MINERVA ANESTESIOL 2002;68:360-4

Closed versus open suctioning techniques

S. M. MAGGIORE, E. IACOBONE, G. ZITO, G. CONTI, M. ANTONELLI, R. PROIETTI

Airway suctioning is classically performed with the disconnection of the patient from the ventilator and the introduction of the suction catheter into the endotracheal tube. Alternatively, it can be accomplished with a closed suctioning system included in the ventilatory circuit, allowing to introduce the suction catheter into the airways without disconnecting the patient from the ventilator. The closedsuction system has some advantages compared to the conventional, open-suction technique. It can be helpful in limiting environmental, personnel and patient contamination and in preventing the loss of lung volume and the alveolar derecruitment associated with standard suctioning in the severely hypoxemic patients. However, the impact of the closed system on ventilator-associated pneumonia as well as its cost-effectiveness and the influence of such devices with ventilatory support remain to be assessed. Key words: Respiration, artificial - Intubation intratracheal - Suction, methods - Ventilators, mechanical - Suction, instrumentation - Pneumonia, bacterial, etiology.

From the Istituto di Anestesia e Rianimazione Universit Cattolica del Sacro Cuore Policlinico A. Gemelli, Roma

he removal of airway secretions during mechanical ventilation is perturbed because of the presence of the endotracheal (ET) tube, the pharmacological sedation-induced inhibition of the muco-ciliary reflex, the ineffectiveness of cough, and the
Address reprint requests to: S. M. Maggiore - Istituto di Anestesia e Rianimazione, Policlinico A. Gemelli - Largo Agostino Gemelli, 8 - 00168 Roma. E-mail: smmaggiore@libero.it

supine position. Repeated ET suctioning is needed to avoid secretion accumulation and its deleterious consequences, i.e. ET tube occlusion, increased work of breathing, atelectasis and pulmonary infections. Nevertheless, suctioning is an uncomfortable, invasive and potentially hazardous procedure. Classically, airway suctioning is performed disconnecting the patient from the ventilator and introducing the suction catheter into the ET tube (open technique). Alternatively, it can be accomplished with a closed suctioning system, allowing to introduce the suction catheter into the airways without disconnecting the patient from the ventilator (closed technique). The potential advantages of the closed system over the conventional open suction technique include reduction of contamination with potentially infectious organisms and maintenance of ventilator parameters. Suctionig techniques and infections Performing ET suctioning with the open technique obviously exposes the environ-

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ment and the personnel to the risk of being contaminated with the patient airway microorganisms. Closed-suction systems may be useful to prevent contamination during tracheal suctioning. The incidence of both patient and environmental contamination has been reported to be reduced with the use of such closed systems. 1-3 Cobley et al. have investigated the difference in environmental contamination occurring with a conventional open suctioning techniques and using a closed system in nine intubated patients with known colonization with Gram-negative bacilli and not receiving antibiotics.3 Environmental contamination was assessed at different times by a Reuter centrifugal air sampler and by blood agar plates placed at various distances from the suction port. Environmental contamination was significantly higher with the open than the closed suctioning technique (+25.3 and +6.7 colony counts from air sampling with the open and the closed procedure after suction, respectively). Such a contamination extended up to 100 cm from the suction site (+11 colony counts from settle plates at 50 cm and +1.2 at 100 cm versus 0 with the open and the closed procedure, respectively). The authors concluded that cross-infection is almost unavoidable with the open technique while the closed system can prevent environmental contamination from respiratory organisms. However, because the closed system remains attached to the ventilator circuit and the suction catheter is reintroduced repeatedly into the patients airway over 24 hours or longer, it could become heavily contaminated with pathogens, carrying the risk of auto-contamination to the patient with microorganisms flourished on the suction catheter. This issue was investigated by Ritz et al. in a cross over study performed in 30 mechanically ventilated patients.2 The authors measured the amount of bacteria present on the suction catheter of the closed system after a 24-hour use period and the amount of bacteria present on the standard catheter after a single use. The results showed no difference in rate or magnitude of contamination

between the two systems. Even if the study limitations (for example, many patients received antibiotics before study entry) do not allow to draw definitive conclusions, this paper suggests that the use of in-line suction catheter for 24 hours does not increase the risk of auto-contamination to the patient. Furthermore, recent data suggest the safety of not routinely changing closed suctioning systems every 24 hours, as suggested by manufacturers. Kollef et al. performed a randomized controlled trial on patients requiring mechanical ventilation, assigned to receive either no-routine in-line suction catheter changes (n=258) or in-line suction catheter changes every 24 hours (n=263).4 No statistically significant differences for ventilator-associated pneumonia (38 versus 39 patients in no-routine and routine change group, respectively), hospital mortality, length of intensive care and hospital stay, or the number of acquired organ system derangements were observed between the two treatment groups. No-routine changes of the closed system was both safe and highly cost-effective, allowing a substantial cost savings (total costs was $ 11,016 versus 837 for routine and no-routine in-line suction catheter changes, respectively) and potentially decreasing the risks of patient and personnel contamination due to the system changes. Another important issue concerns the relationship between the use of closed suctioning systems and the incidence of nosocomial pneumonia and tracheal contamination compared to the conventional open technique.1, 5, 6 In 104 mechanically ventilated patients, Combes et al. found a lower, albeit non significantly, prevalence rate of ventilator-associated pneumonia in patients managed with the closed system compared to those with the open system (7.3 versus 15.9 per 1,000 patient-days, p=0.07) without demonstrating any adverse effect.6 These data confirmed those reported by Johnson et al ., who found no difference in the occurrence of nosocomial pneumonia for both methods of ET suctioning in 35 surgical patients.5 However, in an earlier study, not only did the authors not show a signifi-

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cant protective effect of the closed system on the incidence of nosocomial pneumonia (26 versus 29% in the closed and the open suctioning, respectively, p=NS), they observed a higher frequency of tracheal colonization with the in-line suction catheter (67 versus 37% in the closed and the open suctioning, respectively, p<0.02).1 Concern has been expressed about the efficacy of the closed system in removing secretions.7, 8 Few data exist on this issue, with anedoctal reports suggesting a lower efficacy of the closed system compared to the open technique.7 However, in another study specifically addressing this issue, no significant difference between the quantities of secretions removed with the closedcircuit catheter and with a conventional catheter was found (1.7 versus 1.9 g, respectively, p=NS).8 Suctionig techniques and oxygenation Another advantage of the closed system over the conventional open technique is the maintenance of ventilator parameters during suctioning. Studies examining closed ET suctioning methods reported that such a technique could result in less arterial and systemic venous oxygen desaturation.911 In the prospective, randomized controlled study by Johnson et al., the authors found that suctioning with a closed system was associated with a significantly higher arterial and mixed venous oxygen saturation and a lower increase both in mean arterial pressure and in heart rate, compared to the open technique. 5 However, introducing the in-line suction catheter into the airways without interrupting mechanical ventilation may impede the ventilator to efficiently assist the patient during ES, causing a major patient-ventilator dissynchrony and patient discomfort. A bench study has shown that closed system suction catheters can produce large intermittent drops in airway pressure when a control-mode ventilation is used with slow inspiratory flow settings.12 Craig et al. evaluated the effect of ventilator mode, assist-control or intermit-

tent mandatory ventilation, with the use of a closed system. 9 With pre-oxygenation, desaturation did not occur with both ventilator modes; on the contrary, without preoxygenation, desaturation occurred with assist-control ventilation but not with intermittent mandatory ventilation. This was due to the fact that, during assist-control ventilation, suctioning-induced patient coughing and ventilator autocycling resulted in pressure-limited breaths and patient-ventilator dissynchrony. Because of the relatively high costs of the closed-suction system, a precise definition of the kind of patients at higher risk of desaturation and who may benefit from such a device is important. An interesting study by Carlon et al. compared the open and closed technique in patients ventilated with positive end-expiratory pressures (PEEP) lower or greater than 10 cmH2O.10 No difference in oxygenation was found between open and closed suctioning when patients were ventilated with a PEEP 10 cmH 2O; on the contrary, in patients receiving PEEP higher than 10 cmH2O, oxygen desaturation occurred during open suctioning and it was efficiently prevented by using a closed system. In a recent prospective observational study, we have collected all the complications related to suctioning for all mechanically ventilated patients admitted in the intensive care unit over a 3month period.13 Seventy-nine patients and 4117 ET suctionings were evaluated. Fiftyseven percent of patients had complicated suctionings (12% of the total number of suctionings): oxygen desaturation (35% of patients and 5% of suctionings) and the presence of hemorrhagic secretions (23 of patients and 4% of suctionings) were the most frequent. Patients with episodes of suctioning-induced oxygen desaturation had higher FIO2 (72 vs 58%, p<0.01) and PEEP (7 vs 3 cmH2O, p<0.001) than patients without desaturation, but PEEP was the only independent risk factor for desaturation (ORa, 1.5; IC 95%, 1.17-1.86; p<0.01). In other terms, patients requiring high levels of PEEP are at greater risk of desaturation. This study confirms the importance of preventing the loss of positive airway pres-

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sure and the alveolar derecruitment induced by ET suctioning, which was already suggested by Brochard et al . 14 Therefore, because of the expense of the closed-suction system, its use should probably not be considered routine but only in patients requiring high FIO2 and PEEP, e.g. patients with acute lung injury (ALI), who are at greater risk of suction-related hypoxemia. Cereda et al. measured the changes in end-expiratory lung volume (EELV) with the open and the closed technique in 10 patients with ALI mechanically ventilated in volume-control mode.15 A lower EELV and oxygen saturation drop was observed with the closed system compared with the open, conventional technique. Notably, during suctioning with the closed system, minute ventilation was maintained, albeit a decrease in tidal volume, by an increase in respiratory rate (ventilator autocycling). This mechanism contributed to the lung volume preservation observed with the closed system. Recently, we measured the suctioning-induced changes in EELV, in alveolar recruitment measured by pressurevolume curves, and in oxygenation in 9 ALI patients.16 Five suctioning techniques were compared: a conventional open technique, passing the suction catheter through the swivel adapter suction port of the ventilatory circuit, a closed-suction technique, and both on-ventilator suctioning techniques while triggering 40 cmH2O pressure-supported breaths. EELV decreased with all techniques but it was significantly lower with the open-suction technique (-1466 ml, p<0.001), and was not fully recovered 1min after suctioning. Alveolar recruitment decreased after suctioning with the open technique and using the swivel adapter suction port of the ventilatory circuit (-104 ml and -63 ml with open suctioning and with the swivel adapter, respectively, p<0.01); it was unchanged when a closed system was used, and increased when 40 cmH2O pressure-supported breaths were triggered during on-ventilator suctioning (+71 ml and + 61 ml with pressure-support breaths triggered while using the swivel adapter and the closed system, respectively, p<0.01).

The drop in oxygen saturation paralleled the EELV changes, while the suctioninginduced modifications of respiratory mechanics well explained the changes in alveolar recruitment. Avoiding disconnection from the ventilator and using a closedsuction system limit the large lung volume drop observed with the open technique, which can be fully prevented applying high pressure-supported breaths during on-ventilator suctioning techniques. Conclusions The closed-suction system has some advantages compared to the conventional, open-suction technique. It can be helpful in limiting environmental, personnel and patient contamination and in preventing the loss of lung volume and the alveolar derecruitment associated with standard suctioning in the severely hypoxemic patients with ALI. However, the impact of the closed system on ventilator-associated pneumonia as well as its cost-effectiveness and the influence of such devices with ventilatory support remain to be assessed. Riassunto
Confronto tra tecniche di aspirazione chiusa e aperta Laspirazione delle vie aeree viene generalmente eseguita disconnettendo il paziente dal ventilatore e introducendo un sondino nel tubo endotracheale. In alternativa si pu utilizzare un sistema di aspirazione chiuso inserito nel circuito di ventilazione; ci permette lintroduzione del sondino nelle vie aeree senza disconnettere il paziente dal ventilatore. Il sistema di aspirazione chiuso presenta alcuni vantaggi rispetto alla tecnica di aspirazione aperta convenzionale: pu essere utile nel limitare la contaminazione dellambiente, del paziente e del personale e nel prevenire la perdita di volume polmonare e il dereclutamento alveolare associati alla tecnica di aspirazione standard nei pazienti gravemente ipossiemici. Restano ancora da valutare limpatto del sistema chiuso sulle polmoniti associate a ventilazione meccanica, il rapporto costo-beneficio e leffetto di queste tecniche sul supporto ventilatorio. Parole chiave: Ventilazione meccanica - Intubazione endotracheale - Ventilatori meccanici - Vie aeree, aspirazione.

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