Which is better for ICU, open or closed suction?

Open vs. Closed Suction Systems in ICU: Evidence-Based Recommendations

Based on current evidence, open endotracheal suctioning is recommended over closed suctioning systems in ICU settings as there is no significant difference in VAP incidence between the two methods, but open systems are more cost-effective. 1

Comparison of Open vs. Closed Suction Systems

Efficacy in Preventing Ventilator-Associated Pneumonia (VAP)

• Multiple guidelines and studies consistently show no significant difference between open and closed suctioning systems in reducing overall VAP incidence:
  • The 2018 Anaesthesia guidelines explicitly state that "enclosed tracheal suction systems compared to conventional open tracheal suctioning" show no beneficial impact in terms of hospital-acquired pneumonia (HAP) 1
  • The 2004 Annals of Internal Medicine guidelines concluded that "type of suctioning systems (open or closed) has no effect on the incidence of VAP" 1

Late-Onset VAP Considerations

• Some evidence suggests closed suction systems may have a slight advantage for preventing late-onset VAP 2
• A 2011 study showed a trend toward reduced VAP incidence with closed systems, with a significant benefit specifically for late-onset VAP 3

Cost Considerations

• Open suction systems are more cost-effective:
  • A 2011 study found significantly higher costs with closed systems (US $5.81 vs US $2.94 per patient) 3
  • The 2004 guidelines noted that "cost considerations favor the use of closed suctioning systems that are changed only as clinically indicated" 1, but this is only if the systems are not changed frequently

Clinical Practice Recommendations

1. For most ICU patients: Use open endotracheal suction systems as the default approach
2. For patients expected to require prolonged mechanical ventilation: Consider closed systems if late-onset VAP is a particular concern
3. When using either system:
   • Change circuits for each new patient
   • Change only when soiled, not on a scheduled basis 1
   • Use proper technique including pre-oxygenation before suctioning 1

Important Considerations for Suctioning Technique

Safety Measures

• Regardless of system type:
  • Provide reassurance, sedation, and pre-oxygenation to minimize detrimental effects of airway suctioning 1
  • Maintain airway pressures within safe limits (recommended upper limit of 40 cmH2O) 1
  • Be cautious with patients at risk of barotrauma, volutrauma, or hemodynamic instability 1

Complementary Interventions to Reduce VAP

• Position patients in semi-recumbent position (45° from horizontal) 1
• Consider subglottic secretion drainage, which has been shown to reduce VAP incidence 1, 2
• Use heat and moisture exchangers in patients without contraindications 1

Pitfalls and Caveats

• Closed suctioning may be less effective than open suctioning for secretion clearance during pressure-support ventilation 1
• Closed systems may lead to increased colonization rates with multi-drug resistant organisms 4
• The routine instillation of normal saline during airway suctioning should be avoided due to potential adverse effects on oxygen saturation and cardiovascular stability 1

In summary, while both systems have their place in ICU care, open suction systems remain the standard choice for most patients due to comparable clinical outcomes and lower costs. The decision should be guided primarily by patient-specific factors such as expected duration of mechanical ventilation and risk of late-onset VAP.