Implementing paediatric appropriate use criteria for endotracheal suction to reduce complications in mechanically ventilated children with respiratory infections

Jessica A. Schults*, Karina R. Charles, Jane Harnischfeger, Robert S. Ware, Ruth H. Royle, Joshua M. Byrnes, Debbie A. Long, Amanda J. Ullman, Sainath Raman, Michaela Waak, Anna Lake, Marie Cooke, Adam Irwin, Lyvonne Tume, Lisa Hall

*Corresponding author for this work

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Background: Endotracheal suction is used to maintain endotracheal tube patency. There is limited guidance to inform clinical practice for children with respiratory infections. Objective: The objective of this study was to determine whether implementation of a paediatric endotracheal suction appropriate use guideline Paediatric AirWay Suction (PAWS) is associated with an increased use of appropriate and decreased use of inappropriate suction interventions. Methods: A mixed-method, pre-implementation–post-implementation study was conducted between September 2021 and April 2022. Suction episodes in mechanically ventilated children with a respiratory infection were eligible. Using a structured approach, we implemented the PAWS guideline in a single paediatric intensive care unit. Evaluation included clinical (e.g., suction intervention appropriateness), implementation (e.g., acceptability), and cost outcomes (implementation costs). Associations between implementation of the PAWS guideline and appropriateness of endotracheal suction intervention use were investigated using generalised linear models. Results: Data from 439 eligible suctions were included in the analysis. Following PAWS implementation, inappropriate endotracheal tube intervention use reduced from 99% to 58%, an absolute reduction (AR) of 41% (95% confidence interval [CI]: 25%, 56%). Reductions were most notable for open suction systems (AR: 48%; 95% CI: 30%, 65%), 0.9% sodium chloride use (AR: 23%; 95% CI: 8%, 38%) and presuction and postsuction manual bagging (38%; 95% CI: 16%, 60%, and 86%; 95% CI: 73%, 99%), respectively. Clinicians perceived PAWS as acceptable and suitable for use. Conclusions: Implementation of endotracheal tube suction appropriate use guidelines in a mixed paediatric intensive care unit was associated with a large reduction in inappropriate suction intervention use in paediatric patients with respiratory infections.

Original languageEnglish
Pages (from-to)34-42
Number of pages9
JournalAustralian Critical Care
Issue number1
Early online date22 Sept 2023
Publication statusPublished - 31 Jan 2024


  • Implementation
  • Paediatric intensive care
  • Pediatrics
  • Endotracheal suction
  • Mechanical ventilation
  • Respiratory infection


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