Routine Changing of In-Line Suction Catheters Does Not Reduce Pneumonia
Routine Changing of In-Line Suction Catheters Does Not Reduce Pneumonia in Mechanical Ventilation
ABSTRACT & COMMENTARY
Synopsis: Based on the randomized trial by Kollef and colleagues, it is appropriate and cost-effective to recommend change of in-line suction catheters only when they malfunction or become visibly soiled.
Source: Kollef MH, et al. Mechanical ventilation with or without daily changes of in-line suction catheters. Am J Respir Crit Care Med 1997;156:466-472.
In-line suction catheters that permit endotracheal suctioning of ventilated patients without disconnection of the ventilator circuit are currently in use in many critical care units. The largest manufacturer of these catheter systems recommends changing the catheter every 24 hours because of the possibility of formation of a biofilm that may be a source of organisms causing ventilator-associated pneumonia.
In a randomized trial, Kollef and colleagues compared daily catheter replacement with no regularly scheduled replacement. Patients in the latter group received catheter replacement only in the event of catheter malfunction or visible soiling. Two hundred sixty-three patients received daily catheter changes, and 258 received no routine changes. The two groups were very well matched according to demographics, underlying illnesses, severity of illness measured by Apache II score, and known risk factors for pneumonia such as receipt of H-2 blockers, antibiotic therapy, and factors contributing to aspiration. No difference was found in the rates of pneumonia. Futhermore, there was no difference in mortality, length of stay, duration of intubation, or acquisition of new organ system dysfunction.
COMMENT BY ROBERT MUDER, MD
In-line suction catheters are favored by many critical care units because they permit endotracheal suctioning without disconnecting the patient from the ventilator. One potential drawback of these catheters is the build-up of a biofilm of patient secretions and bacteria that could be aspirated or introduced into the patients respiratory tract, increasing the risk of ventilator-associated pneumonia. On the other hand, entering the closed system to suction by traditional means, or to change the catheter, increases the risk of external bacterial contamination. Several previous studies have shown that frequent changes of ventilator circuit tubing do not decrease (and may increase) the risk of ventilator associated pneumonia.
The study by Kollef and colleagues is convincing because of the large number of patients involved, the close matching of the two treatment groups, the definition of pneumonia used, and the examination of secondary outcomes such as length of intubation and ICU stay.
Based on this study, it is appropriate to recommend change of in-line suction catheters only when they malfunction or become visibly soiled. The cost savings are relatively modestabout $39 per patient or $7 per ventilator-patient day. However, in a 20-bed unit this would amout to $51,000 per year exclusive of the time spent by respiratory therapists in routine catheter changes.
Finally, this study is an excellent example of the use of an evidence-based approach to evalaute patient care practices of unproven efficacy.
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