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Japan Journal of Nursing Science (2010) 7, 1928

doi:10.1111/j.1742-7924.2010.00143.x

REVIEW ARTICLE

Closed suctioning system: Critical analysis for its use


Nahoko HARADA
William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts, USA

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Abstract
Aim: To determine the efcacy and effectiveness of the closed suctioning system. Method: Literature review articles were accessed from the following databases: PubMed, EMBASE, CINAHL, and Cochrane Library. The literature review criteria included: all publication styles except meta-analysis, participants that were 18 years, written in English, and published between 1973 and 2008. Results: This literature review revealed that the efcacy and effectiveness of the closed suctioning system remains to be demonstrated. The device manufacturers studies focused on cost reduction, crosscontamination, and preservation of the oxygen saturation of patients during endotracheal suctioning; however, the clinical studies focused on the use of closed suctioning systems to prevent ventilator-associated pneumonia. The reviewed studies had small sample sizes with heterogeneous demographics and nonrandomized controls. Recent studies suggest that closed suctioning systems are no better than open suctioning systems in terms of mortality, morbidity, or the cost-benet ratio. A few studies did indicate that the closed suctioning system might reduce the loss of lung volume and oxygen desaturation. Conclusion: The studies reviewed in this article suggest that the evidence on the efcacy and effectiveness of closed suctioning systems is inconclusive. Only limited populations will benet clinically from the use of this device. There is a need for further studies with randomized controlled trials to explore the use of closed suction systems and to update current clinical practise guidelines. Key words: critical care medicine, endotracheal tube, pulmonary, respiratory care, suction devices.

INTRODUCTION
Mechanical ventilation often is utilized to assist critically ill patients. Once inserted into the patients airway, an endotracheal tube (ETT) prevents the patient from automatically clearing airway secretions, thus requiring endotracheal suctioning to maintain airway patency. Currently, there are two types of suctioning systems: open and closed. The open suctioning system (OSS) has been used since mechanical ventilation became commonplace. This method requires the patient to be disconnected from the ventilator and preoxygenated. A suction catheter is threaded down the ETT and negative
Correspondence: Nahoko Harada, Boston College, William F. Connell School of Nursing, Cushing Hall, 140 Commonwealth Avenue, Chestnut Hill, MA 02467, USA. Email: haradan@bc.edu, nahokonobuta@gmail.com Received 29 June 2009; accepted 9 December 2009.

pressure is applied to remove secretions, resulting in oxygen desaturation and a loss in lung volume. Although the closed suctioning system (CSS) does not require practitioners to disconnect the patient from the ventilator, its efcacy as a standardized procedure has yet to be determined. This article will evaluate claims of the potential of the CSS as an effective technological improvement over the OSS.

History
During the polio pandemic in 1929, the iron lung, a method of negative-pressure mechanical ventilation, was invented and introduced to clinical medicine. In the 1950s, the rst prototype positive-pressure lung ination device was utilized clinically at Massachusetts General Hospital (Marino, 2007). When these devices were put into general use, secretion management protocols had been standardized but, nevertheless, constituted

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a dangerous practise. In the early days of mechanical ventilation, suctioning induced hypoxia (Bartlett & Finegold, 1978; Good, Wolz, Anderson, Dreisin & Petty, 1979; Haberman et al., 1973), arrhythmia (Freedman & Goodman, 1982; Kubota et al., 1980), and cardiac arrest (Kubota et al., 1982). Pneumonia often resulted from insufcient left brachial tree suctioning (Hart & Mahutte, 1992). Technological improvements included a valve device to prevent the ventilator from disconnecting during suctioning (Bodai, 1982) and a closed-suction catheter that was aimed at reducing the waste products previously associated with the OSS (Van Hooser, 2002). Shortly after these products became available, the rst manufactured CSS came onto the market. The purported benets were widely disseminated though the medical and nursing literature and demand increased for the new device (Birdsall, 1986; Mayhall, 1988). According to a nursing survey in 2000, 58% of intensive care units (ICUs) in the USA used the CSS, compared to 4% that were using the OSS (PaulAllen & Ostrow, 2000).

er or for administering normal saline for irrigation. Activating and deactivating a thumb switch valve at the slightly angled distal end applies negative pressure and a safety feature reduces the risk of unintentional valve activation. The catheters are marked so that clinicians can measure the depth of suction and prevent possible tracheal trauma by blind catheter insertion.

METHODS
A systemic literature review was carried out by using PubMed, EMBASE, CINAHL, and Cochrane Library. The literature review criteria included all publication styles except meta-analysis, participants who were 18 years, and articles that were written in English. As there were a limited number of articles on the CSS, all the available data between 1973 and 2008 were included. The key words that were used included: closed suction, closed endotracheal suction, closed suction system, closed suctioning system, and inline suction catheter.

Basic science of the technology function


In the CSS, sterile catheters remove secretions and may be used for irrigation without disconnecting the patient from the ventilator. The CSS is a disposable mechanical ventilator-associated device (Fig. 1). The exible, 2025 cm translucent suction catheter is covered in a latex-free lm. A t-piece at the proximal end connects to the patients ETT without interfering with the airway circuit. A lavage/irrigation port, also at the proximal end, allows for the attachment of the tube to a humidi-

RESULTS
Twenty-seven studies were reviewed. A comparison was made between the manufacturers recommendations for the use of the CSS and the actual use of the CSS in the clinical setting. Studies that examined the efcacy and effectiveness of the CSS were summarized in Table 1.

Intention of closed suctioning system use: Manufacturers and clinicians Manufacturers indications
According to the manufacturers, using the CSS should reduce the risk of cross-contamination and infection by isolating contact with the catheter, in comparison to the OSS. The technique also should prevent clinicians from exposure to the patients body uids and maintain universal precautions. Additionally, the CSS reduces oxygen desaturation by maintaining ventilation modes and oxygen therapy throughout the procedure, as ventilator disconnection is not necessary. Moreover, manufacturers advertize that using the closed system is also economically advantageous as it saves the cost of single-use suction catheters, gowns, eye protection, and other precautionary safety devices (Kimberly-Clark, 2002; Pruitt, 2005; Smiths Medical, 2008). Based on these manufacturer indications, the desired outcomes that could be

Figure 1 A closed suction system.

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Table 1 Summary of the studies on the use of the closed suctioning system

Author (year)

Study design

Sample size

Sample characteristics

Intervention for both CSS and OSS Outcome

Statistical signicance

Manufacturer efcacy data Randomized comparison Almgren et al. (2004) 12 pigs Eight Dorset sheep ARDS PaO2/FiO2 Healthy sample Tidal volume NS P < 0.001 -14 KPa suction during VC and PC ventilation -100 mmHg suction during VC and PC ventilation Arterial oxygenation Oxygen saturation

Caramez et al. (2006)

Randomized cross-over evaluation Two dogs In vitro Healthy sample

Experimental study

Not stated Not stated

Clinical efcacy data I Naigow & Powaser (1977) Taggart et al. (1988)

In vitro descriptive study

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Hoshi et al. (2004) In vitro

In vitro observational study

-170 mmHg suction during spontaneous breathing -20 L/min suction during SIMV with or without PEEP VC; suction pressure was not stated Airway pressure gradient Physiological recovery -140 mmHg suction during TCPLV/HFOV

P < 0.005

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16 New Zealand white rabbits Healthy/articially injured lungs; articially induced thin/thick secretions ARDS, pneumonia, and trauma patients Not stated -25 L/min suction during IMV/AMV with or without preoxygenation -80 mmHg suctioning NS 17 adults in MICU and SICU SaO2 P < 0.05 84 patients (46 CSS vs 38 OSS) in MICU Nine patients without severe pneumonia 49 patients with an oral (41), nasal (2), or tracheal tube (19) ARF due to pneumonia, COPD exacerbation, sepsis, and CHF Not stated Colonization, nosocomial pneumonia, and mortality Air and sputum sampling Change tube position, bevel orientation, and tube position in the mouth CSS vs OSS CSS vs OSS Post-CS, post-vascular surgery, pulmonary disorder, trauma, DM, and RF ICU (41 in 29 in 62 in 57 in CSS vs OSS Suctioning sputum selectively from the left lower lobe Use of CSS Colonization: P < 0.02; nosocomial pneumonia and mortality: NS Air: P < 0.05; sputum sampling: P < 0.05 NS Colonization in the circuit PaO2 and alveolar-arterial oxygen tension difference SvO2 P < 0.01 P < 0.05 P < 0.0001 30 patients in ICU with acute respiratory failure 20 patients in ICU 189 patients in hospital 1 vs hospital 2 vs hospital 3 vs hospital 4) Trauma, sepsis, pneumonia, and intoxication Not stated 60 patients (30 CSS vs 30 OSS) Not stated CSS vs OSS Primary costs and amount of waste products of CSS NS

Clinical efcacy data II Copnell et al. (2007)

Randomized study

Manufacturer effectiveness data I Craig, Benson & Pierson Clinical observational study (1984)

Deppe et al. (1990)

Two-multicenter clinical randomized study

Cobley et al. (1991)

Clinical observational study

Manufacturer effectiveness data II Clinical observational study Hart & Mahutte (1992)

Clinical effectiveness data I Observational study Ritz et al. (1986)

Carlon et al. (1987)

Interventional study

Clark et al. (1990)

Multicenter observational study

Clinical effectiveness data II Prospective randomized Zielmann et al. (1992) investigation

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Sample size 35 patients (16 CSS vs 19 OSS) 104 patients in ICU (50 CSS vs 54 OSS) 10 patients in ICU ARDS, sepsis, and acute lung injury CSS vs OSS SpO2, VTrt, VErT, PIP, PEEP, plateau, Paw, RR, MAP, HR, PaO2, and PaCO2 Closed head trauma and CVA CSS vs OSS NS Trauma, post-CS, and post-general surgery CSS vs OSS Nosocomial pneumonia, cost-effectiveness, and nursing cost-effectiveness VAP, LOS, and mortality NS Sample characteristics Intervention for both CSS and OSS Outcome Statistical signicance 47 patients in SICU and MICU (23 CSS vs 24 OSS) 10 patients in ICU Mild or moderate lung failure CSS vs OSS with VC Surgical and medical patients CSS vs OSS VAP Lung volume loss, MAP, HR, ETCO2, and SpO2 SpO2, VTrt, VErT, PIP, PEEP, plateau, Paw, RR, and MAP: P < 0.05; HR, PaO2, and PaCO2: NS NS Lung volume loss: P = 0.022; MAP, HR, ETCO2, and SpO2: NS VAP, cross-contamination between bronchial secretions and gastric juices, and colonization frequency 24 patients in ICU (12 CSS vs 12 OSS) Pulmonary inltration, COPD exacerbation, cardiac arrest, and inhalational burn trauma CSS vs OSS 78 patients in ICU (41 CSS vs 37 OSS) Respiratory, cardiovascular, metabolic, GI, sepsis, and neurological disease CSS vs OSS VAP, mortality, LOS, duration of MV, and colonization frequency CSS vs OSS VAP, mortality, cost-effectiveness, and duration of MV CSS without daily change vs OSS VAP, mortality, cost-effectiveness, and duration of MV VAP: P = 0.0037; cross-contamination between bronchial secretions and gastric juices: P = 0.0037; colonization frequency: P < 0.02 NS 443 patients in ICU (210 CSS vs 233 OSS) 457 patients in ICU (236 CSS vs 221 OSS) Post-CS, cardiac, respiratory, digestive, and neurological disease, trauma, and intoxication Post-CS, cardiac, respiratory, digestive, and neurological disease, trauma, and intoxication Cost after 4 days: P = 0.001; VAP, mortality, and duration of MV: NS NS

N. Harada

Table 1 Continued

Author (year)

Study design

Johnson et al. (1994)

Prospective randomized controlled study

Combes et al. (2000)

Prospective randomized study

Clinical effectiveness data III Prospective randomized Cereda et al. (2001) study

Zeitoun et al. (2003)

Fernandez et al. (2004)

Randomized parallel group study Prospective cross-over study

Clinical effectiveness data IV Prospective randomized Rabitsch et al. (2004) study

Topeli et al. (2004)

Prospective randomized study

Clinical effectiveness data V Lorente et al. (2005) Prospective randomized study

Lorente et al. (2006)

Prospective randomized study

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AMV, assisted mechanical ventilation; ARDS, acute respiratory distress syndrome; ARF, acute renal failure; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disorder; CS cardiac surgery; CSS, closed suctioning system; CVA, cerebrovascular accident; DM, diabetes mellitus; ETCO2, end-tidal carbon dioxide; FiO2, fraction of inspired oxygen; GI, gastrointestinal; HFOV, high-frequency oscillatory ventilation; HR, heart rate; ICU, intensive care unit; IMV, intermittent mandatory ventilation; LOS, length of stay; MAP, mean arterial pressure; MICU, medical intensive care unit; MV, mechanical ventilation; NS, not signicant; OSS, open suctioning system; PaCO2, arterial carbon dioxide tension; PaO2, partial pressure of oxygen in arterial blood; Paw, mean airway pressure; PC, pressure control; PEEP, positive end expiratory pressure; PIP, peak inspiratory pressure; plateau, inspiratory plateau pressure; RF, renal failure; RR, respiratory rate; SaO2, oxygen saturation; SICU, surgical intensive care unit; SIMV, synchronized intermittent mandatory ventilation; SpO2, pulse oximeter oxygen saturation; SvO2, mixed venous oxygen saturation; TCPLV, time-cycled pressure-limited ventilation; VAP, ventilator-associated pneumonia; VC, volume control; VErT,, minute ventilation obtained by respitrace; VTrt,, tidal volume obtained by respitrace.

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monitored include the rates of cross-contamination, patient oxygen desaturation levels, and costeffectiveness.

Clinical use
In the clinical setting, the measures that were used to assess the clinical effectiveness of the CSS are not congruent with the manufacturers original indications. Instead, clinicians have used the CSS to prevent nosocomial infection ventilation-associated pneumonia (VAP) in particular. Ventilation-associated pneumonia is dened as pneumonia that occurs >4872 h after endotracheal intubation and it is known as a cause of prolonged length of stay, excess medical costs, and high mortality (American Thoracic Society/Infectious Diseases Society of America, 2005). All the clinical studies that were reviewed in this article identied the prevention of VAP as the desired patient outcome. Even though clinicians are using the CSS in order to prevent VAP, the manufacturers make no claims that the CSS will prevent VAP.

Efcacy and effectiveness of closed suctioning systems


Closed suctioning system products were introduced in the early 1980s and adopted on a large scale (Birdsall, 1986; Mayhall, 1988). Studies to evaluate the devices efcacy and effectiveness appeared in the late 1980s. Efcacy refers to the testing of the product in a controlled laboratory setting, whereas effectiveness refers to the testing of the product in a clinical setting.

1980s. Early articles and studies used unpublished efcacy studies to support the ndings, including An evaluation of the Trach Care suction system; A closed continuous tracheal suction system (Billingsley & Radford, n.d.), Prevention of endotracheal suction induced arterial desaturation data (Wilhem, Doran & Adams, n.d.), and Effects of suctioning patients without interruption of ventilation (Demajo, n.d.), as cited in Deppe et al. (1990) and Mayhall (1988). Manufacturers animal model studies tested the devices efcacy and demonstrated conicting results. An American study demonstrated that the CSS avoided partial pressure of oxygen in arterial blood (PaO2)/ fraction of inspired oxygen (FiO2) mismatch in eight sheep with induced acute respiratory distress syndrome (ARDS) (Caramez et al., 2006). The PaO2 and FiO2 are measures of patients tolerance of the endotracheal suctioning procedure, so that the smaller the mismatch, the less the patients suffer from oxygen desaturation during suctioning. However, when the CSS was used on 12 anesthetized pigs with healthy lungs, the CSS led to similar levels of deoxygenation as the OSS (Almgren, Wickerts, Heinonen & Hogman, 2004). The manufacturers funding is a potential source of bias that is important to consider in evaluating these studies. As a result of conict of interest, the validity of studies can be called into question.

Effectiveness studies Effectiveness studies by manufacturers


Overall, manufacturers effectiveness studies were limited in sample size, lacked clearly dened methodologies, and were not randomized controlled trials. Craig, Benson and Pierson (1984) demonstrated that the CSS did not require preoxygenation with intermittent mandatory ventilation. In this study, most of the participants had either pneumonia or trauma and the data were derived from suctioning twice with or without preoxygenation. The rationale for suctioning frequency was omitted, even though the manufacturers dictate preoxygenating before suctioning. A multicenter prospective randomized trial concluded that the CSS did not signicantly increase nosocomial pneumonia morbidities or mortalities (Deppe et al., 1990). Moreover, the data showed that colonization was more likely to occur in the CSS group than in the OSS group. A similarly designed study also demonstrated a high incidence of colonization with the CSS (Zeitoun, de Barros & Diccini, 2003). In one observational trial (Cobley, Atkins & Jones, 1991), the CSS reduced environmental contamination

Efcacy studies
Studies that were designed to determine CSS efcacy had limited favorable results. Naigow and Powaser (1977) found that arterial oxygenation decreased after using the CSS on animal subjects. Experimental in vitro studies demonstrated that the CSS maintained oxygen saturation when the ventilator mode was in assist mode (Taggart, Dorinsky & Sheahan, 1988). Copnell et al. (2007) suggested that the CSS was not more effective than the OSS when used to suction articially induced thin and thick secretions. Another laboratory study suggested that the tube guide assembly connected with the tracheal tube and thus altered airway pressure gradients (Hoshi et al., 2004). Thus, though in vitro tests demonstrated signicant changes in airway pressure gradients, the clinical signicance of these changes could be minimal. Articles by manufacturers of the CSS were produced when the systems rst entered into use in the

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but the participants demographic data were not reported. Although these results demonstrated no colonization in the CSS group, later studies reported more frequent colonization in the CSS than the OSS groups (Deppe et al., 1990; Rabitsch et al., 2004; Topeli, Harmanci, Cetinkaya, Akdeniz & Unal, 2004). Another study demonstrated successful selective left bronchial cannulation by using the CSS only if used in conjunction with a directional tip catheter. However, the procedure failed to adequately clear secretions in the CSS group (Hart & Mahutte, 1992). The directional tip catheter is not commonly utilized in clinical settings; therefore, this study has limited replicability. In addition to interpreting these results, caution needs to be used in interpretation due to heterogeneous sample demographics. These four studies were funded by product companies; therefore, these were considered to be manufacturers studies.

Effectiveness tests by clinicians


Early clinical studies that examined CSS effectiveness concluded that there was no benet to using the CSS in order to prevent colonization in the circuit (Ritz, Scott, Coyle & Pierson, 1986), nosocomial pneumonia (Johnson et al., 1994), hemodynamic alteration (Clark, Winslow, Tyler & White, 1990), or deoxygenation (Carlon, Fox & Ackerman, 1987). The patient cohorts that were examined in these studies encompassed a range of clinical presentations that were characteristic of ICU settings. Three separate studies tested CSS costbenet ratios by determining the frequency of suctions per day. These studies demonstrated that CSS suctioning had to be carried out at least 15 times (Zielmann, Grote, Sydow, Radke & Burchardi, 1992), 14 times (Johnson et al., 1994), or 24 times (Carlon et al., 1987) in order to outweigh OSS costs. The study by Zielmann et al. consisted of 60 patients in total in a randomized controlled design. The frequency of endotracheal suctioning was quite different from patient to patient, varying from 641 times per day, and the statistical signicance was not stated. The study by Johnson et al., with diversely diagnosed participants, suggested that the lack of cost benet rendered the CSS as unusable in the general ICU population. More recent clinical trials that were conducted to examine CSS effectiveness used the VAP incidence rate as the outcome variable. It was shown that, when compared to the OSS, the CSS did not reduce VAP incidence rates in either adults (Lorente, Lecuona, Jimenez, Mora & Sierra, 2006; Lorente et al., 2005; Topeli et al., 2004;

Zeitoun et al., 2003) or adolescents (Zeitoun et al.). All the identied studies in this section were randomized controlled trials. The participants basic characteristics were similar and consistently represented ICU demographic proles across studies. Another randomized study in Turkey noticed increased colonization but no decreased VAP incidence in its CSS group (Topeli et al.). Only one trial revealed that the CSS improved VAP incidence rates (Rabitsch et al., 2004). The CSS was shown to reduce the incidence of catheter crosscontamination by gastric secretions. Rabitsch et al. concluded that the CSS could be utilized as a potent tool; however, the study was limited by a small sample size (22 patients) and a lack of demographic information. A French prospective randomized study with 100 participants showed no signicance (P = 0.07) in relation to VAP frequency between the CSS and OSS (Combes, Fauvage & Oleyer, 2000). The researcher trained careproviders for 6 months in order to standardize the suction technique. The latest clinical guidelines (Centers for Disease Control and Prevention/Healthcare Infection Control Practices Advisory Committee, 2004; Hess et al., 2003) have yet to rule on using the CSS as a preventive treatment for VAP. It should be noted that studies that were conducted after the guidelines were published demonstrated that the CSS was ineffective against VAP (Lorente et al., 2006; Lorente et al., 2005). Both these studies were well-designed randomized controlled trials with large sample sizes and they included a good representation of ICU diagnoses (cardiac surgery, cardiology, respiratory, digestive, and neurological disorders, and trauma). Only a few studies showed the benet of using the CSS. An Italian clinical study of ICU patients revealed that the CSS reduced lung volume loss (Cereda et al., 2001). The study comprised 10 participants, each with a differing diagnosis such as ARDS, pneumonia, and post-cardiac arrest. As a result, no specic statements could be made about CSS effectiveness as the participating patients medical conditions were not controlled. Fernandez, Piacentini, Blanch and Fernandez (2004) likewise studied changes in lung volume during endotracheal suctioning in critically ill patients with mild-tomoderate lung disease. The patients mean PaO2/FiO2 ratio was 273 28 mmHg. The reduction of lung volume by the CSS was 497 124 mL, whereas the reduction by the OSS was 1281 656 mL (P = 0.022). Although the decreased lung volume quickly recovered in the group with healthy lungs and the observation did not occur in those with severe lung disease, this study

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suggested that the CSS has protective potential. This prospective cross-over study was conducted with 10 participants at one university-afliated hospital. To substantiate the effectiveness of the CSS in respect to lung volume loss, randomized controlled studies with larger samples are necessary.

there was no improvement in the mortality rate associated with the CSS (Lorente et al., 2006; Lorente et al., 2005). The mortality rate with the CSS and OSS in the 2005 study was 13.1% and 13.5%, respectively (P = 0.78) and, in the 2006 study, the mortality rate with the CSS and OSS was 24.76% and 21.46%, respectively (P = 0.43).

DISCUSSION
Efcacy studies and effectiveness studies
As a result of inconsistencies in the ndings from the efcacy studies, it is difcult to determine whether the CSS is more efcacious than the OSS. In terms of the effectiveness of the CSS, inconsistencies in the quality of the study designs, the heterogeneity of the samples, and the small sample sizes impact the ability to ascertain the effectiveness of the CSS. Bacterial colonization might be more likely to occur in the CSS than in the OSS. The CSS might reduce the loss of lung volume when suctioning. Cost and the incidence of VAP were not improved by CSS use.

Length of stay
In order to determine the effects of intervention in the clinical setting, the length of stay is frequently used as an outcome variable (National Quality Measures Clearinghouse, 2005). Recent research has not shown that the CSS can reduce the length of stay in the ICU (Topeli et al., 2004). There was no statistically signicant difference between the CSS group and the OSS group (12.3 1.1 vs 11.5 1.4; P = 0.64). Combes et al. (2000) also found that the CSS was not associated with a shortened length of stay in the ICU when used on patients with head injuries and cerebrovascular problems (P = 0.134). The authors attributed the lack of statistically signicant ndings to the fact that, unlike most ICU populations, trauma patients are less likely to have comorbidities. In addition, the authors suggested that including advanced-age trauma patients in the study might have diminished the risk of developing VAP in the cohort as elderly patients died earlier.

Clinical outcomes Ventilator-associated pneumonia


With regard to VAP, one study demonstrated that the CSS reduced VAP frequency in ICU patients (Rabitsch et al., 2004). With 12 patients in each group (CSS vs OSS), no patients had VAP with CSS use (P = 0.037). Another study demonstrated that the CSS reduces the VAP risk compared to the OSS (Combes et al., 2000). An adjusted risk of VAP was 3.5-fold higher in the OSS group (95% CI: 11.0012.33). Conversely, four other studies showed that the use of the CSS did not improve the VAP frequency during mechanical ventilation (Lorente et al., 2006; Lorente et al., 2005; Topeli et al., 2004; Zeitoun et al., 2003). As mentioned earlier, despite the fact that manufacturers do not indicate the use of CSS for reducing VAP incidence, the CSS has been used for this purpose.

Cost
In general, CSS costs were higher than their OSS counterparts. Lorente et al. (2005) showed that the CSS cost four times as much as the OSS ($US11.11 $US2.25 vs $US2.50 $US1.12; P < 0.001). The CSS was shown to be signicantly more expensive than the OSS when used on patients who were weaned off the ventilator in <4 days (7.2 4.7 vs 1.9 0.6 Euros; P < 0.001) (Lorente et al., 2006). Despite the fact that the OSS uses disposable materials and has a cumulative cost, it is less expensive than the CSS. In contrast, because the OSS requires two caregivers to administer it, there is a hidden cost of care that is not accounted for in these studies. Two early studies suggested that the CSS might reduce nursing time (Johnson et al., 1994; Zielmann et al., 1992). Other studies indicated that the frequency of suctioning also affected the cost-effectiveness (Carlon et al., 1987; Johnson et al.). Additional studies are needed to conrm if the CSS reduces the nursing workload, which closely relates to cost-effectiveness in the health-care system.

Mortality
The relationship between the CSS and patient mortality has yet to be completely understood. One could speculate that the CSS might reduce mortality by decreasing the incidence of VAP. In fact, in a logistic regression analysis by Topeli et al. (2004), VAP was indicated as one of several factors that do increase mortality in ICU patients. However, in two recent randomized controlled studies that specically examined the role of the CSS,

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Complications
Several studies reported complications related to CSS use, including the need for prolonged mechanical ventilation, frequent colonization in the respiratory tract, and a broncho-pleural stula. Three studies concluded that the CSS did not shorten the duration of mechanical ventilation (Lorente et al., 2006; Lorente et al., 2005; Topeli et al., 2004). It is known that early extubation reduces ICU and hospital length of stay (Hawkes, Dhileepan & Foxcroft, 2003). Studies also showed that the CSS resulted in higher incidents of colonization in the respiratory tract. Acinetobacter sp. and Pseudomonous aeruginosa were the leading pathogens in the CSS group and were found in higher concentrations than in the OSS group (Topeli et al., 2004). The data of Topeli et al. are consistent with another study that showed an increased incidence of colonization in the CSS group (Rabitsch et al., 2004). Such ndings imply that CSS use increases colonization. Moreover, as the microorganisms that are associated with CSS colonization are often gram-negative, there is a need for more intensive evaluation and treatment, unlike for gram-positive microorganisms, which may represent normal ora.

There is no difference between the ability of the CSS and the OSS to prevent VAP, shorten ICU length of stay, minimize costs, or reduce critically ill patients mortality rates. The current active guidelines for the caring of patients on mechanical ventilators are based on studies that were conducted in the 1990s. More well-designed research studies with larger sample sizes and improved demographic data are needed in order to update the guidelines. The technical gaps between the early 1990s research and the present day must be lled if more denitive conclusions on CSS effectiveness are to be made.

ACKNOWLEDGMENTS
This article did not receive any source of commercial or private funding or academic grants. The author of the article has no industrial links or afliations. I deeply appreciate the assistance of Dr Deborah E. Becker, School of Nursing, University of Pennsylvania and Dr Ann W. Burgess and Kathleen Keane, William F. Connell School of Nursing, Boston College, USA.

Risk
The CSS is not a risk-free device. Along with the risks that are commonly associated with endotracheal suctioning, Lindgren et al. (2004) stated that the CSS might provoke unpredictable and high levels of intrinsic positive end expiratory pressure during catheter insertion, as well as hinder ventilator regulation when in pressureregulated volume-guaranteed mode. Moreover, Nurkin et al. (2004) suggested that part of the closed suction catheter was misplaced in a premature infant carina, resulting in a fatal broncho-pleural stula.

REFERENCES
Almgren, B., Wickerts, C. J., Heinonen, E. & Hogman, M. (2004). Side effects of endotracheal suction in pressureand volume-controlled ventilation. Chest, 125, 1077 1080. American Thoracic Society/Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcareassociated pneumonia. (2005). American Journal of Respiratory and Critical Care Medicine, 171, 388416. Bartlett, J. G. & Finegold, S. M. (1978). Bacteriology of expectorated sputum with quantitative culture and wash technique compared to transtracheal aspirates. American Review of Respiratory Disease, 117, 10191027. Birdsall, C. (1986). How do you use a closed suction adapter? American Journal of Nursing, 8, 12221223. Bodai, B. I. (1982). A means of suctioning without cardiopulmonary depression. Heart & Lung, 11, 172176. Caramez, M. P., Schettino, G., Suchodolski, K., Nishida, T., Harris, R. S., Malhotra, A. et al. (2006). The impact of endotracheal suctioning on gas exchange and hemodynamics during lung-protective ventilation in acute respiratory distress syndrome. Respiratory Care, 51, 497502. Carlon, G. C., Fox, S. J. & Ackerman, N. J. (1987). Evaluation of a closed-tracheal suction system. Critical Care Medicine, 15, 522525. Centers for Disease Control and Prevention/Healthcare Infection Control Practices Advisory Committee. (2004).

CONCLUSION
Based on the evidence in this review, there are no denitive advantages associated with the use of the CSS over the OSS. There are marked differences between the manufacturers and clinicians indications. Although CSS manufacturers emphasize the products ability to reduce nursing care time and cost and to avoid environmental contamination, only minimal evidence supports these assertions. In the clinical setting, the device might be effective in reducing the loss of lung volume in ventilated patients. However, there is a need for further studies to better describe this protective mechanism.

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Closed suction system in intensive care

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catheters-accessories/closed-suction/suctionpro-72/ suctionpro-72.html Taggart, J. A., Dorinsky, N. L. & Sheahan, J. S. (1988). Airway pressures during closed system suctioning. Heart & Lung, 17, 536542. Topeli, A., Harmanci, A., Cetinkaya, Y., Akdeniz, S. & Unal, S. (2004). Comparison of the effect of closed versus open endotracheal suction systems on the development of ventilator-associated pneumonia. The Journal of Hospital Infection, 58, 1419. Van Hooser, D. T. (2002). Airway clearance with closedsystem suctioning. Aliso Viejo, CA: American Association of Critical Care Nurses. Zeitoun, S. S., de Barros, A. L. & Diccini, S. (2003). A prospective, randomized study of ventilator-associated pneumonia in patients using a closed vs. open suction system. Nursing in Critical Care, 12, 484489. Zielmann, S., Grote, R., Sydow, M., Radke, J. & Burchardi, H. (1992). Endotracheal suctioning using a 24-hour continuous system. Can costs and waste products be reduced?. Anaesthesist, 41, 494498.

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