Introduction
Almost 10 percent of newborns require assistance for breathing. An endotracheal tube is a commonly used artificial airway in neonates. However, the procedure interferes with cough reflux in newborns and normal mucociliary function. It increases airway secretion and reduces their clearance. Endotracheal suctioning, a technique where secretions are removed with little negative impact, overcomes the procedure's complications.
What Is Endotracheal Suctioning?
It is the technique of maintaining the airway by clearing secretions and debris when endotracheal tubes are inserted. The main goal of suctioning is to maintain airway patency and remove secretions. The procedure is performed if the airway gets obstructed by fluids. Most neonates with intubation undergo a suctioning procedure.
Why Is Endotracheal Suctioning Required for Newborns?
Endotracheal suctioning is an essential component of intubated newborn care. Premature infants suffering from respiratory distress (respiratory failure) require endotracheal tube intubation for mechanical ventilation with NICU (Neonatal Intensive Care Unit) monitoring. Mechanical ventilation is a life-saving procedure as it helps get adequate oxygen and aids in gas exchange. It increases secretion production, which the neonates are unable to clear.
When the infants undergo intubation, there is a need for endotracheal suctioning to maintain airway patency and ensure proper gas exchange. Placing the endotracheal tube inhibits the conciliary transport system and undermines the infant’s ability to cough and clear debris and secretion within the airway. Therefore, suctioning is the only option to clear airways in newborns. It helps in oxygenation and ventilation. However, the frequency of suctioning depends on the patient’s need. Nonvigorous newborns with meconium-stained fluid also require suctioning if obstruction inhibits positive pressure ventilation.
However, the suctioning procedure is harmful and could stress vulnerable neonates and lead to bradycardia (reduced heart rate). Consequently, unless otherwise indicated, the procedure must not be carried out regularly. The endotracheal tube may become blocked if endotracheal suctioning is not done when necessary, which could lead to trauma from reintubation, atelectasis (lung collapse), and decreased oxygenation and ventilation.
What Are the Indications for Endotracheal Suctioning in Newborns?
Endotracheal suctioning is indicated in intubated newborns when the healthcare provider notices an audible or visible secretion in the endotracheal tube, coarse breath sounds, coughing, increased breathing effort, oxygen desaturation, and bradycardia. Other indications include:
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Apnea.
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Agitation and restlessness.
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Changes in blood gas value.
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Pale, dusky, or cyanotic appearance of skin.
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Decreased breath sounds.
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Low chest wiggle in newborns using a high-frequency ventilator.
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Increase in oxygen requirement.
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Poor chest wall excursion when using a ventilator.
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Changes in respiratory rate and pattern.
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Tachycardia (increased heart rate).
When Is Endotracheal Suctioning Not Recommended in Intubated Newborns?
Immediately after administration of artificial surfactant, endotracheal tube suctioning is not advisable, even with visible secretions or coarse breathing sounds. It is to ensure the availability of maximum benefit from artificial surfactant use. Therefore, avoiding suctioning for one to two hours after artificial surfactant use is preferable unless ventilation is compromised.
How Is Endotracheal Suctioning Performed in Intubated Newborns?
A sterile catheter is inserted through the endotracheal tube. The catheter is stopped no more than 1 cm (centimeter) past the endotracheal tube. If the catheter passes beyond the endotracheal tube, it stimulates the vagal nerve, resulting in bradycardia and hypotension (reduced blood pressure). While removing the catheter, a negative pressure is applied to remove debris and secretions. Using normal saline in endotracheal suctioning should be avoided as it does not assist in mucous removal. Endotracheal suctioning with hemodynamic monitoring, cerebral blood flow, autonomic neural response, and behavioral assessment have shown significant success of the procedure.
What Are the Types of Endotracheal Suctioning?
Two types of endotracheal suctioning are available:
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Closed Suctioning Technique: The procedure includes a closed sterile and inline suction catheter attached to the ventilator circuit. A suction catheter passes through the airway without disconnecting the ventilator. The advantages of a closed suctioning procedure are that positive end-expiratory pressure is maintained, the severity and frequency of hypoxia decrease, it lowers the risk of ventilator-associated pneumonia, and the healthcare provider's exposure to secretions.
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Open Suctioning Technique: The procedure involves disconnecting from the oxygen source or ventilator circuit.
What Are the Risks Associated With Endotracheal Suctioning in Intubated Newborns?
Endotracheal suctioning is a detrimental procedure in NICU care. The risks include cardiac dysrhythmias (abnormal heartbeat), hypoxemia (low oxygen level in blood), atelectasis, bronchospasm (constriction of bronchiole muscle), infection, trauma to the mucosal lining and airway cilia, and elevated intracranial pressure. It could result in tracheobronchial trauma leading to mucosal necrosis, ulceration, tracheal lesion, perforation of the trachea and hypopharynx, bacteremia, and pneumothorax. Other less common complications are hypoxia, desaturation, and bradycardia.
The endotracheal suctioning procedure results in a severe desaturation event where the hypoxia could last for four minutes or longer. Premature infants needing mechanical ventilation are sensitive to environmental stimuli and easily develop desaturation. If deep suctioning is performed, it causes inflammation and infection.
How Are Complications From Endotracheal Suctioning in Intubated Newborns Reduced?
Complications from endotracheal suctioning can be reduced by preoxygenation, shallow suctioning, sedation, comfort measure, type of catheter, frequency, and duration of endotrachial suctioning procedure.
An Ambu bag is used for preoxygenation for at least one minute with 100 percent oxygen before endotracheal suctioning. The suctioning tube catheter must be inserted shallowly instead of deeply to reduce damage to tracheal tissue. Deep suctioning requires catheter insertion until resistance is experienced. However, in the shallow method, the catheter is inserted only till the length of the endotracheal tube instead of beyond.
Also, the endotracheal suctioning procedure must last at most one minute with no more than two suctioning passes. The neonates must be monitored for oxygen saturation during the procedure to prevent hypoxia and ensure recovery before the next suctioning procedure. If the child develops hypoxia, it is treated with hyperoxygenation and hyperinflation. Designing catheters with multiple side holes prevents an abrupt increase in suction pressure. Therefore, it could reduce trauma to the trachea of neonates.
According to recent research, sedation and music therapy could reduce aggravation and negative afferent vagal stimulation, attenuate neural response to hemodynamic changes, and cause less desaturation.
Conclusion
Endotracheal suctioning must be performed when clinically indicated or based on the patient’s assessment. If the procedure is required, the patient must be adequately monitored to prevent hypoxia. The patient is regularly monitored once the procedure is completed to prevent complications.
