Intensive Care Medicine

, Volume 36, Issue 5, pp 888–896 | Cite as

The effect of endotracheal suction on regional tidal ventilation and end-expiratory lung volume

  • D. G. TingayEmail author
  • B. Copnell
  • C. A. Grant
  • P. A. Dargaville
  • K. R. Dunster
  • A. Schibler



To examine the impact of different endotracheal tube (ETT) suction techniques on regional end-expiratory lung volume (EELV) and tidal volume (V T) in an animal model of surfactant-deficient lung injury.


Six 2-week old piglets were intubated (4.0 mm ETT), muscle-relaxed and ventilated, and lung injury was induced with repeated saline lavage. In each animal, open suction (OS) and two methods of closed suction (CS) were performed in random order using both 5 and 8 French gauge (FG) catheters. The pre-suction volume state of the lung was standardised on the inflation limb of the pressure-volume relationship. Regional EELV and V T expressed as a proportion of the impedance change at vital capacity (%Z VCroi) within the anterior and posterior halves of the chest were measured during and for 60 s after suction using electrical impedance tomography.


During suction, 5 FG CS resulted in preservation of EELV in the anterior (non-dependent) and posterior (dependent) lung compared to the other permutations, but these only reached significance in the anterior regions (p < 0.001 repeated-measures ANOVA). V T within the anterior, but not posterior lung was significantly greater during 5FG CS compared to 8 FG CS; the mean difference was 15.1 [95% CI 5.1, 25.1]%Z VCroi. Neither catheter size nor suction technique influenced post-suction regional EELV or V T compared to pre-suction values (repeated-measures ANOVA).


ETT suction causes transient loss of EELV and V T throughout the lung. Catheter size exerts a greater influence than suction method, with CS only protecting against derecruitment when a small catheter is used, especially in the non-dependent lung.


Suction Lung volume measurement Mechanical ventilation Electrical impedance tomography Lung volume 



We thank Magdy Sourial, Shane Osterfield, Scott Dunlop and Ethel Ryan for their assistance in the completion of this project. DGT is supported by a National Health and Medical Research Council Clinical Research Fellowship (grant ID 491286).

Conflict of interest statement

The authors declare that there are no competing interests.

Supplementary material

Functional EIT movie of closed ETT suction with the Ballard Trachcare™ inline suction system using firstly a 5 FG and then an 8 FG suction catheter. (MP4 6.67 mb)


  1. 1.
    Rimensberger PC, Pache JC, McKerlie C, Frndova H, Cox PN (2000) Lung recruitment and lung volume maintenance: a strategy for improving oxygenation and preventing lung injury during both conventional mechanical ventilation and high-frequency oscillation. Intensive Care Med 26:745–755CrossRefPubMedGoogle Scholar
  2. 2.
    Tingay DG, Mills JF, Morley CJ, Pellicano A, Dargaville PA (2006) The deflation limb of the pressure–volume relationship in infants during high-frequency ventilation. Am J Respir Crit Care Med 173:414–420CrossRefPubMedGoogle Scholar
  3. 3.
    Gothberg S, Parker TA, Griebel J, Abman SH, Kinsella JP (2001) Lung volume recruitment in lambs during high-frequency oscillatory ventilation using respiratory inductive plethysmography. Pediatr Res 49:38–44CrossRefPubMedGoogle Scholar
  4. 4.
    De Jaegere A, van Veenendaal MB, Michiels A, van Kaam AH (2006) Lung recruitment using oxygenation during open lung high-frequency ventilation in preterm infants. Am J Respir Crit Care Med 174:639–645CrossRefPubMedGoogle Scholar
  5. 5.
    Rimensberger PC, Pristine G, Mullen BM, Cox PN, Slutsky AS (1999) Lung recruitment during small tidal volume ventilation allows minimal positive end-expiratory pressure without augmenting lung injury. Crit Care Med 27:1940–1945CrossRefPubMedGoogle Scholar
  6. 6.
    van Kaam AH, De Jaegere A, Haitsma JJ, van Aalderen WM, Kok JH, Lachmann B (2003) Positive pressure ventilation with the open lung concept optimizes gas exchange and reduces ventilator-induced lung injury in newborn piglets. Pediatr Res 53:245–253PubMedGoogle Scholar
  7. 7.
    Lachmann B (1992) Open up the lung and keep the lung open. Intensive Care Med 18:319–321CrossRefPubMedGoogle Scholar
  8. 8.
    Halter JM, Steinberg JM, Schiller HJ, Dasilva M, Gatto LA, Landas S, Nieman GF (2003) Positive end-expiratory pressure after a recruitment maneuver prevents both alveolar collapse and recruitment/derecruitment. Am J Respir Crit Care Med 167:1620–1626CrossRefPubMedGoogle Scholar
  9. 9.
    Schiller HJ, Steinberg J, Halter J, McCann U, Dasilva M, Gatto LA, Carney D, Nieman G (2003) Alveolar inflation during generation of a quasi-static pressure/volume curve in the acutely injured lung. Crit Care Med 31:1126–1133CrossRefPubMedGoogle Scholar
  10. 10.
    Hoellering AB, Copnell B, Dargaville PA, Mills JF, Morley CJ, Tingay DG (2008) Lung volume and cardiorespiratory changes during open and closed endotracheal suction in ventilated newborn infants. Arch Dis Child Fetal Neonatal Ed 93:F436–F441CrossRefPubMedGoogle Scholar
  11. 11.
    Choong K, Chatrkaw P, Frndova H, Cox PN (2003) Comparison of loss in lung volume with open versus in-line catheter endotracheal suctioning. Pediatr Crit Care Med 4:69–73CrossRefPubMedGoogle Scholar
  12. 12.
    Kalyn A, Blatz S, Sandra F, Paes B, Bautista C (2003) Closed suctioning of intubated neonates maintains better physiologic stability: a randomized trial. J Perinatol 23:218–222CrossRefPubMedGoogle Scholar
  13. 13.
    Tingay DG, Copnell B, Mills JF, Morley CJ, Dargaville PA (2007) Effects of open endotracheal suction on lung volume in infants receiving HFOV. Intensive Care Med 33:689–693CrossRefPubMedGoogle Scholar
  14. 14.
    Wolf GK, Grychtol B, Frerichs I, van Genderingen HR, Zurakowski D, Thompson JE, Arnold JH (2007) Regional lung volume changes in children with acute respiratory distress syndrome during a derecruitment maneuver. Crit Care Med 35:1972–1978CrossRefPubMedGoogle Scholar
  15. 15.
    Copnell B, Dargaville PA, Ryan EM, Kiraly NJ, Chin LO, Mills JF, Tingay DG (2009) The effect of suction method, catheter size and suction pressure on lung volume changes during endotracheal suction in piglets. Pediatr Res 64:405–410CrossRefGoogle Scholar
  16. 16.
    Pelosi P, Goldner M, McKibben A, Adams A, Eccher G, Caironi P, Losappio S, Gattinoni L, Marini JJ (2001) Recruitment and derecruitment during acute respiratory failure: an experimental study. Am J Respir Crit Care Med 164:122–130PubMedGoogle Scholar
  17. 17.
    Lindgren S, Odenstedt H, Olegard C, Sondergaard S, Lundin S, Stenqvist O (2007) Regional lung derecruitment after endotracheal suction during volume- or pressure-controlled ventilation: a study using electric impedance tomography. Intensive Care Med 33:172–180CrossRefPubMedGoogle Scholar
  18. 18.
    Grant CA, Fraser JF, Dunster KR, Schibler A (2009) The assessment of regional lung mechanics with electrical impedance tomography: a pilot study during recruitment manoeuvres. Intensive Care Med 35:166–170CrossRefPubMedGoogle Scholar
  19. 19.
    Frerichs I, Braun P, Dudykevych T, Hahn G, Genee D, Hellige G (2004) Distribution of ventilation in young and elderly adults determined by electrical impedance tomography. Respir Physiol Neurobiol 143:63–75CrossRefPubMedGoogle Scholar
  20. 20.
    Frerichs I, Dargaville PA, van GH, Morel DR, Rimensberger PC (2006) Lung volume recruitment after surfactant administration modifies spatial distribution of ventilation. Am J Respir Crit Care Med 174:772–779CrossRefPubMedGoogle Scholar
  21. 21.
    Dunlop S, Hough J, Riedel T, Fraser JF, Dunster K, Schibler A (2006) Electrical impedance tomography in extremely prematurely born infants and during high frequency oscillatory ventilation analyzed in the frequency domain. Physiol Meas 27:1151–1165CrossRefPubMedGoogle Scholar
  22. 22.
    Wrigge H, Zinserling J, Muders T, Varelmann D, Gunther U, von der GC, Magnusson A, Hedenstierna G, Putensen C (2008) Electrical impedance tomography compared with thoracic computed tomography during a slow inflation maneuver in experimental models of lung injury. Crit Care Med 36:903–909CrossRefPubMedGoogle Scholar
  23. 23.
    Tingay DG, Armstrong RA, Carlisle HR, Argus B, Davis PG (2009) Closed endotracheal tube suction causes lung volume derecruitment and less homogeneous ventilation in preterm infants. J Paediatr Child Health 45:A34 (abstract)Google Scholar
  24. 24.
    Barber DC (1989) A sensitivity method for electrical impedance tomography. Clin Phys Physiol Meas 10:368–371CrossRefPubMedGoogle Scholar
  25. 25.
    Barber DC (1989) A review of image reconstruction techniques for electrical impedance tomography. Med Phys 16:162–169CrossRefPubMedGoogle Scholar
  26. 26.
    Morrow BM, Argent AC (2008) A comprehensive review of pediatric endotracheal suctioning: Effects, indications, and clinical practice. Pediatr Crit Care Med 9:465–477CrossRefPubMedGoogle Scholar
  27. 27.
    Albaiceta GM, Taboada F, Parra D, Luyando LH, Calvo J, Menendez R, Otero J (2004) Tomographic study of the inflection points of the pressure–volume curve in acute lung injury. Am J Respir Crit Care Med 170:1066–1072CrossRefPubMedGoogle Scholar
  28. 28.
    Meier T, Luepschen H, Karsten J, Leibecke T, Grossherr M, Gehring H, Leonhardt S (2008) Assessment of regional lung recruitment and derecruitment during a PEEP trial based on electrical impedance tomography. Intensive Care Med 34:543–550CrossRefPubMedGoogle Scholar
  29. 29.
    Victorino JA, Borges JB, Okamoto VN, Matos GF, Tucci MR, Caramez MP, Tanaka H, Sipmann FS, Santos DC, Barbas CS, Carvalho CR, Amato MB (2004) Imbalances in regional lung ventilation: a validation study on electrical impedance tomography. Am J Respir Crit Care Med 169:791–800CrossRefPubMedGoogle Scholar
  30. 30.
    Maggiore SM, Lellouche F, Pigeot J, Taille S, Deye N, Durrmeyer X, Richard JC, Mancebo J, Lemaire F, Brochard L (2003) Prevention of endotracheal suctioning-induced alveolar derecruitment in acute lung injury. Am J Respir Crit Care Med 167:1215–1224CrossRefPubMedGoogle Scholar
  31. 31.
    Cereda M, Villa F, Colombo E, Greco G, Nacoti M, Pesenti A (2001) Closed system endotracheal suctioning maintains lung volume during volume-controlled mechanical ventilation. Intensive Care Med 27:648–654CrossRefPubMedGoogle Scholar
  32. 32.
    Kiraly NJ, Tingay DG, Mills JF, Morley CJ, Dargaville PA, Copnell B (2009) The effects of closed endotracheal suction on ventilation during conventional and high frequency oscillatory ventilation. Pediatr Res 66:400–404CrossRefPubMedGoogle Scholar
  33. 33.
    Kiraly NJ, Tingay DG, Mills JF, Morley CJ, Copnell B (2008) Negative tracheal pressure during neonatal endotracheal suction. Pediatr Res 64:29–33CrossRefPubMedGoogle Scholar
  34. 34.
    Morrow BM, Futter MJ, Argent AC (2004) Endotracheal suctioning: from principles to practice. Intensive Care Med 30:1167–1174CrossRefPubMedGoogle Scholar
  35. 35.
    Monaco FJ, Meredith KS (1992) A bench test evaluation of a neonatal closed tracheal suction system. Pediatr Pulmonol 13:121–123CrossRefPubMedGoogle Scholar
  36. 36.
    Woodgate PG, Flenady V (2001) Tracheal suctioning without disconnection in intubated ventilated neonates. Cochrane Database Syst Rev, issue 2, art. no. CD003065. doi:  10.1002/14651858.CD003065
  37. 37.
    van Veenendaal MB, Miedema M, de Jongh FHC, van der Lee JH, Frerichs I, van Kaam AH (2009) Effect of closed endotracheal suction in high-frequency ventilated premature infants measured with electrical impedance tomography. Intensive Care Med 35:2130–2134CrossRefPubMedGoogle Scholar
  38. 38.
    Lasocki S, Lu Q, Sartorius A, Fouillat D, Remerand F, Rouby JJ (2006) Open and closed-circuit endotracheal suctioning in acute lung injury: efficiency and effects on gas exchange. Anesthesiology 104:39–47CrossRefPubMedGoogle Scholar
  39. 39.
    Almgren B, Wickerts CJ, Hogman M (2004) Post-suction recruitment manoeuvre restores lung function in healthy, anaesthetized pigs. Anaesth Intensive Care 32:339–345PubMedGoogle Scholar
  40. 40.
    Dyhr T, Bonde J, Larsson A (2003) Lung recruitment manoeuvres are effective in regaining lung volume and oxygenation after open endotracheal suctioning in acute respiratory distress syndrome. Crit Care 7:55–62CrossRefPubMedGoogle Scholar
  41. 41.
    Morrow B, Futter M, Argent A (2007) A recruitment manoeuvre performed after endotracheal suction does not increase dynamic compliance in ventilated paediatric patients: a randomised controlled trial. Aust J Physiother 53:163–169PubMedGoogle Scholar
  42. 42.
    Copnell B, Tingay DG, Kiraly NJ, Sourial M, Gordon MJ, Mills JF, Morley CJ, Dargaville PA (2007) A comparison of the effectiveness of open and closed endotracheal suction. Intensive Care Med 33:1655–1662CrossRefPubMedGoogle Scholar

Copyright information

© Copyright jointly held by Springer and ESICM 2010

Authors and Affiliations

  • D. G. Tingay
    • 1
    • 2
    • 3
    Email author
  • B. Copnell
    • 1
    • 2
    • 4
  • C. A. Grant
    • 5
    • 6
  • P. A. Dargaville
    • 7
  • K. R. Dunster
    • 5
    • 6
  • A. Schibler
    • 5
  1. 1.Department of NeonatologyRoyal Children’s HospitalMelbourneAustralia
  2. 2.Neonatal Respiratory ResearchMurdoch Children’s Research InstituteMelbourneAustralia
  3. 3.Department of PaediatricsUniversity of MelbourneMelbourneAustralia
  4. 4.School of Nursing and MidwiferyMonash UniversityMelbourneAustralia
  5. 5.Paediatric Critical Care Research Group, Paediatric Intensive Care UnitMater Children’s HospitalBrisbaneAustralia
  6. 6.Institute of Health and Biomedical InnovationQueensland University of TechnologyBrisbaneAustralia
  7. 7.Department of PaediatricsRoyal Hobart Hospital and University of TasmaniaHobartAustralia

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