Suctioning an adult ICU patient: Clinical practice - Open versus closed suction
Recommendations for practice
Closed suction catheter systems should be used as the system of choice for patients with an ETT or tracheostomy who require suction.
Closed suction catheter systems should be changed as per manufacturer’s instructions.
Closed suction systems should be cleaned as per the manufacturers’ instructions to maintain patency and minimise colonisation.
The evidence review for these recommendations was current to December 2012. Clinicians are advised to check the literature as research may have been published that change these recommendations
Open suction systems (OSS) refer to a single-use catheter inserted into the ETT either by disconnecting the ventilator tubing or via a swivel connector. Closed suction systems (CSS) enable patients to be suctioned by a suction catheter enclosed within a plastic sleeve, without the need for ventilator disconnection (1).
Summary of research on open vs. closed suction systems
Oxygenation (2, 3)
End expiratory lung volume (2)
Sputum clearance (4)
Haemodynamics (3, 5)
Ventilator-associated pneumonia (2, 4, 6-11)
Environmental contamination (6, 12)
Tube colonisation (4, 10)
Length of ventilation (4, 7, 10)
Length of stay (4, 7, 10)
Patient mortality (4, 7, 10)
Costs < 4 days (2, 7, 8, 11)
Costs > 4 days (4, 9)
Yes indicates where the balance of evidence was in 2012.
Ventilator-associated pneumonia (VAP) incidence
Ventilator-associated pneumonia (VAP) has been defined as pneumonia occurring > 48/24 – 72/24 after ETT intubation (13) and has been reported to prolong length of stay, increase medical costs, and result in higher mortality rates (14). Five systematic reviews (SRs) and one crossover randomised controlled trial (RCT) found the incidence of VAP to be independent of the use of either open or closed suction systems (15-19). (Refer to Table 5). A meta-analysis of nine randomised controlled trial also found no difference between patients managed with open and closed suction systems for the incidence of VAP, patient length of ICU stay or for patient mortality (19).
Endotracheal tube (ETT) colonisation
The bulk of existing evidence, regarding colonisation of the tube, as distinct from VAP incidence, weakly favours the use of OSS. An SR found greater respiratory tract and ETT colonisation in CSS than OSS (19), while a Cochrane SR found a significantly increased risk of 49% for CSS ETT tube bacterial colonisation over OSS (4, 20).
Studies highlight variation of health worker clinical practice according to the type of suction system in use. One prospective crossover design RCT found OSS groups to be better than CSS for the use of hand hygiene, glove, mask and eye protection by staff pre suction (100% OSS Vs. 91% CSS), (15).
In one pre/post convenience sample study of a patient population with multi-drug resistant pathogens, CSS use was found to be preferable for decreasing glove and airway equipment contamination during tracheal suction (74% OSS vs. 6% CSS) (21).
End expiratory lung volume
An SR explored the impact of open and closed systems on patient end expiratory lung volume (EELV) (18). This paper reports dated evidence only, based on a study by Cereda (22) supporting the use of CSS for the preservation of EELV. A recent randomised crossover trial (23), showed that while CSS minimised lung volume loss, there was a statistically significant longer time to recovery of pre-suction EELV.
CSS has been found to be advantageous for patient oxygenation in the specific scenario of pre-oxygenated acute lung injury patients if followed by a recruitment manoeuvre immediately post suction (24). Methodological quality of this study is questionable as procedures were inconsistently applied. (24). An SR and a crossover trial (23) found no difference in patient oxygenation with either open or closed suction system use, regardless of pre-oxygenation prior to the suction procedure (18).
One interrupted time series provides weak evidence for better sputum clearance with open systems (24), while an SR has shown no difference in the quantity of secretion removal between open or closed systems used (20).
An SR (18) and an observational study (25) both found little effect on heart rate, mean arterial blood pressure or saturated peripheral venous oxygen content (SpO2) on the patient with the use of either open or closed suction systems.
Patient outcome measures investigated include duration of mechanical ventilation, length of ICU stay, and mortality. Across all three indicators no difference was found within 2 x systematic reviews (18, 20), and 1 x RCT (26). One meta-analysis found a higher association between CSS and mechanical ventilation duration (19).
Use of disposable suction catheters for OSS in short-term ventilation (i.e. < 4 days) was found to be less expensive than CSS (15, 16, 19, 25, 26) although this data did not consider costs of sterile gloves and increased nursing time in OSS. CSS was found to be more cost effective for patients ventilated > 4 days (16). One SR also found savings in nursing time with CSS use for patients ventilated for greater than four days. These findings were attributable to two personnel required for patient disconnection from the circuit if using an open system (20). An SR of 28 RCTs found no difference between the cost of systems whether closed suction catheters were changed 24/24 – 48/24.
Grading of recommendation taxonomy
Grade of recommendation
Body of evidence can be trusted to guide evidence
Body of evidence can be trusted to guide practice in most situations
Body of evidence provides some support for recommendation/s but care should be taken in its application
Body of evidence is weak and recommendation must be applied with caution
Consensus was set as a median of ≥ 7
Grades A–D are based on NHMRC grades (24)
- (AARC) AAfRC. AARC Clinical Practice Guidelines. Endotracheal suctioning of mechanically ventilated patients with artificial airways. Respiratory Care. 2010;Jun; 55(6):758-64.
- Overend TJ, Anderson CM, Brooks D, Cicutto L, Keim M, McAuslan D, et al. Updating the evidence-base for suctioning adult patients: a systematic review. Canadian Respiratory Journal. 2009 May-Jun;16(3):e6-17. PubMed PMID: 19557211. Pubmed Central PMCID: Source: NLM. PMC2706678. English
- Jongerden IP, Kesecioglu J, Speelberg B, Buiting AG, Leverstein-van Hall MA, Bonten MJ. Changes in heart rate, mean arterial pressure, and oxygen saturation after open and closed endotracheal suctioning: A prospective observational study. Journal of Critical Care. 2012;27(6):647-54.
- Subirana M, Sola I, Benito S. Closed tracheal suction systems versus open tracheal suction systems for mechanically ventilated adult patients. Cochrane Database of Systematic Reviews. 2007 (4):CD004581. PubMed PMID: 17943823. English.
- Lasocki S, Lu Q, Sartorius A, Fouillat D, Remerand F, Rouby J-J. Open and closed-circuit endotracheal suctioning in acute lung injury: efficiency and effects on gas exchange. Anesthesiology. 2006 Jan;104(1):39-47. PubMed PMID: 16394688. English.
- Jongerden IP, Buiting AG, Leverstein-van Hall MA, Speelberg B, Zeidler S, Kesecioglu J, et al. Effect of open and closed endotracheal suctioning on cross-transmission with Gram-negative bacteria: a prospective crossover study. Critical Care Medicine. 2011 Jun;39(6):1313-21. PubMed PMID: 21358397. English.
- Jongerden IP, Rovers MM, Grypdononck MH, Bonten MJM. Open and closed endotracheal suction systems in mechanically ventilated intensive care patients: a meta-analysis. Critical Care Medicine. 2007;35(1):260-70.
- Lorente L, Lecuona M, Jimenez A, Mora ML, Sierra A. Tracheal suction by closed system without daily change versus open system. Intensive Care Medicine. 2006 Apr;32(4):538-44. PubMed PMID: 16511633. English.
- Niel-Weise BS, Snoeren RL, Van den Broek PJ. Closed or open endotracheal suction systems? Infection Control & Hospital Epidemiology. 2007;28(5):531-6.
- Siempos I, Vardakas K, Falagas M. Closed tracheal suction systems for prevention of ventilator-associated pneumonia. British journal of anaesthesia. 2008;100(3):299-306.
- Deepu D, Prasanna S, Thambu D, Shyamkumar Nidugala K, Aparna I, Peter JV. 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. Journal of Critical Care. 2011 Oct;26(5):482-8. PubMed PMID: 21106340. English.
- Ricard J-D, Eveillard M, Martin Y, Barnaud G, Branger C, Dreyfuss D. Influence of tracheal suctioning systems on health care workers' gloves and equipment contamination: A comparison of closed and open systems. American journal of infection control. 2011;39(7):605-7.
- Harada N. Closed Suction System: Critical Analysis for its use. Japan Journal of Nursing Science. 2010;7:19-28.
- CDC. Centre for Disease Control & Prevention. Ventilator-associated pneumonia (VAP)2010.
- Jongerden IP, Buiting AG, Leverstein-van Hall MA, Speelberg B, Zeidler S, Keseciouglu J, et al. Effect of open and closed endotracheal suctioning on cross-transmission with gram-negative bacteria: A prospective crossover study. Critical Care Medicine. 2011;39(6):1313-21.
- Lorente L, Lecuona M, Jimenez A. Tracheal suction by closed system without daily changes versus open systems. Intensive Care Medicine. 2006;32:538-44.
- Niel-Weise BS, Snoeren RLMM, Van Den Broek PJ. Policies for endotracheal suctioning of patients receiving mechanical ventilation: A systematic review of randomized controlled trials. Infection Control and Hospital Epidemiology. 2007;28(5):531-6.
- Overend TJ, Anderson CM, Brooks D, Cicutto L, Kein M, McAuslan D, et al. Updating the evidence base for suctioning adult patients: a systematic review. Canadian Respiratory Journal. 2009;16(3):e6-e17.
- Siempos II, Vardakas KZ, Falagas ME. Closed tracheal suction system for prevention of ventilator-associated pneumonia. British Journal of Anesthesia. 2008;100(3):209-306.
- Subirana M, Sola I, Benito S. Closed tracheal suction systems versus open tracheal suction systems for mechanically ventilated adult patients. The Cochrane Collaboration. 2010;7:1-51.
- Ricard J, Eveillard M, Martin M, Barnaud G, Branger C, Dreyfusss D. Influence of tracheal suctioning on health care workers' gloves & equipment contamination: A comparison of closed and open systems. American Journal of Infection Control. 2011;39:605-7.
- Cereda M, Villa F, Colombo E, Greco G, Nacoti M, Pesenti A. Closed system endotracheal suctioning maintains lung volume during volume-controlled mechanical ventilation. Intensive Care Medicine. 2001;27:648-54.
- Corley A, Spooner AJ, Barnett AG, Caruana LR, Hammond NE, Fraser JF. End-expiratory lung volume recovers more slowly after closed endotracheal suctioning than after open suctioning: A randomized crossover study. Journal of Critical Care. 2012;27:742.e1-.e7.
- Lasocki S, Lu Q, Sartorious A, Fouillat D, Remerand F, Rouby J. Open versus closed-circuit endotracheal suctioning in acute lung injury. Anesthesiology. 2006;Jan(104):39-47.
- Jongerden IP, Kesecioglu J, Speelberg B, Buiting AG, Leverstein-van Hall MA, Bonten MJ. Changes in heart rate, mean arterial pressure, and oxygen saturation after open and closed endotracheal suctioning: A prospective observational study. Journal of Critical Care. 2012;Article in press.
- Deepu D, Prasanna S, Thambu D, Shyamkumar N, Aparna I, John VP. An open-labelled randomized controlled trial comparing costs and clinical outcomes of open tracheal suctioning with closed endotracheal suctioning in mechanically ventilated medical intensive care patients. Journal of Critical Care. 2011;26:482-8.
- NHMRC. NHMRC additional levels of evidence and grades for recommendations for developers of guidelines:PILOT PROGRAM 2005 - 2007. Australian Government; 2005.
The information on this page is general in nature and cannot reflect individual patient variation. It reflects Australian intensive care practice, which may differ from that in other countries. It is intended as a supplement to the more specific information provided by the doctors and nurses caring for your loved one. ICNSW attests to the accuracy of the information contained here but takes no responsibility for how it may apply to an individual patient. Please refer to the full disclaimer.