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Does the use of a closed suction system help to prevent

ventilator-associated pneumonia (VAP)?

Maureen A. Seckel, RN, APN,

APRN,BC, CCNS, CCRN, replies:

Tracheal suctioning is an essential

component of airway management
for patients requiring mechanical
ventilation and it is one of the most
common invasive procedures performed in any critical care unit today.
The primary goals of the suctioning
procedure are secretion removal in
Author
Maureen A. Seckel is a clinical nurse
specialist in Medical Critical Care/
Pulmonary at Christiana Care Health
System in Newark, Delaware.
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order to maintain airway patency,

decrease airway resistance, achieve
optimal oxygenation, and reduce
infection risk.1,2 Complications of
tracheal suctioning include respiratory and cardiac arrest, hemodynamic instability, hypoxia, increased
intracranial pressure, bronchospasm,
hemorrhage, and tracheal damage.1,3,4
Currently there are 2 distinct
methods available: open system suctioning (OSS) and closed-system
suctioning (CSS), or inline, suctioning. OSS requires disconnecting
the patient from the ventilator and
introducing a single-use sterile suction catheter into the tracheal tube.
Each suctioning procedure requires
the caregiver to use personal protective equipment including masks, goggles or eye shields, and sterile gloves.
In the1980s CSS became available and this method is the preferred procedure in nearly 60% of
critical care units in the United States
today.5,6 CSS requires a single
patient multiuse catheter enclosed
in a sterile sleeve, which is advanced
through a diaphragm into the trachea.
The caregiver wears gloves but is
not in direct contact with the patients
secretions or the catheter. Additionally, because it is not necessary to
disconnect from the ventilator circuit, the patient is able to maintain
positive end-expiratory pressure
(PEEP) and lung volume.7

Airway Patency
Several early studies8-10 have
demonstrated that OSS and CSS are
equally effective in secretion
removal. With CSS, there is a perception to the caregiver of less effec-

tive suctioning due to the muffled

suctioning sound and feel of the
procedure through the plastic
sleeve.11-13 Decreased sputum visibility in the inline catheter and sleeve
may also contribute. The correct
suction catheter size and length,
along with the correct suction pressure level for both techniques are
important considerations to maintain airway patency and the effectiveness of the procedure.

Achieve Optimal Oxygenation

Hyperoxygenation or the delivery of oxygen greater than what the
patient is receiving, usually 100%
fraction of inspired oxygen before
and after suctioning, has been shown
to reduce suction-induced hypoxia.14
Both OSS and CSS can incorporate
hyperoxygenation before and after
suctioning. However, disconnecting
the patient from the ventilator with
OSS has been shown to cause a drop
in airway pressure, loss of lung volume, and decreased oxygen saturation.2 With the ability to maintain
connection to the ventilator circuit
in CSS, patients are continuously
receiving mechanical ventilation,
PEEP is maintained, and loss of
lung volume with associated derecruitment is avoided.7,15

Decreased Infection Risk

A complication of endotracheal
intubation and mechanical ventilation, VAP has significant morbidity
and mortality.16 Mirroring VAP prevention recommendations for ventilator circuit changes, guidelines for
inline suction catheters include
changing these catheters on an

CRITICALCARENURSE Vol 28, No. 1, FEBRUARY 2008 65

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as-needed basis when they are visibly

soiled or malfunctioning.17-20 Manufacturer recommendations have
included changing the inline catheter
every 24 hours. Despite known
increased inline catheter bacterial
colonization, prolonged catheter
use does not appear to increase the
incidence of VAP.2,21 However, several
studies,22-26 including meta-analysis
investigations, conclude that the use
of either OSS or CSS has no effect on
the incidence of VAP. CSS neither
decreases nor increases the patient
risk of acquiring VAP.
Two additional important considerations for the use of CSS include
decreased environmental exposure
and risk of bacterial transmission
for the patient; in addition, CSS is
superior over OSS in decreasing
repeated caregiver exposure to the
spray of infectious secretions during suctioning. Care must be given
to maintain the ventilator circuit,
prevent accidental disconnects, and
adhere to hand washing and infection control policies.

Costs
Inline suction catheters should
be considered part of the ventilator
circuit and should be changed on an
as-needed basis. Despite the
increased costs of CSS, savings can
be achieved by eliminating routine
or daily changes.

Summary
Both OSS and CSS can be used to
effectively remove secretions and
achieve the primary goals of maintaining airway patency and oxygenation. Although CSS does not appear
to be superior to OSS for VAP prevention, there are several known advantages of CSS, including the following:

maintenance of PEEP and

oxygenation
decreased exposure of caregivers
decreased environmental
exposure and prevention of crosscontamination between patients
Review your unit and hospital policy and procedure. Because suctioning
is a collaborative practice between
respiratory therapy and nursing in
most institutions, policies related to
suctioning and airway management
should be a comprehensive strategy
between both departments.
References
1. Chulay M. Suctioning: endotracheal or tracheostomy tubes. In: Lynn-McHale Wiegand
DJ, Carlson KJ, eds. AACN Procedure Manual for Critical Care. 5th ed. St. Louis, MO:
Elsevier Saunders; 2005:62-70.
2. Jongerden IP, Rovers MM, Grypdonck MH,
et al. Open and closed endotracheal suction
systems mechanically ventilated intensive
care patients: a meta-analysis. Crit Care
Med. 2007;35:260-270.
3. St John RE, Seckel, MA. Airway management. In: Burns SM, ed. AACN Protocol for
Practice: Care of the Mechanically Ventilated
Patients. 2nd ed. Sudbury, MA: Jones and
Bartlett Publishers; 2006:1-57.
4. Thompson L. Suctioning adults with an
artificial airway. Best Pract. 2000;4:1-6.
5. Sole ML, Byers JF, Ludy JE, et al. A multisite
survey of suctioning techniques and airway
management practices. Am J Crit Care. 2003;
12:220-230.
6. Paul-Allen J, Ostrow CL. Survey of nursing
practices with closed-system suctioning. Am
J Crit Care. 2000;9:9-19.
7. Van Hooser DT. Airway Clearance With
Closed-System Suctioning. Aliso Viejo, CA:
American Association of Critical-Care
Nurses; 2002:1-12.
8. Whitmar MT, Hess D, Simmons M. An
evaluation of the effectiveness of secretion
removal with the Ballard closed-circuit suction catheter. Respir Care. 1991;36:844-848.
9. Craig K, Benson M, Pierson D. Prevention
of arterial oxygen desaturation during
closed airway endotracheal suction: effect
of ventilator mode. Respir Care. 1991;29:
1013-1018.
10. Carlon GC, Fox SJ, Ackerman NJ. Evaluation of a closed-tracheal suction system.
Crit Care Med. 1987;15:522-525.
11. Noll ML, Hix CD, Scott G. Closed tracheal
suction systems: effectiveness and nursing
implications. AACN Clin Issues. 1990;
1:318-326.
12. Blackwood B. The practice and perception
of intensive care staff using the closed suction system. J Adv Nurs. 1998;28:1020-1029.
13. Crimslick J, Paris R, McGonagle E, et al.
The closed tracheal suction system: implications for critical care nursing. Dimens Crit
Care Nurs. 1994;13:292-300.

14. Oh H, Seo W. A Meta-analysis of the effects

of various interventions in preventing
endotracheal suction-induced hypoxemia.
J Clin Nurs. 2003;12:912-924.
15. Cereda M, Villa F, Colombo E, et al. Closed
system endotracheal suctioning maintains
lung volume during volume-controlled
mechanical ventilation. Intensive Care Med.
2001;27:648-654.
16. American Thoracic Society and the Infectious Diseases Society of America. Guidelines for the management of adults with
hospital-acquired, ventilator-associated,
and healthcare-associated pneumonia. Am J
Respir Crit Care Med. 2005;171:388-416.
17. Kollef MH, Prentice D, Shapiro SD, et al.
Mechanical ventilation with or without daily
changes on in-line suction catheters. Am J
Respir Crit Care Med. 1997;156:466-472.
18. Hess D. AARC Clinical Practice Guideline.
Care of the ventilator circuit and its relation
to ventilator-associated pneumonia. Respir
Care. 2003;48:869-879.
19. Dodek P, Keenan S, Cook D, et al. Evidencebased clinical practice guideline for the prevention of ventilator-associated pneumonia.
Ann Intern Med. 2004;141:305-313.
20. Center for Disease Control. Guidelines for
preventing health-care-associated pneumonia, 2003. MMWR. 2004;53:1-36.
21. Freytag CC, Thies FL, Konig W, et al. Prolonged application of closed in-line suction
catheters increases microbial colonization
of the lower respiratory tract and bacterial
growth on catheter surface. Infection. 2003;
1:31-36.
22. Lorente L, Lecuona M, Martin MM, et al.
Ventilator-associated pneumonia using a
closed versus an open tracheal suction system. Crit Care Med. 2005;33:115-119.
23. Niel-Weise BS, Snoeren RLMM, van den
Broek PJ. Policies for endotracheal suctioning of patients receiving mechanical ventilation: a systematic review of randomized
controlled trials. Infect Control Hosp
Epidemiol. 2007;28:531-536.
24. Peter JV, Chacko B, Moran JL. Comparison
of closed endotracheal suction versus open
endotracheal suction in the development of
ventilator-associated pneumonia in intensive care patients: an evaluation using metaanalytic techniques. Indian J Med Sci. 2007;
61:201-211.
25. Vonberg R, Eckmanns T, Welte T, et al.
Impact of the suctioning system (open vs.
closed) on the incidence of ventilation-associated pneumonia: meta-analysis of randomized controlled trials. Intensive Care
Med. 2006;32:1329-1335.
26. Zeitoun SS, Leite de Barros ALB, Diccini S.
A prospective, randomized study of ventilator-associated pneumonia in patients using
a closed vs. open suction system. J Clin
Nurs. 2003;12:484-489.

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Ask the Experts

Maureen A. Seckel
Crit Care Nurse 2008, 28:65-66.
2008 American Association of Critical-Care Nurses
Published online http://www.cconline.org

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