Suctioning of Newborn Neonates

Clinical question: Does routine oropharyngeal/nasopharyngeal suctioning of newborn infants'

airways compared to no suction have an effect on mortality and morbidity with and without
meconium‐stained amniotic fluid?

Background

The birth of a baby is one of life's most wondrous moments. Few experiences compare to this
event. Newborn babies have amazing abilities. Yet they are dependent on others for feeding,
warmth, and comfort. The transition from fetus to newborn involves the clearing of lung fluid
and expansion of the lungs with air. While airway oro/nasopharyngeal suctioning can be
successful in clearing the airway immediately after birth.

Respiratory diseases are the chief reason for admission of premature neonates to
NICUs. Maintenance of breathing and patency of airway is the main objective in premature
infant care. Due to low consciousness level of neonates and weakness of their respiratory
muscles, efficient removal of secretion could not happen by coughing. Therefore, intubated
patients need to be suctioned, to prevent airway obstruction, atelectasis and pulmonary
infections.

Oro/nasopharyngeal suction is a method used to clear secretions from the oropharynx

or nasopharynx, or both, through the application of negative pressure via a suction cathete or
bulb syringe (Waltman 2004). Negative pressure is used to clear secretions from the mouth,
nose or pharynx while attempting to avoid trauma to the mucosa. If oro/nasopharyngeal
suction of term infants is required, the Australian Resuscitation Council recommends using a
large bore suction catheter (10 to 12 F), passed no more than 5 cm from the lips, with suction
applied for only a few seconds (ARC 2010). The negative pressure used to remove secretions
should not exceed 100 mmHg (13 kPa, 133 cmH2O, 1.9 pounds per square inch (psi)) (ARC
2010). Oro/nasopharyngeal suction can be performed before the delivery of the infant's
shoulders (intrapartum) (Vain 2004) or following vaginal birth (Gungor 2005) or caesarean
section (postpartum) of the infant (Gungor 2006). Traditionally, oro/nasopharyngeal suctioning
at birth has been used routinely to remove fluids in vigorous infants at birth.

Endotracheal suctioning in intubated newborns undergoing Mechanical Ventilation is a

procedure that is routinely performed by physiotherapists, doctors, nurses, and also by nursing
technicians in Brazil as a component of the resuscitation procedure and bronchial hygiene
therapy. The goal is to maintain airway patency and facilitate ventilation and oxygenation.
However, this technique has specific indications and adverse effects. Proper standardization,
clear indications for use and definitions of the procedure all serve to minimize complications.
Endotracheal suctioning is an important element of care for newborns admitted to the NICU
because most of these patients require invasive MV and repeated and frequent suctioning for
the removal of tracheal secretions. According to the American Association of Respiratory Care
(AARC), proper suctioning in intubated individuals improves gas exchange and respiratory
sounds; decreases airway resistance and peak inspiratory pressure of the ventilator; improves
dynamic compliance; increases the TV release when in limited pressure ventilation mode; and
improves arterial blood gas and oxygen saturation (SpO2) values. However, many institutions
attempt to maintain airway patency in intubated individuals by adopting protocols that include
the routine use of endotracheal suctioning without evaluating whether the procedure is
necessary. These protocols are primarily based on the care ritual than on evidence of the
clinical need for suctioning.

All of the studies included in this review described the technique as mandatory that it should be
performed whenever necessary because the accumulation of tracheobronchial secretions may
impair ventilation and oxygenation; lead to ETT occlusion, atelectasis and increased respiratory
work; and predispose the individual to pulmonary infection. However, one of the most
controversial issues regarding endotracheal suctioning in neonates is the precise time and
frequency at which the technique should be performed on intubated individuals.

According to the AARC and Evidence-based guideline for suctioning the intubated neonate and
infant, the procedure is safer when certain variables are monitored before, during and after it is
performed. Moreover, the Center for Disease Control and Prevention standards for invasive
procedures must be respected during the procedure, the procedure must be conducted by at
least two professionals, a maximum of three probe insertions should be performed, with a
return to the ventilator between suctionings.