Does open or closed endotracheal suction affect the incidence of ventilator associated pneumonia in the intensive care unit? A systematic review

Suction circuit flushing with chlorhexidine decreases ventilator-associated pneumonia: a quasi-experimental study

Background

Endotracheal suctioning of mechanically ventilated patients differs across the world. In many low and middle-income countries, endotracheal suctioning is often performed with a sterile suctioning catheter that is used for 12 h or during the length of one nursing shift. The effect of flushing multiple used endotracheal suction system with chlorhexidine after suctioning to reduce ventilator associated pneumonia (VAP) remains unclear.

Aim

The aim of the study is to assess the effectiveness of flushing multiple-used open endotracheal suction catheters and suctioning system with chlorhexidine gluconate 0.2% to reduce VAP in mechanically ventilated patients in a resource-limited Intensive Care Unit (ICU).

Methods

Due to the difficulty of blinding the intervention for nurses who perform endo-tracheal suction procedures, we adopted a quasi-experimental method with a randomized controlled trial design. A sample of 136 ICU patients were allocated to the intervention (n = 68) or control group (n = 68) between May and November 2020. The intervention was flushing the multiple-used suction catheter and suction system with 40ml chlorhexidine gluconate 0.2% and in the control group we used normal saline to flush the catheter and suction system. The primary outcome was incidence of VAP and the cost of the flushing solutions was the secondary outcome measure.

Results

Patients in the intervention group had a lower incidence of VAP compared to patients in the control group; 15 (22.1%) vs 29 (42.6%), p = 0.01. The incidence of late-onset VAP was 26.2% in the intervention group and 49% in the control group (p = 0.026) and the early-onset VAP was 13.2% in the intervention group and 25% in the control group (p = 0.081). Chlorhexidine gluconate 0.2% reduced the cost of suction system flushing (median: 78.4 vs 300 EGP, p < 0.001).

Conclusion

Using chlorhexidine gluconate 0.2% to flush multiple-used suctioning catheters after every endo-tracheal suction procedure might reduce the incidence of VAP in mechanically ventilated patients. Chlorhexidine gluconate 0.2% can be a cost-effective solution for flushing the suction circuit. Nurses working in resource-limited ICUs and using suctioning catheters multiple times might consider using chlorhexidine gluconate 0.2% instead of normal saline or distilled water when flushing the suction system.

Clinical trial registration

ClinicalTrials.gov, identifier NCT05206721.

Effectiveness of nonpharmacological interventions to prevent adverse events in the intensive care unit: A review of systematic reviews

BACKGROUND

Different types of interventions have been assessed for the prevention of adverse events. However, determining which patient-safety practice is most effective can be challenging when there is no systematised evidence synthesis. An overview following the best methodological standards can provide the best reliable integrative evidence.

OBJECTIVES

The objective of this study was to provide an overview of effectiveness nonpharmacological interventions aimed at preventing adverse events in the intensive care unit.

METHODS

A review of systematic reviews (SRs) was conducted according to the Cochrane Handbook and PRISMA recommendations. PubMed, CINAHL, and Cochrane Library were searched for SRs published until March 2022. Two reviewers independently assessed the study's quality, using AMSTAR-2, and extracted data on intervention characteristics and effect on prevention of adverse events.

RESULTS

Thirty-seven SRs were included, and 27 nonpharmacological interventions were identified to prevent 11 adverse events. Most of the reviews had critically low methodological quality. Among all the identified interventions, subglottic secretion drainage, semirecumbent position, and kinetic bed therapy were effective in preventing ventilator-associated pneumonia; the use of earplugs, early mobilisation, family participation, and music in reducing delirium; physical rehabilitation in improving muscle strength; use of respiratory support in preventing reintubation; the use of a computerised physician order entry system in reducing risk of medication errors; and the use of heated water humidifier was effective in reducing artificial airway occlusion.

CONCLUSIONS

Some nonpharmacological interventions reduced adverse events in the intensive care setting. These findings should be interpreted carefully due to the low methodological quality. SRs on preventing adverse events in the intensive care unit should adhere to quality assessment tools so that best evidence can be used in decision-making.

The effect of an infection control guideline on the incidence of ventilator-associated pneumonia in patients admitted to the intensive care units

BACKGROUND AND AIM

Standard airway care can reduce the incidence of ventilator-associated pneumonia (VAP). This study aimed to determine the effect of implementing infection control guidelines on the incidence of VAP in patients admitted to the intensive care unit (ICU).

MATERIALS AND METHODS

In this clinical trial, 121 patients admitted to the intensive care units of Golestan and Imam Khomeini hospitals of Ahvaz, Iran who were under mechanical ventilation were assigned to two groups of control and intervention in non-randomly allocation. The study was conducted in two consecutive periods. In the intervention group, infection control guidelines were performed to prevent VAP and in the control group, routine care was performed. Data collection is done by used a three-part instrument. The first part included questions on the patients' demographics and clinical information. The second part was the modified clinical pulmonary infection scale (MCPIS) for the early detection of VAP. The third part of the data collection instrument was a developed checklist through literature review. The MCPIS was completed for all patients on admission and the 5th day of the study.

RESULTS

The two groups were homogenous respecting their baseline characteristics (P > 0.05) including the mean MCPIS score (P > 0.05). However, the intervention group had lower body temperature (P < 0.001), lower white blood cell counts (P < 0.038), lower MCPIS score (P < 0.001), and higher PaO2/FIO2 (P < 0.013) at the end of the study. The incidence of VAP was significantly lower in the intervention group when compared to the control group (i.e. 30% vs. 65.6%, P < 0.001).

CONCLUSIONS

The implementation of infection control guidelines could significantly reduce the incidence of VAP and its diagnostic indicators in patients admitted to the ICU. Nurses are advised to use these guidelines to prevent VAP in patients admitted to ICU.

Closed Endotracheal Suction Systems for COVID-19: Rapid Review

BACKGROUND

The increase in admissions to intensive care units (ICUs) in 2020 and the morbidity and mortality associated with SARS-CoV-2 infection pose a challenge to the analysis of evidence of health interventions carried out in ICUs. One of the most common interventions in patients infected with the virus and admitted to ICUs is endotracheal aspiration. Endotracheal suctioning has also been considered one of the most contaminating interventions.

OBJECTIVE

This review aims to analyze the benefits and risks of endotracheal suctioning using closed suction systems (CSS) in COVID-19 patients.

METHODS

A rapid review was carried out using the following databases: PubMed, MEDLINE, CINAHL, LILACS, the Cochrane Library, and IBECS. The data search included articles in English and Spanish, published between 2010 and 2020, concerning adult patients, and using the key words "endotracheal," "suction," and "closed system."

RESULTS

A total of 15 articles were included. The benefits and risks were divided into 3 categories: patient, care, and organization. Relating to the patient, we found differences in cardiorespiratory variables and changes in the ventilator, for example, improvement in patients with elevated positive and end-expiratory pressure due to maladaptation and alveolar collapse. Relating to care, we found a shorter suctioning time, by up to 1 minute. Relating to organization, we found fewer microorganisms on staff gloves. Other conflicting results between studies were related to ventilator-associated pneumonia, bacterial colonization, or mortality.

CONCLUSIONS

Aside from the need for quality research comparing open suction systems and CSS as used to treat COVID-19 patients, closed endotracheal suctioning has benefits in terms of shorter stay in the ICU and reduced environmental contamination, preventing ventilator disconnection from the patient, reducing the suctioning time-though it does produce the greatest number of mucosal occlusions-and preventing interpatient and patient-staff environmental contamination. New evidence in the context of the SARS-CoV-2 virus is required in order to compare results and establish new guidelines.

[Update of the recommendations of the Pneumonia Zero project]

La pandemia por el SARS-Cov-2 ha impactado negativamente en la aplicación de las recomendaciones de Neumonía Zero y se ha acompañado de un incremento de las tasas de Neumonía asociada a ventilación mecánica (NAVM) en las unidades de cuidados intensivos de España. Con el objetivo de disminuir las tasas actuales a 7 episodios por 1000 días de VM, se han actualizado las recomendaciones del proyecto inicial.

Se identificaron, 27 medidas que se clasificaron en 12 medidas funcionales (posición semisentada, higiene estricta de manos, entrenamiento para manipular la vía aérea, valoración diaria de posible extubación, protocolización del destete, traqueostomía precoz, ventilación no invasiva, vigilancia microbiológica, cambio de tubuladuras, humidificación, fisioterapia respiratoria, nutrición enteral postpilórica), 7 mecánicas (control de la presión del neumotaponamiento, tubos con aspiración subglótica, nutrición con sondas de bajo calibre/en intestino delgado, aspiración de secreciones con circuitos cerrados/abiertos, filtros respiratorios, cepillado de dientes, técnicas de presión negativa en la aspiración de secreciones) y 8 farmacológicas (descontaminación selectiva digestiva, descontaminación orofaríngea, ciclo corto de antibióticos, higiene de boca con clorhexidina, antibióticos inhalados, rotación de antibióticos, probióticos, anticuerpos monoclonales).

Cada medida se analizó de forma independiente, por al menos dos miembros del grupo de trabajo, mediante una revisión sistemática de la literatura y una revisión iterativa de las recomendaciones de las sociedades científicas y/o grupos de expertos.

Para la clasificación de la calidad de la evidencia y fuerza de las recomendaciones se siguió la propuesta del grupo GRADE. Para determinar el grado de recomendación, cada medida fue puntuada por todos los miembros del grupo de trabajo en relación con su efectividad, tolerabilidad y aplicabilidad en las UCI españolas a corto plazo de tiempo. Se solicitó el apoyo de expertos externos en alguna de las medidas que se revisaron. Se seleccionaron aquellas medidas que alcanzaron la máxima puntuación.

Effect of open versus closed endotracheal suctioning on intracranial pressure in severe brain-injured children: Study protocol for a randomized controlled trial

AIM

To compare the effects and safety of open and closed endotracheal suction in children with severe brain injury.

DESIGN

A single-blinding, single-centre randomized controlled trial (RCT).

METHODS

The children with severe brain injury admitted to the intensive care unit (ICU) from 1 September 2020-31 August 2022 will be included. And a total of 172 children with severe brain injury are expected to be included. The intracranial pressure, SpO₂ and heart rate before suctioning, at the end of suction, and at 5 and 10 min after suction, the estimated sputum volume for each suction, the incidence of ventilator-associated pneumonia, the duration of mechanical ventilation and the length of ICU stay will be analysed.

RESULTS

This present RCT has been prospectively registered in China Clinical Trial Registry (http://www.chictr.org.cn, ChiCTR2000030963). This present study is expected to provide reliable evidence to the airway management in children with severe brain injury.

Effects of Open and Closed Tracheal Suctioning on Pain in Mechanically Ventilated Patients

Background:

Painful care procedures are the most common cause of stress in patients admitted to Intensive Care Units (ICUs). Tracheal suctioning is the most painful experience for ICU patients. The present study was conducted to compare open and closed endotracheal suctioning in terms of their effect in pain in mechanically ventilated patients.

Materials and Methods:

The present clinical trial recruited 70 mechanically ventilated patients with tracheostomy in 2019. The eligible patients were randomly divided into open and closed suctioning groups. The pain was measured in the patients using the Critical Pain Observational Tool (CPOT) before and during suctioning as well as 10 and 30 min later. The data were analyzed using the repeated measures Analysis Of Variance (ANOVA), paired t-test, and Chi-squared test.

Results:

The pain score was significantly higher in the open suctioning group during (t = 2.59, p = 0.01) and 10 min after suctioning (t = 3.02, p = 0.004). No significant differences were observed in the pain score between the two groups 30 min after suctioning (t = 0.32, p = 0.75). The post hoc Least Significant Difference (LSD) test showed that the CPOT scores 10 min after suctioning was significantly higher than that before suctioning and significantly lower than that during suctioning (p = 0.001). The CPOT score 30 min after suctioning was also significantly lower than that 10 min after suctioning (p < 0.001).

Conclusions:

The present findings suggested a lower pain in the patients with closed suctioning compared to those with open suctioning.