Iranian Journal of Critical Care Nursing Winter 2010, Volume 2, Issue 4; 133-137

Effect of open and closed endotracheal suction systems on heart rhythm

and arterial blood oxygen level in intensive care unit patients
Seyyed Mazhari M.* MSc, Pishgou’ei A. H.1 MSc, Zareian A.1 MSc, Habibi H.1 PhD
*
Faculty of Nursing, Artesh University of Medical Sciences, Tehran, Iran;
1
Faculty of Nursing, Artesh University of Medical Sciences, Tehran, Iran

Abstract
Aims: Many patients need special care, and endotracheal tube and the use of mechanical ventilation is essential. This type
of airway leads to mucosa stimulation and production of mucus. Suctioning is accociated with complications such as severe
hypoxia and significant cardiovascular disorders. Therefore, selecting the least dangerous way of endotracheal tube suction
can reduce severe complications. This study compared the effect of two open and closed methods of suctioning on heart rate
pattern and arterial blood oxygen saturation.
Methods: This crossover clinical trial study performed during 2008-2008 in critical care units of army selected hospitals,
60 patients who were connected to ventilator were selected. Open and closed suction techniques were carried on samples
and heart rate patterns and arterial blood oxygen saturation was measured in patients before and several times after each
type of suction and was compared. For analysis of data the paired t-test and ANOVA and SPSS 17 software were used.
Results: There was a significant difference in heart rate and oxygen saturation in different times after closed suction system
and open suction system (p<0.0001). The difference was more obvious in different periods after open suction method, but
there was no change in cardiac rhythm in both open and closed suction methods (p>0.05).
Conclusion: Open and closed suction methods are effective on heart rate and arterial blood oxygen saturation and it is
suspected that closed suction method causes less changes in patient’s hemodynamic status.

Keywords: Closed Suction, Open Suction, Oxygen Saturation Level, Heart Rate, Heart Rhythm

Introduction lead to tachycardia, dysrhythmias, blood pressure

Progress of sciences and technology has led to
extensive changes in treatment and care methods. So
that many of patients who are in acute or chronic
critical stages are completely or relatively improved
using new methods of treatment, skilled nursing staff
and the advanced technology [1]. Today, about 7.8%
of patients require post-surgery care in CCU and ICU
[2, 3]. Since the main problem of these patients is the
respiratory system, thus endotracheal intubation and
mechanical ventilation are increasing in these units [2,
4]. Establishing these artificial air ways leads to
mucus stimulation and increase in mucus production.
This patients are not able to effectively cough and
excrete the secretions due to larynx closure and lack of
increase in intra thoracic pressure; therefore, the
airway suctioning is highly important [1, 5].
Authorities believe that if the suction is not performed
by a correct and standard method, it will lead to
complications such as cardiac arrhythmias, infection,
blood oxygen decrease, damage to the mucus layer,
carbon dioxide pressure increase, ICP rising,
atelectasis or even death. In addition, suction itself
causes the stimulation of mucus and the evacuation of
oxygen from airways [5, 6]. Hypoxia resulted from
suction puts pressure on cardiovascular system and
* Correspondence; Email: marjanmazhari@yahoo.com
increase, breathing pressure increase and eventually
cyanosis and dizziness [7]. Observing principles
seems necessary to minimize the complications of
endotracheal tube (ETT) suctioning and in spite of
these principles’ observation, selecting an appropriate
method of ETT suction for reducing of complications
is helpful [8].
At the present time, the most common method used
for ETT tube suctioning in patients, is the open
technique that requires patients’ disconnection from
ventilator and results in pressure drop of airways and
lung volume loss [9]. However, there is another
method known as closed suction, in which the patient
is not separated from the ventilator during the suction
[8, 10]. In this method, the patient’s suctioning can be
done by connecting an interface to the ventilator
simultaneous with supplying Oxygen. Therefore, due
to positive pressure during the suction, hemodynamic
disturbances could be prevented.
Researchers believe that in closed suction the pressure
of arterial oxygen is less reduced compared to open
suction. Meanwhile, cardiac complications (such as
tachycardia and dysrhythmias) are more seen in open
suction [9]. However, despite these comments, some
articles have hesitated about the use of these methods.
Statistics show that over the past decade use of closed
Received 2010/01/09; Accepted 2010/02/03
Effect of open and closed endotracheal suction systems on heart rhythm and artery blood oxygen level in intensive care patients ______
suction has had more fans; so that 85 % of intensive
care units of the hospitals in the United States of
America use closed suction that is due to the
decreasing hemodynamic and physiologic disorders
[11]. For this aim, with regard to the importance of the
issue and proving the superiority of each of these two
types of suction on reduction of complications, the
present study was performed to investigate and
compare the effect of these two methods of suctioning
on heart rhythm and rate and the amount of arterial
blood oxygen saturation.
Methods
In this crossover clinical trial which was conducted on
patients who were hospitalized in intensive care units
of the army selected hospitals in 2007-8, 60 patients
were studied. Subjects were connected to a ventilator
and were ventilated in volume; however, they were
controlled before the suction in terms of cardiac
rhythm, and their arterial blood oxygen saturation was
higher than 90% and their heart rate was between 60
to100. All ventilator machines and monitors were of
the same type and were calibrated. After selection of
participants and before endotracheal tube suctioning,
patients were at first hyper oxygenated for 2 minutes
(4-6 breaths) by 100% oxygen with ventilator and
their heart beat pattern (heart rate and rhythm) and the
percentage of their arterial blood oxygen saturation
were measured and recorded by a monitor beside the
patient’s bed and immediately the endotracheal tube
suctioning was carried out. Endotracheal tube
suctioning was done once using a closed technique
and another time by open technique and their interval
was at least 90 minutes in order to let the heart rate
pattern and the percentage of arterial blood oxygen
saturation fully be back to its initial condition after the
first suction [12]. Immediately after suction and
recording of the number and percentage of heart rate
and rhythm, and the percentage of arterial blood
oxygen saturation, all subjects were hyper oxygenated
using ventilator for 2 minutes (3 to 5 breaths) with 100
% oxygen [13]. Two to 5 minutes after suction these
criteria were also recorded by monitor. At every turn
of endotracheal tube suction, suction was done 1-3
times and endotracheal tube suction time was 5 to 10
seconds for both methods [14]. The patient was
excluded from the study if he needed repetitive
suctioning or if he needed suctioning with less than 90
min intervals or any change in his medication state or
his device position within the intervals of two
suctions. Endotracheal tube suctioning was done by a
suitable suction catheter (half of tracheal tube
diameter) [13] with the pressure of 120 mm Hg. The
obtained data was analyzed using SPSS 17 software.
To compare the heart rate in open and closed methods
the repeated measures ANOVA was used. The mean
heart rate and arterial blood oxygen saturation amount
were studied and compared at different stages in two
open and closed methods by paired t-test. According
to suction type, the effect of different times on heart
rate and arterial blood oxygen saturation amount were
studied and compared using repeated measures
ANOVA. To determine the changes in heart rhythm in
both open and closed methods in different times
Cochran’s Q test was used. To evaluate the heart
rhythm at different stages in the two methods, closed
and open tests, McNemar statistical test was used. For
comparing the arterial blood oxygen saturation in
various stages of study with two open and closed
methods, repeated measures two-way ANOVA was
used.
Results
The mean age of subjects was 63±17.48 years with the
range of 21 to 86 years, and 25 patients (41.7%) were
male. The mean of intubation duration was 7.5 days
and patients had at least one and the maximum of 28
tracheal tubes. 17 patients were admitted with CVA
diagnosis.
38 patients’ ventilators were of synchronized
intermittent mandatory ventilation (SIMV) type and
the average of support pressures (Ps) was 9.09±2.979.
Mean fraction of inspired oxygen (FIO2) was 47.88%
and the average of the tidal volume (VT) was
501.93cc with the average of continuous positive
airway pressure on whole voluntary breathing period
(CPAP) equal to 2.938cm of water and mean of
positive end-expiratory pressure (PEEP) equal to
3.660 cm of water. The mean number of exerted
breaths by device was 9.80 and the mean number of
patient respiration was 9.92. In 53 patients, Nelaton
catheter number 14 was used during suction. 36
patients had tracheal tube of size 7.5. The mean of 24-
hour serum intake was 2361.67±631.407 and 21
patients received at least 2000 cc.
Considering the significance of Mauchly test results
(p<0.0001), the variance uniformity assumption was
rejected. Therefore the more conservative test of
Greenhouse-Geisser was used. Heart rate change in
different stages using different suctioning methods
was significant (F (1 and 59) =18.55); p<0.0001). On the
other hand, the interaction of two closed and open
suction methods with the time factor also confirmed a
significant difference (F (2 and127) = 61.33; p<0. 0001).
__________________________________________________________________________________________SeyyedMazhari M. et al.

Consequently, changes in heart rate during different times with closed and open methods revealed a
times with closed and open methods showed a significant difference (F (2.5 and 127) =1.355; p<0.0001).
significant difference (F (2 and127) = 40.59; p<0. 0001).
Table 2- Frequency distribution and comparison of cardiac rhythm
Table 1- Comparison of heart rate mean in open and closed by time (McNemar; p>0.05) and type of suction (Cochran’s Q;
suction method in terms of time and type of suction p>0.05)
Paired t- Steps→ Ope Close
Stages→ Method↓ n d
Open Closed test
Method↓ 57 59
df=59 Sinus
Number
±14.13 ±14.65 T=-0.421 Before Percent 95 98.33
Before suction 3 1
87.80 99.07 p=0.675 suction Non- Number
Immediately ±13.97 T=5.39 Sinus Percent 5 1.67
93±13.61 57 59
after suction 97.72 p=0.0001 Number
Immediate Sinus
2 minutes after ±13.38 ±14.93 T=7.413 Percent 95 9
ly after
suction 94.80 88.93 p=0.0001 Non- Number 3 1
suction
5 minutes after ±13.76 ±15.07 T=-3.037 Sinus Percent 5 1.67
suction 89.25 88.10 p=0.0004 Number 57 59
2 minutes Sinus
F=76.093 F=27.502 Percent 95 98.33
Single factor after
df=2.113 df=2.49 Non- Number 3 1
ANOVA suction
p=0.0001 p=0.0001 Sinus Percent 5 1.67
Number 57 59
5 minutes Sinus
In each interval after suctioning, a significant Percent 95 98.33
after
difference was observed in terms of change in heart Non- Number 3 1
suction
Sinus Percent 5 1.67
rate (p<0.0001), but this statistical difference was not
significant in open and closed suctioning method Table 3- Comparing the mean of arterial blood oxygen saturation
before the suction (p>0.05). In analyzing the results percentage in open and closed suction method in terms of time and
five minutes after the open and closed suction by type of suction
paired t-test, despite the significant difference Stages→
Open Closed
Paired T
(p=0.0004), comparison of means indicated the less Method↓ df=59
±4.383 ±4.061 T=-0.248
difference between open and closed method at this Before suction
94.20 94.30 p=0.805
time (Table 1). Greenhouse-Geisser modifying test Immediately ±5.828 ±4.715 T=7.083
(with regard to the Mauchly sphericity test being after suction 88.62 91.80 p=0.0001
significant; p<0.01), confirmed the statistically 2 minutes after ±4.725 ±4.621 T=-2.365
significant difference (p<0.0001) between heart rate suction 93.37 94.65 p=0/021
5 minutes after ±4.480 ±4.227 T=-2.914
and different suctioning times. So that these changes suction 93.63 94.06 p=0.0005
in different time intervals after closed suction were Single factor F=59.751 F=27.406
less than changes in heart rate in different times with ANOVA p=0.0001 p=0.0001
open suction (Table 1).
In open and closed suction, no statistically significant A significant difference was observed in each of time
difference was observed in terms of heart rhythm intervals after the suction in arterial blood oxygen
change in different stages of suction (p>0.05). saturation rate, but this statistical difference was not
Meanwhile, the frequency of sinus cardiac rhythm in significant before the suction with open and closed
closed method was higher than the open method. In methods (p>0.05). Greenhouse - Geisser (with regard
terms of cardiac rhythm, there was no statistically to Mauchly sphericity test significance p<0.01),
significant difference in each stage of open and closed confirmed a significant statistical difference in arterial
suctioning method (p>0.05; Table 2). blood oxygen saturation during different suction
According to the results of Greenhouse-Geisser times, which were less after closed suction method
statistical test (p<0.0001), arterial blood oxygen compared to open suction method (Table 3).
saturation rate change at different stages was
significant, by different suction methods. (F (1 and 127)
Discussion
=17.361; p<0.0001). On the other hand, the interaction
of two closed and open suction methods along with The study results showed that there is significant
the time factor also confirmed the significant difference in heart rate and arterial blood oxygen
difference ( F (1.7 and 127) =58.780 ;p<0.0001). saturation rate in terms of patient type of suction.
Consequently, changes in heart rate during different The heart rate and the percentage of arterial blood
Effect of open and closed endotracheal suction systems on heart rhythm and artery blood oxygen level in intensive care patients ______
oxygen saturation at different minutes after suction
with open and close methods are different compared to
before the suction, although the difference of these
two factors immediately after the suction is too
obvious compared to two or five minutes after suction.
In addition, these changes have also significant
difference in various times after suction in comparison
of two suction methods, so that the rate of the change
of these two factors is lower when using the closed
suction method. In this regard, Lee et al. found that the
open suction method further enhance the heart rate
immediately after tracheal tube suctioning compared
to closed method and arterial blood oxygen saturation
immediately after the open suction method has a
significant decrease [15 ]. On the other hand, open
suction method averagely increases the heart rate to
six beats compared to the close suction method [9],
while arterial oxygen pressure after suction in both
methods, has a significant decrease but this decrease is
more in the open suction [16], which is in accordance
with the findings of this study.
According to the results of the present study, suction
type (open or close) does not change the heart rhythm.
Nevertheless, some researchers believe that the
prevalence of arrhythmia is considerably higher in
open suction method [15, 17] that apparently is
incompatible with results of present study. However,
with a more precise view on this study’s statistics, it
becomes clear that the result of this part of research is
very close to significant level. Therefore there is the
possibility that with more samples, the significance of
changes in heart rhythm be assured in closed suction
method compared to the open suction.
Conclusion
Suction with close method has less effect on the
pattern of heart rate and arterial blood oxygen
saturation compared to suction with open method and
induce less disorder in patients’ hemodynamic
symptoms.
Acknowledgement: Hereby authors of the article
appreciate the collaboration of the esteemed
management of Army Medical Sciences University
and all respected colleagues and authorities of selected
hospitals of where the study was conducted.
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