Closed Suction System

Overview 

A closed suction system for neonates is a specialized device used in mechanical ventilation to clear airway secretions while minimizing the risk of infection and maintaining ventilation. This system is particularly beneficial in neonatal intensive care units (NICUs), as it allows suctioning to be performed without disconnecting the infant from the ventilator. The system typically consists of a catheter enclosed in a protective sheath, reducing exposure to environmental contaminants. It helps maintain stable oxygenation levels, decreases the likelihood of alveolar collapse, and reduces the spread of pathogens compared to open suction systems.  

1. Purpose of Suctioning: 

Removal of Obstructive Material: 

• Suctioning plays a crucial role in removing secretions, meconium, or any other material that may obstruct the endotracheal tube (ETT) or airways of intubated neonates. 

• Obstruction can compromise the delivery of oxygen and ventilation, leading to respiratory distress. 

Prevention of Complications: 

• Effective suctioning helps prevent complications such as atelectasis, a condition where a part of the lung collapses due to mucus blockage, leading to decreased lung function. 

• Timely removal of secretions supports optimal respiratory function and reduces the risk of infections. 

2. Indications for Suctioning: 

Suctioning is warranted when healthcare providers observe visible or audible signs such as: 

• Agitation and restlessness 

• Apnea 

• Changes in blood gas values 

• Decreased breath sounds 

• Color changes (pale, dusky, or cyanotic) 

• Decreased chest wiggle for neonatal patients on high-frequency ventilators 

• Increasing oxygen requirements 

• Pattern change in ventilator graphics 

• Tachycardia 

• Immediate suctioning may be necessary in cases of meconium aspiration or excessive secretions. 

• Coarse breath sounds. 

• Increased peak inspiratory pressures. 

3. Types of Suction Catheters: 

Soft and Flexible Catheters: 

• Neonatal airways are delicate, and the use of soft, flexible catheters is essential to minimize trauma during suctioning. 

• Proper sizing of the suction catheter ensures effective removal of secretions without causing damage to the airway mucosa. 

4. Pressure Recommendations: 

Optimal Suction Pressure: 

• The recommended suction pressure for neonates typically falls within the range of -60 to -80 mmHg. Suctioning should be completed according to your hospital's policies and procedures manual. 

• High suction pressures can cause mucosal damage, bleeding, and potential complications. Adhering to pressure guidelines is critical for safe and effective suctioning. 

Prevention of Complications: 

• Maintaining appropriate suction pressure helps prevent complications such as barotrauma, where excessive pressure can lead to lung injury. 

5. Frequency of Suctioning: 

Individualized Approach: 

• The frequency of suctioning should be individualized based on clinical assessment. Suctioning is to be done as needed. 

• Routine, scheduled suctioning without clear indications may lead to unnecessary trauma and should be avoided. Only suction when indicated.

Clinical Assessment: 

• Healthcare providers assess the need for suctioning based on the patient's condition, vital signs, presence of secretions, and signs of airway obstruction. 

6. Technique: 

Preparation:  

• Ensure that an appropriate-size bag and mask are connected to an oxygen source at the bedside. 

• Ensure that the oxygen source has the capability of being blended to provide a sufficient variety of oxygen concentrations to meet the patient’s needs. 

• Confirm that the inline catheter is the appropriate size or, if placing a new one, choose the proper catheter size.  

• Select a recommended suction catheter size:  

• 5 Fr or 6 Fr for 2.5 mm ET tube 

• 6 Fr or 8 Fr for 3.0 mm ET tube 

• 8 Fr for 3.5 mm ET tube 

• 8 Fr for 4.0 mm ET tube 

• Alternatively, calculate the proper size suction catheter by determining the catheter size occludes no more than 50% of the internal diameter of the tracheostomy tube. (e.g., 3.0 mm tracheostomy tube × 2 = 6 Fr suction catheter)  

• Rationale: This allows air to continue to enter the lungs during suctioning and limits mucosal trauma. 

Aseptic Technique: 

• Adherence to aseptic technique during suctioning minimizes the risk of introducing infections into the neonatal airways. 

• Proper hand hygiene, use of gloves, and maintaining a sterile field are essential components of the technique. 

• Use of closed suction system will help minimize infections and loss of FRC. 

Duration and Preoxygenation: 

• Limiting the duration of suctioning helps prevent hypoxia. Prolonged suctioning may lead to oxygen desaturation, especially in neonates with compromised respiratory function. Suctioning should be limited to 5 to 10 seconds each pass to avoid desaturation and bradycardia. 

• Preoxygenating the neonate before suctioning optimizes oxygen levels and minimizes the risk of hypoxia. 

7. Monitoring: 

Continuous Vital Sign Monitoring: 

• Continuous monitoring of vital signs, including heart rate, respiratory rate, and oxygen saturation, is imperative during and after suctioning. 

• Prompt identification of adverse effects allows for immediate intervention and prevents complications. 

Documentation: 

• Thorough documentation of the suctioning procedure is essential. This includes recording the characteristics of secretions, the frequency of suctioning, and the neonate's response to the intervention. 

8. Complications and Considerations: 

Vigilance for Complications: 

• Healthcare providers must remain vigilant for potential complications, such as desaturation, bradycardia, and mucosal trauma. 

• Immediate action is necessary if adverse effects are observed during or after suctioning. 

Saline Instillation: 

• Consideration of saline instillation before suctioning may be beneficial

  in thinning secretions, making the suctioning process more effective. 

• However, the decision to use saline should be based on individual patient

  needs and clinical judgment. Saline installation should not be routinely

  used and only done if indicated.

9. Sizing:  

• Each manufacturer has sizing recommendation on the outside of each package but here are some guidelines: 

• 5 Fr or 6 Fr for 2.5 mm ET tube 

• 6 Fr or 8 Fr for 3.0 mm ET tube 

• 8 Fr for 3.5 mm ET tube 

• 8 Fr for 4.0 mm ET tube