Endotracheal Suctioning Research Articles

Tolerance of endotracheal tubes in patients on mechanical ventilation

Modern concepts for sedation and analgesia and guidelines recommend light analgesia and sedation, so that patients on mechanically ventilation are more awake, compared to previous concepts. Hence, these patients are more alert and able to experience their situation on the ventilator and their endotracheal tube (ETT). There is currently no convincing evidence of how patients tolerate the tube under present conditions, which interventions could help them, or whether they want to be sedated deeper because of the tube. Based upon our own observations, a broad range of reactions are possible. The tolerance of the ETT in intensive care patients was explored. A systematic literature research without time constraints in the databases PubMed and CINAHL was performed. Included were quantitative and qualitative studies written in German or English that investigated tolerance of the ETT in adult intensive care patients. Excluded were anesthetic studies including in- and extubation immediately before and after operations. Of the 2348 hits, 14 studies were included, including 4qualitative studies about the experience of intensive care, 8quantitative studies including 2 randomized controlled studies, and 2studies with a mixed approach. Within the studies different aspects could be identified, which may in- or decrease the tolerance of an ETT. Aspects like breathlessness, pain during endotracheal suctioning and inability to speak decrease the tolerance. Information, the presence of relatives and early mobilization appear to increase the tolerance. Tolerance of the ETT is a complex phenomenon. A reflected and critical evaluation of the behavior of the patient with an ETT is recommended. Interventions that increase the tolerance of the ETT should be adapted to the situation of the patient and should be evaluated daily.

Fetal outcome of meconium-stained infants resuscitated by endotracheal suction versus oropharyngeal suction at birth

Objective Meconium aspiration syndrome (MAS) is one of the most important causes of neonatal intensive care unit admission for full-term newborn infants. We aimed to compare between meconium-stained infants who were intubated at birth and full-term infants who were subjected to oropharyngeal suction of meconium at birth in terms of mortality, MAS, respiratory symptoms, and other clinical outcome measures. We also aimed to evaluate plasma thrombin activatable fibrinolysis inhibitor activity (TAFIa) levels, which may be used as a sign of hypoxia or inflammation in neonates with meconium-stained amniotic fluid (MASF). Patients and methods Seventy five newborn infants delivered through MASF with green-stained vocal cord were studied. The neonates studied were classified into two groups. The first group included 40 neonates with MASF who received endotracheal intubation and airway aspiration at birth. The second group included 35 neonates with MASF who were subjected to oropharyngeal suction at birth. Venous blood sample was drawn from all neonates 6 h after birth to measure plasma TAFIa. Results There was a statistically significant difference in the severity of MAS and respiratory oxygen support, more in the oropharyngeal suction group than in the ETT suction group. There was a highly statistically significant difference in days of oxygen treatment, days of mechanical ventilation, and duration of hospital stay. It was prolonged in the oropharyngeal suction group. Also, there was a highly significant association between poor fetal heart rate tracing pattern and severity of MAS in both groups. Meconium thickness had a significant effect on the severity of MAS in the oropharyngeal suction group than the ETT group. A significant difference was found between plasma TAFIa levels and the severity of MAS, proving that MAS was associated with more acidosis, hypoxia, and depressed fibrinolysis. Conclusion There was a higher incidence and severity of MAS in the oropharyngeal group than the ETT group. Risk factors associated with the development of MAS among infants with MASF include thick meconium, fetal acidosis, nonreassuring fetal heart tracing, and low Apgar score. Also, there was an increase in TAFIa levels in neonates with MASF and this may indicate depressed fibrinolysis.

Effect of applying positive pressure with or without endotracheal suctioning during extubation: a laboratory study.

During invasive mechanical ventilation, secretions accumulate in the subglottic space; consequently, there is a risk of aspiration of these secretions into the airway during cuff deflation and extubation. To minimize this risk, 2 extubation methods are used. The first consists of introducing a suction catheter into the endotracheal tube (ETT) and the trachea. After initiating suctioning, the cuff is deflated and the ETT is removed together with the suction catheter. The second technique involves applying positive pressure to the ETT using a resuscitation bag. Once the manual breath is delivered, the ETT cuff is deflated and the ETT is removed without suction. The aim of this laboratory study is to determine the existence and magnitude of differences in leak volume during cuff deflation and extubation using various combinations of positive pressure with or without endotracheal suctioning. An ETT connected to a ventilator was placed in a model trachea. Colored water was instilled in the space above the cuff. To measure the leak volume, a collection chamber was attached to the distal end of the model. Nine procedures were defined, based on the delivery of different positive pressure levels with or without endotracheal suctioning during extubation. The volume of leakage, in milliliters, was the unit of analysis. Procedures yielding values lower than 1 mL were assessed by the Friedman test, and a P value of less than .05 was considered significant. Post hoc comparisons were performed with a Wilcoxon test, followed by a Bonferroni correction. The application of CPAP 15, pressure support ventilation (PSV)15/10, and PSV 20/5 produced 0.4, 0.2, and 0.1 mL of leak volume, respectively. Statistically significant differences were found between CPAP 15 and PSV 15/10 (P = .003) and between CPAP 15 and PSV 20/5 (P = .01), but not between PSV 15/10 and PSV 20/5 (P = .30). The addition of suctioning increased leak volume, with statistically significant differences between CPAP 15 and CPAP 15 + endotracheal suctioning (P = .001) and between PSV 15/10 and PSV 15/10 + endotracheal suctioning (P = .001). Endotracheal suctioning during cuff deflation and extubation produced greater leakage. Application of CPAP 15, PSV 15/10, and PSV 20/5 resulted in the lowest leak values, with the best results being obtained with the use of PSV 15/10 and PSV 20/5.

Respiratory distress in the newborn.

Respiratory distress presents as tachypnea, nasal flaring, retractions, and grunting and may progress to respiratory failure if not readily recognized and managed. Causes of respiratory distress vary and may not lie within the lung. A thorough history, physical examination, and radiographic and laboratory findings will aid in the differential diagnosis. Common causes include transient tachypnea of the newborn, neonatal pneumonia, respiratory distress syndrome (RDS), and meconium aspiration syndrome (MAS). Strong evidence reveals an inverse relationship between gestational age and respiratory morbidity. (1)(2)(9)(25)(26) Expert opinion recommends careful consideration about elective delivery without labor at less than 39 weeks’ gestation. Extensive evidence, including randomized control trials, cohort studies, and expert opinion, supports maternal group B streptococcus screening, intrapartum antibiotic prophylaxis, and appropriate followup of high-risk newborns according to guidelines established by the Centers for Disease Control and Prevention. (4)(29)(31)(32)(34) Following these best-practice strategies is effective in preventing neonatal pneumonia and its complications. (31)(32)(34). On the basis of strong evidence, including randomized control trials and Cochrane Reviews, administration of antenatal corticosteroids (5) and postnatal surfactant (6) decrease respiratory morbidity associated with RDS. Trends in perinatal management strategies to prevent MAS have changed. There is strong evidence that amnioinfusion, (49) oropharyngeal and nasopharyngeal suctioning at the perineum, (45) or intubation and endotracheal suctioning of vigorous infants (46)(47) do not decrease MAS or its complications. Some research and expert opinion supports endotracheal suctioning of nonvigorous meconium-stained infants (8) and induction of labor at 41 weeks’ gestation (7) to prevent MAS.

Ventilator-associated pneumonia in patients admitted to intensive care units, using open or closed endotracheal suctioning.

Background:Critically ill patients under mechanical ventilation require frequent suctioning of airway secretion. Closed suction permits suctioning without disconnection from ventilator; so it might decrease hypoxemia and infection rate.Objectives:This study aimed to evaluate the effect of closed tracheal suction system (CTSS) versus open tracheal suction system (OTSS).Patients and Methods:This is a prospective randomized study, which was carried on 100 patients in surgical Intensive Care Unit requiring mechanical ventilation for more than 48 hours from June 2012 to November 2013. In two groups, suction was performed based on the patients' need as well as physician's or nurses' decision on tracheal secretions. Patients randomly allocated into two groups (50 patients each): CTSS group and OTSS group. Patients were monitored for developing ventilator-associated pneumonia (VAP) during the study. Throat samples were taken on admission and two times per week from each patient. Tracheal samples were performed during endotracheal intubation, two times per week during mechanical ventilation and during extubation.Results:Drainage of subglottic secretions decreased the incidence of VAP (P < 0.05). Also type of the pharmacologic medicine for stress ulcer prophylaxis has significant effect on VAP incidence. Among the patients in OTSS and CTSS groups, 20% and 12% developed VAP, respectively. Use of CTSS compared with OTSS did not show statistically significant effect on VAP incidence in multivariate analysis; however, OR (odds ratio) tended to identify OTSS as an exposure factor for the development of VAP (OR = 1.92; CI = 0.45-8.30; = 0.38) compared with the CTSS. Higher levels of APACHE II score, sinusitis and tracheostomy put the patients at the risk of VAP. However, using heat and moisture exchanger (HME) instead of humidifier decreased this risk.Conclusions:Based on the results obtained from our study, impact of suctioning is similar between CTSS and OTSS regarding the occurrence of VAP. It seems that physicians must consider many factors such as duration of mechanical ventilation, comorbidities, oxygenation parameters, number of required suctioning, and the cost prior to using each type of tracheal suction system.

Survey of Italian intensive care unit nurses’ knowledge about endotracheal suctioning guidelines

Endotracheal suctioning is a common procedure performed by intensive care nurses in order to establish and maintain gas exchange, adequate oxygenation and alveolar ventilation in critically ill patients under mechanical ventilation. As this procedure is associated with several complications and risks nurses should have an adequate knowledge on how to perform the procedure according to the evidence-based practice. Previously only a few studies have analysed nurses' knowledge of the guidelines on endotracheal suctioning. To evaluate the knowledge of the American Association of Respiratory Care (AARC, 2010) evidence-based guidelines on the endotracheal suctioning technique by Italian intensive care nurses in different hospitals. An anonymous questionnaire based on previous studies was sent to a selected sample composed of the intensive care unit (ICU) nurses of 16 ICUs in 11 Italian hospitals. The questionnaire was sent to 379 nurses, with 65% of questionnaires returned completed. The total percentage of correct answers was 58%, and nobody completed the questionnaire without mistakes. Moreover, only 2.5% (n = 6) of the nurses gave 9/10 correct answers. Correct answers were more common amongst the more experienced ICU nurses. Italian ICU nurses' knowledge of guidelines on endotracheal suctioning was not complete; however, experienced nurses demonstrated a better knowledge of the subject.

Evaluation of a bundle to prevent ventilator-associated pneumonia in an intensive care unit

We aimed at evaluating compliance with a bundle to prevent ventilator-associated pneumonia in an Intensive Care Unit. It is a quantitative, descriptive and cross-sectional study, conducted in a public hospital in the state of Santa Catarina. Data were collected in July and August of 2012. The sample consisted of 1,146 observations of the four elements that compose the bundle (head of bed elevation between 30-45°; endotracheal suctioning; cuff pressure between 20-30 cmH2O; and oral care with 0.12% chlorhexidine). Expected compliance was equal to a positivity rate ≥80%. Data analysis revealed overall bundle compliance of 794 (69.2%). When analyzed separately, two practices presented expected compliance (84.7%): oral care and suctioning. Head of bed elevation had the lowest compliance (55.5%), followed by cuff pressure (61.8%). We observed the need for strategies that promote the quality of all the elements that compose the bundle in order for its use to be effective.

Comparison the effects of shallow and deep endotracheal tube suctioning on respiratory rate, arterial blood oxygen saturation and number of suctioning in patients hospitalized in the intensive care unit: a randomized controlled trial.

Endotracheal tube suctioning is essential for improve oxygenation in the patients undergoing mechanical ventilation. There are two types of shallow and deep endotracheal tube suctioning. This study aimed to evaluate the effect of shallow and deep suctioning methods on respiratory rate (RR), arterial blood oxygen saturation (SpO2) and number of suctioning in patients hospitalized in the intensive care units of Al-Zahra Hospital, Isfahan, Iran. In this randomized controlled trial, 74 patients who hospitalized in the intensive care units of Isfahan Al-Zahra Hospital were randomly allocated to the shallow and deep suctioning groups. RR and SpO2 were measured immediately before, immediately after, 1 and 3 minute after each suctioning. Number of suctioning was also noted in each groups. Data were analyzed using repeated measures analysis of variance (RMANOVA), chi-square and independent t-tests. RR was significantly increased and SpO2 was significantly decreased after each suctioning in the both groups. However, these changes were not significant between the two groups. The numbers of suctioning was significantly higher in the shallow suctioning group than in the deep suctioning group. Conclusion : Shallow and deep suctioning had a similar effect on RR and SpO2. However, shallow suctioning caused further manipulation of patient's trachea than deep suctioning method. Therefore, it seems that deep endotracheal tube suctioning method can be used to clean the airway with lesser manipulation of the trachea.

The effect of normal saline instillation on cardiorespiratory parameters in intubated cardiothoracic patients

Objective. The objective of this study was to describe the effect of normal saline instillation (NSI) on cardiorespiratory parameters in intubated cardiothoracic patients. Methods . A comparative design was employed to meet the study objectives. Simple random sampling was used to assign patients to study groups, namely a research group (non-NSI) and a control group (NSI). The data-capturing tool was based on the literature review. Descriptive and comparative statistics were employed to analyse the data. Findings were assessed according to p &lt;0.05. Results. Findings indicated that there were no statistically significant differences in heart rate, blood pressure, arterial partial pressure of oxygen (PaO2), arterial oxygen saturation as measured by blood gas analyser (SaO2) and serum bicarbonate level (HCO3 –) when NSI was used or not used during endotracheal suctioning ( p =0.05). Statistically significant differences were found in pH and patient return rate to baseline arterial oxygen saturation as measured by pulse oximetry (SpO2) after 30 minutes of suctioning: 63.6% of patients in the NSI group failed to return to baseline SpO2 v. 37.5% of patients in the non-NSI group ( χ 2 p =0.035; Fisher’s exact p =0.048). There was a decrease in pH when NSI was used during suctioning. Although these differences were statistically significant, clinically they were not significant. Conclusion. It can be concluded that NSI had no effect on cardiorespiratory parameters in intubated cardiothoracic patients. Even though the patient population was at high risk of haemodynamic disturbance and hypoxia during this manoeuvre, there was no meaningful clinical effect; however, the sample size was too small to establish safety

Pepsin and amylase in oral and tracheal secretions: a pilot study.

Endotracheal intubation increases the risk for microaspiration of secretions around the tube cuff. Pepsin has been used as a biomarker for gastric aspiration. Amylase is a newer proposed biomarker for aspiration of oral contents. To assess the presence of pepsin and amylase in paired oral-tracheal secretions of adult patients treated with mechanical ventilation. In this descriptive study, paired samples of oral and tracheal secretions were obtained from adult patients at baseline and again within 4 hours when a need for endotracheal suctioning was assessed. Assays of pepsin and amylase were processed in a specialty diagnostic laboratory. The sample consisted of 10 men and 3 women with a median age of 56 years. The majority were intubated with a subglottic suction endotracheal tube (9 patients, 69%), receiving synchronized intermittent mandatory ventilation (10 patients; 77%), and receiving enteral feedings (11 patients; 85%) through a tube distally placed in the stomach (8 patients; 67%). Pepsin was present in oral secretions of 9 patients (69%), and in tracheal specimens of 7 patients (54%) at one or both sampling times. Amylase was detected in all patients' oral secretions and in tracheal secretions of 5 patients (38%) at one or both sampling times. Many patients had pepsin, amylase, or both in tracheal aspirates. Pepsin was more commonly detected than was amylase. Although the relationship of this finding to long-term outcomes was not assessed, findings indicate that microaspiration of oral and gastric secretions occurs frequently.

Assessment of Pain During Endotracheal Suction In the Pediatric Intensive Care Unit

This research was planned as a two-level definitive and comparative study to evaluate pain during endotracheal suction (ETS) in pediatric intensive care units (PICUs). This study was comprised of patients admitted to and the nurses working in the PICU. Cases were selected among PICU patients (N = 65) who met the study criteria and nurses (N = 18) who cared for them from January 1 to July 2, 2008. Routine ETS was applied as the first level of the study. For the second level, an inquiry on the knowledge of nurses about suction was given to the nurses, and they were asked to apply suction according to the guidelines they were given. All the obtained data were evaluated by statistical package for the social sciences (SPSS) for Windows 14.0. In summary, 33.8% (n = 22) of the patients were between ages 1 and 12 months, and 64.6% (n = 42) were boys. Although group 2 patients (patient who is in experimental group) had higher scores on the Wong-Baker faces pain rating and Face, Legs, Activity, Cry, Consolability scales, no statistical difference was found between the two groups (p > .05). Patients who received bolus doses of analgesia and sedative drugs had lower Wong-Baker faces pain rating (4.38 ± 0.96; n = 4) and Face, Legs, Activity, Cry, Consolability scores (4.61± 1.94; n = 4) (p > .05). According to these findings, the patients were distressed because of the pain related with suction. Therefore, it is recommended that suction guidelines be used in PICUs during ETS.

Neonatal Intensive Care Units Nurses’ Attitude Toward Advantages and Disadvantages of Open vs Closed Endotracheal Suction

The vital issue of protecting the airway and maintaining ventilation in preterm infants makes tracheal suctioning an important procedure. The decision to use closed or open endotracheal suction method depends on the clinical status of infants and the nurses' skills and preferences. The current study aimed to compare the two methods based on the perceptions of the nurses working in Neonatal Intensive Care Units (NICU). A comparative-descriptive study carried out on 35 NICU nurses in Taleghani and Al-Zahra teaching hospitals in Tabriz, Iran, in 2013. Data were collected by self-administered questionnaire (13 Items). Data analysis, including t-test was performed using SPSS Ver. 13. A P ≤ 0.05 was considered statistically sig-nificant. According to the nurses' point of view, there are differences between characteristics of open and closed endotracheal suctioning methods (P < 0.001). By using closed endotracheal suction, the risk of traumatizing airway, developing pneumonia, increasing intracranial pressure, prolonging emergency suctioning, developing intra-ventricular hemorrhage, blood stream infection, physiological instability and lowering positive end-expiratory pressure (PEEP) are reduced. Meanwhile, lower cost, lower risk of extubation, comfort and easy washing procedure were reported as advantages of open suction. Closed endotracheal suctioning was evaluated to be better than the open method in the preterm neonates. More studies, especially experimental and efficient cost analysis, are recommended.

Neonatal Intensive Care Units Nurses‘ Attitude Toward Advantages and Disadvantages of Open vs Closed Endotracheal Suction

Neonatal Intensive Care Units Nurses‘ Attitude Toward Advantages and Disadvantages of Open vs Closed Endotracheal Suction

The effect of facilitated tucking during endotracheal suctioning on procedural pain in preterm neonates: a randomized controlled crossover study.

Background:Premature infants not only feel and understand the pain, but also respond more intensively compared with term infants. Non-pharmacological methods of pain control are suitable to relieve pain in painful procedures. The facilitated tucking position is considered as a non-pharmacological method of pain control in infants; however, its impact on frequent and repeated procedural pain such as endotracheal suctioning remains to be studied.Objectives:This paper is the report of a study that examined the impact of facilitated tucking position on behavioral pain during suctioning in premature neonates. Design: This was a clinical trial study with a crossover design. Settings: The study was conducted in a level II Neonatal Intensive Care Unit, located in a teaching hospital, affiliated to Tehran University of Medical Sciences, Tehran, Iran. Participants: Thirty four infants were enrolled in this study based on the following inclusion criteria: age between 29 to 37 weeks of gestational age, birth weight 1200 grams or more, having an endotracheal tube, no congenital anomalies, no seizures diagnosis, no chest tubes, no intracranial hemorrhage higher than degree II, not receiving opiates and sedatives four hours before intervention and not receiving any painful procedure at least half an hour before the intervention. Methods: The samples were randomly received a sequence of suctioning with/without or suctioning without/with facilitated tucking. Preterm Infant Pain Profile (PIPP) was used to collect the data. SPSS version 16.0 for Windows (SPSS Inc., Chicago, IL, USA) was used for statistical analysis.Results:While 38.2% of infants experienced severe pain during suctioning without intervention, only 8.8% of them experienced severe pain during suctioning with intervention. The results of the paired t-test show that there is a statistically significant difference in the mean scores of pain between non-intervention and intervention cases (p<0.001), and the mean pain score substantially reduced in cases with intervention.Conclusions:Given the multiplicity of endotracheal suctioning frequency and the impossibility of frequent use of pharmacological methods of pain relief, the facilitated tucking position can be used as a safe non-pharmacological method for procedural pain management.

Nursing application of closed endotraeheal suctioning on mechanical ventilation in children with severe disease

Objective To explore the nursing application of closed endotraeheal suctioning for mechanical ventilation in children with severe disease.Methods Forty in-patients children with severe disease were randomly divided into experimental group with closed endotraeheal suctioning and control group with traditional open suctioning.Several indicators,such as SpO2,heart rate (HR),blood pressure,and rate of airway mucosa injury were evaluated between two groups.Results There were no significant difference in SpO2,HR,and blood pressure between experiment and control group 2 min before endotraeheal suctioning.Decreased SpO2 (P ＜ 0.05),increased blood pressure (P ＜ 0.01) and heart rate (P ＜ 0.01) were found in control group instead of experimental group 2 min after suctioning.Increased rate of airway mucosa injury (P ＜ 0.05) and ventilator-associated pneumonia (VAP) (P ＜ 0.05) had likely taken place in control group subject to experimental group,2 min after endotraeheal suction.Conclusion Closed endotraeheal suctioning can alleviate the lower SpO2,maintain the balance of blood flow,ease the injury in airway mucosa,and decrease infectious rate of airway which help to improve life quality of children with severe disease and facilitate operational procedure of nursing. Key words: Closed endotracheal suction; Mechanical ventilation; Nursing

Assessment of circulatory and pulmonary endothelin-1 levels in a lavage-induced surfactant-depleted lung injury rabbit model with repeated open endotracheal suctioning and hyperinflation

Aims:Endothelin-1 (ET-1) is a mediator of various physiological and pathological processes, including vascular inflammation, cell proliferation and vasoconstriction. Attenuation of ET action using ET-1 antagonists reduces pulmonary vascular leakage and inflammation in several models of lung injuries and experimental acute respiratory distress syndrome (ARDS). Based on these earlier reports, the current study investigates the patterns of ET-1 levels in circulation and pulmonary tissues in an experimental model of lavage-induced surfactant-depleted lung injury. Additionally, we also test the effects of open endotracheal suctioning (OES) and hyperinflation (HI) as recruitment maneuver following OES on ET-1 levels. Main methods:Briefly, 24 Japanese white rabbits were anesthetized and intubated. Normal saline was instilled into the lung and washed mildly. After instillation, rabbits were ventilated at definite settings at a total duration of 3hours. OES and HI were performed every 15minutes from the beginning of the protocol. Key findings:Here, we show that both circulatory and pulmonary ET-1 levels increased in models with lung injury induced by saline lavage compared to healthy control group. No further aggravation in expression of pulmonary ET-1 was seen after OES and HI, although OES and HI worsened arterial hypoxygenation and severity of lung injury. In contrast, circulatory ET-1 levels significantly decreased after OES and HI but were not associated with blood pressure changes. Significance:We conclude that in a saline lavage-induced lung injury model, both circulatory and pulmonary ET-1 levels increased. Further, OES and HI exerted differential effects on ET-1 expression at both circulatory and pulmonary levels.

Transfusion related acute lung injury with massive pulmonary secretion during cardiac surgery. A case report

A Indo-Caribbean patient undergoing cardiac surgery developed Transfusion Related Acute Lung Injury (TRALI) with massive endobronchial secretion of clear fluid mimicking severe pulmonary edema. Hypoxemia and lung stiffness were so severe that didn’t allow closure of the sternum on completion of surgery. The patient was treated with invasive ventilation, high positive pressure and % FiO2 and aggressive endotracheal suction. After several hours, secretions reduced spontaneously and the patient made an uneventful recovery.

The “Other Tube” in the Airway

The “Other Tube” in the Airway

Safety and effective use of landiolol in the ICU.

Supplemental landiolol administration (20 or 40 μg kg-1 min-1) effectively diminished harmful hemodynamic changes during bronchoscopic endotracheal suctioning compared to normal saline. However, inappropriate use of landiolol (i.e., failure of evaluating factors that influence hemodynamic changes) may iatrogenically further complicate pathophysiology, and relatively higher doses of landiolol may be dangerous. We recommend that landiolol should not be routinely used to control cardiovascular responses during bronchoscopic endotracheal suctioning in the intensive care unit. Careful evaluation of factors influencing hemodynamic changes and close monitoring of the patient are mandatory following landiolol administration. Furthermore, a lower initiation dose is recommended.

Development of evidence-based clinical practice guidelines for endotracheal suction in premature infants

Endotracheal suctioning (ETS) for mechanically ventilated premature infants is a routine practice in neonatal intensive care. However, ETS is associated with hypoxemia and bradycardia, which may cause brain damage and negatively affect neurodevelopmental outcomes. This study develops a set of evidence-based clinical-practice ETS guidelines for premature infants. A multidisciplinary task group at a medical center in southern Taiwan was established. Team members analyzed current ETS practice guidelines, constructed foreground questions, reviewed each question systemically, drafted a new set of guidelines, established expert consensus, disseminated the developed guidelines within a hospital setting, and evaluated their efficacy in practice. The developed ETS guidelines address 13 issues with 39 recommendations. The Delphi method found that 75% of experts agreed with all of the recommendations. Issues addressed in the ETS included pre-assessment, frequency of suctioning, pre-oxygenation, suction-tube selection, infection control, suction pressure and depth decision making, humidity with normal saline, suction duration and number, containment and comforting, assessment during and after suctioning, recovery time, and documentation. The panel of clinical and methodological experts recommended that ETS be used in practice and nurses in the neonatal intensive care unit evaluated the ETS as applicable and accessible. The cardiorespiratory responses to ETS of 5 premature infants were within normal ranges without episodes of hypoxemia (oxygen saturation < 85%) or bradycardia (heart rate < 100 beat/min). This set of evidence-based ETS guidelines for premature infants integrated recommendations from the best available literature and obtained a high consensus among clinical experts. Thus, these guidelines are recommended for clinical application.