الاثنين، 18 مايو 2009

Open and Closed Endotracheal Suction Systems in
Mechanically
Ventilated Intensive Care Patients: A Meta-Analysis
Irene P. Jongerden, MS; Maroeska M. Rovers, PhD; Mieke H. Grypdonck, PhD; Marc J. Bonten, MD, PhD
Authors and Disclosures
Published: 02/28/2007
Abstract
Background: Closed suction systems (CSS) are increasingly replacing open suction systems (OSS) to perform endotracheal toilet in mechanically ventilated intensive care unit patients. Yet effectiveness regarding patient safety and costs of these systems has not been carefully analyzed.Objective: To review effectiveness of CSS and OSS, with respect to patient outcome, bacterial contamination, and costs in adult intensive care unit patients.Data Source: Search of MEDLINE, CINAHL, EMBASE, and Cochrane databases and a manual review of article bibliographies.Study Selection: Randomized controlled trials comparing CSS and OSS in adult intensive care unit patients were retrieved.Data Extraction/Synthesis: Assessment of abstracts and study quality was performed by two reviewers. Data were combined in meta-analyses by random effect models. Fifteen trials were identified. No significant differences were found in incidences of ventilator-associated pneumonia (eight studies, 1,272 patients) and mortality (four studies, 1,062 patients). No conclusions could be drawn with respect to arterial oxygen saturation (five studies, 109 patients), arterial oxygen tension (two studies, 19 patients), and secretion removal (two studies, 37 patients). Compared with OSS, endotracheal suctioning with CSS significantly reduced changes in heart rate (four studies, 85 patients; weighted mean difference, -6.33; 95% confidence interval, -10.80 to -1.87) and changes in mean arterial pressure (three studies, 59 patients; standardized mean difference, -0.43; 95% confidence interval, -0.87 to 0.00) but increased colonization (two studies, 126 patients; relative risk, 1.51; 95% confidence interval, 1.12-2.04). CSS seems to be more expensive than OSS.Conclusions: Based on the results of this meta-analysis, there is no evidence to prefer CSS more than OSS.
Introduction
Endotracheal suctioning (ES) is an essential and frequently performed procedure for patients requiring mechanical ventilation. By ES, secretions from the tracheobronchial tree are cleared, guaranteeing optimal oxygenation and avoiding accumulation of secretions, leading to tube occlusion, increased work of breathing, atelectasis, and pulmonary infections.[1-7] Yet ES may also have adverse effects, such as disturbances in cardiac rhythm, hypoxemia (due to interruption of the mechanical ventilation and subsequently the decay of intrathoracic pressure), microbial contamination of airway and environment, and development of ventilator-associated pneumonia (VAP).
The frequency with which ES is performed differs per patient, with reported mean values varying from eight to 17 times per day.[1, 8-13] Nowadays, two systems are available to perform ES: the single-use, open suction system (OSS) and the multiple-use, closed suction system (CSS). OSS requires disconnection from the ventilator during ES, which is not necessary when using CSS. Moreover, in contrast to OSS, the closed suction catheter can remain connected to the patient for as long as 24 hrs, according to the manufacturer, and thus can be used for multiple ES procedures.[14]
CSS has become increasingly popular in the past decade. In the United States, 58% and 4% of intensive care units (ICUs) exclusively used CSS and OSS, respectively.[15]
Preference of CSS more than OSS is mainly based on assumed advantages, like lower incidence of VAP, fewer physiologic disturbances, decreased microbial contamination (and thus lower risk on cross-infections), and lower costs.[8, 10, 16] In a recently published international guideline for the prevention of VAP, it was suggested that cost considerations favor the use of CSS that is changed as indicated, and the system is therefore recommended. This advice, however, is based on one trial that compared costs of CSS with or without daily changes of the system; trials on cost-effectiveness of CSS compared with OSS are lacking.[17]
So far, the evidence to prefer CSS more than OSS has not been systematically reviewed. Therefore, we performed a meta-analysis in which we compared the effectiveness of CSS with that of OSS with respect to infection and survival, cardiorespiratory variables, bacterial contamination, and costs.

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