Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2007 Oct 17;2007(4):CD004581.
doi: 10.1002/14651858.CD004581.pub2.

Closed tracheal suction systems versus open tracheal suction systems for mechanically ventilated adult patients

M Subirana, I Solà, S Benito
Meta-Analysis

Closed tracheal suction systems versus open tracheal suction systems for mechanically ventilated adult patients

M Subirana et al. Cochrane Database Syst Rev. .

Abstract

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 strategy: 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.

PubMed Disclaimer

Conflict of interest statement

None known.

Figures

1
1
Search results
1.1
1.1. Analysis
Comparison 1 Open suction system versus Closed suction system, Outcome 1 Ventilator associated pneumonia (VAP).
1.2
1.2. Analysis
Comparison 1 Open suction system versus Closed suction system, Outcome 2 Time to VAP development.
1.3
1.3. Analysis
Comparison 1 Open suction system versus Closed suction system, Outcome 3 Mortality.
1.4
1.4. Analysis
Comparison 1 Open suction system versus Closed suction system, Outcome 4 Time on ventilation (in days).
1.5
1.5. Analysis
Comparison 1 Open suction system versus Closed suction system, Outcome 5 Colonization.
1.6
1.6. Analysis
Comparison 1 Open suction system versus Closed suction system, Outcome 6 Length of stay in ICU (in days).
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD004581

Similar articles

See all similar articles

Cited by

See all "Cited by" articles

References

References to studies included in this review

Adams 1997 {published data only}
    1. Adams DH, Hughes M, Elliott TS. Microbial colonization of closed‐system suction catheters used in liver transplant patients. Intensive & Critical Care Nursing : the official journal of the British Association of Critical Care Nurses 1997;13(2):72‐6. [MEDLINE: ] - PubMed
Cereda 2001 {published data only}
    1. Cereda M, Villa F, Colombo E, Greco G, Nacoti M, Pesenti A. Closed system endotracheal suctioning maintains lung volume during volume‐controlled mechanical ventilation. Intensive Care Medicine 2001;27(4):648‐54. [MEDLINE: ] - PubMed
Combes 2000 {published data only}
    1. Combes P, Fauvage B, Oleyer C. Nosocomial pneumonia in mechanically ventilated patients, a prospective randomised evaluation of the Stericath closed suctioning system. Intensive Care Medicine 2000;26(7):878‐82. [MEDLINE: ] - PubMed
Conrad 1989 {published data only}
    1. Conrad SA, George RB, Romero MD, Owens MW. Comparison of nosocomial pneumonia rates in closed and open tracheal suction systems [abstract]. Chest 1989;96:Suppl:184.
Deppe 1990 {published data only}
    1. Deppe SA, Kelly JW, Thoi LL, Chudy JH, Longfield RN, Ducey JP, et al. Incidence of colonization, nosocomial pneumonia, and mortality in critically ill patients using a Trach Care closed‐suction system versus an open‐suction system: prospective, randomized study. Critical Care Medicine 1990;18(12):1389‐93. [MEDLINE: ] - PubMed
Gallagher 1994 {published data only}
    1. Gallagher J, Campbell D, Morris A, McArthur C, Judson J. A closed multi‐use suction system does not protect individual patients against cross‐colonization with endemic Acinetobacter calcoaceticus in an Intensive Care Unit. A prospective randomised study. Department of Critical Care Medicine, Auckland Hospital, Auckland New Zealand 1994.
    1. Gallagher J, Campbell D, Morris A, McArthur C, Judson J. A closed multi‐use suction system does not protect intubated patients from cross‐colonization with endemic Acinetobacter calcoaceticus in the ICU [abstract]. Anaesthesia and Intensive Care 1996;24(2):274.
Johnson 1994 {published data only}
    1. Johnson KL, Kearney PA, Johnson SB, Niblett JB, MacMillan NL, McClain RE. Closed versus open endotracheal suctioning: costs and physiologic consequences. Critical Care Medicine 1994;22(4):658‐66. [MEDLINE: ] - PubMed
Lee 2001 {published data only}
    1. Lee CK, Ng KS, Tan SG, Ang R. Effect of different endotracheal suctioning systems on cardiorespiratory parameters of ventilated patients. Annals of the Academy of Medicine, Singapore 2001;30(3):239‐44. [MEDLINE: ] - PubMed
Lorente 2005 {published data only}
    1. Lorente L, Lecuona M, Martin MM, Garcia C, Mora ML, Sierra A. Ventilator‐associated pneumonia using a closed versus an open tracheal suction system. Critical Care Medicine 2005;33(1):115‐9. [MEDLINE: ] - PubMed
Lorente 2006 {published data only}
    1. Lorente L, Lecuona M, Jimenez A, Mora ML, Sierra A. Tracheal suction by closed system without daily change versus open system. Intensive Care Medicine 2006;32(4):538‐44. [MEDLINE: ] - PubMed
Rabitsch 2004 {published data only}
    1. Rabitsch W, Kostler WJ, Fiebiger W, Dielacher C, Losert H, Sherif C, et al. Closed suctioning system reduces cross‐contamination between bronchial system and gastric juices. Anesthesia and Analgesia 2004;99(3):886‐92. [MEDLINE: ] - PubMed
Topeli 2004 {published data only}
    1. Topeli A, Harmanci A, Cetinkaya Y, Akdeniz S, Unal S. Comparison of the effect of closed versus open endotracheal suction systems on the development of ventilator‐associated pneumonia. Journal of Hospital Infection 2004;58(1):14‐9. [MEDLINE: ] - PubMed
Welte 1997 {published data only}
    1. Welte T, Ziesing S, Schulte S, Wagner TOF. Incidence of ventilator associated pneumonia in mechanically ventilated patients: a comparison of closed versus open endotrachela suctioning [abstract]. European Respiratory Journal 1997;10 Suppl:(25):319.
Witmer 1991 {published data only}
    1. Witmer MT, Hess D, Simmons M. An evaluation of the effectiveness of secretion removal with a closed‐circuit suction catheter [abstract]. Respiratory Care 1990;35(11):1117‐8.
    1. Witmer MT, Hess D, Simmons M. An evaluation of the effectiveness of secretion removal with the ballard closed‐circuit suction catheter. Respiratory Care 1991;36:844‐8.
Zeitoun 2003 {published data only}
    1. Zeitoun SS, Barros AL, Diccini S. A prospective, randomized study of ventilator‐associated pneumonia in patients using a closed vs open suction system. Journal of Clinical Nursing 2003;12(4):484‐9. [MEDLINE: ] - PubMed
    1. Zeitoun SS, Barros AL, Diccini S, Juliano Y. [Incidence of ventilator‐associated pneumonia in patients using open‐suction systems and closed‐suction systems: a prospective study ‐‐ preliminary data]. Revista Latino‐Americana de Enfermagem 2001;9(1):46‐52. [MEDLINE: ] - PubMed
Zielmann 1992 {published data only}
    1. Zielmann S, Grote R, Sydow M, Radke J, Burchardi H. [Endotracheal suctioning using a 24‐hour continuous system. Can costs and waste products be reduced?]. Anaesthesist 1992;41(8):494‐8. [MEDLINE: ] - PubMed

References to studies excluded from this review

Almgren 2004 {published data only}
    1. Almgren B, Wickerts CJ, Heinonen E, Hogman M. Side effects of endotracheal suction in pressure‐ and volume‐controlled ventilation. Chest 2004;125(3):1077‐80. [MEDLINE: ] - PubMed
Baker 1989 {published data only}
    1. Baker T, Taylor M, Wilson M, Rish J, Brazeal S. Evaluation of a closed system endotracheal suction catheter [abstract]. American Journal of Infection Control 1989;17:97.
Baun 2002 {published data only}
    1. Baun MM, Stone KS, Rogge JA. Endotracheal suctioning: open versus closed with and without positive end‐expiratory pressure. Critical Care Nursing Quarterly 2002;25(2):13‐26. [MEDLINE: ] - PubMed
Brown 1983 {published data only}
    1. Brown SE, Stansbury DW, Merrill EJ, Linden GS, Light RW. Prevention of suctioning‐related arterial oxygen desaturation. Comparison of off‐ventilator and on‐ventilator suctioning. Chest 1983;83(4):621‐7. [MEDLINE: ] - PubMed
Carlon 1987 {published data only}
    1. Carlon GC, Fox SJ, Ackerman NJ. Evaluation of a closed‐tracheal suction system. Critical Care Medicine 1987;15(5):522‐5. [MEDLINE: ] - PubMed
Çelik 2000 {published data only}
    1. Çelik SS, Elbas NO. The standard of suction for patients undergoing endotracheal intubation. Intensive and Critical Care Nursing 2000;16(3):191‐8. [MEDLINE: ] - PubMed
Clark 1990 {published data only}
    1. Clark AP, Winslow EH, Tyler DO, White KM. Effects of endotracheal suctioning on mixed venous oxygen saturation and heart rate in critically ill adults. Heart Lung 1990;19(5 Pt2):552‐7. [MEDLINE: ] - PubMed
Cobley 1991 {published data only}
    1. Cobley M, Atkins M, Jones PL. Environmental contamination during tracheal suction. A comparison of disposable conventional catheters with a multiple‐use closed system device. Anaesthesia 1991;46(11):957‐61. [MEDLINE: ] - PubMed
Craig 1984 {published data only}
    1. Craig KC, Benson MS, Pierson DJ. Prevention of arterial oxygen desaturation during closed‐airway endotracheal suction: effect of ventilator mode. Respiratory Care 1984;29:1013‐8.
DePew 1994 {published data only}
    1. DePew CL, Moseley MJ, Clark EG, Morales CC. Open vs closed‐system endotracheal suctioning: a cost comparison. Critical Care Nurse 1994;14(1):94‐100. [MEDLINE: ] - PubMed
Eckert 1998 {published data only}
    1. Eckert P, Blanc D, Francioli P, Schaller MD, Feihl F. Microbiological and physiological evaluation of two closed tracheal suction systems [abstract]. American Journal of Respiratory and Critical Care Medicine 1998;157(3):Suppl: A687. [CN‐00428415]
Fernández 2004 {published data only}
    1. Fernandez MD, Piacentini E, Blanch L, Fernandez R. Changes in lung volume with three systems of endotracheal suctioning with and without pre‐oxygenation in patients with mild‐to‐moderate lung failure. Intensive Care Medicine 2004;30(12):2210‐5. [MEDLINE: ] - PubMed
Freytag 2003 {published data only}
    1. Freytag CC, Thies FL, Konig W, Welte T. Prolonged application of closed in‐line suction catheters increases microbial colonization of the lower respiratory tract and bacterial growth on catheter surface. Infection 2003;31(1):31‐7. [MEDLINE: ] - PubMed
Gertsmann 1995 {published data only}
    1. Gertsmann G, Cooper L, Haskill R, Lassen G. Open disconnect versus closed in‐line suctioning during HFOV [abstract]. Respiratory Care 1995;40(11):1201.
Gu 2005 {published data only}
    1. Gu Q, Ge M, Dong DJ. [Effects of lung recruitment maneuver on oxygenation and hemodynamics after open endotracheal suctioning in acute respiratory distress syndrome]. Zhongguo Wei Zhong Bing Ji Jiu Yi Xue 2005;17(8):484‐6. [MEDLINE: ] - PubMed
Hardie 1989 {published data only}
    1. Hardie DK, Kirchoff KT. A comparison of the open versus closed system suctioning [abstract]. Heart Lung 1989;18:305.
Harshbarger 1992 {published data only}
    1. Harshbarger SA, Hoffman LA, Zullo TG, Pinsky MR. Effects of a closed tracheal suction system on ventilatory and cardiovascular parameters. American Journal of Critical Care 1992;1(3):57‐61. [MEDLINE: ] - PubMed
Hopkins 1990 {published data only}
    1. Hopkins M, Mahlmeister M, Koo P, Cohen N. The effect of closed vs open endotracheal suctioning on PaO2 in ventilated patients [abstract]. Heart Lung 1990;19:308.
Kollef 1997 {published data only}
    1. Kollef MH, Prentice D, Shapiro SD, Fraser VJ, Silver P, Trovillion E, et al. Mechanical ventilation with or without daily changes of in‐line suction catheters. American Journal of Respiratory and Critical Care Medicine 1997;156(2 Pt 1):466‐72. [MEDLINE: ] - PubMed
Lindgren 2004 {published data only}
    1. Lindgren S, Almgren B, Hogman M, Lethvall S, Houltz E, Lundin S, et al. Effectiveness and side effects of closed and open suctioning: an experimental evaluation. Intensive Care Medicine 2004;30(8):1630‐7. [MEDLINE: ] - PubMed
Maggiore 2002 {published data only}
    1. Maggiore SM, Iacobone E, Zito G, Conti C, Antonelli M, Proietti R. Closed versus open suctioning techniques. Minerva Anestesiologica 2002;68(5):360‐4. [MEDLINE: ] - PubMed
Mattar 1992 {published data only}
    1. Mattar JA, Sproesser AM, Gomes MA. A comparative study of oxygen transport between open and closed methods of tracheal suctioning. Intensive and Critical Care Digest 1992;11(3):57‐88.
O'Dell‐Batalla 2000 {published data only}
    1. O'Dell‐Batalla IR, Blanco Limpin ME, Guia T. A randomised crossover trial between cath‐guide closed system suctioning and conventional open system in the respiratory airway care of postoperative patients in the recovery room of the Philippine Heart Center [abstract]. The European Respiratory Journal 2000;16. Suppl(31):427.
Prentice 1994 {published data only}
    1. Prentice D, Weilitz PB, Fraser VJ. A prospective randomized trial comparing outcomes of a closed versus open suctioning system [abstract]. Critical Care Medicine 1994;22(1):A92.
Ritz 1986 {published data only}
    1. Ritz R, Scott LR, Coyle MB, Pierson DJ. Contamination of a multiple‐use suction catheter in a closed‐circuit system compared to contamination of a disposable, single‐use suction catheter. Respiratory Care 1986;31(11):1086‐91. [MEDLINE: ] - PubMed
Schön 2002 {published data only}
    1. Schön R. [Closed versus open endobronchial suctioning in mechanically ventilated intensive care patients]. Journal für Anasthesie und Intensivbehandlung 2002;9(2):139‐42.
Stenqvist 2001 {published data only}
    1. Stenqvist O, Lindgren S, Karason S, Sondergaard S, Lundin S. Warning! Suctioning. A lung model evaluation of closed suctioning systems. Acta Anaesthesiologica Scandinavica 2001;45(2):161‐72. [MEDLINE: ] - PubMed
Valderas 2004 {published data only}
    1. Valderas Castilla D, Bravo Páramo C, Torres González JI, Corniero Pico A, Ambit Lemus R, López Almorox E, et al. Repercussion on respiratory and hemodynamic parameters with a closed system of aspiration of secretion [Repercusión sobre parámetros respiratorios y hemodinámicos con un sistema cerrado de aspiración de secreciones]. Enfermería Intensiva 2004;15(1):3‐10. [MEDLINE: ] - PubMed
Vonberg 2006 {published data only}
    1. Vonberg RP, Eckmanns T, Welte T, Gastmeier P. Impact of the suctioning system (open vs. closed) on the incidence of ventilation‐associated pneumonia: meta‐analysis of randomized controlled trials. Intensive Care Medicine 2006;32(9):1329‐35. [MEDLINE: ] - PubMed
Weitl 1994 {published data only}
    1. Weitl J, Bettstetter H. [Indications for the use of closed endotracheal suction. Artificial respiration with high positive end‐expiratory pressure]. Anaesthesist 1994;43(6):359‐63. [MEDLINE: ] - PubMed
Wu 1993 {published data only}
    1. Wu RS, Tao CW, Wong SY, Tan PP. Use of a closed‐airway suctioning system during anesthesia. Ma Zui Xue Za Zhi (Anaesthesiologica Sinica) 1993;31(1):9‐14. - PubMed

References to studies awaiting assessment

Bourgault 2006 {published data only}
    1. Bourgault AM, Brown CA, Hains SM, Parlow JL. Effects of endotracheal tube suctioning on arterial oxygen tension and heart rate variability. Biological Research for Nursing 2006;7(4):268‐78. [MEDLINE: ] - PubMed
Lasocki 2006 {published data only}
    1. Lasocki S, Lu Q, Sartorius A, Fouillat D, Remerand F, Rouby JJ. Open and closed‐circuit endotracheal suctioning in acute lung injury: efficiency and effects on gas exchange. Anesthesiology 2006;104(1):39‐47. [MEDLINE: ] - PubMed
Lee 2004 {published data only}
    1. Lee ES, Kim SH, Kim JS. Effects of a closed endotracheal suction system on oxygen saturation, ventilator‐associated pneumonia, and nursing efficacy. Taehan Kanho Hakhoe Chi 2004;34(7):1315‐25. [MEDLINE: ] - PubMed

Additional references

Chan 2005
    1. Chan AW, Altman DG. Epidemiology and reporting of randomised trials published in PubMed journals. Lancet 2005;365:1159‐62. [MEDLINE: ] - PubMed
Chester 2002
    1. Chester J, Fagon JY. Ventilator‐associated pneumonia. American Journal of Respiratory and Critical Care Medicine 2002;165:867‐903. - PubMed
Collard 2003
    1. Collard HR, Saint S, Matthay MA. Prevention of ventilator‐associated pneumonia: an evidence‐based systematic review. Annals of Internal Medicine 2003;138(6):494‐501. [MEDLINE: ] - PubMed
Cracknell 2006
    1. Cracknell J, Møller A, Pedersen T. Cochrane Anaesthesia Review Group. In: The Cochrane Library, Issue 2, 2006.
Downs 1998
    1. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non‐randomised studies of health care interventions. Journal of Epidemiology and Community Health 1998;56:377‐84. [MEDLINE: ] - PMC - PubMed
Grap 1996
    1. Grap MJ, Glass C, Corley M, Parks T. Endotracheal suctioning: ventilator vs manual delivery of hyperoxygenation breaths. American Journal of Critical Care 1996;5(3):192‐7. [MEDLINE: ] - PubMed
Higgins 2003
    1. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta‐analyses. BMJ 2003;327(7414):557‐60. [MEDLINE: ] - PMC - PubMed
Higgins 2005
    1. Higgins JPT, Green S, editors.Cochrane Handbook for Systematic Reviews of Interventions 4.2.5 [updated May 2005].. In: The Cochrane Library, Issue 3, 2005. Chichester, UK: John Wiley & Sons, Ltd.
Hixson 1998
    1. Hixson S, Sole ML, King T. Nursing strategies to prevent ventilator‐associated pneumonia. AACN Clinical Issues 1998;9(1):76‐90. [MEDLINE: ] - PubMed
Jüni 2001
    1. Jüni P, Altman DG, Egger M. Assessing the quality of controlled clinical trials. BMJ 2001;323:42‐6. [MEDLINE: ] - PMC - PubMed
Kollef 1999
    1. Kollef MH. The prevention of ventilator‐associated pneumonia. New England Journal of Medicine 1999;340(8):627‐34. [MEDLINE: ] - PubMed
McKelvie 1998
    1. McKelvie S. Endotracheal suctioning. Nursing in Critical Care 1998;3(5):244‐8. [MEDLINE: ] - PubMed
McQuillan 1992
    1. McQuillan, P. Introduction of a closed circuit suction system with a multi‐use suction catheter. Stobhill General Hospital (Glasgow) 1992.
Moher 2001
    1. Moher D, Schulz KF, Altman D. The CONSORT statement: revised recommendations for improving the quality of reports of parallel‐group randomised trials. Lancet 2001;357:1191‐4. [MEDLINE: ] - PubMed
Naigow 1977
    1. Naigow D, Powaser MM. The effect of different endotracheal suction procedures on arterial blood gases in a controlled experimental model. Heart & Lung: the journal of critical care 1977;6(5):808‐16. [MEDLINE: ] - PubMed
NNIS 2000
    1. No authors listed. National Nosocomial Infections Surveillance (NNIS) system report, data summary from January 1992‐April 2000, issued June 2000. American Journal of Infection Control 2000;28(6):429‐48. [MEDLINE: ] - PubMed
Noll 1990
    1. Noll ML, Hix CD, Scott G. Closed tracheal suction systems: effectiveness and nursing implications. AACN Clinical Issues in Critical Care Nursing 1990;1(2):318‐28. [MEDLINE: ] - PubMed
Paul‐Allen 2000
    1. Paul‐Allen J, Ostrow CL. Survey of nursing practices with closed‐system suctioning. American Journal of Critical Care 2000;9(1):9‐17. [MEDLINE: ] - PubMed
RevMan 4.2 [Computer program]
    1. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan) [Computer program]. Version 4.2 for Windows. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2003.
Robinson 2002
    1. Robinson KA, Dickersin K. Development of a highly sensitive search strategy for the retrieval of reports of controlled trials using PubMed. International Journal of Epidemiology 2002;31(1):150‐3. [MEDLINE: ] - PubMed
Thompson 2000
    1. Thompson L. Suctioning adults with an artificial airway. Joanna Briggs Institute for Evidence Based Nursing and Midwifery Systematic Reviews. Vol. 9, Adelaide, Australia: Joanna Briggs Institute for Evidence Based Nursing and Midwifery, 2000:1‐95. [ISBN: 0‐9577796‐5‐8]
Wood 1998
    1. Wood CJ. Endotracheal suctioning: a literature review. Intensive and Critical Care Nursing 1998;14(3):124‐36. [MEDLINE: ] - PubMed
Woodgate 2001
    1. Woodgate PG, Flenady V. Tracheal suctioning without disconnection in intubated ventilated neonates. Cochrane Database of Systematic Reviews 2001, Issue 2. [Art. No.: CD003065. DOI: 10.1002/14651858.CD003065. Art. No.: CD003065. DOI: 10.1002/14651858.CD003065] - PubMed

MeSH terms

LinkOut - more resources