The effects of the shallow and the deep endotracheal suctioning on oxygen saturation and heart rate in high-risk infants. Partially ventilated endotracheal suction. Use in newborns with respiratory distress syndrome. The efficacy of facilitated tucking for relieving procedural pain of endotracheal suctioning in very low birthweight infants. Comparison of the effect of closed versus open endotracheal suction systems on the development of ventilator-associated pneumonia. Need for endotracheal intubation and suction in meconium-stained neonates. Closed suctioning of intubated neonates maintains better physiologic stability: a randomized trial. Closed versus open endotracheal suctioning in preterm infants: effects on cerebral oxygenation and blood volume. An investigation into the benefits of resiting nasoenteric feeding tubes. Benefits of orotracheal and nasotracheal intubation in neonates requiring ventilatory assistance.
An experimental study involving repeated-measures within subjects was conducted to examine the effects of shallow and deep endotracheal suctioning (ETS) on the SpO(2) and HR in 27 ventilated high-risks infants. The order in which subjects received the ETS protocol was randomly assigned. The results showed no significant changes in both the SpO(2) and HR responses before, during and after ETS between the two ETS protocols. It is concluded that when there is no beneficial effect of performing deep ETS, it should not be carried out due to the potential hazard of direct irritation with more negative pressure on the airways in high-risk infants. Ventilator adapters that permit endotracheal suction without disconnection from mechanical ventilation may overcome several of the theoretical contributors to the hypoxia and bradycardia associated with neonatal endotracheal suction. Such an adapter allows for partially ventilated endotracheal suction (PVETS) as opposed to traditional, nonventilated endotracheal suction. To test the clinical value of PVETS using an endhole adapter, changes in transcutaneous partial pressure of oxygen and heart rate were compared during paired PVETS and nonventilated endotracheal suction events on 32 occasions in 11 premature neonates with respiratory distress syndrome. Partially ventilated endotracheal suction was associated with a significant decrease in the incidence and severity of hypoxic events. Partially ventilated endotracheal suction, however, did not affect the incidence of bradycardic events; PVETS had a small but statistically significant effect on reducing the severity of bradycardia. No clear relationship between bradycardic and hypoxic events was evident. This study compared the efficacy of a behavioral pain reducing intervention (facilitated tucking) with standard neonatal intensive care unit (NICU) care for decreasing procedural pain (endotracheal suctioning) in very low birthweight (VLBW) infants.
                A prospective randomized crossover design with infants as their own controls were used. The sample consisted of 40 VLBW infants, 23-32 weeks gestation, and weighing 560-1498 g with tracheal intubation. The infants were observed twice during each endotracheal suctioning experience; one suctioning was done according to normal nursery routine; another was done using facilitated tucking (the caregiver "hand-swaddling" the infant by placing a hand on the infant's head and feet while providing flexion and containment). The Premature Infant Pain Profile (PIPP) measured the infant's pain response, and severity of illness of each infant was measured by the Score for Neonatal Acute Physiology (SNAP) and the NTISS (Neonatal Therapeutic Intervention Scoring System). Repeated measures analysis of variance (RMANOVA) determined the efficacy of facilitated tucking for reducing procedural pain (PIPP) and the effects of order of intervention vs. control. Regression analyses examined the relationship of gestational age, severity of illness, and number of painful procedures to the pain response.
                There was a significant difference between the PIPP scores for tucking and nontucking positions (p = 0.001) and a nonsignificant interaction with order (p = 0.64) as well as a nonsignificant main effect for order (p = 0.46). In the regression analyses, all predictors taken together did not significantly predict PIPP scores in the tucked position (p = 0.11) or nontucked position (p = 0.57).
                Facilitated tucking is a developmentally sensitive, nonpharmacological comfort measure that can relieve procedural pain in VLBW infants. Nurses need to be increasingly aware of infant pain during daily care taking, and to use validated pain assessment instruments. Further clinical research on individual pain assessment is needed for better understanding of the quality and significance of pain for each infant, and the factors that affect pain expression. The aim of this study was to compare the effect of closed versus open endotracheal suction systems on the development of ventilator-associated pneumonia (VAP). A prospective, randomized, controlled trial was performed in a medical intensive care unit (MICU) of a university hospital in patients who received mechanical ventilation for more than 48 h. Patients were randomized to receive endotracheal suction with either closed catheters (closed suction group; N-41) or single-use catheters (open suction group; N=37). Cultures were taken from the ventilator tubing of 42 patients to determine the rate of colonization. There was no difference between the groups in terms of the frequency of development of VAP, mortality in the MICU, length of MICU stay and duration of mechanical ventilation. Thirteen patients in the open suction group and 16 patients in the closed suction group became colonized (P=0.14). The colonization rates by Acinetobacter spp. and Pseudomonas aeruginosa were more frequent in the closed suction group than in the open suction group (P<0.01 and P=0.04, respectively). In conclusion, closed endotracheal suction resulted in increased colonization rates of ventilator tubing with multi drug-resistant micro-organisms but did not increase the development of VAP and MICU outcome compared with open endotracheal suction. In a prospective study, we determined whether routine immediate tracheal aspiration at birth is necessary in meconium-stained but otherwise normal infants delivered vaginally and having a 1-minute Apgar score greater than 8. A total of 572 newborn infants who met these criteria were randomly allocated to one of two groups. All infants underwent oropharyngeal suctioning with a DeLee catheter while the head was still on the perineum. In group I (n = 308) suctioning of the trachea under direct vision was performed instantly at birth; in group II (n = 264) this procedure was not done. There was no mortality among infants in the study, but morbidity, mainly pulmonary and laryngeal disorders, occurred in six of 308 group I infants and in none of the group II infants (P less than 0.025). Immediate tracheal suction is not a harmless intervention, and should be considered superfluous in a vigorous term neonate born with meconium-stained amniotic fluid. To evaluate the physiological variance in a closed (CS) vs an open suction (OS) protocol in intubated infants.
                Infants were stratified into three weight groups in a randomized crossover trial. Heart rate, respiratory rate, blood pressure, oxygen saturation, transcutaneous oxygen and carbon dioxide, and end-tidal carbon dioxide were recorded prior to suctioning, during suctioning, and recovery to baseline. Following the procedures, recovery time to baseline parameters was measured. Data were analyzed using repeated measures ANOVA.
                Overall, there was significantly less deviation from baseline physiological parameters with CS. Infants <1000 g had clinically significant decreases in heart rate with the OS method (-18% OS vs -6% CS; p=0.016). Recovery time in the OS group was twice that of the CS cohort (4 vs 2 minutes; p<0.001).
                CS maintains better physiologic stability in intubated infants. The aim of our study was to compare, using near-infrared spectroscopy (NIRS), the effects on cerebral intracellular oxygenation and cerebral blood volume (CBV) of closed endotracheal suctioning (CS), which permits continuous ventilation of the patient, with open endotracheal suctioning (OS), which requires disconnection from the ventilator. Eleven preterm infants were studied. Each patient underwent one CS, followed, after 60 min, by one OS, or vice versa, three times during the same day. Modifications in CBV and oxidized cytochrome oxidase (CytO2) were continuously detected by NIRS; arterial oxygen saturation (SaO2) heart rate (HR), transcutaneous carbon dioxide tension and mean arterial blood pressure were simultaneously recorded. Significant reductions in HR and SaO2 were observed following OS; the magnitude and duration of these negative effects of suctioning were significantly reduced with CS. In addition, the decrease in CBV was more pronounced than following CS. No changes in CytO2 concentration were seen. Partial nasal obstruction in preterm infants increases the airway resistance. In spite of this, nasal feeding tubes are often used, if only because oral tubes are difficult to secure. A palatal appliance has been devised that maintains the position of oroenteric feeding tube(s) and is not associated with local complications. In order to assess the effects of resiting feeding tubes, two related studies were carried out. The first study, a trial, included respiratory monitoring of 29 infants on the third and/or seventh day after either the appliance and oroenteric tubes had been inserted, or, in the control group, after the nasoenteric tubes had been passed. After seven days, the infants using the palatal appliance had significantly less periodic breathing, central apnea, and movement than the control group. The second study showed that the removal of feeding tubes that had been in situ for several days reduced apnea rates and produced a significant increase in transcutaneous PO2. To investigate differences in orotracheal (OT) and nasotracheal (NT) intubation for ventilatory assistance, we randomly assigned 91 neonates to be intubated via either of the two routes: 46 infants were assigned to the OT group and 45 infants were assigned to the NT group. Inability to intubate the nostril in three neonates, and respiratory or cardiac instability during attempted NT intubation in three neonates, resulted in the assignment of 52 infants to the OT group and 39 infants to the NT group; patients in both groups were of comparable size, sex, and clinical problems. Initial malposition of the endotracheal tube and need to retape, reposition, or replace the tube during the mean duration of intubation of 247 +/- 42 hours for the OT group and 273 +/- 57 hours for the NT group were similar. Daily Gram stains of tracheal aspirates showed that inflammation (greater than or equal to ten polymorphonuclear cells per 400 power fields) was common (51% OT group, 53% NT group). Cultures grew potential pathogens in 37% of the patients from the OT group and 31% of the NT group. There was no difference in the clinical or radiologic incidence of pneumonia. Postextubation problems were comparable: atelectasis, 48% OT and 59% NT; stridor, 15% OT and 26% NT. OT intubation may be preferred for prolonged ventilatory assistance in neonates because of the relative ease of initial intubation.
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.