• This guideline:
  
  • relates only to a closed suction catheter system in ventilated babies, which is non-aerosol generating
  • describes a standard safe approach, but it may be necessary for an adapted method to be employed (see If ETT clearance proves difficult with standard approach)
• Goal of ETT suctioning should be to maximise the amount of secretions removed with minimal adverse effects 
• Should not be a routine procedure, but in response to indications

• To maintain airway patency 
• To remove respiratory secretions or aspirated fluid from within the ETT 
• To optimise oxygenation and ventilation in an intubated baby 
• To obtain secretions for culture analysis

• In line/closed circuit catheter  
  
  • catheter size <0.5 diameter of ETT
• PPE as per local guidelines for non-aerosol generating procedures
• Sodium chloride 0.9%
• 1 mL syringe

• Do not attempt to carry out this procedure unless trained in the use of endotracheal closed suction catheter system

Preparation

• Wash hands and put on PPE

• Auscultate chest before suctioning

• Ensure full monitoring of heart rate and SpO₂ in place 

• Ensure baby is adequately oxygenated; consider increasing FiO₂ by up to 0.1 before procedure, e.g. if baby receiving FiO₂ of 0.3 (or 30% oxygen), increase oxygen delivery to up to FiO₂ 0.4 (or 40% oxygen)

  • if possible, use dedicated suction procedure (e.g. special procedures on Draegar VN500) which automatically enriches oxygen during suction 

• Ensure baby positioned appropriately for secretion clearance and stress reduction 

• Ensure closed suction device is unlocked

• Check suction pressure – maximum 13 kPa. Use lowest pressure that effectively clears secretions

• Check ETT placement by confirming measurement at the lips is as documented

Measuring catheter advancement

Method 1 (compatible with Halyard Health brand of closed suction catheters)

• Note the printed number on the cut ETT
• Add 5 cm to this to give the total distance of suction catheter advancement
• Stabilise the Y adaptor with one hand and advance catheter until calculated length is visible in irrigation port window.
• Catheter tip will be within 0.5–1 cm of the end of the ETT
• Note the nearest coloured band to the irrigation port window. Coloured bands allow for easy visualisation on subsequent suction procedures

Method 2

• Stabilise the Y adaptor with one hand
• Advance catheter until printed depth numbers on catheter align with the same numbers printed on the ETT
• Catheter tip will be within 0.5–1 cm of the end of the ETT

Performing suctioning

• Ensure suction catheter correctly advanced using either methods 1 or 2 (above)
• Depress thumb control valve and hold while withdrawing catheter slowly
• When tip of suction catheter reaches dome, release thumb control valve and stop withdrawing
• Procedure should take ≤10 sec and the duration of negative pressure should be ≤5 sec
• Repeat procedure if necessary
• Do not use sodium chloride 0.9% instillation routinely. Sodium chloride 0.9% ≤0.5 mL may be instilled before suctioning if secretions are thick and tenacious and cannot be extracted by suctioning alone
• After each suctioning episode ensure the closed circuit is flushed with sodium chloride 0.9% according to manufacturer’s instructions 

If ETT clearance proves difficult with standard approach

• Advancement of the catheter to 0.5 cm below the ETT tip may be effective 
• An experienced clinician should determine if this is appropriate
• See https://vimeo.com/428618217/9cc5803f88 for demonstration of this technique

• Record procedure in nursing documentation, noting distance tube was passed and colour of band on catheter tube closest to this measured distance

Equipment

• Leave thumb valve in locked position when not in use to prevent inadvertent activation
• Leave catheter tip in dome between use 
• Device is single use only and replace every 24 hr as per manufacturer’s guidance

Monitoring

• Ensure monitoring of heart rate and SpO₂ continues after procedure

• Auscultate baby’s chest after procedure and document any changes observed

• If FiO₂ was adjusted before procedure, return to original settings, or ensure baby’s target FiO₂ is maintained

Reporting adverse events

• Report adverse incidents using local risk management procedure

• Hypoxaemia

• Atelectasis

• Bradycardia

• Tachycardia

• Blood pressure fluctuations

• Decreased tidal volume

• Airway mucosal trauma

• Dislodgement of ETT

• Extubation

• Pneumothorax

• Pneumomediastinum

• Bacteraemia

• Pneumonia

• Fluctuations in intracranial pressure and cerebral blood flow velocity

• Further details on ETT closed suction can be found in the manufacturer’s guidance