I have researched this subject fairly extensively over the years as there is still much contoversy over correct suctioning technique.
During ETT suctioning the application of negative pressure sucks air from the airways and alveoli, the literature does not recommend applying negative pressure while inserting the suction catheter as this can increase the chances of atelectasis and hypoxia.
It is not recommended to insert a suction catheter too far into nasal passages and a simple method is to use the finger port (while kinking off the catheter) rather that the catheter to suction nares, especially if secretions are thick and copius.
Following is a list of references related to neonatal suctioning, hope this helps
1. Pilbeam, S. P. (2006). Mechanical Ventilation Physiological and Clinical Applications. St Louis: Mosbey Elsevier.
2. Curley, M. A., & Moloney-Harmon, P. A. (2001). Critical Care Nursing of Infants and Children 2nd Edition. Philadelphia: Saunders.
3. Moore, T. (2003). Suctioning techniques for the removal of respiratory secretions. Nursing Standard , 47-53.
4. Ireton, J. (2007). Tracheostomy Suction: a protocol for practice. Paediatric Nursing , 14-18.
5. Tracheal Suctioning of Adults with an Artificial Airway. (2000). Best Practice; Evidence Based Practice Information Sheets for Health Professionals , pp. 1-4.
6. Auckland District Health board. (n.d.). Retrieved March 2007, from National Guidelines Newborn: http://www.adhb.govt.nz/newborn/Guidelines.htm
7. Morrow, B., & Futter, M. a. (2006). Effect of Endotracheal Suction on Lung Dynamics in Mechanically-Ventilated Paediatric Patients. Australian Journal of Physiotherapy , 121-126.
8. Ward-Larson, C., Horn, R. A., & Florence, G. (2004). Facilitated Tucking for relieving Pain of Endotracheal Suctioning in Very Low Birthweight Infants. The American ournal of Child Nursing , 152-156.
9. Cordero, L., Sananes, M., & Ayers, L. (2001). A Comparison of two airway suctioning frequencies in mechanically ventilated very low birthweight infants. Respiratory Care , 783-8.
10. Wilson, G., hughes, G., Rennie, J., & Morley, C. (1992). Evaluation of Two endotracheal Suction Regimes in Babies Ventilated for Respiratory Distress Syndrome. Neonatal Network , 43-44.
11. Kuriakose, A. (2008). Using the Synergy Model as Best Practice in Endotracheal Tube Suctioning of Critically Ill Patients. Dimensions of Critical Care Nursing , 10-15.
12. Christensen, R., Rigby, G., Schmutz, N., Lambert, D., Weidmeier, S., Burnett, J., et al. (2007). ETCare; a randomised, controlled, masked trial comparing two solutions for upper airway care in the NICU. Journal of Perinatology , 479-484.
13. Klockare, M., Dufva, A., Danielsson, A.-M., Hatherly, R., Larsson, S., Jacobsson, H., et al. (2006). Comparison between direct humidification and nebulization of the respiratory tract at mechanical ventilation: distribution of the saline solution studied by gamma camera. Journal of Clinical Nursing , 301-307.
14. Pritchard, M., Flenady, V., & Woodgate, P. (2001). Preoxygenation for trachael suctioning in intubated, ventilated newborn infants. The Cochrane Library
15. Tingay, D., Copnell, B., Mills, J., Morley, C., & Dargaville, P. (2007). Effects of endotracheal suction on lung volume in infants receiving HFOV. Intensive Care Medicine , 689-693.
16. Copnell, B., Tingay, D. G., Kiraly, N. J., Sourial, M., Gordon, M. J., Mills, J. F., et al. (2007). A Comparison of the effectiveness of open and closed endotrachael suction. Intensive Care Medicine , 1655-1662.
17. Maggiore, S. M., Iacobone, E., Zito, G., Conti, G., Antonelli, M., & Proietti, R. (2002). Closed Versus open suction techniques. Minerva Anestesiologica , 360-364.
18. Woodgate, P., & Flenady, V. (2001). Trachael Suctioning without disconnection in intubated neonates. The Cochrane Database of Systematic Reviews .
19. Leur, J. P., Zwaveling, J. H., Loef, B. G., & Schans, C. P. (2003). Endotrachael suctioning versus minimally invasive airway suctioning in intubated patients: a prospective randomised controlled trial. Intensive Care Medicine , 426-432.
20. Choong, K., Chatrkaw, P., Frndova, H., & Cox, P. (2003). Comparison of loss in lung volume with open versus in-line catheter endotrachael suctioning. Pediatric Critical Care Medicine , 69-73.
21. Maggiore, S. M., Lellouche, F., Pigeot, J., Taille, S., Deye, N., Durrmeyer, X., et al. (2003). Prvention of Endotracheal Suctioning-induced Alveolar Derecruitment in Acute Lung injury. American Journal of Respiratory and Critical Care Medicine , 1215-1224.
22. Oberwaldner, B. (2000). Physiotherapy for airway clearance in paediatrics. Eurpean Respiratory Journal , 196-204.
23. Ahn, Y., & Hwang, T. (2003). The Effects of Shallow versus Deep Suctioning on the Cytological Components of Respiratiry Aspirates in High-Risk Infants. Respiration , 172-178