Comparative study between open suction system versus closed suction system on patients put on a mechanical ventilator in intensive care unit care

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.

IntroductionVentilator-associated events (VAEs) are one of the main sources of concern in critically ill patients due to the high frequency and mortality. We conducted this analysis to compare the effects of open endotracheal suctioning system with closed one on the incidences of VAEs in adult patients receiving mechanical ventilation (MV).Materials and methodsA comprehensive literature search was performed in PubMed, Scopus, Cochrane Library, and hand searching bibliographies of retrieved articles. The search was confined to randomized controlled trials with human adults comparing closed tracheal suction systems (CTSS) vs open tracheal suction systems (OTSS) in prevention of ventilator-associated pneumonia (VAP). Full-text articles were used in order to extract the data. Data extraction was only started after completing the quality assessment.ResultsThe search resulted in 59 publications. Among them, 10 were identified as eligible for meta-analysis. There was a significant increase in incidence of VAP when using OTSS compared to CTSS, so that OCSS increased the incidence of VAP by 57% (OR 1.57, 95% CI 1.063–2.32, p = 0.02).DiscussionOur results showed that using CTSS can significantly decrease VAP development compared to OTSS. This conclusion does not yet mean the routine use of CTSS as a standard VAP prevention measure for all patients since individual patient’s disease and cost are other factors that should be in mind when determining the choice of the suctioning system. High-quality trials with a larger sample size are highly recommended.How to cite this articleSanaie S, Rahnemayan S, Javan S, Shadvar K, Saghaleini SH, Mahmoodpoor A. Comparison of Closed vs Open Suction in Prevention of Ventilator-associated Pneumonia: A Systematic Review and Meta-analysis. Indian J Crit Care Med 2022;26(7):839–845.

Background:Critically ill patients under mechanical ventilation require frequent suctioning of airway secretion. Closed suction permits suctioning without disconnection from ventilator; so it might decrease hypoxemia and infection rate.Objectives:This study aimed to evaluate the effect of closed tracheal suction system (CTSS) versus open tracheal suction system (OTSS).Patients and Methods:This is a prospective randomized study, which was carried on 100 patients in surgical Intensive Care Unit requiring mechanical ventilation for more than 48 hours from June 2012 to November 2013. In two groups, suction was performed based on the patients' need as well as physician's or nurses' decision on tracheal secretions. Patients randomly allocated into two groups (50 patients each): CTSS group and OTSS group. Patients were monitored for developing ventilator-associated pneumonia (VAP) during the study. Throat samples were taken on admission and two times per week from each patient. Tracheal samples were performed during endotracheal intubation, two times per week during mechanical ventilation and during extubation.Results:Drainage of subglottic secretions decreased the incidence of VAP (P < 0.05). Also type of the pharmacologic medicine for stress ulcer prophylaxis has significant effect on VAP incidence. Among the patients in OTSS and CTSS groups, 20% and 12% developed VAP, respectively. Use of CTSS compared with OTSS did not show statistically significant effect on VAP incidence in multivariate analysis; however, OR (odds ratio) tended to identify OTSS as an exposure factor for the development of VAP (OR = 1.92; CI = 0.45-8.30; = 0.38) compared with the CTSS. Higher levels of APACHE II score, sinusitis and tracheostomy put the patients at the risk of VAP. However, using heat and moisture exchanger (HME) instead of humidifier decreased this risk.Conclusions:Based on the results obtained from our study, impact of suctioning is similar between CTSS and OTSS regarding the occurrence of VAP. It seems that physicians must consider many factors such as duration of mechanical ventilation, comorbidities, oxygenation parameters, number of required suctioning, and the cost prior to using each type of tracheal suction system.

Ventilator-associated pneumonia is a common complication in ventilated patients. Endotracheal suctioning is a procedure that may constitute a risk factor for ventilator-associated pneumonia. It can be performed with an open system or with a closed system. In view of suggested advantages being reported for the closed system, a systematic review comparing both techniques was warranted. To compare the closed tracheal suction system and the open tracheal suction system in adults receiving mechanical ventilation for more than 24 hours. We searched CENTRAL (The Cochrane Library 2006, Issue 1) MEDLINE, CINAHL, EMBASE and LILACS from their inception to July 2006. We handsearched the bibliographies of relevant identified studies, and contacted authors and manufacturers. The review included randomized controlled trials comparing closed and open tracheal suction systems in adult patients who were ventilated for more than 24 hours. We included the relevant trials fitting the selection criteria. We assessed methodological quality using method of randomization, concealment of allocation, blinding of outcome assessment and completeness of follow up. Effect measures used for pooled analyses were relative risk (RR) for dichotomous data and weighted mean differences (WMD) for continuous data. We assessed heterogeneity prior to meta-analysis. Of the 51 potentially eligible references, the review included 16 trials (1684 patients), many with methodological weaknesses. The two tracheal suction systems showed no differences in risk of ventilator-associated pneumonia (11 trials; RR 0.88; 95% CI 0.70 to 1.12), mortality (five trials; RR 1.02; 95% CI 0.84 to 1.23) or length of stay in intensive care units (two trials; WMD 0.44; 95% CI -0.92 to 1.80). The closed tracheal suction system produced higher bacterial colonization rates (five trials; RR 1.49; 95% CI 1.09 to 2.03). 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.

To investigate the efficiency of closed tracheal suction system (CTSS) using novel splash-proof ventilator circuit component on ventilator-associated pneumonia (VAP) and the colonization of multiple-drug resistant bacteria (MDR) in patients undergoing mechanical ventilation (MV) prevention. A prospective single-blinded randomized parallel controlled intervention study was conducted. 330 severe patients admitted to the intensive care unit (ICU) of the First Hospital of Jiaxing from January 2014 to May 2016 were enrolled, and they were divided into open tracheal suction group, closed tracheal suction group, and splash-proof suction group on average by random number table. The patients in the three groups used conventional ventilator circuit component, conventional CTSS, and CTSS with a novel splash-proof ventilator circuit component for MV and sputum suction, respectively. The incidence of VAP, airway bacterial colonization rate, MDR and fungi colonization rate, duration of MV, length of ICU and hospitalization stay, and financial expenditure during hospitalization, as well as the in-hospital prognosis were recorded. After excluding patients who did not meet the inclusion criteria, incomplete data, backed out and so on, 318 patients were enrolled in the analysis finally. Compared with the open tracheal suction group, the total incidence of VAP was decreased in the closed tracheal suction group and splash-proof suction group [20.95% (22/105), 21.90% (23/105) vs. 29.63% (32/108)], but no statistical difference was found (both P > 0.05), and the incidence of VAP infections/1 000 MV days showed the same change tendency (cases: 14.56, 17.35 vs. 23.07). The rate of airway bacterial colonization and the rate of MDR colonization in the open tracheal suction group and splash-proof suction group were remarkably lower than those of closed tracheal suction group [32.41% (35/108), 28.57% (30/105) vs. 46.67% (49/105), 20.37% (22/108), 15.24% (16/105) vs. 39.05% (41/105)] with significantly statistical differences (all P < 0.05). Besides, no significantly statistical difference was found in the fungi colonization rate among open tracheal group, closed tracheal group, and splash-proof suction group (4.63%, 3.81% and 6.67%, respectively, P > 0.05). Compared with the closed tracheal suction group, the duration of MV, the length of ICU and hospitalization stay were shortened in the open tracheal suction group and splash-proof suction group [duration of MV (days): 8.00 (4.00, 13.75), 8.00 (5.00, 13.00) vs. 9.00 (5.00, 16.00); the length of ICU stay (days): 10.00 (6.00, 16.00), 11.00 (7.00, 19.00) vs. 13.00 (7.50, 22.00); the length of hospitalization stay (days): 16.50 (9.25, 32.00), 19.00 (10.50, 32.50) vs. 21.00 (10.00, 36.00)], and financial expenditure during hospitalization was lowered [10 thousand Yuan: 4.95 (3.13, 8.62), 5.47 (3.84, 9.41) vs. 6.52 (3.99, 11.02)] without significantly statistical differences (all P > 0.05). Moreover, no significantly statistical difference was found in the in-hospital prognosis among the three groups. CTSS performed using novel splash-proof ventilator circuit component shared similar advantages in preventing VAP with the conventional CTSS. Meanwhile, it is superior because it prevented the colonization of MDR and high price in the conventional CTSS.Clinical Trail Registration Chinese Clinical Trial Registry, ChiCTR-IOR-16009694.

Ventilator-Associated Pneumonia

Introduction:Endotracheal suctioning is a method commonly used to clean airway secretions in patients under mechanical ventilation (MV). This study aimed to compare the effects of open and closed suction methods on the occurrence of ventilator associated pneumonia (VAP).Methods:This comparative study was carried out on adult intensive care unit (ICU) patients in need of MV for more than 48 hours, from October 2018 to January 2019. Patients were randomly allocated to either closed tracheal suction system (CTSS) group or open tracheal suction system (OTSS) group. Patients were monitored for developing VAP within 72 hours of intubation and the findings were compared between groups. Results:120 cases with the mean age of 57.91±19.9 years were randomly divided into two groups (56.7% male). The two groups were similar regarding age (p = 0.492) and sex (p = 0.713) distribution. 22 (18.3%) cases developed VAP (12 (20%) in OSST group and 10 (16.7%) in CSST; p = 0.637). The most prevalent bacterial causes of VAP were Acinetobacter_Baumannii (72.7%), Klebsiella pneumoniae (18.2%), and Methicillin-Resistant Staphylococcus aureus (9.1%), respectively. There was not any significant difference between groups regarding the mean duration of remaining under MV (p = 0.623), mean duration of hospitalization (p = 0.219), frequency of VAP (p = 0.637), and mortality (p = 0.99). Conclusion:It seems that type of endotracheal suction system (OSST vs. CSST) had no effect on occurrence of VAP and other outcomes such as duration of need for MV and ICU stay as well as mortality.

BackgroundEndotracheal suctioning of mechanically ventilated patients differs across the world. In many low and middle-income countries, endotracheal suctioning is often performed with a sterile suctioning catheter that is used for 12 h or during the length of one nursing shift. The effect of flushing multiple used endotracheal suction system with chlorhexidine after suctioning to reduce ventilator associated pneumonia (VAP) remains unclear.AimThe aim of the study is to assess the effectiveness of flushing multiple-used open endotracheal suction catheters and suctioning system with chlorhexidine gluconate 0.2% to reduce VAP in mechanically ventilated patients in a resource-limited Intensive Care Unit (ICU).MethodsDue to the difficulty of blinding the intervention for nurses who perform endo-tracheal suction procedures, we adopted a quasi-experimental method with a randomized controlled trial design. A sample of 136 ICU patients were allocated to the intervention (n = 68) or control group (n = 68) between May and November 2020. The intervention was flushing the multiple-used suction catheter and suction system with 40ml chlorhexidine gluconate 0.2% and in the control group we used normal saline to flush the catheter and suction system. The primary outcome was incidence of VAP and the cost of the flushing solutions was the secondary outcome measure.ResultsPatients in the intervention group had a lower incidence of VAP compared to patients in the control group; 15 (22.1%) vs 29 (42.6%), p = 0.01. The incidence of late-onset VAP was 26.2% in the intervention group and 49% in the control group (p = 0.026) and the early-onset VAP was 13.2% in the intervention group and 25% in the control group (p = 0.081). Chlorhexidine gluconate 0.2% reduced the cost of suction system flushing (median: 78.4 vs 300 EGP, p < 0.001).ConclusionUsing chlorhexidine gluconate 0.2% to flush multiple-used suctioning catheters after every endo-tracheal suction procedure might reduce the incidence of VAP in mechanically ventilated patients. Chlorhexidine gluconate 0.2% can be a cost-effective solution for flushing the suction circuit. Nurses working in resource-limited ICUs and using suctioning catheters multiple times might consider using chlorhexidine gluconate 0.2% instead of normal saline or distilled water when flushing the suction system.Clinical trial registrationClinicalTrials.gov, identifier NCT05206721.

Background Ventilator-associated pneumonia is a common complication in ventilated patients. Endotracheal suctioning is a procedure that may constitute a risk factor for ventilator-associated pneumonia. It can be performed with an open system or with a closed system. In view of suggested advantages being reported for the closed system, a systematic review comparing both techniques was warranted. Objectives To compare the closed tracheal suction system and the open tracheal suction system in adults receiving mechanical ventilation for more than 24 hours. Search methods We searched CENTRAL (The Cochrane Library 2006, Issue 1) MEDLINE, CINAHL, EMBASE and LILACS from their inception to July 2006. We handsearched the bibliographies of relevant identified studies, and contacted authors and manufacturers. Selection criteria The review included randomized controlled trials comparing closed and open tracheal suction systems in adult patients who were ventilated for more than 24 hours. Data collection and analysis We included the relevant trials fitting the selection criteria. We assessed methodological quality using method of randomization, concealment of allocation, blinding of outcome assessment and completeness of follow up. Effect measures used for pooled analyses were relative risk (RR) for dichotomous data and weighted mean differences (WMD) for continuous data. We assessed heterogeneity prior to meta-analysis. Main results Of the 51 potentially eligible references, the review included 16 trials (1684 patients), many with methodological weaknesses. The two tracheal suction systems showed no differences in risk of ventilator-associated pneumonia (11 trials; RR 0.88; 95% CI 0.70 to 1.12), mortality (five trials; RR 1.02; 95% CI 0.84 to 1.23) or length of stay in intensive care units (two trials; WMD 0.44; 95% CI -0.92 to 1.80). The closed tracheal suction system produced higher bacterial colonization rates (five trials; RR 1.49; 95% CI 1.09 to 2.03). Authors' conclusions 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.

Aims: Nosocomial pneumonia is a prevalent complication in patients admitted to intensive care units. Endotracheal suction (ES) is used to clean the airways of secretions in patients under mechanical ventilation (MV). The objective of this study was to compare the effects of an open endotracheal suction system (OESS) versus a closed endotracheal suction system (CESS) on the incidence of ventilator-associated pneumonia (VAP).&#x0D; Study Design: Retrospective examination of hospital records.&#x0D; Place and Duration of Study: Reanimation Intensive Care Unit, Van Training and Research Hospital, Van, Turkey, between January 2018 and December 2019.&#x0D; Methodology: Age, gender, and length of stay in the intensive care unit and under mechanical ventilation (MV), mortality and isolated microorganism status of 73 (35.6%) patients with VAP were analyzed retrospectively. These features were compared according to the ES type applied. Sample: The study was conducted among 205 patients who were connected to a mechanical ventilator for more than 48 h in the reanimation intensive care unit (RICU) of a tertiary care hospital.&#x0D; Results: There was no difference between OESS and CESS groups in terms of mortality rates, length of stay in the RICU, and duration of MV. There was a significant difference in terms of incidence of VAP between the OESS group and the CESS group (41.8% and 29%, respectively; P = .045) Acinetobacter baumanii was the most frequently isolated microorganism in both groups.&#x0D; Conclusion: CESS treatment was associated with a lower incidence of VAP in patients of the RICU.

Cross-transmission of Gram-negative bacteria increases the likelihood of acquisition of infections and emergence of antibiotic resistance in intensive care units. Respiratory tracts of mechanically ventilated patients are frequently colonized with Gram-negative bacteria and endotracheal suctioning may facilitate cross-transmission. It is unknown whether closed suction systems, as compared with open suction systems, prevent cross-transmission. The objective was to determine whether closed suction systems, as compared with open suction systems, reduce the incidence of cross-transmission of Gram-negative bacteria in intensive care units. We performed a prospective crossover study in which both systems were tested unitwide in four intensive care units. Two intensive care units from a university hospital and two from a teaching hospital participated in the trial between January 2007 and February 2008. All patients admitted to the intensive care unit for >24 hrs were included. Closed suction systems and open suction systems were used for all patients requiring mechanical ventilation during 6-month clusters with the order of systems randomized per intensive care unit. Acquisition and cross-transmission rates of selected Gram-negative bacteria were determined through extensive microbiological surveillance and genotyping. Among 1,110 patients (585 with closed suction systems and 525 with open suction systems), acquisition for selected Gram-negative bacteria was 35.5 and 32.5 per 1,000 patient-days at risk during closed suction period and open suction period, respectively (adjusted hazard ratio, 1.14; 95% confidence interval, 0.9-1.4). During closed suction period, adjusted hazard ratios for acquisition were 0.66 (95% confidence interval, 0.45-0.97) for Pseudomonas aeruginosa and 2.03 (95% confidence interval, 1.15-3.57) for Acinetobacter species; acquisition rates of other pathogens did not differ significantly. Adjusted hazard ratios for cross-transmission during closed suction period 0.9 (0.4-1.9) for P. aeruginosa, 6.7 (1.5-30.1) for Acinetobacter, and 0.3 (0.03-2.7) for Enterobacter species. Overall cross-transmission rates were 5.9 (closed suction systems) and 4.7 (open suction systems) per 1,000 patient-days at risk. Closed suction systems failed to reduce cross-transmission and acquisition rates of the most relevant Gram-negative bacteria in intensive care unit patients.

Epidemiology, etiology, and diagnosis of hospital-acquired pneumonia and ventilator-associated pneumonia in Asian countries

Background: Endotracheal suctioning is a method commonly used to clean airway secretions in patients under mechanical ventilation. This study aimed to compare the effects of open and closed suction methods on the occurrence of ventilator-associated pneumonia (VAP). In the open endotracheal suction, the approach necessitates the participation of two nurses and may result in a momentary interruption of ventilation and oxygen supply due to the patient’s disconnection from the ventilation device during suctioning. In the closed endotracheal suction, the approach can be performed through connections in a closed suction set while the patient is ventilated without separating the patient from the ventilator. Objective: (1). To compare the close endotracheal suction with open endotracheal suction for the prevention of VAP. (2) To assess the incidence of VAP among intubated patients. Materials and Methods: The study was conducted among 60 patients who are on mechanical ventilator in the critical care unit in tertiary care hospital. For the study, simple random sampling technique is used for the selection of sample. Using a lottery method of sampling, one in the experimental group and one in the control group on the basis of inclusion criteria. Results: The study was done on patients who are on mechanical ventilators in the critical care unit in tertiary care hospitals. The data analysis was done using descriptive and inferential statistics. The study finding revealed that in VAP scoring of the patient’s 1st and 2nd day in open endotracheal suction, there are no significant changes in open endotracheal suction then null hypothesis was accepted (t = 0.9, P = 0.37). VAP scoring of the patient’s 2nd and 3rd day and 3rd and 1st day in open endotracheal suction, there are significant changes in open endotracheal suction method in null hypothesis was rejected (P &lt; 0.05). VAP scoring of the patient’s 1st and 2nd day and 2nd and 3rd day and 3rd and 1st day in closed endotracheal suction, there are significant changes in closed endotracheal suction then null hypothesis was rejected (P &lt; 0.05). Conclusion: The study assessed the efficacy of open endotracheal suction versus closed endotracheal suction on age, sex, duration of hospital stays, return of mechanical ventilation, and mode of ventilation are not significant but the duration of mechanical ventilation is significant. The nurses play a vital role in assessing the cardiac monitor while doing suctioning to prevent cardiorespiratory complications.

Studies have shown a decreasing ventilator-associated pneumonia (VAP) incidence after prophylactic interventions bundles. The use of closed suction systems (CSS) has been suggested beneficial as a prophylactic measure. To investigate the effects of a CSS on VAP incidence, suction circuit contamination and adverse events (AEs) compared to an open suction system (OSS) approach in a general mixed intensive care unit (ICU). Adult patients on mechanical ventilation were consecutively included. Data were collected during four 1-month periods where CSS and OSS were used on an alternating basis. Airway cultures were obtained at intubation, after 72 h and every Monday. After changing CSS and at extubation, the catheter tip was cultured. AEs and desaturation events during suction were monitored. Descriptive analysis and differences between the groups were analysed using comparative methods. No differences in airway colonization at admission between the groups were detected (Table 2). The CSS group had a higher Simplified Acute Physiology Score (SAPS) III and also a non-significant increase in VAP incidence. Positive cultures were obtained in 50% of all the retrieved CSS catheters. There was no inter-patient contamination in either group. Six AEs versus one (CSS/OSS) related to tube-occlusion and secretion clogging was seen. Desaturations at suctioning were rare in both groups. No beneficial effects were seen on VAP incidence or inter-patient contamination compared to OSS. A high frequency of circuit contamination in the CSS group paralleled with experienced secretions clearance problems seem unfavourable and in concordance with previous studies.

Background: Endotracheal suctioning is one of the fundamental procedures practiced in intensive care units. There are two methods used for suctioning: open and closed suction systems. Objective: To compare the effects of open and closed suction system on oxygen saturation among mechanically ventilated patients. Comparative quasi experimental research design was carried out to achieve the study’s objectives . A purposive sample included 80 patients taken from intensive care unit (ICU). Patient appraisal document was utilized for gathering data, which included three parts: bio-demographic data , health relevant data and an assessment sheet to monitor saturation level of oxygen. Results: the results indicates that the closed suctioning has a significant effect on oxygen saturation. After the procedure, oxygen saturation (SpO₂) reduced significantly but recovered completely after 15 minutes, showing a highly significant (p&lt;.001) .Whereas the majority of oxygen saturation is not greatly impacted by the open suction system, which exceeds the statistical significant level (&gt; 0.05). Conclusion: Using a closed suction system reduces fluctuations in oxygen saturation when compared to an open system among patients under mechanical ventilation. Recommendation: Future studies should employ larger sample sizes to enable comparative analysis of suction techniques and their association with acquired infections in intensive care units (ICUs).