Subglottic Suctioning Endotracheal Tubes

Subglottic Suctioning Endotracheal Tubes,

Literature Synopsis

Continuous or frequent intermittent suctioning of subglottic secretions, via an endotracheal tube (ETT) specially designed with a dorsal lumen to accommodate this, is associated with up to a 50% decreased incidence of aspiration and VAP. Guidelines support the use of subglottic suctioning and drainage for patients dependent on mechanical ventilation.

Most recently in 2012, a systematic review and meta-analysis of 10 randomized trials support the use of subglottic drainage for VAP prevention. This analysis showed a reduced incidence of VAP with the use of subglottic suctioning ETTs, [RR]=0.56, [CI]: 0.42-0.69, p<0.00001).

2008 -Society for Healthcare Epidemiology of America Guidelines: A guideline of practical recommendations to assist acute care hospitals in implementing and prioritizing their ventilator-associated pneumonia (VAP) prevention efforts.1

Recommends the use of cuffed ETT with in line subglottic suction to prevent aspiration and reduce VAP risk factor.

Articles Cited in Guideline
Study Type and Author / Results - Details in Annotated Bibliography
Systematic Meta-Analysis
Drainage vs. Standard
(Dezfulian, 2005)2 / Pro-Analyzed 5 RCTs to assess the efficacy of subglottic secretion drainage in preventing VAP. Study showed that subglottic secretion drainagecan reduced the incidence ofVAP by nearly 50% in patients requiring mechanical ventilation.
CDC Guideline
(Tablan, 2003)3 / Pro - If feasible, use an endotracheal tube with a dorsal lumen above the endotracheal cuff to allow drainage (by continuous or frequent intermittent suctioning) of tracheal secretions that accumulate in the patient’s subglottic area. (See CDC Section)
Review
(Kollef, 2004)4 / Pro-This review did not specifically address subglottic suctioning. However, it recommended the use of endotracheal tube with separate dorsal lumen based on the beneficial effect on lowering the incidence of VAP.
Continuous vs. Closed Lumen Care
(Valles, 1995)5 / Pro-Study focused on ICU patients requiring prolonged intubation (>3 days). The study findings conclude that the incidence of nosocomial pneumonia in mechanically ventilated patients can be significantly reduced by using continuoussubglottic suctioning through the dorsal lumen.
* Continuous vs. w/o Suctioning
(Kollef, 1999)6 / Pro- Study focused on cardiothoracic surgery patients requiring mechanical ventilation. Findings showed that the occurrence of VAP can be significantly delayed with the use of continuous aspiration of subglottic secretions.
Review
(Cook, 1998)7 / Con - This article did not focus on suctioning, but summarized 12 studies that evaluate risk factors for ICU-acquired pneumonia in critically ill patients. One of the VAP risk factors identified was failed subglottic suctioning.
Drainage vs. Sucralfate
(Mahul,1992)8 / Pro- Study focused patients requiring mechanical ventilation for 3 days. Findings showed subglottic drainage was effective at lowering nosocomial pneumonia, but sucralfate prevention was not.

2008-Canadian VAP Prevention Guidelines:Evidence-based, clinical practice guidelines for the prevention of ventilator-associated pneumonia9

Subglottic Secretion Drainage is recommended for patients requiring to be mechanically ventilated for more than 72hrs.

Articles Cited in Guideline
Study Type and Author / Results - Details in Annotated Bibliography
Drainage vs. Conventional Oral ETT(Smulders, 2002)10 / Pro- Study focused on ICU patients expected to be mechanicalventilated >72 h. Findings showed that intermittent subglottic secretion drainage reduces the rate of VAP in patient receiving mechanical ventilation.
Drainage vs. Control
(Bo, 2000)11 / Pro- Study focused on surgical patients who required intubation. Study showed that the morbidity of VAP can be reduced by using subglottic secretion drainage; especially for gram- positive cocci and Haemophiliusinfluenzae caused VAP cases.
Continuous vs. Closed Lumen Care
(Valles,1995)5 / Pro- Study focused on medical and surgical patients requiring prolonged intubation (> 3 days). Findings conclude that the incidence of nosocomial pneumonia in mechanically ventilated patients can be significantly reduced by using continuoussubglottic suctioning.
(Previously cited by SHEA)
Drainage vs. Sucralfate
(Mahul,1992)8 / Pro- Study focused on patients who required mechanical ventilation for 3 days. Findings showed that subglottic drainage was effective at reducing nosocomial pneumonia, but sucralfate prevention was not.
(Previously cited by SHEA)

2004-Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia.12

Recommendsthe use of specifically designed ETT with dorsal lumen for the continues aspiration of subglottic secretion.

Articles Cited in Guideline
Study Type and Author / Results - Details in Annotated Bibliography
Continuous vs. w/o Suctioning
(Kollef, 1999)6 / Pro- Study focused on cardiothoracic surgery patients requiring mechanical ventilation. Findings showed that VAP occurrence can be significantly delayed with the use of continuous aspiration of subglottic secretion.
(Previously cited by SHEA )
Continuous vs. Closed Lumen Care
(Valles, 1995)5 / Pro- Study focused on patients requiring prolonged intubation (> 3 days) in the medical – surgical ICU. Findings conclude that the incidence of nosocomial pneumonia in mechanically ventilated patients can be significantly reduced by using continuous suctioning. (Previously cited by SHEA and ZAP)
Drainage vs. Sucralfate
(Mahul,1992)8 / Pro- Study focused on patients who required mechanically ventilated for more than 3 days. Study showed that the prevention of micro-aspiration with the use of subglottic drainage was effective at reducing nosocomial pneumonia, but sucralfate prevention was not.
(Previously cited by SHEA and ZAP)

2003- CDC Guidelines for preventing Health-Care-Associated Pneumonia; Evidence-based, clinical practice guidelines for the prevention of healthcare-associated pneumonia, including VAP.3

Recommends the use of an ETT dorsal lumen above the endotracheal cuff to allow drainage by continuous or frequent intermittent suctioning of tracheal secretion that accumulates in patient’s subglottic area.

Articles Cited in Guideline
Study Type and Author / Results - Details in Annotated Bibliography
Intermittent Drainage vs. Standard ETT
(Smulders, 2002)10 / Pro- Study focused on ICU patients expected to be mechanicalventilated >72 h .Findings showed that intermittent subglottic secretion drainage reduces the rate of VAP in patient receiving mechanical ventilation.
(Previously cited by ZAP)
Continuous vs. w/o Suctioning
(Kollef, 1999)6 / Pro- Study focused on cardiothoracic surgery patients requiring mechanical ventilation. Findings showed that the occurrence of VAP can be significantly delayed with the use of continuous aspiration of subglottic secretion. (Previously cited by SHEA and ATS)
Review
(Cook, 1998)7 / Con - This article did not focus on suctioning, but summarized 12 studies that evaluate risk factors for ICU-acquired pneumonia in critically ill patients. One of the VAP risk factors identified was failed subglottic suctioning. (Previously cited by SHEA)
Continuous vs. Closed Lumen ETT
(Valles, 1995)5 / Pro- Study focused on patients requiring prolonged intubation (> 3 days) in the medical – surgical intensive care unit. Findings conclude that the incidence of nosocomial pneumonia in mechanically ventilated patients can be significantly reduced by using continues suctioning. (Previously cited by SHEA, ZAP and ATS}
Drainage vs. Sucralfate
(Mahul,1992)8 / Pro- Study focused on patients who required mechanically ventilated patient for more than 3 days. Study findings conclude that the prevention of micro-aspiration with the use of subglottic drainage was effective at reducing nosocomial pneumonia, but sucralfate prevention was not. (Previously cited by SHEA, ATS, and ZAP)

Post Guideline Publications:

Post Guideline Publications, 2007-2013
Study Type and Author / Results - Details in Annotated Bibliography
Systematic Review and Meta-Analysis
(Wang, 2012)13 / Pro – Study reviewed 10 RCTs with 2,213 patients. Findings confirm that subglottic secretion drainage (SSD) was beneficial in preventing VAP. Finding showed that SSD reduced incidence of VAP [RR]=0.56, [CI]: 0.42-0.69, p<0.00001).
Systematic Review and Meta-Analysis
(Leasure,2012)14 / Pro- Study reviewed 12 original articles and 4 reviews that evaluated the effectiveness of subglottic secretion drainage (SSD) in reducing the occurrence of VAP. The findings of review support the recommendation for use of ETTs with SSD based on a 52% reduction rate.
Literature Review
(Barbas, 2012)15 / Pro and Con – Review of 10 RCTs (2,213 patients) assessing the effectiveness of subglottic suctioning ETTs in the prevention of VAP. Findings show that the use of subglottic suctioning ETTs reduces the incidence of VAP, early onset VAP, duration of mechanical ventilation and an increase in time to VAP diagnosis. However, the use of subglottic ETTs does not decrease the incidence of late onset VAP, the length of stay in the ICU or hospital, or hospital mortality.
Literature Review
(Blot, 2011)16 / Pro - Review of recent, new, non-pharmacological VAP prevention measures. Supports the use of subglottic secretions drainage using an endotracheal tube with a separate dorsal lumen to avoid micro-aspiration.
Systematic Review and Meta-Analysis
(Muscedere, 2011)17 / Pro- Study focused on 13 RCTs evaluating subglottic secretion drainage in adult mechanically ventilated patients. Study findings support the use of subglotticendotracheal tube in reduction rate of VAP.
Intermittent Drainage vs. Closed Suctioning System
(Juneja,2011)18 / Pro -Study focused on patients requiring mechanical ventilation for more than 72 hours. Study findings conclude that intermittent subglottic drainage reduces the incidence of VAP.
Cost Benefit Analysis
Conventional Tubes vs. Continuous Subglottic Suctioning Tubes
(Hallais, 2011)19 / Pro- Study in France analyzed the cost benefit of 416 surgical ICU patients receiving mechanical ventilation for 3,487 ventilation days. Finding showed replacing conventional ventilator tubes with continuous subglottic suctioning tubes were cost the cost averted per VAP episode is €1,383.69.
Business Case
Continuous ETT vs. Standard ETT
(Speroni ,2011)20 / Pro- Study was focused on medical and surgical ICU patients who were expected to be ventilated for >48 hrs. Study findings recommend the use of Continues -ETT over Standard S-ETT based on the final attributable cost of VAP.
Correspondence re: Lacherade study
(Taylor, 2011)21 / Con – Discusses the validity of the analysis in the Lacherade, 2010 study. States that while there were significant decreases in VAP rates in the intervention arm, the decreases did not translate into any reduction in the rate of clinically relevant outcomes.
Correspondence re: Lacherade study
(Silvestri, 2011)22 / Con – Discusses the validity of the analysis in the Lacherade, 2010 study. States that the results were not strong enough for the inclusion of this technique in VAP prevention strategies. Mortality was not impacted. However, this study had a small sample size and was underpowered.
Sub-glottic Suctioning ETT vs Conventional Tubes
(Lacherade, 2010)23 / Pro – RCT at 4 French centers. 333 adult patients intubated with subglottic ETTs who were expected to be intubated for > 48 hours, randomly assigned to receive subglottic secretion drainage (SSD) (n=169) or no SSD (n=164). Findings showed SSD results in a significant reduction in VAP, including late-onset VAP.
Systematic Literature Review
(Scherzer, 2010)24 / Pro – Review of6 randomized control studies regarding subglottic secretion aspiration in the prevention of VAP. Results consistently show that subglottic secretion aspiration significantly reduces the incidence of VAP in a variety of patient populations.
Literature Review
(Deem, 2010)25 / Con – Review of 9 RCTs and 1 prospective observational trial regarding the use of subglottic suctioning ETTs in the prevention of VAP. There is no clear evidence about the efficacy and effectiveness of subglottic suctioning in reducing the development of VAP.
Literature Review and Meta Analysis
(Gentile, 2010)26 / Pro – Review of 6 RCTs regarding the use of subglottic suctioning ETTs in the prevention of VAP. Analysis included 896 patients. Findings show that subglottic suctioning reduced the incidence of VAP by nearly half in patients expected to require 72 hours of mechanical ventilation, primarily by reducing early-onset VAP.
Systematic Review
(Overend, 2009)27 / Pro-Analyzed 15 RCT and 13 RCO of mechanically ventilated adult patients. Study showed that new evidence continues to be varied in strength for suctioning practice, but the evidence has improved since 2001 suggesting that members of the health care team should incorporate this evidence into their practice.
Subglottic Suctioning Prior to Position Change vs No Targeted Suctioning
(Chao, 2009)28 / Pro – Time sequence study in a general ICU in China comparing the use of continuous or intermittent subglottic suctioning prior to position change (intervention) (n=646) vs conventional care which does not include targeted subglottic suctioning (control) (n=574). Findings show that the RR of developing VAP in the study group was 0.32 of the control group.
Continuous Aspiration of Subglottic Secretions vs Conventional Care
(Bouza, 2008)29 / Pro – RCT comparing the incidence of VAP in patients admitted for major heart surgery(MHS). 714 patients were randomized over a 2 year period. 359 patients were randomized to the intervention arm (continuous aspiration of subglottic secretions vs the control arm (conventional care). Findings showed that CASS is safe and reduces the use of antimicrobial agents in the overall population and the incidence of VAP in patients who are at risk. Should be encouraged in patients undergoing MHS.
Literature Review
(Depew, 2007)30 / Pro- Review of meta-analysisthat looked at 5RCTs that compared aspiration of subglottic secretion vs. standard ETT care. Findings conclude that there insufficient outcome evidence to support the use of subglottic technology – aside from the VAP rate reduction.
Subglottic Suctioning Prior to Position Change vsNo Targeted Suctioning
(Tsai, 2008)31 / Pro – Time sequence study in China comparing the use of continuous or intermittent subglottic suctioning prior to position change (intervention) (n=237) vs conventional care which does not include targeted subglottic suctioning (control) (n=227). Preliminary results indicated that intermittent, targeted subglottic suctioning may significantly reduce VAP.
Brief Report
(Dragoumanis, 2007)32 / Con – Studied 40 patients with Hi-Lo® Evacendotracheal tube. Dysfunction of the suction lumen occurred in 19 of the 40 patients, 17 of which were attributable to blockage of the subglottic suction port by suctioned tracheal mucosa.

Annotated Bibliography

1. Coffin S, MD, Klompas M, MD, Classen D, MD, et al. Strategies to prevent Ventilator‐Associated pneumonia in acute care hospitals•. Infection Control and Hospital Epidemiology. 2008;29(S1, A Compendium of Strategies to Prevent Healthcare‐Associated Infections in Acute Care Hospitals):pp. S31-S40.

2. Dezfulian C, Shojania K, Collard HR, Kim HM, Matthay MA, Saint S. Subglottic secretion drainage for preventing ventilator-associated pneumonia:A meta-analysis. American Journal of Medicine. 2005;11-18(118).

Pro- Meta Analysis – Drainage vs. Standard Endtracheal Treatment - Study evaluated 896 patients from 5 RCT who required mechanical ventilation. Subglottic secretion drainage reduced the incidence of ventilator-associated pneumonia by nearly half (risk ratio [RR] = 0.51; 95% confidence interval [CI]: 0.37 to 0.71), primarily by reducing early-on set pneumonia (pneumonia occurring within 5 to 7 days after intubation).Subglottic secretion drainage appears effective in preventing early-onset ventilator-associated pneumonia among patients expected to require >72 hours of mechanical ventilation.

3. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidleines for preventing healthcare-associated pneumonia, 2003: Recommendations of CDC and the healthcare infection control practices advisory committee. MMWR Recomm Rep. 2004;53:1-36.

4. Kollef MH. Prevention of hospital-associated pneumonia and ventilator-associated pneumonia.Crit Care Med. 2004;32(6):1396-1405.

Pro - Review - Synthesized the available clinical data for the prevention of hospital-associated pneumonia (HAP) and ventilator- associated pneumonia (VAP) This review did not specifically address subglottic suctioning, but recommends the use of endotracheal tube with separate dorsal lumen based on 4 papers that showed beneficial effect.

5. Valles J, Artigas A, Rello J, et al. Continuous aspiration of subglottic secretions in preventing ventilator-associated pneumonia.Annals of Internal Medicine. 1995(122):179–186.

Pro- Continuous vs. Closed Lumen ETT - Study focused on 190 ICU patients expected to be intubated for >3 days. The incidence rate of VAP was 19.9 episodes/1000 ventilator days in the patients receiving continuous aspiration of subglottic secretions and 39.6 episodes/1000 ventilator days in the control patients (closed lumen ETT) (relative risk, 1.98; 95% CI, 1.03 to 3.82). Episodes of ventilator-associated pneumonia developed later in patients receiving continuous aspiration (12.0 ± 7.1 days) than in the control patients (5.9 ± 2.1 days) (P < 0.001).This difference was due to a significant (P< 0.03) reduction in the number of gram-positive cocci and Haemophilusinfluenzaeorganisms in the patients receiving continuous aspiration.

6. Kollef MH, Skubas NJ, Sundt TM. A randomized clinical trial of continuous aspiration of subglottic secretions in cardiac surgery patients.Chest. 1999;116(5):1339-1346.

Pro- Continuous vs. w/o Suctioning -Study focused on 371 cardiac surgery patient requiring mechanical ventilation in the Cardiothoracic ICU. VAP was seen in 8 patients (5.0%) receiving continues suctioning and in 15 patients (8.2%) receiving routine postoperative medical care without suctioning (relative risk, 0.61%; 95% confidence interval, 0.27 to 1.40; p = 0.238).Episodes of VAP occurred statistically later among patients receiving continuous suctioning ([mean ± SD] 5.6 ± 2.3 days) than among patients who did not receive suctioning (2.9 ± 1.2 days); (p = 0.006). No statistically significant differences for hospital mortality, overall duration of mechanical ventilation, lengths of stay in the hospital or CTICU, or acquired organ system derangements were found between the two treatment groups. The occurrence of VAP can be significantly delayed among patients undergoing cardiac surgery using this simple-to-apply technique of continuous suctioning.

7. Cook DJ, Kollef MH. Risk factors for ICU-acquired pneumonia.JAMA. 1998;279(20):1605-1606.

Con - This review did not focus on subglottic suctioning intervention, but summarizes 12 studies that evaluate risk factors for ICU-acquired pneumonia in critically ill patients. One of the VAP risk factors identified was failed subglottic suctioning.

8. Mahul P, Auboyer C, Jospe R, et al. Prevention of nosocomial pneumonia in intubated patients: Respective role of mechanical subglottic secretions drainage and stress ulcer prophylaxis. Intensive Care Medecine. 1992(18):20-25.

Pro-Drainage vs. Sucralfate - Study focused 145 patients who required mechanically ventilated for > 3 days.Subglottic secretion drainage(SSD) treatment was associated with: a) a twice lower incidence of nosocomial pneumonia (NP) (no-SSD: 29.1%, SSD: 13%); b) a prolonged time of onset of NP (no-SSD: 8.3±5 days, SSD: 16.2±11 days); c) a decrease in the colonization rate from admission to end-point day in tracheal aspirates (no-SSD:+21.3%, SSD:+6.6%) and in subglottic secretions (no-SSD:+33.4%, SSD:+2.1%). Study findings conclude that the prevention of micro-aspiration with the use of subglottic drainage was effective at reducing nosocomial pneumonia, but sucralfate prevention was not.