Endotracheal suctioning is one of the most commonly performed NICU/PICU interventions but the practice requires special care for neonatal and pediatric airways. 

By Lisa Spear

Endotracheal suctioning is a common intervention in the neonatal intensive care unit (NICU) and the pediatric intensive care unit (PICU), but the practice requires special care for the much smaller and more sensitive airways, explained Suhas G. Kallapur, MD, chief of the Divisions of Neonatology and Developmental Biology at David Geffen School of Medicine at UCLA.

Even though endotracheal suctioning is an effective method for clearing secretions from the airway and an essential procedure for intubated children, the practice is still often poorly understood, with limited research confined to adults and preterm infants.1

Still, there are many ways that respiratory therapists and other healthcare providers can minimize potential harm. By working carefully with the delicate airways of these patients, clinicians can prevent stimulation to the vagal nerve—stimulation that can occur during endotracheal suctioning. If the tube is placed incorrectly, the nerve stimulation can lead to a cascade of negative downstream consequences, including bradycardia, arrythmia, and hypoxemia. A skilled clinician can avoid such outcomes if they take the right precautions when managing pediatrics and neonates. 

Above all, to minimize harm, “you have to be gentle with everything you do,” said Tim Strom, RRT-NPS, AE-C, neonatal and pediatric respiratory therapy manager at UCLA Medical Center in Los Angeles. In some cases, clinicians can bypass endotracheal tube suctioning altogether by using other methods to clear the airways, including chest physiotherapy techniques that use vibrations or to move secretions from the airways. Small handheld non-invasive devices can supplement this process to clear the upper airways.

When to Perform Endotracheal Suctioning

The first step is to know when to suction because you don’t want to over-suction the patient. As needed suctioning as opposed to performing suctioning on a set schedule is advised by the latest guidelines released in February from the American Association for Respiratory Care (AARC).

First, the AARC instructs to listen for breath sounds.2 Is there crackling or rattling when the patient inhales? Are there other indications of audible secretions? Is the sound different on just the right or the left side of the chest?

Then, notice any visual evidence of mucus. Are secretions coming up the endotracheal tube? Visual secretions in the artificial airway, as well as a sawtooth pattern on the ventilator waveform are indicators for suctioning pediatric and adult patients, the AARC guidelines state.

These factors are all important to think about when deciding whether to move forward, said Robert Menchaca, NICU respiratory manager at Memorial Hermann Healthcare System in Houston, Texas, where he currently manages a 40-bed unit. 

“You want to suction only when the baby requires it, when the baby is asking to be suctioned, and the way that you know that is by listening to their breath sounds,” Menchaca said. “Sometimes you can just put your hand on the baby’s chest and you can just feel that they are very tenacious in secretions.”

Pay Close Attention to Catheter Size and Suction Pressure

If there is cause to move forward with endotracheal tube suctioning, research has indicated that catheter size and suction pressure should be considered in relation to each other, according to a review paper in the Journal of Pediatric Intensive Care.3

“You want to have the proper size suction catheter. You don’t want the suction catheter to fit too tight because then it creates a stronger suction and it can actually collapse parts of the lungs, so you want to be very careful not to have too large of a catheter,” said Menchaca. Over time, most clinicians who regularly perform suctioning will get a feel for the different catheter sizes and the process will become more intuitive.

‘Know Your Catheters’

Overall, to minimize discomfort in your patient, it helps to familiarize yourself with the available catheters. “Know your catheter. Know the style of catheter that you are using. They are not all one certain length. Certain manufacturers might have different dimensions of an elbow connector or different dimensions of the Y connector. If we as a clinician do not know how far to insert that catheter, we are going to increase the risk of causing discomfort and stimulation,” explained James Donegan, RRT, clinical resource manager at Medline Industries.

Specific scenarios might call for different catheter types. For example, when working with an infant with a trach tube, most clinicians might find that an elbow style connector works better for those patients.

“Why that’s really important to talk about it is that if we don’t know what those physical characteristics are of the different catheter types, we are really guessing as far as how far to insert it,” explained Donegan. “In short, we often don’t know if we have inserted too far until we have stimulated a vagal response, which has cause hypertension, a bradycardic episode, caused a rapid change in their oxygen level, avoiding that problem before it becomes one is very big and I think it just starts with just understanding what the physical characteristics are of the catheter type you are using.” 

Avoid Going Too Deep

Always keep your eye on how deep the endotracheal tube is going. Strom said, “a lot of people will overlook the suction depth of how deep you are going with the catheters.”

The endotracheal tubes have numbers on them to indicate how deep in centimeters the tube is moving into the airway. For instance, if the endotracheal tube is taped at 8 centimeters at the lip, the catheter will also have another marking of how many centimeters that will match the number on the tube. When they match up, that indicates that the catheter is at the tip of the endotracheal tube and you can begin suctioning.

“If I am talking with a brand new respiratory therapist grad, one thing I like to share is that you don’t want to pass the ET tube if you are doing endotracheal suctioning, you want to stay within the ET tube because you are suctioning out the ET tube, you are not suctioning out the lungs,” said Menchaca, who has worked at Memorial Hermann Healthcare System for more than 37 years.

As the depth of suction increases, so does the risk of trauma to the airway. “If you go outside the endotracheal tube when you suction neonates, their tissue is very fragile. You don’t want to cause harm to the baby by suctioning them too deep because you could actually cause a tear in the lung wall,” said Menchaca.

Additionally, whenever you are putting a catheter down an endotracheal tube when trying to remove secretions, you are also sucking out all their air as well, which can lead to a decrease in oxygenation and ventilation.

To prepare for endotracheal suctioning, Strom said, he and his team at UCLA Health will administer a small amount of oxygen. Typically, they will give 10% fraction of inspired oxygen (FiO2) to neonates before beginning the procedure.

Unlike in adult patients, healthcare providers need to be very vigilant of potential oxygen toxicity in infants. If given too high a dose of oxygen, these babies could experience serious health consequences, explained Donegan.

Also, Strom said, “Sometimes we will put saline down there to lavage it and help loosen up the secretions. I typically will only do it if I know I have a lot of thick secretions.” 

Then, he might give the patients manual breath using the ventilator. Every ventilator has a button that said manual breaths. When you push that button, and then you give them some extra breaths, you are also blowing off carbon dioxide while increasing the mean airway pressure. “That gives them a little bit of oxygen reserves, so when we do suction them, we hopefully won’t derecruit their lungs so much,” Strom said. 

Focus on Infection Control

When administering care, it is also essential to pay close attention to infection control protocols. At Memorial Hermann Healthcare System in Houston, the clinicians use in-line suction catheters, which are connected to the ventilator circuit to introduce the catheter. It is a closed system, which helps with the prevention of infection, said Menchaca. At UCLA Medical Center, clinicians are trained to change the suction canister, the suction tubing, and the patients’ in-line catheters on their endotracheal tubes every 24 hours. 

Overall, no matter what the age of your patient, the process will become easier the more experience you have and the more you familiarize with the necessary equipment.


Lisa Spear is associate editor of RT magazine. For more info, please contact [email protected].


  1. Tume LN, Copnell B. Endotracheal Suctioning of the Critically Ill Child. J Pediatr Intensive Care. 2015 Jun;4(2):56-63.
  2. Blakeman TC, et al. AARC Clinical Practice Guidelines: Artificial Airway Suctioning. Respir Care. 2022 Feb;67(2):258-271. 
  3. Tume LN, Copnell B. Endotracheal Suctioning of the Critically Ill Child. J Pediatr Intensive Care. 2015 Jun;4(2):56-63.