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

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Authors

Donna Gillies1, Kaye Spence2

Background - Methods - Results - Characteristics of Included Studies - References - Data Tables & Graphs


1Sydney West Area Mental Health Service, Parramatta, Australia [top]
2Grace Centre for Newborn Care, The Children's Hospital at Westmead, Westmead, Australia [top]

Citation example: Gillies D, Spence K. Deep versus shallow suction of endotracheal tubes in ventilated neonates and young infants. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD003309. DOI: 10.1002/14651858.CD003309.pub2.

Contact person

Donna Gillies

Sydney West Area Mental Health Service
Cumberland Hospital
Locked Bag 7118
Parramatta
NSW
2150
Australia

E-mail: Donna_Gillies@wsahs.nsw.gov.au

Dates

Assessed as Up-to-date: 30 May 2011
Date of Search: 30 May 2011
Next Stage Expected: 01 June 2013
Protocol First Published: Issue 3, 2002
Review First Published: Issue 3, 2003
Last Citation Issue: Issue 7, 2011

What's new

Date / Event Description
30 May 2011
New citation: conclusions changed

Updated search identified two studies.
One study was included and one study was excluded.
The previous version of this review had no included studies.

03 June 2010
Updated

This review updates the existing review of "Deep versus shallow suction of endotracheal tubes in ventilated neonates and young infants" published in the Cochrane Database of Systematic Reviews (Spence 2003).

History

Date / Event Description
04 March 2003
New citation: conclusions changed

Substantive amendment

Abstract

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 methods

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.

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.

Plain language summary

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

There is no evidence from trials about the optimum depth for catheter insertion when suctioning clear the endotracheal tube in babies in neonatal intensive care. Babies in neonatal intensive care often need mechanical ventilation to assist breathing. This involves inserting an endotracheal tube (ETT) down the baby's windpipe so that a machine ventilator can help the baby breathe. Lung secretions can build up in the tube and cause blockages. Build-up is minimized by suctioning the ETT clear with a catheter (small tube). One of the variations of technique possible for suctioning is depth of catheter insertion into the ETT. However, the review found no trials to show what depth of insertion of catheter into the endotracheal tube gains optimal clearance without damaging the baby's lungs.

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Background

Description of the condition

Mechanical ventilation is commonly used to assist breathing in a variety of conditions in the Neonatal Intensive Care Unit. Mechanical ventilation is achieved through the placement of an endotracheal tube that is left in-situ. There are a number of potential problems associated with this intervention. Tube blockage, discomfort, hypoxaemia, hypercapnia and lobar collapse are all possible complications associated with endotracheal tubes.

The presence of the endotracheal tube causes soft tissue irritation and increased secretions due to suppression of normal ciliary action. In addition, the infant is unable to cough (Sturges 1979), which reduces the ability to clear secretions. The aim of endotracheal suctioning is to reduce the problems resulting from a build-up of secretions and, therefore, possible tube obstruction. Documented complications associated with endotracheal suctioning include hypoxaemia, bradycardia, tachycardia, atelectasis, pneumonia, fluctuations in blood pressure and intracranial pressure, localised trauma to the airway, sepsis, tube blockage, and tube dislodgement (Boothroyd 1996; Simbruner 1981; Gunderson 1986; Brodsky 1987; Durand 1989; Shorten 1991).

Protocols for maintaining patency of the endotracheal tube vary widely among institutions and are not, in general, based on sound evidence (Tolles 1990; Copnell 1995). Potentially harmful suctioning techniques such as frequent and deep suctioning, head turning, and multiple catheter passes have been questioned (Wrightson 1999). However, much of the practice of suctioning endotracheal tubes appears to be based on ritual rather than a physiological rationale or reliable evidence. Endotracheal tube suctioning remains a routine practice in the neonatal intensive care unit (Cameron 2000) with different practices across NICU's. Therefore, it is important that methods of suctioning the endotracheal tube that minimise complications are identified and implemented into practice.

There have been many protocols and guidelines published to assist caregivers in determining the most appropriate method for suctioning endotracheal tubes in neonates (Hodge 1991; Runton 1992; Knox, 1993; Young 1995; Wrightson 1999; Pollard 2001; AARC 2010). However, surveys from practice indicate that protocols vary widely and are not, in general, based on sound evidence (Tolles 1990; Copnell 1995).

Description of the intervention

The traditional method of deep suctioning appears to have been based on the concern that shallow suctioning would result in inadequate removal of secretions and subsequent tube blockage has increased the practice of deep suctioning (Bailey 1988). Although some research had shown that deep suction into the bronchial tree increases the mucous obtained on suction (Bailey 1988), others have reported that the removal of secretions using a dry shallow technique was adequate for obtaining samples of mucous (Darlow 1997). Trauma to the lower airways may result from deep suctioning due to the suction catheter being passed into the airway beyond the tip of the endotracheal tube (Miller 1981; Brodsky 1987; Bailey 1988) and from repeated insult from suction catheters (Grylack 1984). In addition, deep suctioning has been associated with lobar collapse (Boothroyd 1996) and pneumothorax (Jaw 1991) in paediatric patients. Because of this potential for airway damage, several authors have recommended that shallow suctioning should be used (Bailey 1988; Runton 1992; Harling 2000), but deep suctioning is still commonly used in the care of neonates and young infants (Bailey 1988) and there remains little evidence for the relative benefits and risks of the two types of suctioning (Morrow 2008; Gardner 2009).

Why it is important to do this review

This review was undertaken to identify evidence from randomised controlled trials concerning the benefits or risks of deep versus shallow suctioning of endotracheal tubes in ventilated neonates and infants.

Objectives

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

Subgroup analyses were planned on the basis of endotracheal tube size (with five subgroups ranging from 2 mm to 4 mm) and the duration of tube placement (with two subgroups, less than or equal to 48 hours or greater than 48 hours).

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Methods

Criteria for considering studies for this review

Types of studies

Controlled trials using random or quasi-random allocation of patients to either deep or shallow endotracheal suctioning. Crossover trials were included.

Types of participants

Neonates receiving ventilatory support via an endotracheal tube.

Types of interventions

Deep suction: catheter is passed into the endotracheal tube until a cough or gag reflex is obtained or resistance is met.

Shallow suction: catheter is passed into the endotracheal tube so that the catheter does not extend beyond the length of the tube, but is passed to the tip of the tube.

Types of outcome measures

Primary outcomes
  1. Tube removal (for suspected or actual blockage of the endotracheal tube).
  2. Volume and consistency of secretions removed during suctioning procedure (mucous plugs, tenacious, minimal, copious, thin).
  3. Tracheal or bronchial damage (ulceration, inflammation and/or ciliary damage).
Secondary outcomes
  1. Level of oxygenation, absolute or percentage change after suctioning (measured by transcutaneous oxygenation, saturation or arterial blood gas).
  2. Heart rate, absolute or percentage change after suctioning (measured on a cardio-respiratory monitor).
  3. Atelectasis (lung collapse on chest x-ray).
  4. Air leak (pneumothorax on chest x-ray).

Search methods for identification of studies

The searches were updated to cover the Cochrane Register of Controlled Trials (March 30 2010), 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 for endotracheal suctioning and limiting the search to neonates. Reference lists of identified reviews and studies were also checked. There were no language restrictions.

Clinical trials registries were also searched for ongoing or recently completed trials (ClinicalTrials.gov, Controlled-Trials.com External Web Site Policy, and WHO International Clinical Trials Registry Platform (ICTRP) External Web Site Policy).

Data collection and analysis

The current standard methods of the Cochrane Neonatal Review Group Guidelines were employed in creating this update.

Selection of studies

The two review authors worked independently to search for and assess trials for inclusion. Any disagreements were resolved by consensus.

Data extraction and management

The two review authors worked independently to extract data and assess methodological quality and potential biases. Any disagreements were resolved by consensus.

Assessment of risk of bias in included studies

The standard methods of the Cochrane Neonatal Review Group were employed.

The reviewers independently assessed risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of interventions (Higgins 2011). Disagreements were resolved by discussion.

We completed the Risk of Bias table addressing the following methodological issues:

  1. Sequence generation: Was the allocation sequence adequately generated? For each included study we described the method used to generate the allocation sequence.We assessed the methods as:
    • low risk (any truly random process, e.g. random number table; computer random number generator);
    • high risk (any non-random process, e.g. odd or even date of birth; hospital or clinic record number);
    • unclear risk.
  2. Allocation concealment: Was allocation adequately concealed?For each included study, we described the method used to conceal the allocation sequence and determined whether intervention allocation could have been foreseen in advance of, or during recruitment, of changed after assignment. We assessed the methods as:
    • low risk (e.g. telephone or central randomisation; consecutively numbered sealed opaque envelopes);
    • high risk (open random allocation; unsealed or non-opaque envelopes, alternation; date of birth);
    • unclear risk.
  3. Blinding of participants, personnel and outcome assessors: Was knowledge of the allocated intervention adequately prevented during the study? We assessed the methods as:
    • low risk;
    • high risk;
    • unclear risk.
  4. Incomplete outcome data: Were incomplete outcome data adequately addressed?For each included study and for each outcome, we described the completeness of data including attrition and exclusions from the analysis. We stated whether attrition and exclusions were reported, the numbers included in the analysis at each stage (compared with the total randomised participants), reasons for attrition or exclusion where reported, and whether missing data were balanced across groups or were related to outcomes. We assessed the methods as:
    • low risk;
    • high risk;
    • unclear risk.
  5. Selective outcome reporting: Are reports of the study free of suggestion of selective outcome reporting?For each included study we described how we examined the possibility of selective outcome reporting bias and what we found. We assessed the methods as:
    • low risk (where it is clear that all of the study's pre-specified outcomes and all expected outcomes of interest to the review have been reported);
    • high risk (where not all the study's pre-specified outcomes have been reported; one or more reported primary outcomes were not pre-specified; outcomes of interest are reported incompletely and so cannot be used; study fails to include results of a key outcome that would have been expected to have been reported);
    • unclear risk.
  6. Other sources of bias: Was the study apparently free of other problems that could put it at a high risk of bias?For each included study, we described any important concerns regarding other possible sources of bias. We assessed whether each study was free of other problems that could put it at risk of bias:
    • low risk;
    • high risk;
    • unclear risk.

Measures of treatment effect

To measure the effect of the different methods of suctioning the relative risk (RR) and 95% confidence intervals (CI) were to be calculated for bivariate outcomes. The weighted mean difference (WMD) and its 95% CI was to be calculated for continuous outcomes. In the case of crossover trials, data from both periods were to be used for analysis if possible. The fixed effect model was to be used in the meta-analysis if there was no heterogeneity among studies. Subgroup analyses were to be performed as proposed if data permitted.

Assessment of heterogeneity

We planned to estimate the treatment effects of individual trials and examine heterogeneity between trials by inspecting the forest plots and quantifying the impact of heterogeneity using the I-squared statistic. If we detected statistical heterogeneity, we planned to explore the possible causes (for example, differences in study quality, participants, intervention regimens, or outcome assessments) using post hoc subgroup analyses.

Data synthesis

To measure the effect of the different methods of suctioning the relative risk (RR) and 95% confidence intervals (CI) were to be calculated for bivariate outcomes. The weighted mean difference (WMD) and its 95% CI was to be calculated for continuous outcomes. However, as there was only one included study which reported continuous outcomes, only mean differences could be calculated.

In the case of crossover trials, data from both periods were to be used for analysis if possible. Data from the one included study were reported as means and SDs for the two groups prior to, during, and after suctioning. Because data were available for two suctioning periods these data were pooled. Individual or paired analysis data were not reported and because this was the only identified study it was not possible to impute a correlation coefficient. Therefore, data from this study is presented as parallel group data. Because of this, the standard deviation of each group is probably an underestimate and it is, therefore, less likely that any differences between groups would be significant. However, the authors of this study did report using a repeated measures analysis and did not find any significant difference between groups.

The fixed effect model was to be used in the meta-analysis if there was no heterogeneity among studies. As there was only one identified study a fixed effect model was, therefore, used.

Subgroup analysis and investigation of heterogeneity

Subgroup analyses were planned on the basis of endotracheal tube size (with five subgroups ranging from 2 mm to 4 mm) and the duration of tube placement (with two subgroups, less than or equal to 48 hours or greater than 48 hours) if data permitted.

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Results

Description of studies

The original review search strategy had resulted in 85 references. However, none of these were identified as potentially relevant. A further 149 references were identified in the updated search, of which two were potentially relevant. One small crossover trial of 27 neonates (Youngmee 2003) 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. The other identified paper was a duplicate publication of Youngmee 2003.

The reported outcomes were oxygen saturation and heart rate, at baseline, at two hyperoxygenation/hyperventilation intervals prior to suctioning and for one interval after the first and second suction, during the first and second suction and following the second suction. Each infant received shallow and deep suctioning during the two suctioning phases. The order in which they received deep and shallow suctioning was randomised.There were no significant differences when shallow and deep suctioning methods were compared.

Data was reported for all 27 infants for shallow and deep suctioning at each phase. Therefore, first interval data was not available. The data for the outcomes of oxygen saturation (%) and heart rate during suctioning and post protocol were collected for this review.

Risk of bias in included studies

There was no apparent risk of bias in the one study included in this review.

Effects of interventions

SHALLOW VS. DEEP SUCTIONING (COMPARISON 1):

Oxygen Saturation (Outcome 1.1) and Heart Rate (Outcome 1.2):

There were no significant differences in oxygen saturation or heart rate during (oxygen saturation: MD -3.72 95% CI -10.95 to 3.51; heart rate: MD 3.68 95% CI -8.34 to 15.70) or after suctioning (oxygen saturation: MD -0.20 95% CI -4.47 to 4.37: heart rate: MD 1.67 95% CI -10.17 to 13.51) when neonates receiving deep suction were compared to those receiving shallow suction.

Discussion

As there only one small randomised controlled trial identified in this systematic review it is not possible to determine whether deep or shallow suctioning of the endotracheal tube is more effective or causes less harm for ventilated neonates and infants.

Research describing the potential negative effects of deep suctioning has been reported dating back to the 1960s (Thambiran 1966). Insertion of suction catheters to the end of the endotracheal tube has been recommended based on findings from electron microscopy in young rabbits where there was an increase in the area of tracheal necrosis and inflammation when deep suctioning was performed (Bailey 1988). A study comparing uncontrolled deep suctioning to controlled shallow suctioning in low birth weight infants suggested there was more severe tracheal pathology at autopsy in the infants who received deep suctioning (Brodsky 1987). However, these findings were not statistically significant, and this study used historical controls with several confounding factors. In a series of case reports where granulation tissue in the bronchi of premature infants was identified, the authors postulated that these findings were a response to repeated mechanical trauma of endotracheal tube suctioning (Miller 1981). The recommendations resulting from all of these findings were for modifications to the suction procedure to avoid the catheter tip extending beyond the tip of the endotracheal tube (Bailey 1988; Brodsky 1987; Miller 1981). Despite these recommendations from the 1980s the practice of deep suctioning continues in some NICU's (Tolles 1990; Copnell 1995). This may be a deliberate practice due to the belief that deep suctioning works better at removing secretions and helps maintain tube patency. However, we could not find any evidence from randomised trials to support or refute this practice. Given that there is some evidence from small observational studies of risk associated with deep suctioning (Bailey 1988; Brodsky 1987; Jaw 1991; Boothroyd 1996) there appears to be no evidence at this stage to recommend deep suctioning. This is in line with the American Association for Respiratory Care Clinical Practice Guidelines 2010 (AARC 2010) which suggests that shallow suctioning should be used based on the current evidence from infant and paediatric studies.

Authors' conclusions

Implications for practice

There is no evidence from randomised controlled trials to refute or support the practice of deep or shallow suctioning of endotracheal tubes in ventilated neonates and infants. However, given the evidence from uncontrolled and observational studies which have compared the techniques, there appears to be a realistic concern regarding the practice of deep suctioning.

Implications for research

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 to conclusively establish whether there are any benefits to deep versus shallow suctioning. Given the review authors' concern that a randomised controlled trial comparing deep with shallow suctioning may be considered unethical based on the available anecdotal evidence that deep suctioning results in trauma to the trachea, we would suggest a randomised controlled trial may be possible in a neonatal intensive care unit where the standard suctioning practice includes a deep suctioning technique.

Acknowledgements

The Cochrane Neonatal Review Group has been funded in part with Federal funds from the Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health, Department of Health and Human Services, USA, under Contract No. HHSN267200603418C.

Contributions of authors

In the original review: Kaye Spence wrote the review and checked the searches; Donna Gillies critiqued the review and checked the searches; Lyn Waterworth critiqued the review.

In this first update:

Donna Gillies checked searches, did data extraction, data analysis and wrote the update.

Kaye Spence checked searches and did the data extraction.

Declarations of interest

  • None noted.

Differences between protocol and review

As there were only two review authors in this review update, any differences could not be resolved by discussion with a third reviewer and were, therefore, resolved by consensus.

Potential conflict of interest

  • None noted.

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Characteristics of studies

Characteristics of Included Studies

Youngmee 2003

Methods

Randomised crossover trial of shallow versus deep suction. The order of type of suctioning was allocated using a random numbers table.

Participants

High risk preterm infants, mean 33 weeks gestation, postnatal age 2-32 days, 20 were ventilated for prematurity, 3 for aspiration, 4 for other reasons, 11 female and 16 male.

Setting was an NICU in a metropolitan hospital in Korea.

Interventions

Standard ETT suction protocol with shallow (sum of ETT length and proximal tubing) passage of suction catheter and standard ETT suction protocol with deep (inserted until resistance met) passage of suction catheter.

Outcomes

Heart rate and Oxygen saturation (SpO2).

Notes
Risk of bias table
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk

Using the randomisation table if the number is odd then sequence is shallow first. If the number is even the order is deep first. (From correspondence with the first author)

Allocation concealment (selection bias) Unclear risk

Not stated

Blinding (performance bias and detection bias) Unclear risk

Not stated

Selective reporting (reporting bias) Low risk

Characteristics of excluded studies

  • None noted.

Characteristics of studies awaiting classification

  • None noted.

Characteristics of ongoing studies

  • None noted.

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References to studies

Included studies

Youngmee 2003

Published and unpublished data

Ahn Y, Hwang T. The effects of shallow versus deep endotracheal suctioning on the cytological components of respiratory aspirates in high-risk infants. Respiration 2003;70(2):172-8.

* Youngmee A, Yonghoon J. The effects of the shallow and the deep endotracheal suctioning on oxygen saturation and heart rate in high-risk infants. International Journal of Nursing Studies 2003;40(2):97-104.

References to excluded studies

  • None noted.

Studies awaiting classification

  • None noted.

Ongoing studies

  • None noted.

Other references

Additional references

AARC 2010

American Association for Respiratory Care. AARC Clinical Practice Guidelines. Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respiratory Care 2010;55(6):758-64.

Bailey 1988

Bailey C, Kattwinkel J, Teja K, Buckley T. Shallow versus deep endotracheal suctioning in young rabbits: pathologic effects on the tracheobronchial wall. Pediatrics 1988;82(5):746-51.

Boothroyd 1996

Boothroyd AE, Murthey BV, Darbyshire A, Petros AJ. Endotracheal suctioning causes right upper lobe collapse in intubated children. Acta Paediatrica 1996;85(12):1422-5.

Brodsky 1987

Brodsky L, Reidy M, Stanievich JF. The effects of suctioning techniques on the distal mucosa in intubated low birth weight infants. International Journal of Pediatric Otorhinolaryngology 1987;14(1):1-4.

Cameron 2000

Cameron J, Haines J. Management of Respiratory Disorders. In: Boxwell G, editor(s). Neonatal Intensive Care Nursing. London: Routledge, 2000:96-124.

Copnell 1995

Copnell B, Fergusson D. Endotracheal suctioning: time-worn ritual or timely intervention? American Journal of Critical Care 1995;4(2):100-5.

Darlow 1997

Darlow BA, Sluis KB, Inder TE, Winterbourn CC. Endotracheal suctioning of the neonate: comparison of two methods as a source of mucous material for research. Pediatric Pulmonology 1997;23(3):217-21.

Durand 1989

Durand M, Sangha B, Cabal LA, Hoppenbrouwers T, Hodgman JE. Cardiopulmonary and intracranial pressure changes related to endotracheal suctioning in preterm infants. Critical Care Medicine 1989;17(6):506-10.

Gardner 2009

Gardner DL, Shirland L. Evidence-based guideline for suctioning the intubated neonate and infant. Neonatal Network - Journal of Neonatal Nursing 2009;28(5):281-302.

Grylack 1984

Grylack LJ, Anderson KD. Diagnosis and treatment of traumatic granuloma in tracheobronchial tree of newborn with history of chronic intubation. Journal of Pediatric Surgery 1984;19(2):200-1.

Gunderson 1986

Gunderson LP, McPhee AJ, Donovan EF. Partially ventilated endotracheal suction. Use in newborns with respiratory distress syndrome. American Journal of Diseases of Children 1986;140(5):462-5.

Harling 2000

Harling E. Diagnostic and Therapeutic Procedures. In: Boxwell G, editor(s). Neonatal Intensive Care Nursing. London: Routledge, 2000:285-314.

Higgins 2011

Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org.

Hodge 1991

Hodge D. Endotracheal suctioning and the infant: a nursing care protocol to decrease complications. Neonatal Network 1991;9(5):7-13.

Jaw 1991

Jaw MC, Soong WJ, Chen SJ, Hwang B. Pneumothorax: a complication of deep endotracheal tube suction: report of 3 cases. Chinese Medical Journal 1991;48(4):313-7.

Knox, 1993

Knox AM. Performing endotracheal suction on children: a literature review and implications for nursing practice. Intensive and Critical Care Nursing 1993;9(1):48-54.

Miller 1981

Miller KE, Edwards DK, Hilton S, Collins D, Lynch F, Williams R. Acquired lobar emphysema in premature infants with bronchopulmonary dysplasia: An iatrogenic disease? Radiology 1981;138(3):589-92.

Morrow 2008

Morrow BM, Argent AC. A comprehensive review of pediatric endotracheal suctioning: Effects, indications, and clinical practice. Pediatric Critical Care Medicine 2008;9(5):465-77.

Pollard 2001

Pollard C. Endotracheal suction in the infant with an artificial airway. Nursing in Critical Care 2001;6(2):76-82.

Runton 1992

Runton N. Suctioning artificial airways in children: appropriate technique. Pediatric Nursing 1992;18(2):115-8.

Shorten 1991

Shorten DR, Byrne PJ, Jones RL. Infant responses to saline instillations and endotracheal suctioning. JOGNN 1991;20(6):464-9.

Simbruner 1981

Simbruner G, Coradello H, Foder M, Havelec L, Lubec G, Pollak A. Effect of tracheal suction on oxygenation, circulation, and lung mechanics in newborn infants. Archives of Disease in Childhood 1981;56(5):326-30.

Sturges 1979

Sturgess JM. Mucous secretions in the respiratory tract. Pediatric Clinics of North America 1979;26(3):481-501.

Thambiran 1966

Thambiran AK, Ripley SH. Observations on tracheal trauma following suction: an experimental study. British Journal of Anaesthesia 1966;38(6):459-62.

Tolles 1990

Tolles CL, Stone K. National survey of neonatal endotracheal suctioning procedures. Neonatal Network 1990;9(2):7-14.

Wrightson 1999

Wrightson DD. Suctioning smarter: answers to eight common questions about endotracheal suctioning in neonates. Neonatal Network 1999;18(1):51-5.

Young 1995

Young J. To help or hinder: endotracheal suction and the intubated neonate. Journal of Neonatal Nursing 1995;1:23-8.

Other published versions of this review

Spence 2003

Spence K, Gillies D, Waterworth L. Deep versus shallow suction of endotracheal tubes in ventilated neonates and young infants. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003309. DOI: 10.1002/14651858.CD003309.

Classification pending references

  • None noted.

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Data and analyses

1 Deep versus shallow suctioning

For graphical representations of the data/results in this table, please use link under "Outcome or Subgroup".

Outcome or Subgroup Studies Participants Statistical Method Effect Estimate
1.1 Oxygen saturation 1 Mean Difference (IV, Fixed, 95% CI) No totals
1.1.1 Suctioning 1 Mean Difference (IV, Fixed, 95% CI) No totals
1.1.2 Post protocol 1 Mean Difference (IV, Fixed, 95% CI) No totals
1.2 Heart rate 1 Mean Difference (IV, Fixed, 95% CI) No totals
1.2.1 Suctioning 1 Mean Difference (IV, Fixed, 95% CI) No totals
1.2.2 Post protocol 1 Mean Difference (IV, Fixed, 95% CI) No totals

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Sources of support

Internal sources

  • Department of Neonatology, The Children's Hospital at Westmead, Australia
  • Centre for Research and Evidenced-based Nursing, The Children's Hospital at Westmead, Australia
  • NETS, Western Sydney Area Health Service, Australia

External sources

  • Neonatal Review Group Support Project funded by Department of Health and Aging, Australian Government, Australia

This review is published as a Cochrane review in The Cochrane Library, Issue 7, 2011 (see http://www.thecochranelibrary.com External Web Site Policy for information). Cochrane reviews are regularly updated as new evidence emerges and in response to feedback. The Cochrane Library should be consulted for the most recent version of the review.