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Objective: To provide a comprehensive, evidence-based review routinely. There is no clear evidence for the superiority of closed-
of pediatric endotracheal suctioning: effects, indications, and or open-system suctioning, nor is there clear evidence for appro-
clinical practice. priate vacuum pressures and suction catheter size. Sterility does
Methods: PubMed, Cumulative Index of Nursing and Allied not seem to be necessary when suctioning. Preoxygenation has
Health Literature, and PEDro (Physiotherapy Evidence Database) short-term benefits, but the longer-term impact is unknown.
electronic databases were searched for English language articles, Routine saline instillation before suctioning should not be per-
published between 1962 and June 2007. Owing to the paucity of formed. Recruitment maneuvers performed after suctioning have
objective pediatric data, all reports dealing with this topic were not been shown to be useful as standard practice.
examined, including adult and neonatal studies. Conclusions: Endotracheal suctioning is a procedure used reg-
Results: One hundred eighteen references were included in the ularly in the pediatric intensive care unit. Despite this, good
final review. Despite the widespread use of endotracheal suction- evidence supporting its practice is limited. Further, controlled
ing, very little high-level evidence dealing with pediatric endotra- clinical studies are needed to develop evidence-based protocols
cheal suctioning exists. Studies of mechanically ventilated neo- for endotracheal suctioning of infants and children, and to exam-
natal, pediatric, and adult patients have shown that suctioning ine the impact of different suctioning techniques on the duration
causes a range of potentially serious complications. Current prac- of ventilatory support, incidence of nosocomial infection, and
tice guidelines are not based on evidence from controlled clinical length of pediatric intensive care unit and hospital stay. (Pediatr
trials. There is no clear evidence that endotracheal suctioning Crit Care Med 2008; 9:465– 477)
improves respiratory mechanics, with most studies pointing to the KEY WORDS: endotracheal suction; pediatric; mechanical venti-
detrimental effect it has on lung mechanics. Suctioning should be lation; suction catheter
performed when obstructive secretions are present rather than
I nfants and children with life- compromised and normal mucociliary mucus characteristics; nor do they seem to
threatening conditions frequently function is impaired (2). Inadequately consider the relationships between ETT
require admission to the pediatric humidified inspired gas and the presence and catheter size (length and diameter) and
intensive care unit (PICU), where of the endotracheal tube (ETT) may cause suction pressures; and the potential effects
they may be intubated and mechanically irritation of the airways and increased these may have on the pediatric lung. Sur-
ventilated. Globally, respiratory tract in- secretion production (3). In addition, veys conducted in clinical settings suggest
fections contribute significantly to mor- many children with respiratory tract in- that practice guidelines and protocols vary
bidity and mortality in the pediatric pop- fections have increased sputum volume widely and are not, in general, based on
ulation (1). and altered sputum rheology, which fur- sound evidence (12, 13).
Intubated patients are unable to clear ther impedes secretion clearance. There- This article presents a comprehensive
secretions effectively, as glottic closure is fore, all infants and children with an ar- review of the pediatric ET suctioning liter-
tificial airway require endotracheal (ET) ature, including precautions and contrain-
suctioning to remove secretions and pre- dications; effects (clinical and mechanical);
*See also p. 539. vent airway obstruction (4, 5). frequency of suctioning; open- and closed
From the Division of Paediatric Critical Care and ET suctioning is known to have many systems; preoxygenation; saline instilla-
Children’s Heart Disease (BMM, ACA), School of Child
complications. Despite this, the practice tion; catheter size selection; vacuum
and Adolescent Health, University of Cape Town, Cape pressure; sterility; duration of suction ap-
Town; and Director of Pediatric Intensive Care Unit of ET suctioning continues without ade-
(ACA), Red Cross War Memorial Children’s Hospital, quate evidence for the different tech- plication; depth of catheter insertion; and
Cape Town, South Africa. niques used (6). Although recommenda- postsuction recruitment maneuvers
Supported, in part, by the grants from the Medical
tions and clinical guidelines have been (RM). Clinical recommendations are
Research Council of South Africa (BMM) and the Health made on the basis of these results.
Sciences Faculty of the University of Cape Town. made regarding suction pressures, depth
The authors have not disclosed any potential con- of insertion of the suction catheter, and
flicts of interest. catheter size (5, 7–11) few of these have METHODS
For information regarding this article, E-mail:
been objectively shown to be appropriate Electronic literature searches for articles
brenda.morrow@uct.ac.za
Copyright © 2008 by the Society of Critical Care or safe. The available guidelines do not published between January 1962 and June
Medicine and the World Federation of Pediatric Inten- address any dimensions of the suction 2007 were conducted using PubMed, Cumu-
sive and Critical Care Societies catheters other than the cross sectional lative Index of Nursing and Allied Health
DOI: 10.1097/PCC.0b013e31818499cc diameter, and do not factor in variation in Literature and PEDro (Physiotherapy Evi-
Analgesia ET suctioning is a frequently performed procedure that causes pain and B. Extrapolated from neonatal
discomfort. As the procedure is often performed immediately after RCT (42).
secretions are detected, there may be insufficient time to administer
analgesia and allow it to take full effect. Therefore, it is recommended that
all ventilated patients receive regular or infused analgesia for the duration
of ventilation.
Frequency of Routine suctioning should be avoided (64, 137), with the possible exception of D. No experimental evidence.
suctioning paralyzed patients. Suctioning should be performed only when clinically
indicated (9).
Suctioning system Although there may be short-term benefits of closed-system suctioning in terms B. Extrapolated from adult
of reduced lung volume loss and hypoxia (51), there is no clear benefit for the (107–109) and neonatal (33,
use of closed- or open-system suctioning, and practitioners should continue 39) systematic reviews.
with the method at which they are proficient (33, 107–109).
Monitoring Considering the known complications of ET suctioning, the patient’s heart D. No experimental evidence.
rate, blood pressure, and oxygen saturation should be carefully monitored
at all times during the procedure. Clinical observations should include
patient color (to detect early cyanosis); signs of respiratory distress (such as
sweating, tachypnea, marked costal recessions); and signs of pain or
anxiety. Where possible, respiratory mechanics should be monitored to
detect lung volume changes.
Preoxygenation Considering the short-term effects of hyperoxygenation in reducing hypoxia B. One pediatric randomized
(34, 55), patients should receive increased inspired oxygen levels for a cross-over trial (55);
brief period (ⱕ60 secs) before suctioning (9, 55). The optimal level of recommendation extrapolated
preoxygenation is not known, but can be individually determined by the from neonatal (34) and adult
patient’s clinical condition and response to handling. The clinical context (111) systematic reviews, and
should be taken into consideration, as some pathological processes may neonatal randomized
make an individual more susceptible to the adverse effects of hypoxemia cross-over trials (32, 61).
(e.g., severe pulmonary hypertension).
Suction catheter Table 1 can be used as a guideline for suction catheter selection. Doubling D. In vitro studies (122) and
size the ETT internal diameter gives an indication of which FG catheter size to anecdotal evidence
use for efficacy and safety (e.g., with a 3.5-mm internal diameter ETT, a (7, 8, 11).
size 6 or 7 FG catheter could be used).
Vacuum pressure Medical and paramedical staff should use the lowest pressure that effectively D. In vitro studies (122) and
removes the secretions with the least adverse clinical reaction. Suction expert opinion (70, 74, 124).
pressures should be at least ⱕ360 mm Hg.
Sterility A strictly sterile technique is not necessary (53), but staff should adhere to A. Large RCT of infants and
strict infection control measures to protect themselves and other patients children (53).
(110, 126).
Duration of To limit the adverse effects of lengthy duration of suctioning and to minimize D. In vitro studies (122) and
suctioning airway trauma, the catheter should be inserted in the absence of vacuum expert opinion (9, 10, 11).
pressure, and suction only applied on catheter withdrawal. The application
of suction should be limited to ⱕ10 secs (9, 10, 11). Patients should be
reconnected to the ventilator, and given several recovery breaths before
repeating the suctioning procedure if secretions have not been adequately
cleared by the previous suctioning event.
Depth of catheter Considering that there are no known benefits to performing deep ET C. Extrapolated from
insertion suctioning, and there is an increased risk of direct trauma (36) and vagal randomized cross-over
nerve stimulation with deep rather than shallow suctioning (37), the studies in high-risk neonates
catheter should only be passed to the end of the ETT. The depth of (36, 37).
insertion can be determined by direct measurement.
Use of saline Saline should never be used routinely for suctioning. B. Pediatric RCT (52).
When to Suggested that suctioning be discontinued if there are no more secretions in D. No experimental evidence.
discontinue the large airways; if the child desaturates to ⱕ80% (assuming baseline SaO2
suctioning ⱖ90%); if the child experiences a cardiac arrhythmia or bradycardia; or if
the child becomes extremely agitated (respiratory signs of distress, anxiety,
or pain responses). Where possible, suctioning should be discontinued if the
child has acute pulmonary hemorrhage or pulmonary edema. At all times,
however, a patent airway must be ensured. In the event of hypoxia or
bradycardia, the appropriate pediatric life support measures should be
implemented.
Recruitment Recruitment maneuvers should not be performed routinely after endotracheal B. Pediatric RCT (48).
maneuvers suctioning (48).
ET, endotracheal; ETT, endotracheal tube; FG, French gauge; RCT, randomized controlled trials.