Intensive Care Medicine

, Volume 41, Issue 3, pp 402–411 | Cite as

Impact of closed versus open tracheal suctioning systems for mechanically ventilated adults: a systematic review and meta-analysis

  • Akira KuriyamaEmail author
  • Noriyuki Umakoshi
  • Jun Fujinaga
  • Tadaaki Takada
Systematic Review



Whether closed tracheal suctioning systems (CTSS) reduce the incidence of ventilator-associated pneumonia (VAP) compared with open tracheal suctioning systems (OTSS) is inconclusive. We conducted a systematic review and meta-analysis of randomized controlled trials that compared CTSS and OTSS.


PubMed, the Cochrane Central Register of Controlled Trials, the Web of Science, Google Scholar, and a clinical trial registry from inception to October 2014 were searched without language restrictions. Randomized controlled trials of CTSS and OTSS that compared VAP in mechanically ventilated adult patients were included. The primary outcome was the incidence of VAP. Secondary outcomes were mortality and length of mechanical ventilation. Data were pooled using the random effects model.


Sixteen trials with 1,929 participants were included. Compared with OTSS, CTSS was associated with a reduced incidence of VAP (RR 0.69; 95 % CI 0.54–0.87; Q = 26.14; I 2 = 46.4 %). Compared with OTSS, CTSS was not associated with reduction of mortality (RR 0.96; 95 % CI 0.83–1.12; Q = 2.27; I 2 = 0.0 %) or reduced length of mechanical ventilation (WMD −0.45 days; 95 % CI −1.25 to 0.36; Q = 6.37; I 2 = 5.8 %). Trial sequential analysis suggested a lack of firm evidence for 20 % RR reduction in the incidence of VAP. The limitations of this review included underreporting and low quality of the included trials, as well as variations in study procedures and characteristics.


Based on current, albeit limited evidence, it is unlikely that CTSS is inferior to OTSS regarding VAP prevention; however, further trials at low risk of bias are needed to confirm or refute this finding.


Endotracheal suctioning Closed tracheal suctioning systems Adults Ventilator-associated pneumonia Meta-analysis Systematic review Trial sequential analysis 



The authors would like to thank Dr. Arzu Topeli and Dr. Deepu David for providing relevant information, and would like to thank Ms. Ryoko Ono for editing the figures.

Conflicts of interest

None to declare for any author.

Financial disclosures

None to declare.

Supplementary material

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Supplementary material 3 (TIFF 752 kb)
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Supplementary material 5 (DOC 53 kb)
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Supplementary material 6 (PDF 113 kb)


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Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2014

Authors and Affiliations

  • Akira Kuriyama
    • 1
    Email author
  • Noriyuki Umakoshi
    • 2
  • Jun Fujinaga
    • 2
  • Tadaaki Takada
    • 3
  1. 1.Department of General MedicineKurashiki Central HospitalKurashikiJapan
  2. 2.Department of Emergency MedicineKurashiki Central HospitalKurashikiJapan
  3. 3.Department of Emergency and Critical Care MedicineUrasoe General HospitalUrasoeJapan

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