Closed Versus Open Endotracheal Suctioning and Ventilator-Associated Pneumonia in Severe Traumatic Brain Injury

Ventilator-associated pneumonia (VAP) is a common and serious complication in mechanically ventilated patients, and patients with severe traumatic brain injury (TBI) are particularly vulnerable. Open suctioning may increase hypoxia and environmental contamination, while closed suctioning may reduce pathogen exposure and help maintain oxygenation, but the evidence remains controversial.

One hundred twenty adult patients with severe TBI (Glasgow Coma Scale \[GCS\] 3-8) will be randomly allocated 1:1 using a computer-generated sequence with sealed opaque envelopes. Both groups receive pre-oxygenation with 100% fraction of inspired oxygen (FiO2) before suctioning and the same standardized VAP prevention measures (head-of-bed elevation, daily sedation interruption, and oral antiseptic care).

VAP will be diagnosed using Centers for Disease Control and Prevention/National Healthcare Safety Network (CDC/NHSN) criteria, supported by the Clinical Pulmonary Infection Score (CPIS) assessed every 48 hours. Endotracheal aspirate cultures are taken at intubation and after 48 hours. The study will be conducted in the intensive care unit (ICU) of Minia University Hospital over about one year.

• Closed endotracheal suction system (Device): In-line closed suction catheter system that allows endotracheal suctioning without disconnecting the ventilator.
• Open endotracheal suction (Procedure): Endotracheal suctioning using sterile disposable catheters with ventilator disconnection during the procedure.

Primary outcomes

• Incidence Density of Ventilator-Associated Pneumonia [Baseline up to 72 hours]: Number of confirmed ventilator-associated pneumonia (VAP) episodes per 1,000 ventilator-days. VAP is diagnosed by a new or progressive infiltrate on chest radiograph plus at least two of: fever >38°C, leukocytosis or leukopenia, purulent tracheal secretions, with a positive quantitative culture of endotracheal aspirate, supported by a Clinical Pulmonary Infection Score (CPIS) greater than 6.

Secondary outcomes

• PaO2/FiO2 Ratio After Suctioning [Baseline up to 72 hours]: Ratio of partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) measured following suctioning procedures.
• Duration of Mechanical Ventilation [Baseline up to 72 hours]: Total duration of mechanical ventilation in days
• Intensive Care Unit (ICU) Length of Stay، [Baseline up to 72 hours]: Number of days from intensive care unit (ICU) admission to ICU discharge.
• Intensive Care Unit (ICU) Mortality [Baseline up to 72 hours]: Number of patients who die during the ICU stay.

Sex: All, ages: 18 Years to any

Inclusion Criteria:

* Age ≥ 18 years
* Isolated head trauma where the primary injury is traumatic brain injury (severe traumatic brain injury (TBI) ,Glasgow Coma Scale (GCS)3-8)
* Requirement of endotracheal intubation and mechanical ventilation within 24 hours of admission
* Expected duration of mechanical ventilation ≥ 48 hours
* First sputum culture taken at intubation must be negative (patients provisionally enrolled; those with a positive first culture are excluded retrospectively)

Exclusion Criteria:

* Evidence of pneumonia at intubation (new or progressive infiltrate on chest radiograph plus at least two of: fever >38°C, leukocytosis or leukopenia, purulent tracheal secretions) or a positive first sputum culture
* Pre-existing chronic lung disease with active infection
* Immunocompromised patients (e.g., chemotherapy, long-term steroids, HIV)
* Patients transferred from another ICU after more than 48 hours of ventilation
* Early mortality within 48 hours