Evidence-Based Clinical Practice Guideline for the Prevention of Ventilator-Associated Pneumonia Prevention of endotracheal suctioning-induced alveolar derecruitment in acute lung injury. [Endotracheal suctioning using a 24-hour continuous system. Can costs and waste products be reduced?]. Nosocomial pneumonia in mechanically ventilated patients, a prospective randomised evaluation of the Stericath closed suctioning system Comparison of the effect of closed versus open endotracheal suction systems on the development of ventilator-associated pneumonia. Effect of different endotracheal suctioning systems on cardiorespiratory parameters of ventilated patients. Tracheal suction by closed system without daily change versus open system Changes in lung volume with three systems of endotracheal suctioning with and without pre-oxygenation in patients with mild-to-moderate lung failure A prospective, randomized study of ventilator-associated pneumonia in patients using a closed vs. open suction system. Incidence of colonization, nosocomial pneumonia, and mortality in critically ill patients using a Trach Care™ closed‐suction system versus an open‐suction system: Prospective, randomized study Closed suctioning system reduces cross-contamination between bronchial system and gastric juices. Microbial colonization of closed-system suction catheters used in liver transplant patients. [Effects of a closed endotracheal suction system on oxygen saturation, ventilator-associated pneumonia, and nursing efficacy]. Ventilator-associated pneumonia using a closed versus an open tracheal suction system Open and Closed-circuit Endotracheal Suctioning in Acute Lung Injury: Efficiency and Effects on Gas Exchange Closed versus open endotracheal suctioning: Costs and physiologic consequences Effects of Endotracheal Tube Suctioning on Arterial Oxygen Tension and Heart Rate Variability
Critically ill patients in the intensive care unit ( ICU ) are at high risk for infections associated with increased morbidity , mortality , and health care costs ( 1 - 3 ) . The overall infection rate in critically ill patients approaches 40 % and may be as high as 50 % or 60 % in patients who remain in the ICU for more than 5 days ( 4 , 5 ) . Respiratory tract infections account for 30 % to 60 % of all such infections . The incidence of pneumonia acquired in the ICU ranges from 10 % to 65 % ( 6 - 11 ) . Among patients at high risk for ventilator-associated pneumonia ( VAP ) are those who have chronic obstructive pulmonary disease , burns , neurosurgical conditions , the acute respiratory distress syndrome , and witnessed aspiration ; those who are reintubated ; and those who receive paralytic agents or enteral nutrition ( 12 , 13 ) . The attributable morbidity and mortality of VAP are clinical ly important . In a prospect i ve , matched cohort study , patients with VAP remained in the ICU 4.3 days ( 95 % CI , 1.5 to 7.0 days ) longer than patients who did not have VAP and had a trend toward an increased risk for death ( absolute risk increase , 5.8 % [ CI , 2.4 % to 14.0 % ] ) ( 14 ) . Six other studies using a matching strategy found a prolonged length of ICU stay associated with VAP ( range , 5 to 13 days ) and attributable mortality ranging from an absolute risk increase of 0 % to 50 % ( 15 - 20 ) . Therefore , strategies to decrease the incidence of VAP could decrease morbidity , mortality , and health care costs and improve patient safety . A survey of the use of VAP prevention strategies identified differences across countries ( 21 ) . For example , changing the ventilator circuit for each new patient was reported more frequently by French ICU directors than those in Canada ( 21 ) . This survey also showed that some effective strategies were used infrequently , suggesting inadequate translation of r and omized trial results into practice . One potential catalyst for knowledge translation is an evidence -based clinical practice guideline . Therefore , a Joint Planning Group of the Canadian Critical Care Society and Canadian Critical Care Trials Group commissioned the development of an evidence -based clinical practice guideline for the prevention of VAP . In this paper , we describe the methods used to create the guideline and the recommendations generated . Methods The Joint Planning Group selected an 11-member VAP Prevention Guideline Panel made up of 9 intensivists from university-affiliated and community hospitals , an ICU nurse , and an ICU respiratory therapist . Panel members were experts in critical care medicine ( n= 9 ) , VAP ( n= 4 ) , evidence -based medicine ( n= 4 ) , and guideline development ( n= 3 ) . The context was mechanically ventilated adult patients cared for in the ICU . The target audience was ICU clinicians in university-affiliated and community hospitals . To identify potentially relevant evidence , we search ed 3 bibliographic data bases ( MEDLINE , EMBASE , and the Cochrane Data base of Systematic Review s ) to 1 April 2003 for r and omized trials that evaluated interventions influencing VAP ( Appendix ) . We had no language restrictions . We also review ed personal files and practice guidelines on this subject previously published by the Centers for Disease Control and Prevention ( 22 ) and the American Thoracic Society ( 23 ) . We included r and omized trials and systematic review s of r and omized trials that 1 ) studied adult critically ill patients ; 2 ) had VAP as an outcome ; and 3 ) evaluated any of the following interventions : physical strategies ( route of endotracheal intubation , systematic search for maxillary sinusitis , frequency of ventilator circuit changes , type of airway humidification , frequency of humidifier changes , endotracheal suctioning system , subglottic secretion drainage , chest physiotherapy , and tracheostomy timing ) , positional strategies ( kinetic beds , semi-recumbent positioning , and prone positioning ) , and pharmacologic strategies ( stress ulcer prophylaxis and prophylactic antibiotics , including selective decontamination of the digestive tract ) . Since study authors used various definitions of VAP , we used the definitions they provided . The most common definition was a new or persistent radiographic infiltrate plus fever , leukocytosis , change in the volume or color of sputum , or isolation of a pathogen . If available , histologic evidence of pneumonia was also used . A priori , we decided to review only systematic review s of r and omized clinical trials for antibiotic prophylaxis and only r and omized clinical trials for all other topics . We excluded crossover and beforeafter studies . We also excluded r and omized trials of ventilator weaning , including noninvasive mechanical ventilation , and nutritional interventions evaluating VAP because guidelines addressing these topics have recently been published ( 24 , 25 ) . In duplicate and independently , 3 pairs of panel members critically appraised each trial ( 26 , 27 ) and systematic review ( 28 ) . Each member of a pair compared his or her independent appraisal of a given trial or systematic review with that of the other member of the pair . For each r and omized trial , we abstract ed sample , allocation , intervention , co- interventions , exclusions after r and omization , blinding of outcome assessment , definition of VAP , crude VAP events , relative risk for VAP , and other outcomes . For each intervention , we summarized the risk differences and calculated a pooled risk difference . For each systematic review , we abstract ed number of trials , population , intervention , selection criteria , search strategy , validity assessment , method of pooling results , homogeneity assessment , VAP definition , pooled event rates , and other outcomes . Before the panel meeting , each pair of appraisers achieved consensus on the validity and results of the trials they review ed . One month before the panel meeting , panel members received the evidence tables for review prepared by the 3 pairs of appraisers . A priori , panel members agreed to read all circulated documents and evidence tables in advance , to use levels of evidence to generate a status statement for each item , and to abide by the group process and consensus methods . The Canadian Critical Care Society appointed a chair to ensure that the panel achieved its objectives through group process ( 29 ) . At the panel meeting , each member recorded any potential conflicts of interest ( 30 ) . The pair of panel members responsible for critical appraisal of each intervention provided a structured written and oral presentation of the evidence . After the panel discussion , the initial evidence summary was revised if necessary . The panel members assigned levels of evidence , semi-quantitative scores to summarize the evidence and describe the intervention , and a status statement . We classified trials as level 1 if they had all of the following : concealed r and omization , blinded outcome adjudication , an intention-to-treat analysis , and an explicit definition of VAP . Trials were classified as level 2 if any one of these characteristics was unfulfilled and as level 3 if allocation was not strictly r and omized . We used a semi-quantitative score ( 0 , 1 , 2 , or 3 ) to evaluate each intervention with respect to the validity of the r and omized trials ; the effect size of each intervention ; the confidence intervals around the estimate of effect ; the homogeneity of the trial results ; and the safety , feasibility , and economic consequences of the intervention . The language of the status statement for each item was keyed to the levels of evidence and the semi-quantitative scores . We used the term recommended if there were no reservations about endorsing an intervention and the term considered if the evidence supported an intervention but there were minor uncertainties about the benefits , harms , or costs . No recommendation was made if evidence regarding an intervention was inadequate or if there were major uncertainties about the benefits , harms , or costs . After the panel meeting , the chair compiled the summaries and status statements and sent them to all panel members to check accuracy and clarity . In addition , the pairs of evidence appraisers wrote background documents for the interventions they appraised , including the rationale for each intervention , appraisal of r and omized trials and systematic review s , and harms and costs of the interventions . The chair and the writing committee organized the background documents , the evidence summaries , a table of the semi-quantitative scores , and the status statement for each item . We formatted the document with a structured abstract ( 31 ) , a summary of the evidentiary basis for each recommendation , and a status statement for each item . We also created a quick reference guide . The draft guideline document was su bmi tted for structured external review by the executives of the Canadian Critical Care Society and the Canadian Critical Care Trials Group and the respective executives of the Canadian Association of Critical Care Nurses , Canadian Society of Respiratory Therapists , Canadian Infectious Disease Society , and Canadian Thoracic Society . External review ers were asked to critique whether the guideline was logical , clear , and practical and to critique the guideline development process . The panel revised the document on the basis of this feedback . The final guideline was returned to the external review ers for further comments and official endorsement by their respective organizations . The final guideline was then piloted in 2 institutions . To record the agreement of each panel member with the final status statement for each item , we sent the final document to all panel members . Independently , blinded to each other 's ratings , panel members used a Likert scale from 1 to 9 that was anchored by disagree completely at the low end and agree completely at the high end . The panel will formally review and up date this guideline every 2 years ( 32 ) . The funding source played no role in study selection for this guideline and had no role in its We studied endotracheal suctioning-induced alveolar derecruitment and its prevention in nine patients with acute lung injury .  Changes in end-expiratory lung volume measured by inductive plethysmography , positive end-expiratory pressure-induced alveolar recruitment assessed by pressure-volume curves , oxygen saturation , and respiratory mechanics were recorded . Suctioning was performed after disconnection from the ventilator , through the swivel adapter of the catheter mount , with a closed system , and with the two latter techniques while performing recruitment maneuvers during suctioning ( 40 cm H2O pressure-supported breaths ) . End-expiratory lung volume after disconnection fell more than with all other techniques ( -1,466 + /- 586 , -733 + /- 406 , -531 + /- 228 , -168 + /- 176 , and -284 + /- 317 ml after disconnection , through the swivel adapter , with the closed system , and with the two latter techniques with pressure-supported breaths , respectively , p < 0.001 ) , and was not fully recovered 1 minute after suctioning . Recruitment decreased after disconnection and using the swivel adapter ( -104 + /- 31 and -63 + /- 25 ml , respectively ) , was unchanged with the closed system ( -1 + /- 10 ml ) , and increased when performing recruitment maneuvers during suctioning ( 71 + /- 37 and 60 + /- 30 ml ) ( p < 0.001 ) . Changes in alveolar recruitment correlated with changes in lung volume ( rho = 0.88 , p < 0.001 ) and compliance ( rho = 0.9 , p < 0.001 ) . Oxygenation paralleled lung volume changes . Suctioning-induced lung derecruitment in acute lung injury can be prevented by performing recruitment maneuvers during suctioning and minimized by avoiding disconnection Suctioning of the airways is often required in critically ill , intubated , or tracheotomised patients . In addition to the primary cost of these disposable material s , expenditures for waste disposal and environmental problems due to plastics should also be considered . In this study , the primary costs and amount of waste products of the closed suction system " Trach Care " were compared with a conventional disposable system . Other advantages and disadvantages of a closed suction system are discussed . METHODS . In this prospect i ve , r and omised investigation , both the open disposable suction system and the closed Trach Care system were used , in 60 patients ( 30 in each group ) who were intubated for 1 week or more . During the first 7 days , we counted the number of times  endotracheal suctioning  was performed and measured the time it took . The costs of purchasing the systems , amounts of waste products , and costs of disposal were compared . RESULTS . The frequency of endotracheal suctioning was quite different from patient to patient and varied from 6 to 41 times per day . On average it was necessary 15 times per day per patient in both groups . Using the disposable system , a mean time of 3.5 min was measured in contrast to 2.5 min with the closed system . The costs of purchase were much lower with the disposable system taking into account all material s needed ( 17.36 DM vs 53.36 DM per day ) , whereas the weight of litter produced by the closed system was lower ( 429 g vs 745 g per day ) , the costs of disposal being accordingly different . During endotracheal suctioning O2 desaturation was not observed with the closed system , whereas in patients with acute respiratory failure  O2 saturation fell rapidly from 90 % to as far as 70 % when a disposable system was used . CONCLUSION . The closed Trach Care suction system is more expensive to acquire , but may reduce the risk of exogenous nosocomial pneumonias as disconnections from the ventilator are minimised . The workload , weight of waste products , and costs of disposal are lower using the Trach Care system . From the physician 's viewpoint , the main advantage of the Trach Care system becomes evident in patients with acute respiratory failure and patients with elevated intracranial pressure . In these cases , we now favor the Trach Care system as a matter of principle Objective : To compare the ventilator-associated pneumonia ( VAP ) incidence rates in mechanically ventilated patients according to the type of endotracheal suctioning ( closed versus open ) . Setting : The Neurosurgery Intensive Care Unit of the Grenoble University Hospital , France . Design : A prospect i ve r and omised study performed after a 6-month period of nursing personnel training . Patients : One hundred four consecutive patients needing mechanical ventilation for more than 48 h were r and omised into two groups . To be eligible , patients had to have no active infection or respiratory affection in their passes . In the Stericath group ( S + , n = 54 ) , patients were not disconnected from the ventilator during suctioning . The others were routinely managed ( S– , n = 50 ) . In both groups patterns of frequency and duration of suctioning were performed according to a st and ardised protocol .¶ Measurements : The non-adjusted incidence rate of VAP was lower for S + than for S– ( 7.32 versus15.89 per 1000 patient-days , p = 0.07 ) . Multivariate analysis performed using the Cox model showed an adjusted risk of VAP 3.5 times higher in S– ( 95 % Cl : 11.00–12.33 ) . The risk being 4.3 higher in patients receiving gastric acid secretion inhibitors ( 1.08–16.82 ) . In non-censored cases ( n = 76 ) length of ICU stay increased by an average of 16.8 days when VAP was present ( p = 0.0008 ) . No adverse effect due to Stericath use was noted and volume of tracheal aspirate was similar between groups ( p = 0.178 ) . Conclusion : The use of Stericath  reduced the incidence rate of VAP without demonstrating any adverse effect The aim of this study was to compare the effect of closed versus open endotracheal suction systems on the development of  ventilator-associated pneumonia ( VAP ) . A prospect i ve , r and omized , controlled trial was performed in a medical intensive care unit ( MICU ) of a university hospital in patients who received mechanical ventilation for more than 48 h. Patients were r and omized to receive endotracheal suction with either closed catheters ( closed suction group ; N-41 ) or single-use catheters ( open suction group ; N=37 ) . Cultures were taken from the ventilator tubing of 42 patients to determine the rate of colonization . There was no difference between the groups in terms of the frequency of development of VAP , mortality in the MICU , length of MICU stay and duration of mechanical ventilation .  Thirteen patients in the open suction group and 16 patients in the closed suction group became colonized ( P=0.14 ) . The colonization rates by Acinetobacter spp . and Pseudomonas aeruginosa were more frequent in the closed suction group than in the open suction group ( P<0.01 and P=0.04 , respectively ) . In conclusion , closed endotracheal suction result ed in increased colonization rates of ventilator tubing with multi drug-resistant micro-organisms but did not increase the development of VAP and MICU outcome compared with open endotracheal suction INTRODUCTION We conducted this prospect i ve r and omised cross-over study to evaluate the effect of closed system ( CS ) versus open system ( OS ) endotracheal suctioning on heart rate ( HR ) , mean arterial pressure ( MAP ) , respiratory rate ( RR ) , oxygen saturation ( SpO2 ) and electrocardiogram ( ECG ) rhythm of patients on mechanical ventilation . MATERIAL S AND METHODS Fourteen adult patients were r and omly allocated to receive either CS or OS suctioning in the first instance . For the subsequent suctioning , they were crossed over to the alternate suctioning system . The various cardiorespiratory parameters were recorded at BL1 ( baseline 1 ) , S1 ( first suction pass ) , BL2 ( baseline 2 , i.e. immediately post first suction pass ) , S2 ( second suction pass ) , T2 ( 2 minutes post suction ) and T5 ( 5 minutes post suction ) . RESULTS Compared to CS , OS suctioning was found to result in higher HR at S1 ( P < or = 0.05 ) and S2 ( P < or = 0.05 ) ; higher MAP at BL2 ( P < or = 0.05 ) ; lower SpO2 at BL2 ( P < or = 0.01 ) and S2 ( P < or = 0.01 ) . There was no significant difference in RR between the two suctioning systems . OS suctioning was also noted to result in a significantly higher incidence of arrhythmia ( P < = or 0.05 ) . CONCLUSION Our study shows that OS suctioning results in more adverse changes in cardiorespiratory parameters compared to CS suctioning Background Tracheal suctioning costs are higher with a closed tracheal suction system ( CTSS ) than with an open system ( OTSS ) , due to the need for complete daily change as recommended by the manufacturer . However , is it necessary to change the closed system daily ? Objective To evaluate the tracheal suctioning costs and incidence of ventilator-associated pneumonia ( VAP ) using closed system without daily change vs OTSS . Design Prospect i ve and r and omised study . Setting An Intensive Care Unit in a university hospital . Patients Patients requiring mechanical ventilation . Interventions Patients were r and omly assigned to CTSS without daily change or OTSS . We used a CTSS that allowed partial or complete change . Measurements and results There were no significant differences between both groups of patients ( 236 with CTSS and 221 with OTSS ) in gender , age , diagnosis ,  APACHE-II score , mortality , number of aspirations per day , percentage of patients who developed VAP ( 13.9 vs 14.1 % ) or the number of ventilator-associated pneumonia per 1000 days of mechanical ventilation ( 14.1 vs 14.6 ) . There were not significant differences in tracheal suctioning costs per patient/day between CTSS vs OTSS ( 2.3 ± 3.7 vs 2.4 ± 0.5 Euros ; p = 0.96 ) ; however , when length of mechanical ventilation was lower than 4 days , the cost was higher with CTSS than with OTSS ( 7.2 ± 4.7 vs 1.9 ± 0.6 Euros ; p < 0.001 ) ; and when length of mechanical ventilation was higher than 4 days , the cost was lower with CTSS than with OTSS ( 1.6 ± 2.8 vs 2.5 ± 0.5 Euros ; p < 0.001 ) . Conclusion CTSS without daily change is the optimal option for patients needing tracheal suction longer than 4 days Objective To compare changes in lung volume , oxygenation , airway pressure , and hemodynamic effects induced by suctioning with three systems in critically ill patients with mild-to-moderate lung disease , and also to evaluate the effects of hyperoxygenation applied prior to the maneuver as suggested by some guidelines . Design Prospect i ve crossover study . Setting General intensive care department of a university-affiliated hospital . Patients Ten mechanically ventilated patients with mild-to-moderate acute respiratory failure . Interventions Patients were ventilated in volume control mode with a mean tidal volume of 490±88 ml , PEEP 7±4 cmH2O and FiO2 0.36±0.05 . Suctioning was performed sequentially with a quasi-closed system , with an open system 10 min later , and finally with a closed system . Thereafter , pure oxygen was applied for 2 min and the whole suctioning sequence was repeated in reverse order . Measurements and main results Patients ’ mean PaO2/FiO2 ratio was 273±28 mmHg . The reductions in lung volume during suctioning were similar with the quasi-closed ( 386±124 ml ) and closed system ( 497±338 ml ) , but significantly higher with the open system ( 1281±656 ml , P=0.022 ) . We found no significant hemodynamic adverse effects , and no significant SpO2 reductions with all the studied suctioning techniques . Pre-oxygenation with pure oxygen did not induce additive effects in lung volume changes . With and without pre-oxygenation , lung volume returned to baseline in every patient within 10 min . Conclusions Suctioning with closed and quasi-closed systems reduces the substantial losses in lung volume observed with the open system . Nevertheless , in patients without severe lung disease these changes were transient and rapidly reversible The objective of this study was to verify the incidence of nosocomial pneumonia in intubated and extended mechanically ventilated patients having endotracheal suctioning by an open vs. closed suction method aim ing to decrease nosocomial pneumonia .  Twenty-four ( 51.1 % ) patients received open-tracheal suction and 23 ( 48.9 % ) received closed-tracheal suction .  The inclusion criteria were : surgical and medical patients older than 13 years , undergoing mechanical ventilation for more than 48 hours . Additional data were gathered using the Acute Physiology and Chronic Health Evaluation II , and details on smoking , alcoholism , diabetes mellitus , renal failure , previous lung disease , and previous use of antibiotics , steroids , H2 antagonists and antacids . Among the 24 patients having open-tracheal suction , 11 developed nosocomial pneumonia while of the 23 patients undergoing closed-tracheal suction , seven developed infection ( P = 0.278 ) . Risk factors for nosocomial pneumonia were not significantly different between the two groups . In the final logistical regression model the following variables remained : groups ( open and closed ) [ odds ratio ( OR ) = 0.014 ; confidence interval ( CI ) = 0.001 - 0.416 ; P = 0.014 ] and use of prior antibiotics ( OR = 2.297 ; CI = 1.244 - 4.242 ; P = 0.008 ) . Use of a closed suction system did not decrease the incidence of nosocomial pneumonia when compared with the open system . The exogenous risk factors were the most important for acquiring this infection Eighty-four intubated , mechanically ventilated patients were prospect ively evaluated for incidences of colonization and nosocomial pneumonias dependent on whether they received  endotracheal suctioning by an “ open ” suction method vs. “ closed ” suction ( Trach Care ™ Closed Suction System ) method . Results show that closed suctioning is associated with a significant ( 67 % vs. 39 % p < .02 ) increase in colonization compared with open suctioning . However , difference in the incidence of nosocomial pneumonia was not significantly ( 26 % vs. 29 % ) different between closed and open suctioning . Differences in severity of illness ( Acute Physiology and Chronic Health Evaluation II and Therapeutic Intervention Scoring System ) , age , sex , presence of NG tubes , use of H2 antagonists or antacids , use of antibiotics , and history of smoking were all nonsignificant . Survival analysis demonstrated that the probability of survival without developing nosocomial pneumonia was greater among closed-suctioning patients vs. open-suctioned patients ( p < .03 ) . This study shows that suctioning performed via the Trach Care closed-suction system  increases the incidence of colonization but not the incidence of nosocomial pneumonia , and may actually decrease mortality when compared with open-suction systems In this prospect i ve , r and omized study , we evaluated whether a closed suctioning ( CS ) system ( TrachCare ) influences crossover contamination between bronchial system and gastric juices when compared with an open suctioning system ( OS ) . The secondary aims were an analysis of the frequency of ventilator-associated pneumonia ( VAP ) and an analysis of alteration in gas exchange . Antibiograms were performed from tracheal secretions and gastric juice aspirates on Days 1 and 3 of intubation in 24 patients in a medical intensive care unit . Five cross-contaminations were observed in the OS group on Day 3 versus Day 1 ; the 5 strains shared common genotypes as determined by r and om amplification of polymorphic DNA . No cross-contaminations were seen in the CS group ( P = 0.037 ) . VAP occurred in 5 patients of the OS group but in none of the CS group patients ( P = 0.037 ) . Spao(2 ) decreased significantly in the OS group compared with presuctioning values -- the opposite of the CS group . Whereas presuctioning values were comparable between groups , postsuctioning Spao(2 ) was significantly higher in the CS group . CS significantly reduced cross-contamination between bronchial system and gastric juices and reduced the incidence of VAP when compared with OS .  Hypoxic phases can be reduced by the help of CS The microbial colonization and the associated risk of respiratory infection during the application of a multiple-use closed-system suction catheter ( CSSC ) and a single-use open-system suction catheter ( OSSC ) on liver transplant patients was evaluated in this preliminary study . The cost differential for the two systems was also compared . Twenty post-orthotopic liver transplant ( OLTx ) patients who were mechanically ventilated via an endotracheal ( ET ) tube were studied . Ten subjects were r and omly allocated  ET suction  by the CSSC and 10 with OSSC . Both groups were similar according to age , sex , clinical severity , presence of a naso-gastric tube , use of H2 antagonists and antibiotics used . St and ard protocol s were followed to intubate and suction the patients and to change ventilatory equipment . Suctioning performed with the CSSC did not significantly increase the risk of microbial colonization of the respiratory tract . Similarly there was no apparent difference in the incidence of nosocomial pneumonia between the two suction systems , based on the microbiological and clinical data . The mean daily cost of using the CSSC compared to the OSSC was 11.6 times higher . This may be balanced by a reduction in nursing time and reduced risk of spread of infection associated with the CSSC PURPOSE The purpose of this study was to examine the effects of a closed endotracheal suction system(CES ) on oxygen saturation , ventilator associated pneumonia(VAP ) , and nursing efficacy in mechanically ventilated patients . METHOD This study was conducted in the intensive care unit of a University Hospital in Gwangju City . Data was collected from July to October , 2003 . Seventy mechanically ventilated patients were r and omly divided into two groups ; 32 for CES and 38 for open endotracheal suction system(OES ) protocol . Twenty one nurses were also involved to examine the nurses ' attitude of usefulness about CES . RESULT SaO(2 ) was significantly different between CES and OES . The incidence of VAP in CES was lower than that of OES .  Nursing efficacy was related to time , cost , and usefulness of the suction system . Time of suctioning in CES was shorter than that of OES . CES also contributed significantly to lower the cost of treatment than OES . The usefulness score of CES  increased after 6 months of use . CONCLUSION CES prevented VAP , was cost effective , and a safe suctioning system . CES ncan be used with patients with sensitivity to hypoxygenation and with a high risk of VAP Objective : The aim of this study was to analyze the prevalence of ventilator-associated pneumonia ( VAP ) using a closed-tracheal suction system vs. an open system . Design : Prospect i ve and r and omized study , from October 1 , 2002 , to December 31 , 2003 . Setting : A 24-bed medical-surgical intensive care unit in a 650-bed tertiary hospital . Patients : Patients requiring mechanical ventilation for > 24 hrs . Interventions : Patients were r and omized into two groups ; one group was suctioned with the closed-tracheal suctioning system and another group with the open system . Measurements : Throat swabs were taken at admission and twice a week until discharge to classify pneumonia in endogenous and exogenous . Main Results : A total of 443 patients ( 210 with closed-tracheal suction system and 233 with the open system ) were included . There were no significant differences between groups of patients in age , sex , diagnosis groups , mortality , number of aspirations per day , and Acute Physiology and Chronic Health Evaluation II score . No significant differences were found in either the percentage of patients who developed VAP ( 20.47 % vs. 18.02 % ) or in the number of VAP cases per 1000 mechanical ventilation-days ( 17.59 vs. 15.84 ) . There were also no differences in the VAP incidence by mechanical ventilation duration . At the same time , we did not find any differences in the incidence of exogenous VAP . Likewise , there were also no differences in the microorganisms responsible for pneumonia . Patient cost per day for the closed suction was more expensive than the open suction system ( $ 11.11 ± $ 2.25 vs. $ 2.50 ± $ 1.12 , p < .001 ) . Conclusion : We conclude that in our study , the closed-tracheal suction system did not reduce VAP incidence , even for exogenous pneumonia Background : Closed-circuit endotracheal suctioning ( CES ) is advocated for preventing hypoxemia caused by the loss of lung volume result ing from open endotracheal suctioning ( OES ) . However , the efficiency of CES and OES on tracheal secretion removal has never been compared in patients with acute lung injury . The authors design ed a two-part study aim ed at comparing gas exchange and efficiency between OES and CES performed at two levels of negative pressure . Methods : Among 18 patients with acute lung injury , 9 underwent CES and OES at 3-h intervals in a r and om order using a negative pressure of −200 mmHg . Nine other patients underwent CES twice using two levels of negative pressure ( −200 and −400 mmHg ) applied in a r and om order . After each CES , a recruitment maneuver was performed using 20 consecutive hyperinflations . Tracheal aspirates were weighed after each suctioning procedure . Arterial blood gases were continuously recorded using an intravascular sensor . Results : Open endotracheal suctioning induced a significant 18 % decrease in arterial oxygen tension ( Pao2 ) ( range , + 13 to −71 % ) and an 8 % increase in arterial carbon dioxide tension ( Paco2 ) ( range , −2 to + 16 % ) that persisted 15 min after the end of the procedure . CES using −200 cm H2O did not change Pao2 , but tracheal aspirate mass was lower compared with OES ( 0.6 ± 1.0 vs. 3.2 ± 5.1 g ; P = 0.03 ) . Increasing negative pressure to −400 cm H2O during CES did not change Pao2 but increased the tracheal aspirate mass ( 1.7 ± 1.6 vs. 1.0 ± 1.3 g ; P = 0.02 ) . Conclusions : Closed-circuit endotracheal suctioning followed by a recruitment maneuver prevents hypoxemia result ing from OES but decreases secretion removal . Increasing suctioning pressure enhances suctioning efficiency without impairing gas exchange Objective To examine the physiologic consequences and costs associated with two methods of endotracheal suctioning : closed vs. open . Design A prospect i ve , r and omized , controlled study . Setting An eight-bed trauma intensive care unit ( ICU ) in a 460-bed level I trauma center . Patients The study included 35 trauma/general surgery patients ( 16 in the open suction group , 19 in the closed suction group ) who were treated with a total of 276 suctioning procedures ( 127 open , 149 closed ) . Measurements and Main Results Physiologic data collected after hyperoxygenation , immediately after suctioning , and 30 sees after suctioning , were compared with baseline values . Open endotracheal suctioning result ed in significant increases in mean arterial pressure throughout the suctioning procedure . Both methods result ed in increased mean heart rates . However , 30 sees after the procedure , the open-suction method was associated with a significantly higher mean heart rate than was the closed method . Closed suctioning was associated with significantly fewer dysrhythmias . Arterial oxygen saturation and systemic venous oxygen saturation decreased with open suctioning . In contrast , arterial oxygen saturation and systemic venous oxygen saturation increased with the closed suction method . There was no difference between the two methods in the occurrence of nosocomial pneumonia .  Open endotracheal suctioning  cost 1.88 more per patient per day and required more nursing time . Conclusions The closed suction method result ed in significantly fewer physiologic disturbances .  Closed suctioning appears to be an effective and cost-efficient method of endotracheal suctioning that is associated with fewer suction-induced complications . ( Crit Care Med 1994 ; 22:658–666 The purpose of this study was to examine the autonomic mechanisms underlying changes in heart rate ( HR ) and systolic blood pressure ( SBP ) responses to endotracheal tube ( ETT ) suctioning and to compare the open versus closed methods of ETT suctioning on these measures and on arterial oxygen tension . Eighteen orally intubated participants , 33 to 82 years of age ( M = 60 years ) , were r and omized for the order of suctioning method . Arterial oxygen tension ( PaO 2 ) was measured before suctioning and 30 s and 5 min following suctioning . Beat-to-beat HR and arterial blood pressure data were collected for 10-min periods before and after suctioning . HR and SBP measures were analyzed before suctioning and 1 min and 5 min following suctioning . Although there were no significant effects of ETT suctioning on the autonomic mechanisms of HR modulation and no significant differences between the two methods of suctioning , ETT suctioning result ed in an increase in HR , SBP , and PaO 2 . However , there was a decrease in the parasympathetic nervous system indicator of HR variability ( HRV ) following open suctioning . All patients in this study maintained a PaO 2 level 80 mm Hg , which may account for our lack of significant autonomic changes . This suggests that hyperoxygenation with 100 % oxygen for a minimum of 1 min ( or 20 breaths ) , as delivered by preoxygenation modes available on most microprocessor ventilators , should be the method of choice for all hyperoxygenation procedures to avoid a decrease in PaO 2 following suctioning
OBJECTIVES This study attempted to identify which is the more effective suction system .
The objective was to compare open versus closed suction systems according to a systematic review .