The Paediatric AirWay Suction (PAWS) appropriateness guide for endotracheal suction interventions

Jessica Schults; Karina Charles; Debbie Long; Georgia Brown; Beverley Copnell; Peter Dargaville; Kylie Davies; Simon Erikson; Kate Forrest; Jane Harnischfeger; Adam Irwin; Tina Kendrik; Anna Lake; George Ntoumenopoulos; Michaela Waak; Mark Woodard; Lyvonne Tume; Marie Cooke; Marion Mitchell; Lisa Hall; Amanda Ullman

doi:10.1016/j.aucc.2021.10.005

The Paediatric AirWay Suction (PAWS) appropriateness guide for endotracheal suction interventions

Aust Crit Care. 2022 Nov;35(6):651-660. doi: 10.1016/j.aucc.2021.10.005. Epub 2021 Dec 23.

Authors

Jessica Schults¹, Karina Charles², Debbie Long³, Georgia Brown⁴, Beverley Copnell⁵, Peter Dargaville⁶, Kylie Davies⁷, Simon Erikson⁷, Kate Forrest⁸, Jane Harnischfeger⁹, Adam Irwin¹⁰, Tina Kendrik¹¹, Anna Lake⁹, George Ntoumenopoulos¹², Michaela Waak¹³, Mark Woodard¹⁴, Lyvonne Tume¹⁵, Marie Cooke¹⁶, Marion Mitchell¹⁷, Lisa Hall¹⁸, Amanda Ullman¹⁹

Affiliations

¹ University of Queensland, School of Nursing, Midwifery and Social Work, Australia; Metro North Hospital and Health Service, Queensland, Australia; Child Health Research Centre, The University of Queensland, Queensland, Australia; Paediatric Intensive Care, Queensland Children's Hospital, Queensland, Australia. Electronic address: j.schults@uq.edu.au.
² Paediatric Intensive Care, Queensland Children's Hospital, Queensland, Australia; Queensland Children's Hospital, Brisbane, Australia; School of Nursing and Midwifery, Griffith University, Queensland, Australia.
³ Child Health Research Centre, The University of Queensland, Queensland, Australia; Paediatric Intensive Care, Queensland Children's Hospital, Queensland, Australia; School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane City, Queensland, Australia.
⁴ Paediatric Intensive Care Unit, Royal Children's Hospital, Victoria, Australia.
⁵ School of Nursing and Midwifery, La Trobe University, Bundoora, Victoria, Australia.
⁶ Departement of Paediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia; Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia.
⁷ Paediatric Critical Care Unit, Perth Children's Hospital, Western Australia, Australia.
⁸ Paediatric Intensive Care Unit, Starship Child Health, Auckland Hospital, New Zealand.
⁹ Queensland Children's Hospital, Brisbane, Australia.
¹⁰ University of Queensland, Centre for Clinical Research, The University of Queensland, Australia; Infection Management and Prevention Service, Queensland Children's Hospital, Queensland, Australia.
¹¹ Newborn and Paediatric Emergency Transport Service (NETS), The Sydney Children's Hospital Network, New South Wales, Australia.
¹² Physiotherapy Department, St Vincent's Hospital, New South Wales, Australia.
¹³ Child Health Research Centre, The University of Queensland, Queensland, Australia; Paediatric Intensive Care, Queensland Children's Hospital, Queensland, Australia.
¹⁴ Paediatric Critical Care Unit, Perth Children's Hospital, Western Australia, Australia; Curtin University, School of Nursing, Perth, Australia.
¹⁵ School of Health & Society, University of Salford, Manchester UK; Paediatric Intensive Care Unit, Alder Hey Children's Hospital, Liverpool UK.
¹⁶ School of Nursing and Midwifery, Griffith University, Queensland, Australia.
¹⁷ School of Nursing and Midwifery, Griffith University, Queensland, Australia; Princess Alexandra Hospital, Brisbane, Australia.
¹⁸ School of Public Health, Faculty of Medicine, University of Queensland, Australia.
¹⁹ University of Queensland, School of Nursing, Midwifery and Social Work, Australia; Children's Health Queensland Hospital and Health District, Brisbane, Australia.

PMID: 34953635
DOI: 10.1016/j.aucc.2021.10.005

Abstract

Background/objective: Endotracheal suction is an invasive and potentially harmful technique used for airway clearance in mechanically ventilated children. Choice of suction intervention remains a complex and variable process. We sought to develop appropriate use criteria for endotracheal suction interventions used in paediatric populations.

Methods: The RAND Corporation and University of California, Los Angeles Appropriateness Method was used to develop the Paediatric AirWay Suction appropriateness guide. This included defining key terms, synthesising current evidence, engaging an expert multidisciplinary panel, case scenario development, and two rounds of appropriateness ratings (weighing harm with benefit). Indications (clinical scenarios) were developed from common applications or anticipated use, current practice guidelines, clinical trial results, and expert consultation.

Results: Overall, 148 (19%) scenarios were rated as appropriate (benefit outweighs harm), 542 (67%) as uncertain, and 94 (11%) as inappropriate (harm outweighs benefit). Disagreement occurred in 24 (3%) clinical scenarios, namely presuction and postsuction bagging across populations and age groups. In general, the use of closed suction was rated as appropriate, particularly in the subspecialty population 'patients with highly infectious respiratory disease'. Routine application of 0.9% saline for nonrespiratory indications was more likely to be inappropriate/uncertain than appropriate. Panellists preferred clinically indicated suction versus routine suction in most circumstances.

Conclusion: Appropriate use criteria for endotracheal suction in the paediatric intensive care have the potential to impact clinical decision-making, reduce practice variability, and improve patient outcomes. Furthermore, recognition of uncertain clinical scenarios facilitates identification of areas that would benefit from future research.

Keywords: Endotracheal suction; Intensive care; Mechanical ventilation; Pediatrics; Quality improvement; RAND/UCLA.

MeSH terms

Child
Humans
Suction*