Tracheal suctioning without disconnection in intubated, ventilated neonates

Sometimes newborn babies have trouble breathing and need mechanical help. Air can be supplied through a tube inserted into their nose, mouth or trachea (windpipe). There are some potential problems with the tube. Soft tissue can be damaged increasing secretion of fluids that can block the tube, raise blood pressure or cause damage and infections. Using suction to clear the tubes can be done either with or without disconnection from the ventilator. The review of trials found there was some evidence that suctioning without disconnection improves stability. These improvements were small so this can not be recommended as the only way to suction the babies. More research is needed.

Authors' conclusions: 

There is some evidence to suggest suctioning without disconnection from the ventilator improves the short term outcomes; however the evidence is not strong enough to recommend this practice as the only method of endotracheal suctioning. Future research utilising larger trials needs to address the implications of the different techniques on ventilator associated pneumonia, pulmonary morbidities and neurodevelopment. Infants less than 28 weeks also need to be included in the trials.

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Background: 

Assisted mechanical ventilation is a necessity in the neonatal population for a variety of respiratory and surgical conditions. However, there are a number of potential hazards associated with this life saving intervention. New suctioning techniques have been introduced into clinical practice which aim to prevent or reduce these untoward effects.

Objectives: 

To assess the effects of endotracheal suctioning without disconnection in intubated ventilated neonates.

Search strategy: 

The review has drawn on the search strategy for the Cochrane Neonatal Review Group. A comprehensive search of Cochrane databases, MEDLINE and CINAHL, and the Society for Pediatric Research abstracts was undertaken by the review authors (July 2011).

Selection criteria: 

All trials that utilised random or quasi-random patient allocation and in which suctioning with or without disconnection from the ventilator was compared.

Data collection and analysis: 

Standard methods of the Cochrane Neonatal Group were used. Each review author separately reviewed trials for eligibility and quality and extracted data; they then compared and resolved differences. Analysis was performed using the fixed-effect model and outcomes were reported using relative risk (RR) for categorical data and mean difference (MD) for outcomes measured on a continuous scale.

Main results: 

Four trials (252 infants) were included in this review. The trials employed a cross-over design in which suctioning with or without disconnection was compared. Suctioning without disconnection resulted in a reduction in episodes of hypoxia (typical RR 0.48, CI 95% 0.31 to 0.74; 3 studies; 241 participants). There were also fewer infants who experienced episodes where the transcutaneous partial pressure of oxygen (TcPO2) decreased by > 10% (typical RR 0.39, 95% CI 0.19 to 0.82; 1 study; 11 participants). Suctioning without disconnection resulted in a smaller percentage change in heart rate (weighted mean difference (WMD) 6.77, 95% CI 4.01 to 9.52; 4 studies; 239 participants) and a reduction in the number of infants experiencing a decrease in heart rate by > 10% (typical RR 0.61, CI 0.40 to 0.93; 3 studies; 52 participants).The number of infants having bradycardic episodes was also reduced during closed suctioning (typical RR 0.38, CI 95% 0.15 to 0.92; 3 studies; 241 participants).

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