Clinician reasoning and policy evidence underpinning neonatal endotracheal suctioning practices: a qualitative study
This qualitative study reveals that neonatal endotracheal suctioning practices in Australian and New Zealand NICUs are often guided by clinician experience and policies based on limited or outdated evidence, highlighting an urgent need for transparent, evidence-based guidelines to ensure consistent and safe care.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
In the delicate environment of a neonatal intensive care unit, where tiny lungs struggle to breathe, medical staff must constantly manage the airways of babies who are on ventilators. These infants have airways so small and fragile that mucus can easily block them, cutting off oxygen. To prevent this, doctors and nurses use a thin tube to gently suck out secretions, a procedure known as endotracheal suctioning. It is a routine but high-stakes task; if done too often or too roughly, it can cause the baby's heart rate to drop or their oxygen levels to fall. For decades, a common question has lingered in these units: should a tiny amount of sterile salt water be squirted into the tube before suctioning? Some believe this helps loosen thick mucus, while others worry it might damage the baby's lungs or cause infection. Because there is very little research specifically on newborns, hospitals have been left to make their own rules, leading to a patchwork of different practices across the country.
A team of researchers set out to understand how medical professionals in Australia and New Zealand think about this problem. They gathered a group of nine experienced clinicians, including neonatologists, nurses, and physiotherapists, to discuss their daily decision-making. At the same time, the researchers collected and analyzed the official written policies from sixteen different intensive care units to see what evidence those rules were actually based on. The goal was not just to see what the rules said, but to understand the reasoning behind them and to check if those rules were supported by solid science or just old habits.
The conversations revealed a deep sense of uncertainty among the staff. Many clinicians admitted that they did not know where their hospital's specific rules came from. They suspected that policies were often created to meet accreditation requirements or based on historical traditions rather than new, high-quality research. When it came to the use of salt water, the rules varied wildly. Some hospitals banned it entirely, while others allowed small amounts only for very thick mucus. The researchers found that the documents supporting these rules often cited studies that were decades old, focused on adults or older children, or were simply not available at all. In many cases, the policies relied on low-quality evidence or studies that did not apply to newborns at all.
Because the official guidance was often unclear or weak, the clinicians explained that they relied heavily on their own experience to make decisions. The most senior staff described a nuanced approach, watching the baby closely and adjusting their actions based on how the infant was reacting. They learned over years of practice when to suction and when to hold back. In contrast, less experienced staff often felt safer sticking rigidly to the written rules, even when the baby did not seem to need it. This fear of making a mistake or being criticized led to a culture of risk aversion, where staff might perform the suctioning procedure more often than necessary just to be safe. The researchers noted that this defensive approach could paradoxically increase the risk of harm to the baby.
A key finding was how the staff interpreted the negative events that sometimes happen during suctioning. It is common for a baby's oxygen levels to drop briefly or their heart rate to slow down while the tube is being used. The experienced clinicians in the study understood that these reactions were usually caused by the suctioning process itself—such as the loss of air in the lungs or the stimulation of nerves—rather than by the salt water. However, many hospital policies treated the salt water as the primary cause of these problems. This created a disconnect between what the doctors saw at the bedside and what the written rules claimed. The staff felt that the policies were overly cautious and failed to distinguish between the risks of the procedure and the risks of the salt water.
The study concluded that the current landscape of care is shaped more by tradition, fear, and individual experience than by clear, newborn-specific science. The researchers found that despite the passage of time, the lack of high-quality trials evaluating these procedures remains a major issue. The uncertainty identified by the clinicians in 2015 has not been resolved, and modern guidelines still rely on data from adults or older children. The authors argue that for care to be consistent and safe, hospitals need transparent guidance that admits where the evidence is weak. Instead of rigid rules based on old assumptions, they suggest that policies should be built on expert consensus that acknowledges the limits of current knowledge, helping staff make better decisions without relying solely on guesswork or fear.
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