The Science Journal of the American Association for Respiratory Care

2003 OPEN FORUM Abstracts

OPEN VERSUS CLOSED ENDOTRACHEAL SUCTIONING DURING ARDSnet PROTOCOL.

G.Schettino MD.PhD, M.P.Caramez,MD.PhD, K.Suchodolski MD, T.Nishida MD , D.Hess, RRT.PhD and RM Kacmarek, RRT.PhD

Department of Anesthesia and Critical Care, and Respiratory Care, Massachusetts General Hospital and Harvard Medical School.

Previous studies have demonstrated that disconnecting patients from the ventilator during open suctioning (OS) can cause alveolar derecruitment, transient hypoxemia, especially with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) [1, 2]. The use of closed suction systems (CS), which allow non-interrupted ventilatory support during suctioning, have the advantage of supplying oxygen-enriched gas and ventilation with positive end expiratory pressure (PEEP) throughout suctioning. This theoretically should limit or prevent hypoventilation, alveolar collapse and hypoxemia. There are two recent reports regarding endotracheal suctioning during ALI/ARDS [3, 4] but ventilator management has not provided by the ARDSnet protocol. In this study we evaluated the physiologic effects of OS and CS during pressure and volume control ventilation, using the ARDSnet protocol in lung lavage injured sheep. Mechanical ventilation was provided according to ARDSnet protocol with volume (VC) and pressure control (PC) ventilation. (VT= 6ml/kg; RR< 35/min; PEEP set by FiO2/PEEP). CS was performed using a 14 French, TrachCare catheter with a suctioning time of 10 s and pressure of - 100 mmHg. OS was performed with the same time and pressure but with the ventilator disconnected from the animal. Flow and airway pressure were continuously recorded. Cardiac output and pressures were monitored with a pulmonary artery catheter. Arterial blood-gases were monitored with a continuous intravascular system. The mean PEEP and FiO2 were 18.2 cmH2O and 0.9 respectively during the experiment. PaO2/FiO2 was recorded before, 1, 5 and 10 min after suctioning and changes are illustrated in the enclosed figure. OS caused a greater PaO2/FiO2 decrease than CS during both VC and PC (P < 0.05). No difference in oxygenation was observed between VC and PC during CS. Pulmonary shunt and PaCO2 recorded 10 min after suctioning were greater than pre -suctioning for both OS and CS. No significant changes in hemodynamics were detectable pre vs post suctioning with OS or CS. In conclusion, PaO2/FiO2 was better during CS with both VC and PC modes than OS during ARDSnet ventilation, however the use of CS did not prevent increased hypercapnia 10 min post suctioning. Hemodynamics were not affected by either suctioning procedure.

REFERENCES:
1. Brochard L, Mion G, Isabey D, et al. Am Rev Respir Dis 1991; 144(2): 395-400.

2. Cereda M, Villa F, Colombo E, Greco G, Nacoti M, Pesenti A:Intensive Care Med 2001; 27(4): 648-54.

3. Dyhr T, Bonde J, Larsson A: Crit Care 2003; 7(1): 55-62.

4. Maggiore SM, Lellouche F, Pigeot J, et al.: Am J Respir Crit Care Med 2003; 167(9): 1215-24.

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