Efficacy of closed and open tracheal suction systems for prevention of ventilator-associated pneumonia: a meta-analysis_Chinese Journal of Evidence-Based Medicine

Authors：

WONG Waiman ^1,2 ,  WANG Yan ¹

1. Macao Polytechnic Institute, Macau 999078, P.R.China;
2. Hospital Infection Control Committee, Centro Hospitalar Conde de S?o Januário, Macau 999078, P.R.China;

Corresponding?author：

WANG Yan, Email: ywang@ipm.edu.mo

Keywords：

Closed tracheal suction system; Open tracheal suction system; Ventilator-associated pneumonia; Systematic review; Meta-analysis; Randomized controlled trial

DOI：

10.7507/1672-2531.202006212

Video：

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Objective To systematically review the efficacy of closed and open tracheal suction system on the prevention of ventilator-associated pneumonia.Methods The Cochrane Library, CNKI, WanFang Data, Airiti Library, PubMed, CINAHL and Proquest databases were electronically searched to collect randomized controlled trials (RCTs) on closed and open tracheal suction system on the prevention of ventilator-associated pneumonia. Two reviewers independently screened literature, extracted data, and assessed the risk bias of included studies. Then, meta-analysis was performed by RevMan 5.3 software.Results A total of 11 RCTs involving 1 187 patients were included. The results of meta-analysis showed that compared with open tracheal suction system, closed tracheal suction system was associated with a reduced incidence of ventilator-associated pneumonia (RR=0.55, 95%CI 0.44 to 0.67, P<0.000 01), late-onset ventilator-associated pneumonia (RR=0.47, 95%CI 0.28 to 0.80, P=0.005), length of stay in intensive care unit (MD=?0.85, 95%CI ?1.66 to ?0.04, P=0.04) and rate of microbial colonization (RR=0.69, 95%CI 0.56 to 0.86, P=0.000 9). However, there were no significant differences between two groups in time to ventilator-associated pneumonia development (MD=0.96, 95%CI ?0.21 to 2.12, P=0.11), length of mechanical ventilation (MD=?2.24, 95%CI ?4.54 to 0.06, P=0.06), and rate of mortality (RR=0.88, 95%CI 0.73 to 1.05, P=0.15).Conclusions Current evidence shows that compared with open tracheal suction system, closed tracheal suction system can reduce the incidence of ventilator-associated pneumonia and late-onset ventilator-associated pneumonia, shorten the hospital stay in intensive care unit, and reduce rate of microbial colonization. Due to limited quality and quantity of the included studies, more high quality studies are required to verify above conclusions.

Citation： WONG Waiman, WANG Yan. Efficacy of closed and open tracheal suction systems for prevention of ventilator-associated pneumonia: a meta-analysis. Chinese Journal of Evidence-Based Medicine, 2021, 21(1): 21-27. doi: 10.7507/1672-2531.202006212 Copy

1.	Centers for Disease Control and Prevention. Pneumonia (Ventilator-associated [VAP] and non-ventilator-associated Pneumonia [PNEU]) event. National Healthcare Safety Network (NHSN) patient safety component manual. Available at: https://www.cdc.gov/nhsn/pdfs/pscmanual/6pscvapcurrent.pdf.
2.	Ding C, Zhang Y, Yang Z, et al. Incidence, temporal trend and factors associated with ventilator-associated pneumonia in mainland China: a systematic review and meta-analysis. BMC Infect Dis, 2017, 17(1): 468.
3.	Magill SS, O'Leary E, Janelle SJ, et al. Changes in prevalence of health care-associated infections in U. S. hospitals. N Engl J Med, 2018, 379(18): 1732-1744.
4.	Klompas M, Branson R, Eichenwald EC, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol, 2014, 35(8): 915-936.
5.	Melsen WG, Rovers MM, Groenwold RH, et al. Attributable mortality of ventilator-associated pneumonia: a meta-analysis of individual patient data from randomised prevention studies. Lancet Infect Dis, 2013, 13(8): 665-671.
6.	Mietto C, Pinciroli R, Patel N, et al. Ventilator associated pneumonia: evolving definitions and preventive strategies. Respir Care, 2013, 58(6): 990-1007.
7.	Azam F, Alireza K, Gholamreza M, et al. Open and closed endotracheal suctioning and arterial blood gas values: a single-blind crossover randomized clinical trial. Crit Care Res Pract, 2015: 470842.
8.	陳佩卿, 徐偉樺, 沙煒惠, 等. 置放氣管內管病人使用密閉式抽痰或開放式抽痰對生理參數, 環境菌落數及疼痛之成效探討. 領導護理, 2018, 19(2): 24-35.
9.	Vijai MN, Ravi PR, Setlur R, et al. Efficacy of intermittent sub-glottic suctioning in prevention of ventilator-associated pneumonia- a preliminary study of 100 patients. Indian J Anaesth, 2016, 60(5): 319-324.
10.	Solà I, Benito S. Closed tracheal suction systems versus open tracheal suction systems for mechanically ventilated adult patients. Cochrane Database Syst Rev, 2007, (4): CD004581.
11.	田苗, 張豪, 左紅霞, 等. 國內外不同吸痰方式對預防呼吸機相關性肺炎的 Meta 分析. 湖北醫藥學院學報, 2018, 37(6): 504-510.
12.	中華醫學會重癥醫學分會. 呼吸機相關性肺炎診斷, 預防和治療指南(2013). 中華內科雜志, 2013, 52(6): 524-543.
13.	Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions. The Cochrane Collaboration, 2019. Available at: http://www.cochrane-handbook.org.
14.	Ardehali SH, Fatemi A, Rezaei SF, et al. The effects of open and closed suction methods on occurrence of ventilator associated pneumonia: a comparative study. Arch Acad Emerg Med, 2020, 8(1): e8.
15.	張宏. 密閉式吸痰對 VAP 的預防作用研究. 現代醫藥衛生, 2019, 35(17): 2684-2686.
16.	Elmansoury A, Said H. Closed suction system versus open suction. Egypt J Chest Dis Tuberc, 2017, 66(3): 509-515.
17.	Alipour N, Manouchehrian N, Sanatkar M, et al. Evaluation of the effect of open and closed tracheal suction on the incidence of ventilator associated pneumonia in patients admitted in the intensive care unit. Arch Anesth Crit Care, 2016, 2(2): 193-196.
18.	Hamishekar H, Shadvar K, Taghizadeh M, et al. Ventilator-associated pneumonia in patients admitted to intensive care units, using open or closed endotracheal suctioning. Anesth Pain Med, 2014, 4(5): e21649.
19.	遲紅麗, 林淑梅, 翟旭杰. 人工鼻聯合密閉式吸痰管預防呼吸機相關性肺炎的療效. 中國老年學雜志, 2013, 33(18): 4629-4631.
20.	余棟栽, 李倩文, 譚家香, 等. 持續氣囊上吸引聯合密閉式吸痰預防呼吸機相關性肺炎的臨床研究. 中外醫療, 2013, 32(14): 35-36.
21.	David D, Samuel P, David T, et al. An open-labelled randomized controlled trial comparing costs and clinical outcomes of open endotracheal suctioning with closed endotracheal suctioning in mechanically ventilated medical intensive care patients. J Crit Care, 2011, 26(5): 482-488.
22.	Cha KS, Park HR. [Endotracheal colonization and ventilator-associated pneumonia in mechanically ventilated patients according to type of endotracheal suction system]. J Korean Acad Nurs, 2011, 41(2): 175-181.
23.	吳偉英. 兩種不同吸痰方式對呼吸機相關性肺炎應用效果評價. 現代預防醫學, 2011, 38(9): 1778-1779.
24.	吳瑤, 行雯婧, 陳欣揚, 等. 兩種吸痰方式預防心胸外科術后機械通氣患者呼吸道感染的效果. 華西醫學, 2011, 26(8): 1226-1229.
25.	于海容, 王婧婷, 黃婷婷, 等. 機械通氣患者密閉式與開放式吸痰效果比較的系統評價. 解放軍護理雜志, 2014, 31(14): 1-6.
26.	Kuriyama A, Umakoshi N, Fujinaga J, et al. Impact of closed versus open tracheal suctioning systems for mechanically ventilated adults: a systematic review and meta-analysis. Intensive Care Med, 2015, 41(3): 402-411.
27.	董亮, 于濤, 楊毅, 等. 封閉式和開放式吸痰系統臨床效果與安全性評價的Meta分析. 中華內科雜志, 2012, 51(10): 763-768.
28.	Afshari A, Safari M, Oshvandi K, et al. The effect of the open and closed system suctions on cardiopulmonary parameters: time and costs in patients under mechanical ventilation. Nurs Midwifery Stud, 2014, 3(2): e14097.
29.	Philippart F, Gaudry S, Quinquis L, et al. Randomized intubation with polyurethane or conical cuffs to prevent pneumonia in ventilated patients. Am J Respir Crit Care Med, 2015, 191(6): 637-645.
30.	Nseir S, Ader F, Lubret R, et al. Pathophysiology of airway colonization in critically ill COPD patient. Curr Drug Targets, 2011, 12(4): 514-520.
31.	Nseir S, Zerimech F, Jaillette E, et al. Microaspiration in intubated critically ill patients: diagnosis and prevention. Infect Disord Drug Targets, 2011, 11(4): 413-423.
32.	Diaconu O, Siriopol I, Polo?anu LI, et al. Endotracheal tube biofilm and its impact on the pathogenesis of ventilator-associated pneumonia. J Crit Care Med (Targu Mures), 2018, 4(2): 50-55.
33.	萬國華. 呼吸治療技術與醫院空氣質量. 長庚科技學刊, 2014, (21): 1-12.
34.	Cook TM, El-Boghdadly K, McGuire B, et al. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the difficult airway society, the association of anaesthetists the intensive care society, the faculty of intensive care medicine and the royal college of anaesthetists. Anaesthesia, 2020, 75(6): 785-799.
35.	Centers for Disease Control and Prevention. Ventilator-Associated Event (VAE). National Healthcare Safety Network (NHSN) patient safety component manual. Available at: https://www.cdc.gov/nhsn/PDFs/pscManual/10-VAE_FINAL.pdf.
36.	康德英, 洪旗. 如何評價 Meta-分析的統計分析結果. 中國循證醫學, 2001, 1(2): 106-108.

1. Centers for Disease Control and Prevention. Pneumonia (Ventilator-associated [VAP] and non-ventilator-associated Pneumonia [PNEU]) event. National Healthcare Safety Network (NHSN) patient safety component manual. Available at: https://www.cdc.gov/nhsn/pdfs/pscmanual/6pscvapcurrent.pdf.
2. Ding C, Zhang Y, Yang Z, et al. Incidence, temporal trend and factors associated with ventilator-associated pneumonia in mainland China: a systematic review and meta-analysis. BMC Infect Dis, 2017, 17(1): 468.
3. Magill SS, O'Leary E, Janelle SJ, et al. Changes in prevalence of health care-associated infections in U. S. hospitals. N Engl J Med, 2018, 379(18): 1732-1744.
4. Klompas M, Branson R, Eichenwald EC, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol, 2014, 35(8): 915-936.
5. Melsen WG, Rovers MM, Groenwold RH, et al. Attributable mortality of ventilator-associated pneumonia: a meta-analysis of individual patient data from randomised prevention studies. Lancet Infect Dis, 2013, 13(8): 665-671.
6. Mietto C, Pinciroli R, Patel N, et al. Ventilator associated pneumonia: evolving definitions and preventive strategies. Respir Care, 2013, 58(6): 990-1007.
7. Azam F, Alireza K, Gholamreza M, et al. Open and closed endotracheal suctioning and arterial blood gas values: a single-blind crossover randomized clinical trial. Crit Care Res Pract, 2015: 470842.
8. 陳佩卿, 徐偉樺, 沙煒惠, 等. 置放氣管內管病人使用密閉式抽痰或開放式抽痰對生理參數, 環境菌落數及疼痛之成效探討. 領導護理, 2018, 19(2): 24-35.
9. Vijai MN, Ravi PR, Setlur R, et al. Efficacy of intermittent sub-glottic suctioning in prevention of ventilator-associated pneumonia- a preliminary study of 100 patients. Indian J Anaesth, 2016, 60(5): 319-324.
10. Solà I, Benito S. Closed tracheal suction systems versus open tracheal suction systems for mechanically ventilated adult patients. Cochrane Database Syst Rev, 2007, (4): CD004581.
11. 田苗, 張豪, 左紅霞, 等. 國內外不同吸痰方式對預防呼吸機相關性肺炎的 Meta 分析. 湖北醫藥學院學報, 2018, 37(6): 504-510.
12. 中華醫學會重癥醫學分會. 呼吸機相關性肺炎診斷, 預防和治療指南(2013). 中華內科雜志, 2013, 52(6): 524-543.
13. Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions. The Cochrane Collaboration, 2019. Available at: http://www.cochrane-handbook.org.
14. Ardehali SH, Fatemi A, Rezaei SF, et al. The effects of open and closed suction methods on occurrence of ventilator associated pneumonia: a comparative study. Arch Acad Emerg Med, 2020, 8(1): e8.
15. 張宏. 密閉式吸痰對 VAP 的預防作用研究. 現代醫藥衛生, 2019, 35(17): 2684-2686.
16. Elmansoury A, Said H. Closed suction system versus open suction. Egypt J Chest Dis Tuberc, 2017, 66(3): 509-515.
17. Alipour N, Manouchehrian N, Sanatkar M, et al. Evaluation of the effect of open and closed tracheal suction on the incidence of ventilator associated pneumonia in patients admitted in the intensive care unit. Arch Anesth Crit Care, 2016, 2(2): 193-196.
18. Hamishekar H, Shadvar K, Taghizadeh M, et al. Ventilator-associated pneumonia in patients admitted to intensive care units, using open or closed endotracheal suctioning. Anesth Pain Med, 2014, 4(5): e21649.
19. 遲紅麗, 林淑梅, 翟旭杰. 人工鼻聯合密閉式吸痰管預防呼吸機相關性肺炎的療效. 中國老年學雜志, 2013, 33(18): 4629-4631.
20. 余棟栽, 李倩文, 譚家香, 等. 持續氣囊上吸引聯合密閉式吸痰預防呼吸機相關性肺炎的臨床研究. 中外醫療, 2013, 32(14): 35-36.
21. David D, Samuel P, David T, et al. An open-labelled randomized controlled trial comparing costs and clinical outcomes of open endotracheal suctioning with closed endotracheal suctioning in mechanically ventilated medical intensive care patients. J Crit Care, 2011, 26(5): 482-488.
22. Cha KS, Park HR. [Endotracheal colonization and ventilator-associated pneumonia in mechanically ventilated patients according to type of endotracheal suction system]. J Korean Acad Nurs, 2011, 41(2): 175-181.
23. 吳偉英. 兩種不同吸痰方式對呼吸機相關性肺炎應用效果評價. 現代預防醫學, 2011, 38(9): 1778-1779.
24. 吳瑤, 行雯婧, 陳欣揚, 等. 兩種吸痰方式預防心胸外科術后機械通氣患者呼吸道感染的效果. 華西醫學, 2011, 26(8): 1226-1229.
25. 于海容, 王婧婷, 黃婷婷, 等. 機械通氣患者密閉式與開放式吸痰效果比較的系統評價. 解放軍護理雜志, 2014, 31(14): 1-6.
26. Kuriyama A, Umakoshi N, Fujinaga J, et al. Impact of closed versus open tracheal suctioning systems for mechanically ventilated adults: a systematic review and meta-analysis. Intensive Care Med, 2015, 41(3): 402-411.
27. 董亮, 于濤, 楊毅, 等. 封閉式和開放式吸痰系統臨床效果與安全性評價的Meta分析. 中華內科雜志, 2012, 51(10): 763-768.
28. Afshari A, Safari M, Oshvandi K, et al. The effect of the open and closed system suctions on cardiopulmonary parameters: time and costs in patients under mechanical ventilation. Nurs Midwifery Stud, 2014, 3(2): e14097.
29. Philippart F, Gaudry S, Quinquis L, et al. Randomized intubation with polyurethane or conical cuffs to prevent pneumonia in ventilated patients. Am J Respir Crit Care Med, 2015, 191(6): 637-645.
30. Nseir S, Ader F, Lubret R, et al. Pathophysiology of airway colonization in critically ill COPD patient. Curr Drug Targets, 2011, 12(4): 514-520.
31. Nseir S, Zerimech F, Jaillette E, et al. Microaspiration in intubated critically ill patients: diagnosis and prevention. Infect Disord Drug Targets, 2011, 11(4): 413-423.
32. Diaconu O, Siriopol I, Polo?anu LI, et al. Endotracheal tube biofilm and its impact on the pathogenesis of ventilator-associated pneumonia. J Crit Care Med (Targu Mures), 2018, 4(2): 50-55.
33. 萬國華. 呼吸治療技術與醫院空氣質量. 長庚科技學刊, 2014, (21): 1-12.
34. Cook TM, El-Boghdadly K, McGuire B, et al. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the difficult airway society, the association of anaesthetists the intensive care society, the faculty of intensive care medicine and the royal college of anaesthetists. Anaesthesia, 2020, 75(6): 785-799.
35. Centers for Disease Control and Prevention. Ventilator-Associated Event (VAE). National Healthcare Safety Network (NHSN) patient safety component manual. Available at: https://www.cdc.gov/nhsn/PDFs/pscManual/10-VAE_FINAL.pdf.
36. 康德英, 洪旗. 如何評價 Meta-分析的統計分析結果. 中國循證醫學, 2001, 1(2): 106-108.

Chinese Journal of Evidence-Based Medicine

Efficacy of closed and open tracheal suction systems for prevention of ventilator-associated pneumonia: a meta-analysis

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