal ETT area and the external catheterarea). This hypothesis was subsequentlyconfirmed in a prospective observationalclinical study with the suction-inducedchange in dynamic compliance being di-rectly related to the catheter area: areadifference ratio (70). This suggests thatthe most severe lung volume changes arelikely to occur during ET suctioning ofneonates and young infants intubatedwith small internal diameter ETT, as inthese patients the catheters used will al-ways be relatively large compared withthe ETT size. Similar changes in lungvolume loss would also occur in olderchildren if the catheters selected wereinappropriately large relative to ETT size.

The catheter sizes recommended forpediatric use by Shann (7) range from55% to 100% of the corresponding ETT’sinternal diameter. Morrow (123) demon-strated that for ETTs �3.5 mm internaldiameter, the recommended catheters alloccluded the ETT by more than 75%.Potentially low intrapulmonary and in-trathoracic pressures could be generatedin this situation.

In a prospective study of 17 ventilatedpediatric patients, it was found that cath-eter diameter did not influence the mag-nitude of change in SaO2, heart rate, andintracranial pressure (54). When using acatheter with outer diameter:ETT innerdiameter of 0.4, repeated suction passeswere required to adequately clear the air-way, and catheters with an outer diam-eter:inner diameter ratio �0.7 were dif-ficult to insert into the ETT. Theseauthors found that using a suction cath-eter with outer diameter:inner diameterof 0.7 was easiest to introduce into theETT and was most effective in clearingsecretions.

The selection of catheter size shouldbe made considering both the ETT sizeand the secretion consistency, as smalldiameter catheters will not effectivelyclear thick secretions (122). The recom-mendation for catheter size selection pre-sented in Table 1 was developed by theauthors from the findings of an in vitrostudy (122) and has not been subjected torigorous testing by means of a prospec-tive controlled clinical trial. It is recom-mended that this be used as a guidelineuntil stronger evidence is available.

The suction catheter should be largeenough to effectively suction thick secre-tions but not so large that it traumatizesor occludes the ETT, which would lead togreater negative pressure accumulation(122) and lung volume loss (70).

Vacuum Pressure. The issue of select-ing suction pressures relates to the bal-ance between effective suctioning of se-cretions and potential risk to the patient.The suction pressure should be highenough to be effective in removing secre-tions, but not so high that it causes mu-cosal damage or lung volume loss. Thereis still no high-level evidence supportinga maximum, safe, and effective suctionlevel.

Negative pressure in the lungs pro-duced during suctioning would only oc-cur while air was flowing through thesuction catheter. As soon as secretionsare drawn into the catheter, the pressurein the lungs would return to that of the


atmosphere (80). An observational studyof pediatric patients suggested that suc-tioning in the presence of ETT secretionsmay not result in loss of lung volume(70). However, routine suctioning, whichoften occurs in the absence of secretions,is likely to cause significant atelectasis.Repeating suctioning maneuvers aftermucus has been removed is also likely tocause loss of lung volume. Therefore, al-though suction pressures should be lim-ited, the issue may not be as critical whensuctioning only when indicated to do soin the presence of secretions.

Results of an animal study, in whichthe suction catheter was passed to thecarina, showed that mucosal trauma oc-curred when using suction pressures ofboth 100 mm Hg and 200 mm Hg; how-ever, damage was greater at the highersuction level (66). This study also sug-gested that efficiency of aspiration wasnot affected by the suction pressure used.Conversely, in an in vitro study, it wasshown that suction pressures up to 360mm Hg measured at the vacuum sourcewere more effective in removing secre-tions than using vacuum pressures of 200mm Hg (122). These suction pressureswere the lowest two options on the com-mercially available suction units in use atthe time of these investigations.

In two pediatric ET suction studies,Morrow et al. (48, 70) used suction pres-sures of approximately 360 mm Hg mea-sured at the source with the tubingclamped. Although not measured, muchlower suction pressures would actuallyhave been delivered at the distal end ofthe catheter than were indicated on thegauge because of the resistance offered

by the suction tubing and suction cath-eter (123).

These suction pressures are higherthan those recommended by most au-thors, who advocate a range between 70and 150 mm Hg (74, 124). Young (11)suggested that these pressures may beincreased up to 200 mm Hg to aspiratethick secretions. In a neonatal study, suc-tion pressures between 200 and 300 mmHg were used (60). Singh et al. (54) didnot show any difference in the change ofphysiologic parameters when suctioningchildren using vacuum pressures of 80mm Hg, 100 mm Hg or 120 mm Hg.Clinical studies have not investigatedcomparatively the effects of higher suc-tion pressures on physiologic changes,efficacy of secretion removal, or patientoutcome.

The potential impact of high suctionpressures (potential mucosal damage andlung volume loss) needs to be weighedagainst the potential damage that mayoccur with repeated suction passes whenusing a lower vacuum level. This war-rants investigation.

Sterility. There is a risk of introducingpathogens into the respiratory tract dur-ing ET suctioning, largely as a result ofenvironmental exposure of the suctioncatheter (96). Therefore, it has been sug-gested that a strictly aseptic technique beused during ET suctioning (9, 125). Dur-ing suctioning, however, the catheter ispassed into the ETT through an unsterileport which may be colonized with poten-tially pathogenic organisms. This will oc-cur regardless of operator sterility. In arandomized controlled trial of 486 intu-bated children and infants, it was found

that reusing a disposable suction catheterin the same patient over a 24-hr perioddid not affect the incidence of nosocomialpneumonia (53).

The increased prevalence of commu-nity-acquired infections among youngchildren who have not yet become im-mune either by vaccination or naturalexposure, results in more patients pre-senting with transmissible infections, es-pecially during seasonal epidemics (e.g.,respiratory viruses, measles, varicella, ro-tavirus, and pertussis). The emergence ofmultidrug-resistant organisms in thePICU setting and the spread among pa-tients poses the threat of outbreaks ofuntreatable infectious diseases associatedwith significant mortality and morbidity.Use of infection control precautions toprevent transmission among patients is,therefore, a top priority (110). Consider-ing that transmission of infectious organ-isms from patient to patient frequentlyoccurs on the hands of healthcare work-ers (110), hand washing before and afterpatient contact is essential despite thewearing of gloves, and regardless of suc-tioning method (open or closed).

There are reports of nursing staff ac-quiring tuberculosis from children re-quiring ET suctioning (126, 127), imply-ing a potential risk of infection to theperson performing the procedure. Withexposure to respiratory secretions, preg-nant healthcare workers are at risk ofexposing their fetuses to potentially dam-aging pathogens such as hepatitis C, cy-tomegalovirus, and parvovirus B19. Stan-dard and transmission-based precautionsare the only preventive measures for min-imizing this risk (110).

Therefore, it is essential to adhere tostrict infection control procedures, partic-ularly in developing countries, where thereis a higher incidence of infectious diseasessuch as tuberculosis (1, 128, 129). Moreresearch into the influence of different suc-tioning techniques on the occurrence ofnosocomial pneumonia is needed.

The recommended contact and stan-dard precautions for patients with pre-sumed infectious diseases include the useof gloves (either “clean” or sterile); faceprotection (face masks and goggles) foropen ET suctioning, which is likely tocause splashes or sprays of secretions;washing hands before and after donninggloves; and wearing a gown to protect theskin and prevent contamination of theclothes (110, 130).

Although the same suction cathetermay be used for several suction passes

Table 1. A proposed guideline for suction catheter selection based on in vitro investigations by Morrowet al. (122)

Age Weight (kg) ETT (mm ID)

Mucus Consistency,Catheter Size (FG)

Liquid Medium Thick

Newborn �1 2.0 5 5 5Newborn 1 2.5 5 5 6Newborn 2 3.0 5 6 6Newborn 3.5 3.5 5 6 73 months 6 3.5 5 6 71 year 10 4.0 6 7 72 years 12 4.5 6 7 83 years 14 4.5 6 7 84 years 16 5.0 7 8 86 years 20 5.5 7 8 88 years 24 6.0 8 10 1010 years 30 6.5 8 10 1212 years �30 7.0 8 10 12

ETT, endotracheal tube; mm ID, mm internal diameter; FG, French gauge.


(53), external environmental contami-nation should be limited. The suctioncatheter should be immediately dis-carded if it comes into contact with anysurfaces, and should not be used tosuction the nose or mouth before intro-duction into the ETT.

Although strict sterility in the suc-tioning process may be unnecessary, ad-herence to standard infection controlprocedures is mandatory.

Duration of Suctioning. Increasingthe duration of suction application hasbeen shown to significantly increase theamount of negative pressure within alung model (122) and has been impli-cated in the degree of hypoxia inducedclinically (69, 80). Although there is cur-rently no strong evidence supporting anappropriate duration of suctioning, mostauthors recommend between 10 and 15secs (9, 11). Runton (10) suggests thatthe actual time of negative pressure ap-plication during suctioning of children belimited to �5 secs.

Depth of Catheter Insertion. Thedepth of insertion of the suction catheterduring ET suctioning varies according toinstitutional practice (6). Although thedefinitions of deep and shallow suction-ing are inconsistent in the literature, inmost cases shallow ET suctioning refersto passing the catheter to the tip of theETT, whereas in deep ET suctioning thecatheter is passed beyond the ETT intothe trachea or bronchi, usually until re-sistance is felt.

In two randomized crossover studiesof high-risk neonates (36, 37), it wasshown that there were no significant dif-ferences in SaO2 or heart rate responsesbetween shallow and deep ET suction(37). During deep suctioning more freshclustered columnar cells were detachedfrom the respiratory epithelium, al-though shallow ET suction caused lesstracheal epithelial loss and inflammation.Deep suctioning was not superior in sam-pling from the lower respiratory tract(36).

No studies met the inclusion criteriafor a systematic review of deep vs. shallowET suctioning of ventilated infants (6)and, it was therefore, concluded thatthere was insufficient concerning thebenefits or risks of the respective tech-niques despite some anecdotal evidenceregarding possible airway damage.

In an animal model, inserting thecatheter to 1 cm beyond the ETT tipresulted in significantly less mucosal ne-

crosis and inflammation than with deepersuctioning (2).

Mucosal inflammation as a result ofdeep ET suctioning could cause squa-mous metaplasia, ulceration, and for-mation of obstructive granulation tis-sue (67). Cases of pneumothorax havebeen reported after deep ET suctioning(64, 65).

In specific situations, such as follow-ing surgical repair of tracheo-esophagealfistulas, deep suctioning may be hazard-ous as the surgical site may be compro-mised by direct catheter trauma.

Recruitment Maneuvers PerformedAfter ET Suctioning. RM have been sug-gested as a method of reversing suc-tioning-induced lung volume loss andimproving arterial oxygenation, by rein-flating the collapsed lung segments be-fore resuming ventilation (87, 99, 131). ARM refers to the application of a sus-tained inflation pressure to the lungs fora specified duration to return the lung tonormal volumes and distribution of air.

Collapsed alveoli are subject toLaplace’s law and a high inspiratory pres-sure is required to expand these atelec-tatic lung units. Laplace’s law, however,also implies that, in the presence of nor-mally aerated or hyperinflated alveoli to-gether with collapsed alveoli, there is arisk that the RM would preferentiallyoverdistend the aerated units before ex-panding collapsed areas.

In lung-injured rabbits, a RM (infla-tion pressure of 30 cm H2O sustained for30 seconds) resulted in a significant sus-tained increase in end-expiratory lungvolume, PaO2 and dynamic compliancedespite equal positive end-expiratorypressure levels used before and after themaneuver (132). Cakar et al. (133) con-cluded that responses to RMs differedamong different models of ALI, usingdogs as experimental subjects.

In anesthetized sheep, airway narrow-ing and atelectasis caused by ET suction-ing was completely reversed by hyperoxy-genation and a RM (85). Similarly, atimed re-expansion inspiratory maneuversuccessfully reversed apnea-induced de-creases in dynamic compliance in anes-thetized lambs (134). In a porcine lungmodel ventral lung regions re-expandedfaster than dorsal regions after suction-ing irrespective of ventilation mode. Inthe dorsal regions, however, where loss ofvolume and compliance were most pro-nounced, recruitment was significantlyfaster with volume-controlled compared

with pressure-controlled ventilation(135).

Morrow et al. (48) conducted a pro-spective randomized controlled trial in-vestigating the effect of a postsuctioningRM in 34 infants and children (after ex-cluding patients with large ET leaks) withvariable lung pathology, who were receiv-ing conventional pressure-limited, time-cycled mechanical ventilation. The RMwas performed by manually applying asustained inflation pressure of 30 cm H2Ofor 30 secs. The RM may have improvedairway resistance and oxygenation, butgenerally had no effect on dynamic com-pliance as compared with the controlgroup. In both patient groups, pulmonarycompliance dropped significantly afteropen-ET suctioning, indicating a loss oflung volume. However, in most cases pul-monary compliance had returned to base-line levels within 10 mins of the suction-ing procedure, regardless of whether aRM was applied or not. The efficacy of theRM may have been influenced by themanual nature of the technique. Most ofthe patients studied had acute respiratorydistress syndrome (ARDS) or ALI by def-inition, but these were all cases of pul-monary (primary) lung injury. It has pre-viously been found, in adults, thatpatients with extrapulmonary ARDSshowed a greater increase in PaO2 afterRM than those with pulmonary ARDS(136). In the study by Morrow et al. (48),there was a variable response to the RMamong different patients, with two pa-tients with severe lung disease experienc-ing a compliance increase of �100%.This suggests that postsuctioning RMmay be effective under certain condi-tions, and warrants further investigation.

In a prospective randomized con-trolled study using eight adults with ALIor ARDS (137), patients received open-ETsuctioning with or without a RM per-formed after the suctioning procedure.The RM consisted of two hyperinflationsof 45 cmH2O sustained for 20 secs. TheRM was well tolerated and produced arapid recovery in end-expiratory lung vol-ume, respiratory system compliance, andPaO2. The study was limited by the smallsample size.

Other adult studies have investigatedthe use of RM in various situations, usingdifferent techniques, and with variableresults. In adults with ARDS, an “ex-tended sigh” as a RM resulted in a sus-tained increase in both PaO2 and staticrespiratory compliance. In addition, nomajor hemodynamic or respiratory com-


plications were noted (136). Similarly,when a sustained positive pressure wasapplied to adults with severe ARDS afterfirst being turned prone, there were sig-nificant, sustained improvements in oxy-genation index, PaO2/FIO2 and alveolar-arterial O2 difference (138). The ARDSClinical Trials Network (2003) (139)found a variable response to RM, withsome patients experiencing a drop inSaO2 although others’ increased mark-edly. The RM caused greater decreases insystolic blood pressure compared withcontrols, and respiratory system compli-ance did not increase more after RM thansham RM. RMs were terminated early in afew cases because of hypotension or de-saturation. This group concluded thatmore information regarding efficacy andsafety is needed from clinical studies be-fore RMs can be recommended as part ofstandard ventilator management in pa-tients with ALI or ARDS.

Other studies investigating the use ofRM in pediatric patients have involvedsmall sample sizes and used subjects withnormal lungs (140, 141). Tingay et al.(88) reported that term infants receivinghigh-frequency oscillatory ventilation ex-perienced a significant but transient lossof lung volume which, in most cases, hadresolved within 1 min without the needfor a recruitment maneuver. These au-thors noted that in one patient postsuc-tion lung volume was higher than atbaseline and that, in this case, perform-ing a RM would have placed the lung atthe risk of overdistension. Conversely,one infant still had a deficit in lung vol-ume at the end of the study period, andmay have benefited from a RM.

Physiotherapists working in adult in-tensive care units often use manual hy-perinflation techniques in conjunctionwith other manipulations to expand thelung (142, 143). These maneuvers areusually repeated short manual inflationsreaching a predetermined set pressure orvolume with a brief inspiratory hold.Studies reporting the efficacy and safetyof manual hyperinflation have been con-flicting with some reporting improve-ments in atelectasis, lung compliance,and gas exchange (142, 144, 145), al-though others have found no change(146). Care should be taken when apply-ing adult hyperinflation studies to pedi-atric practice. In infants and children,performing hyperinflation maneuvers (asopposed to recruitment/inflation maneu-vers aiming to normalize lung volumes)

may be dangerous because of the highrisk of baro- or volutrauma.

A pediatric crossover study foundthat hyperinflation (five breaths over 10secs administered at approximatelytwice the patient’s tidal volume) per-formed after suctioning immediatelyrestored PaO2 to presuction levels (55).Considering that preoxygenation alonecompletely prevented the fall in PaO2

with suctioning, one needs to questionthe recommendation made by the au-thors to use postsuction hyperinflationmaneuvers in addition to preoxygen-ation (as this approach was not com-pared with others in this study), espe-cially when one considers the potentialrisks of hyperinflation in the pediatricpopulation.

Although further investigation isclearly necessary, the routine practice ofperforming RM after ET suctioning inchildren does not seem to be beneficial(and may in fact be harmful) and is there-fore not recommended for clinical use.

Limitations. Because of the paucity ofhigh-level pediatric evidence, a broadrange of studies were included in thisreview, including those outside the tar-geted age group and those of all evidencelevels. This constitutes a limitation ofthis article, but was deemed necessary topresent a comprehensive review of the ETsuctioning literature, much of which maybe able to be extrapolated to the pediatricpopulation or at least stimulate furtherresearch in this neglected group. Fur-thermore, only published articles in theEnglish language were considered, whichmight bias the review’s findings.

Recommendations. Table 2 summa-rizes the recommendations derived fromthis literature review. The evidence isgraded according to the system describedby Harbour and Miller (147), as summa-rized below:

Levels of Evidence

1�� High quality meta-analyses,systematic reviews of RCTs or RCTswith a very low risk of bias.

1� Well-conducted meta-analyses,systematic reviews of RCTs, or RCTswith a low risk of bias.

1� Meta-analyses, systematic re-views or RCTs, or RCTs with a highrisk of bias.

2�� High quality systematic reviewsof case-control or cohort studies, or

high-quality case-control, or cohortstudies with a very low risk of con-founding and bias, and a high proba-bility that the relationship is causal.

2� Well-conducted case-control orcohort studies with a low risk of con-founding, bias, or chance and a mod-erate probability that the relation-ship is causal.

2� Case-control or cohort studieswith a high risk of confounding, bias,or chance and a significant risk thatthe relationship is not causal.

3 Nonanalytic studies, e.g., case re-ports, case series.

4 Expert opinion.

Grades of Recommendations

A. At least one meta-analysis, system-atic review, or RCT rated as 1��and directly applicable to the targetpopulation, or a systematic reviewof RCTs, or a body of evidence con-sisting principally of studies rated as1� directly applicable to the targetpopulation and demonstrating over-all consistency of results.

B. A body of evidence including studiesrated as 2�� directly applicable tothe target population and demon-strating overall consistency of re-sults or extrapolated evidence fromstudies rated as 1�� or 1�.

C. A body of evidence including studiesrated as 2� directly applicable tothe target population and demon-strating overall consistency of re-sults or extrapolated evidence fromstudies rated as 2��.

D. Evidence level 3 or 4 or extrapolatedevidence from studies rated as 2�.

Considering the physiologic and anatom-ical differences between different agegroups, where recommendations havebeen based on extrapolations from neo-natal or adult studies, this is explicitlystated in Table 2.

CONCLUSION

ET suctioning, although necessary tomaintain patency of the airways, is not abenign procedure. All staff performingthe procedure should be aware of thepositive and negative effects of ET suc-tioning, and methods to prevent or min-


Table 2. Clinical recommendations for endotracheal suctioning of infants and children

Clinical Practice Recommendation Grade of Recommendation

Analgesia ET suctioning is a frequently performed procedure that causes pain anddiscomfort. As the procedure is often performed immediately aftersecretions are detected, there may be insufficient time to administeranalgesia and allow it to take full effect. Therefore, it is recommended thatall ventilated patients receive regular or infused analgesia for the durationof ventilation.

B. Extrapolated from neonatalRCT (42).

Frequency ofsuctioning

Routine suctioning should be avoided (64, 137), with the possible exception ofparalyzed patients. Suctioning should be performed only when clinicallyindicated (9).

D. No experimental evidence.

Suctioning system Although there may be short-term benefits of closed-system suctioning in termsof reduced lung volume loss and hypoxia (51), there is no clear benefit for theuse of closed- or open-system suctioning, and practitioners should continuewith the method at which they are proficient (33, 107–109).

B. Extrapolated from adult(107–109) and neonatal (33,39) systematic reviews.

Monitoring Considering the known complications of ET suctioning, the patient’s heartrate, blood pressure, and oxygen saturation should be carefully monitoredat all times during the procedure. Clinical observations should includepatient color (to detect early cyanosis); signs of respiratory distress (such assweating, tachypnea, marked costal recessions); and signs of pain oranxiety. Where possible, respiratory mechanics should be monitored todetect lung volume changes.


Preoxygenation Considering the short-term effects of hyperoxygenation in reducing hypoxia(34, 55), patients should receive increased inspired oxygen levels for abrief period (�60 secs) before suctioning (9, 55). The optimal level ofpreoxygenation is not known, but can be individually determined by thepatient’s clinical condition and response to handling. The clinical contextshould be taken into consideration, as some pathological processes maymake an individual more susceptible to the adverse effects of hypoxemia(e.g., severe pulmonary hypertension).

B. One pediatric randomizedcross-over trial (55);recommendation extrapolatedfrom neonatal (34) and adult(111) systematic reviews, andneonatal randomizedcross-over trials (32, 61).

Suction cathetersize

Table 1 can be used as a guideline for suction catheter selection. Doublingthe ETT internal diameter gives an indication of which FG catheter size touse for efficacy and safety (e.g., with a 3.5-mm internal diameter ETT, asize 6 or 7 FG catheter could be used).

D. In vitro studies (122) andanecdotal evidence(7, 8, 11).

Vacuum pressure Medical and paramedical staff should use the lowest pressure that effectivelyremoves the secretions with the least adverse clinical reaction. Suctionpressures should be at least �360 mm Hg.

D. In vitro studies (122) andexpert opinion (70, 74, 124).

Sterility A strictly sterile technique is not necessary (53), but staff should adhere tostrict infection control measures to protect themselves and other patients(110, 126).

A. Large RCT of infants andchildren (53).

Duration ofsuctioning

To limit the adverse effects of lengthy duration of suctioning and to minimizeairway trauma, the catheter should be inserted in the absence of vacuumpressure, and suction only applied on catheter withdrawal. The applicationof suction should be limited to �10 secs (9, 10, 11). Patients should bereconnected to the ventilator, and given several recovery breaths beforerepeating the suctioning procedure if secretions have not been adequatelycleared by the previous suctioning event.

D. In vitro studies (122) andexpert opinion (9, 10, 11).

Depth of catheterinsertion

Considering that there are no known benefits to performing deep ETsuctioning, and there is an increased risk of direct trauma (36) and vagalnerve stimulation with deep rather than shallow suctioning (37), thecatheter should only be passed to the end of the ETT. The depth ofinsertion can be determined by direct measurement.

C. Extrapolated fromrandomized cross-overstudies in high-risk neonates(36, 37).

Use of saline Saline should never be used routinely for suctioning. B. Pediatric RCT (52).When to

discontinuesuctioning

Suggested that suctioning be discontinued if there are no more secretions inthe large airways; if the child desaturates to �80% (assuming baseline SaO2

�90%); if the child experiences a cardiac arrhythmia or bradycardia; or ifthe child becomes extremely agitated (respiratory signs of distress, anxiety,or pain responses). Where possible, suctioning should be discontinued if thechild has acute pulmonary hemorrhage or pulmonary edema. At all times,however, a patent airway must be ensured. In the event of hypoxia orbradycardia, the appropriate pediatric life support measures should beimplemented.


Recruitmentmaneuvers

Recruitment maneuvers should not be performed routinely after endotrachealsuctioning (48).

B. Pediatric RCT (48).

ET, endotracheal; ETT, endotracheal tube; FG, French gauge; RCT, randomized controlled trials.


imize its complications. Currently, objec-tive evidence in support of clinicalpractice recommendations is limited,particularly, in the pediatric population(Table 2). Further controlled clinical tri-als are necessary to develop an evidence-based protocol for ET suctioning of in-fants and children, as well as to examinethe impact of different suctioning tech-niques on the duration of mechanicalventilatory support, incidence of nosoco-mial infections and length of PICU andhospital stays.

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