Endotracheal suctioning in preterm infants using four-handed versus routine care

J Obstet Gynecol Neonatal Nurs. Jan-Feb 2013;42(1):92-104. doi: 10.1111/1552-6909.12004.


Objective: To evaluate the effect of four-handed care on preterm infants' physiologic and behavioral responses to and recovery from endotracheal suctioning versus routine endotracheal (ETT) suctioning.

Design: Randomized crossover design with infants as their own controls.

Setting: Single-family-room newborn intensive care unit in an academic health center.

Participants: Ten intubated infants on conventional ventilation with inline suctioning who were fewer than 37 weeks gestation at birth, and less than one week of age.

Methods: Each infant was observed twice on a single day. One observation involved routine ETT suctioning and one involved four-handed care. Physiologic and behavioral response data were collected.

Results: No differences were noted when comparing baseline heart rate (HR) or oxygen saturation (SpO(2)) data to those obtained during and after suctioning while in the routine care condition. In the four-handed care condition, mean SpO(2) increased from preobservation 95.49 to during observation saturation 97.75 (p = .001). Salivary cortisol levels did not differ between groups at baseline or postsuctioning. No significant difference in behavior state was observed between the two conditions. More stress and defense behaviors occurred postsuctioning when infants received routine care as opposed to four-handed care (p = .001) and more self-regulatory behaviors were exhibited by infants during (p = .019) and after suctioning (p = .016) when receiving four-handed care. No statistical difference was found in the number of monitor call-backs postsuctioning.

Conclusions: Four-handed care during suctioning was associated with a decrease in stress and defense behaviors and an increase in self-regulatory behaviors.

Publication types

  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural

MeSH terms

  • Biomarkers
  • Child Development
  • Cross-Over Studies
  • Crying
  • Family Nursing
  • Female
  • Humans
  • Hydrocortisone / blood
  • Infant, Newborn
  • Infant, Premature*
  • Intensive Care Units, Neonatal
  • Intubation, Intratracheal / nursing*
  • Male
  • Multivariate Analysis
  • Pain / prevention & control*
  • Stress, Physiological
  • Stress, Psychological / prevention & control*
  • Suction / methods*


  • Biomarkers
  • Hydrocortisone