A prospective, randomized study of ventilator-associated pneumonia in patients using a closed vs. open suction system. Ventilator-associated pneumonia using a closed versus an open tracheal 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. Comparison of the effect of closed versus open endotracheal suction systems on the development of ventilator-associated pneumonia. Nosocomial pneumonia in mechanically ventilated patients, a prospective randomised evaluation of the Stericath closed suctioning system. Closed system endotracheal suctioning maintains lung volume during volume-controlled mechanical ventilation. Tracheal suction by closed system without daily change versus open system. [Endotracheal suctioning using a 24-hour continuous system. Can costs and waste products be reduced?]. Randomized, controlled trial on tracheal colonization of ventilated infants: can gravity prevent ventilator-associated pneumonia? Closed versus open endotracheal suctioning: costs and physiologic consequences. Closed suctioning system reduces cross-contamination between bronchial system and gastric juices. Open and closed-circuit endotracheal suctioning in acute lung injury: efficiency and effects on gas exchange.
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 aiming 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. 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.
                Prospective and randomized study, from October 1, 2002, to December 31, 2003.
                A 24-bed medical-surgical intensive care unit in a 650-bed tertiary hospital.
                Patients requiring mechanical ventilation for >24 hrs.
                Patients were randomized into two groups; one group was suctioned with the closed-tracheal suctioning system and another group with the open system.
                Throat swabs were taken at admission and twice a week until discharge to classify pneumonia in endogenous and exogenous.
                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 US dollars +/- 2.25 US dollars vs. 2.50 US dollars +/- 1.12 US dollars, p < .001).
                We conclude that in our study, the closed-tracheal suction system did not reduce VAP incidence, even for exogenous pneumonia. Eighty-four intubated, mechanically ventilated patients were prospectively 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 less than .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 less than .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. 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 prospective, randomized, 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 randomized 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 resulted 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. To compare the ventilator-associated pneumonia (VAP) incidence rates in mechanically ventilated patients according to the type of endotracheal suctioning (closed versus open).
                The Neurosurgery Intensive Care Unit of the Grenoble University Hospital, France.
                A prospective randomised study performed after a 6-month period of nursing personnel training.
                One hundred four consecutive patients needing mechanical ventilation for more than 48 h were randomised 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 standardised protocol.
                The non-adjusted incidence rate of VAP was lower for S+ than for S- (7.32 versus 15.89 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% CI: 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).
                The use of Stericath reduced the incidence rate of VAP without demonstrating any adverse effect. A closed suction system (CS) maintains connection with the mechanical ventilator during tracheal suctioning and is claimed to limit loss in lung volume and oxygenation. We compared changes in lung volume, oxygenation, airway pressure and hemodynamics during endotracheal suctioning performed with CS and with an open suction system (OS).
                Prospective, randomized study.
                Intensive care unit in a university hospital.
                We enrolled ten patients, volume-controlled (VC) ventilated with a Siemens Servo 900 ventilator (PaO2/FIO2 192 +/- 70, PEEP 10.7 +/- 3.9 cmH2O).
                We performed four consecutive tracheal suction maneuvers, two with CS and two with OS, at 20-min intervals. During the suction maneuvers continuous suction was applied for 20 s.
                We measured end-expiratory lung volume changes (delta VL), tidal volume (VTrt), respiratory rate (RR) and minute volume (VErt) by respiratory inductive plethysmography; arterial oxygen saturation (SpO2), airway pressure and arterial pressure (PA). Loss in lung volume during OS (delta VL 1.2 +/- 0.7 l) was significantly higher than during CS (delta VL 0.14 +/- 0.1 l). During OS we observed a marked drop in SpO2, while during CS the change was only minor. During CS ventilation was not interrupted and we observed an immediate increase in RR (due to the activation of the ventilator's trigger), while VTrt decreased, VErt was maintained.
                Avoiding suction-related lung volume loss can be helpful in patients with an increased tendency to alveolar collapse; CS allows suctioning while avoiding dramatic drops in lung volumes and seems to be safe during the VC ventilation setting that we used. 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?
                To evaluate the tracheal suctioning costs and incidence of ventilator-associated pneumonia (VAP) using closed system without daily change vs OTSS.
                Prospective and randomised study.
                An Intensive Care Unit in a university hospital.
                Patients requiring mechanical ventilation.
                Patients were randomly assigned to CTSS without daily change or OTSS. We used a CTSS that allowed partial or complete change.
                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 4days, the cost was lower with CTSS than with OTSS (1.6+/-2.8 vs 2.5+/-0.5 Euros; p<0.001).
                CTSS without daily change is the optimal option for patients needing tracheal suction longer than 4 days. Suctioning of the airways is often required in critically ill, intubated, or tracheotomised patients. In addition to the primary cost of these disposable materials, 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 prospective, randomised 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 materials 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. The goal was to test the hypothesis that intubated infants positioned on their sides would be less likely to contract bacterial colonization in their tracheae, compared with those positioned supine.
                We conducted a prospective, randomized, controlled trial with 60 intubated infants; 30 infants were positioned supine (supine group), and 30 infants were maintained in the lateral position (lateral group). Tracheal aspirates were cultured and bacterial colony counts were recorded after 48 hours and after 5 days of mechanical ventilation.
                After 2 days, the numbers of positive tracheal cultures in the supine group (67%) and in the lateral group (47%) showed no statistical difference. After 5 days of mechanical ventilation, tracheal cultures differed significantly between groups. Cultures were positive for 26 infants (87%) in the supine group and 9 infants (30%) in the lateral group. Compared with the lateral group, more infants in the supine group experienced increased colony counts or had new organisms in their tracheal aspirates over time (21 vs 8 infants). The most common organisms isolated from tracheal aspirates in both groups were Gram-negative rods.
                Respiratory contamination is very common among ventilated infants. Therefore, judicious use of mechanical ventilation cannot be overemphasized. Gravitational force can ameliorate the onset of respiratory colonization. The mechanism and clinical applicability of such observations need to be explored further. To examine the physiologic consequences and costs associated with two methods of endotracheal suctioning: closed vs. open.
                A prospective, randomized, controlled study.
                An eight-bed trauma intensive care unit (ICU) in a 460-bed level I trauma center.
                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).
                Physiologic data collected after hyperoxygenation, immediately after suctioning, and 30 secs after suctioning, were compared with baseline values. Open endotracheal suctioning resulted in significant increases in mean arterial pressure throughout the suctioning procedure. Both methods resulted in increased mean heart rates. However, 30 secs 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.
                The closed suction method resulted 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. In this prospective, randomized 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 random 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. Closed-circuit endotracheal suctioning (CES) is advocated for preventing hypoxemia caused by the loss of lung volume resulting 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 designed a two-part study aimed at comparing gas exchange and efficiency between OES and CES performed at two levels of negative pressure.
                Among 18 patients with acute lung injury, 9 underwent CES and OES at 3-h intervals in a random 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 random 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.
                Open endotracheal suctioning induced a significant 18% decrease in arterial oxygen tension (Pa(O2)) (range, +13 to -71%) and an 8% increase in arterial carbon dioxide tension (Pa(CO2)) (range, -2 to +16%) that persisted 15 min after the end of the procedure. CES using -200 cm H2O did not change Pa(O2), 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 Pa(O2) but increased the tracheal aspirate mass (1.7 +/- 1.6 vs. 1.0 +/- 1.3 g; P = 0.02).
                Closed-circuit endotracheal suctioning followed by a recruitment maneuver prevents hypoxemia resulting from OES but decreases secretion removal. Increasing suctioning pressure enhances suctioning efficiency without impairing gas exchange.
Results from 16 trials showed that suctioning with either closed or open tracheal suction systems did not have an effect on the risk of ventilator-associated pneumonia or mortality. More studies of high methodological quality are required, particularly to clarify the benefits and hazards of the closed tracheal suction system for different modes of ventilation and in different types of patients.