Appendix C: Subglottic Suctioning and Subglottic

ETT, Literature Synopsis

Ventilator Associated Pneumonia Prevention Bundle
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 2011, a systematic review and meta-analysis of 13 randomized trials
support the use of subglottic drainage for VAP prevention. The 2011 analysis found a 45%
reduction of VAP along with a 1.5 days reduction in length of stay and 1.1 days of
ventilation.

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
Systematic Meta-Analysis
Drainage vs. Standard
(Dezfulian, 2005) 2
CDC Guideline- 20033
Review
(Kollef, 2004) 4
Continuous vs. Closed Lumen Care
(Valles, 1995) 5
* Continuous vs. w/o Suctioning
(Kollef, 1999) 6
Contempo
(Cook, 1998) 7
Drainage vs. Sucralfate
(Mahul, 1992) 8
Results - Details in Annotated Bibliography
Pro- Analyzed 5 RCT to assess the efficacy of subglottic secretion drainage
in preventing VAP. Study showed that subglottic secretion drainage can
reduced the incidence of VAP by nearly half in patients requiring
mechanical ventilation.
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)
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 VAP incidences.
Pro- Study focused on ICU patients expected to be intubated for >3 days.
The study findings conclude that the incidence of nosocomial pneumonia in
mechanically ventilated patients can be significantly reduced by using
continues subglottic suctioning through the dorsal lumen.
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.
Pro- 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.
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.

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2008-Canadian VAP Prevention Guidelines: Evidence-based, clinical practice guidelines for the prevention of
ventilator-associated pneumonia1

 Subglottic Secretion Drainage is recommended for patients requiring to be mechanically ventilated for more
than 72hrs.

Articles Cited in Guideline
Study Type and Author
Drainage vs. Conventional Oral ETT
(Smulders, 2002)9
Drainage vs. Control
(Bo, 2000)10
Continuous vs. Closed Lumen Care
(Valles, 1995)5
Drainage vs. Sucralfate
(Mahul, 1992)8
Results - Details in Annotated Bibliography
Pro- Study focused on ICU patients expected to be
mechanical ventilated >72 h. Findings showed that intermittent
subglottic secretion drainage reduces the rate of VAP in patient
receiving mechanical ventilation.
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 Haemophilius
influenzae caused VAP cases.
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 continues subglottic suctioning.
(Previously cited by SHEA)
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. 11

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

Articles Cited in Guideline

Study Type and Author
Continuous vs. w/o Suctioning
(Kollef, 1999) 6
Continuous vs. Closed Lumen Care
(Valles, 1995) 5
Drainage vs. Sucralfate
(Mahul, 1992) 8
Results - Details in Annotated Bibliography
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 )
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 continues suctioning. (Previously cited by
SHEA and ZAP)
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)

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 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
Intermittent Drainage vs. Standard ETT
(Smulders, 2002) 9
Continuous vs. w/o Suctioning
(Kollef, 1999) 6
Contempo
(Cook, 1998)7
Continuous vs. Closed Lumen ETT
(Valles, 1995) 5
Drainage vs. Sucralfate
(Mahul, 1992) 8
Results - Details in Annotated Bibliography
Pro- Study focused on ICU patients expected to be
mechanical ventilated >72 h .Findings showed that intermittent
subglottic secretion drainage reduces the rate of VAP in patient receiving
mechanical ventilation.
Pro- Study focused on cardiothoracic c 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)
Pro- 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)
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}
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, 2007-2012

Study Type and Author
Systematic Review and Meta-Analysis
(Leasure, 2012)12
Systematic Review and Meta-Analysis
(Muscedere, 2011) 13
Intermittent Drainage vs. Closed Suctioning
System
(Juneja, 2011) 14
Cost Benefit Analysis
Conventional Tubes vs. Continuous
Subglottic Suctioning Tubes
(Hallais, 2011) 15
Business Case
Continues ETT vs. Standard ETT
(Speroni ,2011) 16
Results - Details in Annotated Bibliography
Pro- Study reviewed 12 original articles and 4 reviews that evaluated the
effectiveness of subglottic secretion drainage (SDD) 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.
Pro- Study focused on 13 RCTs evaluating subglottic secretion drainage in
adult mechanically ventilated patients. Study findings support the use of
subglottic endotracheal tube in reduction rate of VAP.
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.
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.
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

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 VAP.
Pro- Analyzed 15 RCT and 13 RCO of mechanically ventilated adult
patients. Study showed that new evidence continues to be varied in
Systematic Review strength for suctioning practice, but the evidence has improved since 2001
(Overend, 2009) 17 suggesting that members of the health care team should incorporate this
evidence into their practice.
Pro- Review of meta-analysis 2 that looked at 5RCT that compared
Literature Review aspiration of subglottic secretion vs. standard ETT care. Findings conclude
(Depew, 2007) 18 that there insufficient outcome evidence to support the use of subglottic
technology – aside from the VAP rate reduction.

4
 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. Available from:
http://www.jstor.org/stable/10.1086/591062.

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
Haemophilus influenzae organisms 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.
Pro- 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.

9. Smulders K, van der Hoeven H, Weers-Pothoff I, Vandenbroucke-Grauls C. A randomized clinical trial of

intermittent subglottic secretion drainage in patients receiving mechanical ventilation. Chest. 2002;121(3):858-862.
Pro- Intermittent Drainage vs. Standard ETT - Study focused on 150 patient expected to be mechanical ventilated >72 h the general ICU.
VAP was seen in 3 patients (4%) receiving suction secretion drainage and in 12 patients (16%) in the control group (relative risk,
0.22; 95% confidence interval, 0.06 to 0.81; p = 0.014). Intermittent subglottic secretion drainage reduces the incidence of VAP in
patients receiving mechanical ventilation.

10. Bo H. Influence of the subglottic secretion drainage on the morbidity of ventilator associated pneumonia in
mechanically ventilated patients. . Chinese J Tuberc Respir Dis. 2000(23):472-4.
Pro- Drainage vs. Control - Study focused on 68 patients who required intubation in the surgical ICU. The morbidity of VAP in the
drainage group (n = 35) (23%) was lower than that in the control group (n = 33) (45%) (P < 0.05). The difference was due to the
significant reduction of VAP caused by gram-positive cocci and Haemophilus influenzae organisms. However, no difference was observed

4
 in the incidence of VAP caused by non-fermental bacteria. After intubation the onset of VAP was delayed in drainage group (14 +/- 8
day) as compared with the control group (6 +/- 4 day) (P < 0.05). The same organisms were isolated among 61% (14/23) patients with
VAP as what were previously isolated from the subglottic secretions. The presence of subglottic secretion may be an origin of the
pathogenetic organisms of VAP. The morbidity of VAP in mechanically ventilated patients can be reduced by drainage , especially
for VAP caused by gram-positive cocci and Haemophilus influenzae organisms. Subglottic secretion drainage may be a simple and
effective method for prevention of VAP.

11. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults
with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med.
2005;171(4):388-416.

12. Leasure A, Stirlen J, Lu S. Prention of ventilator- associated penyumonia through aspiration of subglottic
secreations: A systematic review and meta-analysis. Dimensions of Crital Care Nursing. 2012;31(2):102-117.
Pro- Systematic Review & Meta Analysis - Study reviewed 12 original articles and 4 reviews that evaluated the effectiveness of subglottic
secretion aspiration in reducing the occurrence of VAP. Study findings showed that the effectiveness of subglotti secretion aspiration
in reducing VAP Rates was 52% across a pooled total of 1701 cases (risk ratio, 0.52; 95% confidence interval, 0.43-0.64 in rates) .

13. Muscedere J, Rewa O, McKechnie K, Jiang X, Laporta D, Heyland DK. Subglottic secretion drainage for the
prevention of ventilator-associated pneumonia: A systematic review and meta-analysis. Crit Care Med.
2011;39(8):1985-1991.
Pro- Systematic Review – Study focused on 13 RCT‘s studies who reported a reduction in VAP rates in the subglottic secretion drainage
arm. The overall risk ratio for ventilator-associated pneumonia was 0.55 (95% confidence interval, 0.46-0.66; p < .00001) with no
heterogeneity (I = 0%). The use of subglottic secretion drainage was associated with reduced intensive care unit length of stay (-
1.52 days; 95% confidence interval, -2.94 to -0.11; p = .03); decreased duration of mechanically ventilated (-1.08 days; 95%
confidence interval, -2.04 to -0.12; p = .03), and increased time to first episode of ventilator-associated pneumonia (2.66 days; 95%
confidence interval, 1.06-4.26; p = .001).

14. Juneja D, Javeri Y, Singh O, Nasa P, Pandey R, Uniyal B. Comparing influence of intermittent subglottic
secretions drainage with/without closed suction systems on the incidence of ventilator associated pneumonia.. Indian
J Crit Care Med. 2011;15(3):168-72.
Pro- Intermittent vs. Continuous suctioning – Study focused on 311 patients requiring mechanical ventilation for more than 72 hours. Data
was collected retrospectively for following four groups: group A, no intervention; group B, only continues suctioning ; group C, only
intermittent drainage; and group D, intermittent drainage with continues suctioning . Incidence of VAP per 1000 ventilator days in
groups A, B, C, and D were 25, 23.9, 15.7 and 14.3, respectively (P=0.04). There was no significant difference in the duration of MV
(P=0.33), length of ICU (P=0.55) and hospital stay (P=0.36) and ICU mortality (P=0.9) among the four groups. Intermittent drainage
of secretions reduces the incidence of VAP. Continuous suctioning alone or in combination with intermittent has no significant
effect on VAP incidence.

15. Hallais C, Merle V, Guitard PG, et al. Is continuous subglottic suctioning cost-effective for the prevention of
ventilator-associated pneumonia? Infect Control Hosp Epidemiol. 2011;32(2):131-135.
Cost/benefit analysis - Study analyzed the cost benefit of 416 surgica patients receiving mechanical ventilation for 3,487 ventilation days in
the SICU. A total of 32 VAP episodes were observed (7.9 episodes per 100 ventilated patients; incidence density, 9.2 episodes per 10,000
ventilation-days). Based on a hypothesized 29% reduction in the risk of VAP with Continuous Subglottic Suctioning (CSS) Tubes than
Conventioal Ventilation (CV) Tubes, 9 VAP episodes could have been averted. The additional cost of CSS for 2006 was estimated to be
€10,585.34. The cost per averted VAP episode was €1,176.15. Assuming a VAP cost of €4,387, a total of 3 averted VAP episodes would
neutralize the additional cost. For a low VAP incidence of 6.6%, the cost per averted VAP would be €1,323. The cost of a CV tube was
€1.01. The cost of a CSS tube (Hi-Lo Evac) was €5.50, and the cost of 1 secretion-receiving bottle was €2.50If each patient required 2
tubes during ventilation, the cost would be €1,383.69 per averted VAP episode. Findings conclude that replacement of CV with CSS was a
cost-effective method for treatment and for reducing VAP rates.

16. Speroni KG, Lucas J, Dugan L, et al. Comparative effectiveness of standard endotracheal tubes vs. endotracheal
tubes with continuous subglottic suctioning on ventilator-associated pneumonia rates. Nurs Econ. 2011;29(1):15-20,
37.
Pro- Business Case – Study focused on 154 intubated adult patients (77 = S-ETT; 77 = CSS-ETT). The Standard -ETT group had one
case of VAP; the Continues -ETT group had none. The mean total hospital charges were higher for the S-ETT group ($103,600;
CSS-ETT= $88,500) (p = 0.3). Although the average number of intubation days and ICU days were greater for the CSS-ETT group, there
were no cases of VAP compared to the Standard -ETT group. Based upon the one Standard -ETT VAP case and the VAP attributable
costs, it is cost effective to use the Continues-ETT.

17. Overend T, Anderson C, Brooks D, et al. Updating the evidence-base for suctioning adult patients: A systematic
review.. Can Respir J. 2009;16(3).
Pro- Systematic Review- Analyzed 15 RCT and 13 RCO of adult mechanically ventilated patients. Study findings showed that new
evidence continues to be varied in strength for suctioning practice, but the evidence has improved since 2001. Study recommends
members of the health care team should incorporate this evidence into their practice based on the growing body of evidence for
the use of suctioning.

18. Depew C, McCarthy M. Subglottic secretion drainage: A literature review.. AACN Adv Crit Care. 2007;18(4):366-
79.
Pro – Review of meta-analysis (Dezfulian, 2005)) that looked at 5RCT 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