There is sparse evidence regarding endotracheal suctioning procedures in neonatal intensive care. We undertook a systematic literature review on following topics:

1. Suctioning frequencies

2. Pre-oxygenation

3. Installation of normal saline

4. Catheter size

5. Suctioning depth

6. Suctioning strength

7. In-line suctioning versus open suctioning

8. Recruitment manoeuvres

Results showed some evidence that suctioning could safely be performed as rarely as every eight hours plus as needed, that catheter size should not be larger than 70% of internal diameter of endotracheal tube size, that catheter only should be inserted as far as the tip of the tube, and that closed in-line suctioning systems could be used, and might be beneficial in neonates.

There is to sparse evidence regarding pre-oxygenation, installation af saline, strength of vacuum and recruitment manoeuvres to give evidence based recommendation.

The Neonatal unit in University Hospital of Copenhagen then changed suctioning guidelines accordingly to the recommendations found in the literature review.

We planned an implementation strategy inspired by Berwick and Bataldan´s ‘The Breakthrough Series’, and Rogers ‘Diffusion of Innovations’, starting with baseline monitoring of chosen indicators such as incidence of occlusion of tubes, re-intubations, days on ventilator, length of stay, incidence of VAP, morbidity and mortality.

The implementation process was and is monitored by visual charts, graphs and numbers of the chosen indicators, and is a interdisciplinary focus in the unit.