Investigation into the effect of closed-system suctioning on the frequency of pediatric ventilator-associated pneumonia in a developing country*

Abstract

To investigate the effect of closed-system vs. open endotracheal suctioning on the frequency of ventilator-associated pneumonia and outcome in a pediatric intensive care unit in a developing country. Prospective observational and nonrandomized controlled clinical study. A 20-bed pediatric intensive care unit in a tertiary pediatric hospital. Infants and children mechanically ventilated for >24 hrs. : Pediatric intensive care unit suctioning systems were alternated monthly. An 8-month interim analysis was planned with a priori efficacy and futility study termination boundaries set at p < .006 and p > .52, respectively. Demographic, clinical, and laboratory data were prospectively recorded. Ventilator-associated pneumonia was diagnosed using the Clinical Pulmonary Infection Score, and the results were confirmed retrospectively using Centers for Disease Control criteria. A total of 250 patients (median [interquartile range] age of 3.8 [1.2-15.0] months) in 263 pediatric intensive care unit admissions were included. Fifty-nine admissions developed ventilator-associated pneumonia, with a calculated rate of 45.1 infections per 1000 ventilated days. There was no difference in characteristics or outcome between patients on closed-system suctioning (n = 83) and those on open endotracheal suctioning (n = 180). The frequencies of ventilator-associated pneumonia for patients on closed-system suctioning and open endotracheal suctioning were 20.5% and 23.3%, respectively (p = .6), reaching the a priori set limit of futility. Patients who developed ventilator-associated pneumonia spent a median (interquartile range) of 22 (13-37) and 11 (8-16) days in the hospital and pediatric intensive care unit, respectively, compared to 14.5 (10-24) and 6 (4-8) days for those without ventilator-associated pneumonia (p < .001). A 22% proportion of patients who developed ventilator-associated pneumonia died compared to 11.3% of those without ventilator-associated pneumonia (p = .03). Risk factors for ventilator-associated pneumonia identified on multiple logistic regression were duration of mechanical ventilation, transport out of the pediatric intensive care unit, and blood transfusion. Closed-system suctioning did not affect the frequency of ventilator-associated pneumonia or patient outcome in this setting.