Endotracheal Suction in Newborns and Health Issues

Newborn and Endotracheal Suctioning 

Endotracheal suction in newborns: NICU Preterm Infant Care,Risks While Performing Suctioning,Suctioning Issues and Nursing Care Researches,Complications of Neonatal Suctioning,Suctioning Practices and Experiences ,Saline Insertion and Suctioning,Sedation and Music Therapy While Suctioning.

Endotracheal suction in newborns: NICU Preterm Infant Care

    Neonates with respiratory distress syndrome (RDS) who require endotracheal (ET) tube intubation and mechanical ventilation (MV) are the major population in need of a modern neonatal intensive care unit (NICU). MV is life saving to provide adequate oxygen and gas exchange in these neonates. 

    During the period(s) of MV, ET suctioning (ETS) procedure has to be performed by nurses to maintain patent airways to ensure adequate gas exchange. ETS is the only method that can be used to maintain the airway by clearing the airway secretions and debris when the ET tube is inserted, as the ET tube essentially stops the conciliary transport system and inhibits the infant's capacity to cough and clear out the secretions and debris in the airway. 

    ETS involves steps of inserting a sterile catheter through the ET tube, stopping no more than 1 cm past the end of the ET tube, and using negative pressure while withdrawing the ET catheter to clear out the secretions and debris (Turner & Loan, 2000) .

Risks While Performing Suctioning 

    ETS could be one of the most detrimental procedures in NICU care, causing tracheobronchial trauma including mucosal necrosis, tracheal lesions, ulceration, perforation of the trachea and hypopharynx, pneumothorax, and bacteremia (Turner & Loan, 2000). 

    Other complications of ETS include hypoxia and desaturation, bradycardia, and increased intracranial pressure (Shiao, 2002; Skov, Ryding, Pryds, & Greisen, 1992). 

    The trauma to the tracheobronchial tissues can be cumulative over the duration of ET insertion regardless of modes of MV support, including conventional MV and all new forms of high frequency ventilators, and these traumas cannot be recovered until 28 days after removing the FT tube and discontinuing MV (Turner & Loan). 

    ETS tops all NICU procedures in causing worst desaturation events (Shiao, 2002) and in causing hypoxia lasting 4 minutes or longer (Wrightson, 1999).

    Neonates, particularly preterm, who need MV are very sensitive to environmental stimuli and easily develop episodes of desaturation. In addition to RDS, the presence of patent ductus arteriosus and the increased oxygen-hemoglobin affinity of fetal hemoglobin are cardiopulmonary causes of hypoxemia in preterm neonates. 

    Ventilatory weaning, though aggressive, must follow a fine line between oxygen toxicity and hypoxemia. Thus, a better monitoring approach is crucial during MV support in neonates (Shiao, 2002). 

    Significant changes have been demonstrated for ETS procedures with hemodynamic monitoring, cerebral blood flows, autonomic neural responses, and behavioral assessment (Bernert et al., 1997; Segar, Merrill, Chapleau, & Robillard, 1993; Shiao, 2002; Skov et al. , 1992).

Suctioning Issues and Nursing Care Researches 

    Since the 1970s, nurse researchers including Turner and the ETS critical care nursing study groups, as well as researchers from medical sciences, have investigated ETS procedures closely, leading to publications with very clear understanding of pathophysiology for the airway system and ETS trauma in neonates ( Turner & Loan, 2000). 

    Interventions minimizing the detrimental effects of ETS include preoxygenation, shallow suctioning, sedations, and comforting measures, the nature of catheters and ETS, and the frequencies and duration of ETS procedure.

Complications of Neonatal Suctioning 

    The summary reviews from Wrightson (1999) supported the use of hyperoxygenation (preoxygenation) for different durations before the ETS procedure, although the most conclusive study on preoxygenation indicated providing 1 minute 100% oxygen before ETS using a manual Ambu bag (Kerem, Yatsiv, & Goitein, 1990). 

    When closed ETS system (insufflation of suction catheter using a special adapter to allow MV to continue while suctioning occurs) is used to cause less interruption of oxygen supply, hyperoxygenation can be supplied Ming MV (Turner & Loan, 2000). 

    Unlike adults, hyperinflation using peak inspiration pressure is not recommended in neonates because of the potential to cause pneumothorax from excessive pressure due to the infant's poor alveolar compliance. Hyperventilation is commonly used in combination with hyperoxygenation in neonates, and the individual effect has not been documented.

Suctioning Practices and Experiences 

    Also supported from the reviews was the use of shallow ETS method (to insert the suction catheter only 1 cm beyond the ET tube) instead of deep ETS method (stopping suction catheter when it meets resistance, indicating that the catheter is touching the tracheal carina or tissue), since this caused less damage to the tracheal tissue (Wrightson, 1999). 

    The newest shallow ETS method, however, suggests advancing the suction catheter to the same length as the ET tube (Ahn & Hwang, 2003) and not beyond the ET tube to prevent trauma to the tracheal tissue.

Saline Insertion and Suctioning 

    Saline insertion before ETS was not supported by the reviews (Wrightson, 1999). Turning the infant's head sideways for ETS to reach the left lung was not supported either as it only increases the chances of trauma ting the airway with the increased risk of dislocating and removing the ET tube from the airway, without the benefits of removing airway secretions. 

    As the length of the trachea is only about 4 cm in neonates, 3 cm of the tube can be moved in and out of the trachea when the infant's head is turned sideways or extended; thus, turning the head sideways will only increase the risk of ET tube removal and lead to airway trauma from the deep suction method.

    Without any benefits of re moving the airway secretions (Turner & Loan, 2000), Chest physical therapy was not supported as it only stimulates afferent vagal nerves to produce aggravating bradycardia and hypoxia in infants without obvious benefit fits in removing airway secretions (Turner & Loan; Wrightson). 

    Three additional matters for ETS are suggested from Wrightson's reviews (1999). ETS should only be performed on an as needed basis by observing and assessing (including auscultation) the signs of secretion in the airway and in the ET tube. ETS procedures should not last longer than 1 minute, with no more than two consecutive ETS passes each time. 

    Also, the monitor readings including oxygen saturation should be examined to prevent hypoxia and to ensure the recovery from ETS procedure before next ETS.

Sedation and Music Therapy While Suctioning

    Other recent studies indicated that sedations and music therapy, involving the comforting management of infants with ETS, caused less aggravations and negative afferent vagal stimulation, and attenuated autonomic neural responses for hemodynamic changes in the infants (Burgess, Oh , Brann, Brubakk, & Stonestreet, 2001) and caused less desaturation (Chou, Wang, Chen, & Pai, 2003). 

    ETS catheters are now designed with multiple side holes to prevent abruptly increased suction pressure; Thus, the trauma to the trachea in neonates is less than using earlier catheters with fewer or a single side hole (Turner & Loan, 2000). 

    Future research could be designed for the following areas in neonates, including more advanced monitoring of tissue oxygenation to prevent hypoxia associated with ETS, comforting interventions in addition to preoxygenation with ETS to prevent detrimental hypoxia and cerebral effects, and ways to eliminate ETS trauma to the airway tissue such as the shallow ETS method.