Comparison of a Closed (Trach Care MAC) With an Open Endotracheal Suction System in Small Premature Infants

Abstract

OBJECTIVE:To determine whether ventilated, low birth weight infants treated with closed versus open tracheal suction in a neonatal intensive care unit (NICU) differ as to airway bacterial colonization, nosocomial pneumonia, bloodstream infection (BSI), incidence and severity of bronchopulmonary dysplasia (BPD), neonatal mortality, frequency of suction, reintubation, and nurse preference. STUDY DESIGN:A total of 175 low birth weight infants (Յ1250 gm) consecutively born (1997 to 1999), intubated, and ventilated in the delivery room were randomized on admission to the NICU to a closed (Trach Care MAC) or open suction group. Closed multi-use catheters were changed daily; open catheters were changed after every use. Two-pass endotracheal suctioning (both groups) was performed every 8 hours or as needed. Side-port connectors were not used; thus open suction required disconnection from ventilators. Tracheal aspirate cultures were obtained on admission and weekly thereafter. Nosocomial BSI (occurring after 48 hours of life) was documented by positive blood cultures. Radiographs taken before, during, and after tracheal aspirate cultures or BSIs were graded using a semiquantitative system for pneumonia and a modified score for BPD. Nurse preference regarding suction method was recorded. RESULTS:Of the original 175 patients, 10 (5 from each group) died and 32 others (16 from each group) were extubated at or before 7 days of life. The study population comprised 67 patients in the closed group and 66 in the open group who were ventilated longer than 1 week. Groups were not statistically different in terms of demographic and clinical characteristics, such as birth weight (837 vs 876 gm), ventilation (27 vs 26 days), and length of stay (49 vs 40 days). Airway colonization with Gram-positive cocci occurred in the majority of patients by 2 weeks of life, regardless of group. A total of 39% of infants in the closed group and 44% of infants in the open group became airway colonized with Gram-negative bacilli; differences were statistically significant. No Gram-negative bacilli species was more likely to be associated with either suction. Nosocomial pneumonia was diagnosed in five patients from each group. Nosocomial BSIs occurred in six closed suction infants and five open suction infants. A comparable number of infants in each group developed severe BPD and were discharged from the hospital on oxygen. A total of 28% of closed suction patients and 27% of open suction patients died. Infants in the closed versus open group were suctioned on average 4.4 and 4.1 times per day and were reintubated 9.7 and 8.6 times per 100 ventilator days, respectively. A total of 40 of 44 NICU nurses considered closed suction to be easier to use, less time-consuming, and better tolerated by the patient. CONCLUSIONS:Closed suction obviates the physiological disadvantage of ventilator disconnection without increasing the rate of bacterial airway colonization, frequency of endotracheal suction and reintubation, duration of mechanical ventilation, length...

Comparison of a Closed with an Open Endotracheal Suction: Costs and the Incidence of Ventilator-associated Pneumonia

“…Although, the occurrence of VAP seems to be higher in multiple-use, open suction group, it did not meet the level of statistical significance. Our results are consistent with those findings of other researchers who reported that suctioning performed by closed-suction system does not increase the incidence of nosocomial pneumonia 10,12,22 . Even though, Combes et al argued that the incidence rate of VAP was lower for closed-suction system than open-suctioning, there was no follow up studies supporting their data 11 .…”

“…The reason for the increased colonization rate was explained by more frequent suctioning in the closed-suction system due to ease of the procedure. On the other hand, Cordero et al reported that closed suction group showed less colonization by Gram-negative bacilli compared to open suction group 10 . In the present study, the ratio of colonization by MRSA (colonization rate*100/number of discharged patient) was 8.86 for multiple-use, open suction group, 2.27 for single-use, open suction group and 4.94 for multiple-use, closed suction group.…”

“…Closed-suction systems allow patients to maintain same ventilation, PEEP, and oxygenation during suctioning 15 . It is more comfortable both to nursing staffs and patients 10 . In addition, closed suction are cost-effective for patients requiring ventilation for one day or longer 16 .…”

“…The benefits of closed suction over open suction include the maintenance of positive pressure ventilation during suctioning, less desaturation, and a reduced risk of disseminating contaminated bronchial secretions 8,9 . In addition, many critical care nurses consider closed suction to be easier to use, less time-consuming and better tolerated by the patient 10 . In some reports, closed suction was associated with lower incidence rate of ventilator-associated pneumonia (VAP) 11 and even with the high probability for survival 12 .…”

Effects of a closed system suction connector on airwayresistance in ventilated neonates

“…Another type of connector is the one that belongs to CSS devices, with sizes suitable for different sized ETTs. This system is advantageous in terms of maintaining tidal volume during aspiration and thus they are widely used in NICUs (7,8). Previously, Kazancı et al reported a 4%-16% increase in resistance with the use of CSS connectors when compared to standard connectors in their in vitro study (4).…”