Deep versus shallow suction of endotracheal tubes in ventilated neonates and young infants

Deep versus shallow suction of endotracheal tubes in ventilated neonates and young infants

BACKGROUND

Mechanical ventilation is commonly used in Neonatal Intensive Care Units to assist breathing in a variety of conditions. Mechanical ventilation is achieved through the placement of an endotracheal tube (ETT) which is left in-situ. The ETT is suctioned to prevent a build-up of secretions and blockage of the airway. Methods of suctioning the endotracheal tube vary according to institutional practice and the individual clinician performing the task. The depth of suctioning is one of these variables. The catheter may be passed to the tip of the ETT or beyond the tip into the trachea or bronchi to facilitate removal of secretions. However, trauma to the lower airways may result from the suction catheter being passed into the airway beyond the tip of the endotracheal tube.

OBJECTIVES

To compare the effectiveness and complications of deep (catheter passed beyond the tip of the ETT) versus shallow (catheter passed to length of ETT only) suctioning of the endotracheal tube in ventilated infants.

SEARCH STRATEGY

In this first update the searches were expanded to the Cochrane Central Register of Controlled Trials (The Cochrane Library, March 30), MEDLINE (from January 1966 to May 30 2011), CINAHL (from 1982 to May 30 2011) and EMBASE (1980 to May 2011) using text words and subject headings relevant to endotracheal suctioning. There were no language restrictions.

SELECTION CRITERIA

Controlled trials using random or quasi-random allocation of neonates receiving ventilatory support via an endotracheal tube to either deep or shallow endotracheal suctioning.

DATA COLLECTION AND ANALYSIS

The updated search resulted in 149 potentially relevant references. Two of the studies from this search were identified as potentially relevant. We included one of the potentially relevant studies and the other was excluded because it did not fit the inclusion criteria.

MAIN RESULTS

One small crossover trial (n = 27) of shallow versus deep suctioning met the criteria for inclusion in this review. The reported outcomes were oxygen saturation and heart rate, during and after suctioning. There were no significant differences when shallow and deep suctioning methods were compared.

AUTHORS' CONCLUSIONS

There is no evidence from randomised controlled trials concerning the benefits or risks of deep versus shallow suctioning of endotracheal tubes in ventilated neonates and infants. Further high quality research is required.

Evidence-based guideline for suctioning the intubated neonate and infant

The endotracheal tube (ETT) is the most common artificial airway used in NICUs. Suctioning of the ETT is imperative to maintain patency and prevent complications. An extensive review of the literature revealed a lack of standardized criteria or guidelines for suctioning the ETT of neonates and infants in the NICU. The purpose of this article is to report the implementation of an evidence-based guideline that can be utilized in NICU care.

The management of endotracheal tubes and nasal cannulae: the role of nurses

The management of endotracheal tubes and nasal cannulae covers a large part of work time of nurses involved in the care of very preterm infants. These procedures, although continuously performed, have not yet been scientifically demonstrated. In fact, there is limited evidence regarding several points such as the frequency of endotracheal suctioning, the level of suction pressure, the duration of suctioning, the depth of catheter insertion, the sterility, and the use of normal saline during endotracheal suction. With regard to the nasal cannulae, there is a more recent use of this device consisting in delivering end-expiratory pressure or gas flow to reduce the frequency of apneas and desaturations in preterm infants or for the management of RDS. This approach is defined high-flow nasal cannulae (HFNC). In this article, we review the literature on the airway management of intubated patients as well as of infants managed with nasal-CPAP or nasal cannulae. Potential fields of research on this topic are suggested.

Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support

BACKGROUND

Chest physiotherapy (CPT) has been used in many neonatal nurseries around the world to improve airway clearance and treat lung collapse; however, the evidence to support its use has been conflicting. Despite the large number of studies there is very little evidence of sufficiently good quality on which to base current practice.

OBJECTIVES

To assess the effects of active CPT techniques, such as percussion and vibration followed by suction compared with suction alone, on the respiratory system in infants receiving mechanical ventilation. Additionally, differences between types of active CPT techniques were assessed.

SEARCH STRATEGY

Our search included The Cochrane Library (Issue 2, 2007), MEDLINE (1966 to 2007), EMBASE (1988 to 2007), CINAHL, Science Citation Index, previous reviews including cross-references, abstracts, conference proceedings and grey literature.

SELECTION CRITERIA

Trials in which ventilated newborn infants up to four weeks of age were randomly or quasi-randomly assigned to receive active CPT or suction alone. Infants receiving CPT for the extubation period were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted quality assessments and data extraction for included trials. We analysed data for individual trial results using relative risk (RR) and mean difference (MD). Results are presented with 95% confidence intervals (CI). Due to insufficient data, we could not undertake meta-analysis.

MAIN RESULTS

Three trials involving 106 infants were included in this review. In one trial (n = 20) CPT was no better than standard care in clearing secretions. No increase in the risk of intraventricular haemorrhage was noted. Two trials compared different types of active CPT. One trial (n = 56) showed that non-resolved atelectasis was reduced in more neonates receiving the lung squeezing technique (LST) when compared to postural drainage, percussion and vibration (PDPV) (RR 0.25; 95% CI 0.11 to 0.57). No difference in secretion clearance or in the rate of intraventricular haemorrhage or periventricular leucomalacia was demonstrated. The other trial (n = 30) showed that the use of percussion or 'cupping' resulted in an increased incidence of hypoxaemia (RR 0.53; 95% CI 0.28 to 0.99) and increased oxygen requirements (MD -9.68; 95% CI -14.16 to -5.20) when compared with contact heel percussion. There was insufficient information to adequately assess important short and longer-term outcomes, including adverse effects.

AUTHORS' CONCLUSIONS

The results of this review do not provide sufficient evidence on which to base clinical practice. There is a need for larger randomised controlled trials to address these issues.