Is Closed Suction System Better than Open Suction System to Minimize the Risk of Infection?

Pushpa Choudhary

Department of Continuing Nursing Education, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India

Corresponding Author: Pushpa Choudhary, Department of Continuing Nursing Education, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India, Phone: +91 9001526775, e-mail: pushpachoudhary447@gmail.com

How to cite this article: Choudhary P. Is Closed Suction System Better than Open Suction System to Minimize the Risk of Infection? Indian J Respir Care 2024;13(4):219–220.

Source of support: Nil

Conflict of interest: None

The impact of diseases like coronavirus disease 2019 (COVID-19) extends worldwide and can significantly disrupt people’s health and ultimately communities. Among individuals identified with COVID-19, 5% need to be admitted to the intensive care unit (ICU), and of those, approximately 88% need ventilator support to assist with breathing.¹ Airway suctioning is a crucial component of routine care for patients with an endotracheal tube or tracheostomy. When the amount of sputum increases, the risk of complications like airway obstruction, lung consolidation, and infection also rises.² Suctioning is considered a high-risk procedure by the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC). There are two different methods to perform the suctioning procedure: one is the more commonly used open suction system (OSS), and the other is the closed suction system (CSS). Currently, there is debate over the advantages and disadvantages of each system. For healthcare-associated pneumonia, guidelines given by the CDC and the Healthcare Infection Control Practices Advisory Committee in 2003 stated that a recommendation regarding the preferential use of either OSS or CSS cannot be made for the prevention of pneumonia, leaving the issue unresolved.³

The purpose of this review was to compare the OSS and CSS, with a particular focus on determining which method better minimizes the risk of infection. In the past, the standard practice for intubated patients was the OSS, which required disconnection from the mechanical ventilator and the use of a disposable, one-time-use suction catheter. However, over the past 2 decades, the CSS has become the standard of care. The CSS is considered safer and is associated with fewer complications. As the name suggests, the CSS involves a suction catheter that remains attached to the ventilator circuit and is connected directly to the patient. While there are benefits to using the CSS, a reduction in the incidence of ventilator-associated pneumonia has not been shown.²^,⁴ Without disconnecting the ventilatory circuit, the CSS enables the removal of secretions from the trachea to the bronchus, which helps to prevent alveolar hypoxia and derecruitment. The CSS requires less time and is simpler for critical care nurses to use. In contrast, one of the main drawbacks of OSS is the loss of lung volume and positive end-expiratory pressure (PEEP) during the procedure, particularly in patients with severe respiratory failure, which can lead to oxygen desaturation.⁴ The proposed benefits of the CSS over the conventional OSS include improved oxygenation, reduced clinical signs of hypoxemia, and the ability to maintain PEEP. Additionally, the CSS helps minimize contamination among patients, the healthcare team, and the environment, which ultimately reduces respiratory pollution and the risk of pulmonary infections, and results in less lung volume loss.⁵

In contrast, a meta-analysis conducted by Siempos et al. regarding randomized controlled trials on CSS for the prevention of nosocomial infections, including ventilator-associated pneumonia (VAP), showed that the use of the CSS was not linked to a lower incidence of VAP or mortality when compared to the OSS.⁶ Similarly, a systematic review conducted by Sola and Benito concluded that the use of a CSS was associated with an increased incidence of colonization.⁷ Johnson et al. conducted a meta-analysis and found that the CSS led to significantly fewer physiological disturbances. They concluded that the CSS is a cost-efficient and effective technique for airway suctioning, with fewer complications caused by suctioning.⁸ Pagotto et al. also reported that there is no significant difference between these two methods with reference to the incidence of VAP. However, they emphasized that the CSS is used more often than the OSS for suctioning due to the procedure’s ease, though the method’s effectiveness may be somewhat reduced, according to their findings. In some studies, the OSS appears to offer advantages, including a lower incidence of pneumonia, fewer physiological changes during the procedure, reduced bacterial contamination, and lower costs. Proponents of the CSS argue that the ventilator circuit is disconnected while using the OSS, which, combined with the negative vacuum pressure, can lead to a significant reduction in lung volume and subsequently cause hypoxemia.⁹ Yilmaz and Özden conducted a single-blind randomized trial and concluded that both the OSS and CSS were comparable in terms of hemodynamic changes, secretion volume, and suction frequency. The study found that the CSS was as effective as the OSS.¹⁰ In contrast, a meta-analysis conducted by Sanaie et al., aimed at reassessing the effectiveness of the CSS vs the OSS in preventing VAP among patients with mechanical ventilation, concluded that the use of the CSS can significantly reduce the development of VAP compared to the OSS. However, this finding does not support the regular use of the CSS as a standard technique for VAP prevention for patients, as factors such as the patient’s specific condition and cost considerations should also be taken into account when choosing the appropriate suctioning system.¹¹

In conclusion, there is insufficient evidence to favor one specific suctioning method over the other for minimizing the risk of infection. However, the CSS can be the preferred technique in hospitals.¹² In healthcare settings with limited resources where the CSS is not available, the OSS can still be used effectively. Regardless of the suctioning method, it is crucial to regularly change the catheter, maintain a sterile technique, and ensure patient hyperoxygenation (steps of the procedure are given in Fig. 1) before suctioning to reduce the risk of colonization by microorganisms and nosocomial infections.

Fig. 1: Steps of suctioning procedure

ACKNOWLEDGMENTS

I would like to extend my gratitude to the Librarians at the All India Institute of Medical Sciences, Jodhpur, for allowing access to the online literature database.

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