Losed and Open Endotracheal Suction - Assignment Example

? Critical literature Review: Closed Endotracheal Suction Versus Open Endotracheal Suction in the Incident of Ventilator-Associated Pneumonia in Intensive Care Unit Name Institution Closed endotracheal suction versus open endotracheal suction in the incident of ventilator-associated pneumonia in the intensive care unit. Introduction Endotracheal suctioning is an important part of care, and is often performed in the intubated mechanically ventilated patients because intubated mechanically ventilated patients are often unable to clear their always (Johnson et al, 1994). There are two methods of edotrachea suctioning: closed endotracheal suction and open endothelial suction (Johnson et al, 1994). The later is more common than the former, and it involves disconnecting the ventilator from the patient and then suctioning his or her airway (Anton, & Buiting, 2011). However, disconnecting a ventilator is dangerous because it can cause some disturbances including the loss of lung volume, oxygen desaruration, and a large drog in in the pressure of the airways (Anton, & Buiting, 2011). Therefore, open suctioning is not appropriate for patients affected by an acute respiration distress syndrome. Closed suctioning systems have partly replaced the open suctioning systems. This is because closed suctioning systems allow uninterrupted ventilation, which helps avoid gas-exchange impairment during suctioning and helps decrease the loss of uninterrupted ventilation (Anton, & Buiting, 2011). In closed suctioning systems, the loss of lung volume and the generating of negative airway pressure occur whenever the flow from a ventilator is somewhat lower than the expected suction flow. Studies have shown that using closed suctioning in volume-controlled ventilation condition may lead to unpredictably high positive end-expiratory pressure in cases where the suction catheter is inserted (Lasocki et al 2006). While in open endotracheal suctioning, suctions are performed while the respiratory circuits are disconnected, in the closed endotracheal system, sactions are performed while the respiration circuits are connected (Anton, & Buiting, 2011). Inspite of the existing differences, the two methods have continued to be used to perform endotracheal to the mechanically ventilated intensive care unit patients (Maggiore et al, 2003). The potential merits of CES in comparison with OES has made researchers to conduct studies with a focus on comparing the CES to OES. However, it is worth noting that these studies did not show how one of these methods is superior to the other. With a view to propose a research to be conducted to ascertain whether either of the two methods of endotracheal suctioning is superior, two articles were selected based on a laid down procedure. The articles were then critically analyzed with a view to justify the need to carry out this research. After highlighting major shortcomings in the two articles, this paper proposes a study to be conducted to investigate whether CES or OES whichever is superior. PART A: RATIONALE OF SELECTING THE ARTICLES Two articles were found to be important to help justify the aforementioned research. The articles were quite relevant given their topical address of the subject at hand. Fundamentally, the selection of the articles was based on a definite criterion. This was done using a practical procedure in which the internet was used as an important source. This way, information had to be obtained basing on the rules laid down. Either topical or the use of the leading words, was adopted as an easy way to obtain important resources. Limited to this research, the topic was related to closed endotracheal suction versus open endotracheal suction in the incident of ventilator-associated pneumonia in the intensive care unit. In the course of searching these two articles, no specific country was narrowed down. However, it is undisputed that the study sought to narrow down to the subject of closed endotracheal suction versus open endotracheal suction. There were various articles as displayed in the search engine that sought to address the issue. However, with most being descriptive and outdated, the selection was narrowed down to 5 years (2003 to 2007). Moreover, the selection was also narrowed down to those articles that addressed the issue in English. The final distinctive elements used in arriving at the selected two articles were the number of hits produced by each article, the quality research articles, i.e. whether the article was peer reviewed or not. Whether the articles were in pdf full text or not, whether the article had an abstract to give an overview of the article, was also the last criteria for selecting an article. Finally, the two articles in this part of the essay were chosen PART B: CRITIQUE OF THE RESEARCH METHODOLOGY DESIGN AND PROCESS Quantitative research methods can be thought of as distinct method that is often marked by certain norms and beliefs. This method was employed in the two articles selected above. The subject of focus was investigating the subject effectiveness of closed and open suction system with respect to clinical outcome. Seeking to investigate how best and appropriate either of this method as used in the two articles beforehand addressed the issue exhaustively, the objective was to compare and contrast these research method across 7 areas; (1) conception of the topic, (2) conceptualization of the abstract, (3) the approach to the topic, (4) approach to literature review, (5) how best the article integrated the results into the discussion, (6) the relevant of the methodology and design employed, (7) the conclusion reached. In adopting this criterion of analysis, it is suggested that appreciation of alternative goals and assumptions of scholars is made which would go a long way to help avoid any misunderstanding and contribute to the better ways of addressing the issue. Research Topic Suggesting that an ideal title should be one that provides a brief and clear overview of the article and that which has a research design, Cormack (2008) might have envisaged a case where certain authors miss this point when writing articles. Within the contextual framework of Cormack (2008), Zeitoun, Diccini, and Barros (2003) use of such words as Ventilator-associated Pneumonia and Closed versus Open suction System was a clear indication that the article facilitated the investigation process. The inclusion of the research design in the title of this article is also a clear evidence that the authors distinctively sought to locate the study. Similarly, Moran, Chacko and Peter (2007) clearly captured the meta-analytic method in the title. Variances in the title were realized where Zeitoun, Diccini, and Barros (2003) made the title of the article brief and concise contrary to Moran, Chacko and Peter (2007) who used a relatively long title. Unlike Zeitoun, Diccini, and Barros (2003), Moran, Chacko and Peter (2007) partially followed Cormack Framework. In both articles Moran, Chacko and Peter (2007) and Zeitoun, Diccini, and Barros (2003), had titles which can well be described as constituting the words that convincingly summarize the idea behind the entire article. In the view of Comarck (2008), a brief and concise title should be able to address key issues under consideration, and bring into focus the type of research design employed. The failure of some of the articles to adopt this brings into focus the question about whether such articles ought to be validated. Abstract In the view of Cormack (2008) framework, a brief and concise abstract, which summarizes the main points of the study, is appropriate. Cormack holds that an abstract should briefly include details of the research, method and sample, outcome, recommendations and conclusions. This framework stipulates that an abstract that provides a brief background concerning the subject under discussion prepares the reader for such a study. With a clear framework, Zeitoun, Diccini, and Barros (2003) detailed every element, except recommendations, in an effort to make the abstract informative. With short and clear background information concerning the study, there is no doubt; this article provided an effective article overview. Key points are well highlighted. On the other hand, a brief summary of the topic under discussion was provided in the article, however, failure to provide recommendations even after having reached a conclusion is in itself a flaw. The fact that the abstract need to be concise, brief and provie a summary of the key point of the study, it does not mean that it should be too short to address and inform the reader of the issue being discussed. One thing worth contending with, however, is that the articles had clear objectives as outlined in the hypothesis. Introduction Uniformity was well witnessed in the introductory part. It is quite evident that across all the two articles, Zeitoun, Diccini, and Barros (2003) and Moran, Chacko and Peter (2007). Utilized the introductory part to highlight the rationale for carrying out research in the respective fields. However, variances were witnessed in the weight the researchers gave to the supporting evidence. Whereas Zeitoun, Diccini, and Barros (2003) provided a detailed literature review alongside empirical backing quantifying most of the elements to elaborate clearly the need to have the issues of closed endotracheal suction versus open endotracheal suction. Moran, Chacko and Peter (2007) did not highlight specific studies that failed to close up the gap in the area they sought to investigate. According to Comarc (2008) an introduction should be captivating, and need to expose the research clearly and steer clear the research problem with a clear description of the study, and should provide a clear evidence of the source. A notable shortcoming of the two articles was their failure to address the clear theories to be tested. Literature Review Comarck (2008) explains that the purpose of the literature review is to identify any limitations and strengths of previous studies for a need to conduct a new research study. There should be evidence that sufficient knowledge has been gathered on the topic (Comarck 2008). Due to the non-descriptive nature of a quantitative study, Zeitoun, Diccini, and Barros (2003) and Moran, Chacko and Peter (2007) did not enlist the positive and negative arguments for purposes of demonstrating a balanced view of the issue. Evidences used in both articles cannot merit being regarded as current. In certain exception, studies as old as 1989, which did not have any historical relevance were used in this study. An inclusion of the evidences which are less than ten years or even up to date studies was not justified in this study. Although according to Cormack (2008) such evidences might serve the purpose of providing a historical backing, contrary to what was done in these two articles, the use of such sources fails to justify this connotation. On a broader perspective, the use of old age sources might be regarded as a flaw to the entire research. According to Polit and Beck (2008) the quality of information depends on the type of data the literature review contains. In both articles the sources used as evidences were both primary and secondary, with a focus on primary sources. In this case, primary data is the collection method designed for the purpose of a specific research, whereas secondary data is the available information collected by other researchers or organizations for other purposes. Nevertheless, the profound interest of researchers in their own subject could create researcher’s bias. It is worth contenting in the view of Cormack (2008) framework that a detailed literature review should provide a clue as to why there was needed such a research. There is no doubt literature review when explored in any research would help justify the rationale for carrying out an investigation. Design and Methods In the view of Cormack (2008) framework, research design is a framework employed by a research to help investigate the issue under consideration. Its use is based on whether the researcher was interested in quantifying or qualifying a certain phenomenon and should inform the reader whether the interest was on the mathematical description or the underlying connectivity. While in both articles a quantitative research method was employed, this methodology was characterized by a scientific approach and aimed at finding the explanation rather than a mere understanding The aim was gathering and working with structured data, and, therefore, adopted questionnaires that required single answers represented by numbers or named codes, subsequently translated and interpreted as statistical evaluations. Considering the experimental approach adopted by the two articles, the researchers justified their findings using statistical evaluation, which seems more convincing. For instance, through statistical analysis, Moran, Chacko and Peter (2007), noted that no differential treatment was observed on the type of suctioning (open v's closed, n=9 studies), on mortality (n =5, CL -.04, P = .8, RD .01; 95%. The empirical evidences in both articles included the rigorous statistical analysis. The tools of gathering data were geared towards a quantitative research. Statistical values such as the mean, median, standard deviation, the significant value upon which a hypothesis can be regarded justified are evidenced in these two articles. It is worth noting that clarity of methodology is an important determinant for assessing the quality of the study and should provide information about the research method which permits replication of the study (Rumrill, Cook, and Wiley, 2011). Certainly, the two articles had section including the research design, selection criteria, sample size, the procedure used and methods of data collection. Both articles used some studies to supplement the information obtained from the sample with numerical data and percentages. However, the failure to justify the methodology and design used as reflected across the two articles is a flaw on the side of the researchers. By this, it does mean that one cannot ascertain, to what accuracy considering various weaknesses and strengths of various research designs the data used can be relied upon as a good representation of the parameter under consideration. Data collection According to Cormack (2008), this section should clarify the steps adopted by the researcher for collecting data. It should provide in detail the important information such as who, what, when, how and where data were collected (Nieswiadomy, 2008). The Hawthorn effect relates to the affectation of participants’ response when aware of being observed and, therefore, also affects data validity. Moran, Chacko and Peter (2007) stared clear of the steps utilized in collecting data (2007). As clearly highlighted Moran, Chacko and Peter (2007) utilized standardized data collection forms to abstract data. It is stated that two investigators were responsible for this process. The differences in abstraction were settled through consensus. In the case of Zeitoun, Diccini, and Barros (2003), the recruitment of the respondents was from the General Hospital ICU unit as Sao Paulo Brazil. Patients who were included in this study were put into two groups: those intubated during odd dates and having closed suction and those with endotracheal suction. More data collected were chronic health Evaluation (APACHE) 11 scores and Acute Physiology. Therefore, the two articles Cormack (2008) data collection procedure. Data analysis and Results Moran, Chacko and Peter (2007) states that Inverse variance weighted difference was used to analyze baseline characteristics. The method of Mantel Haenszel was used to assess the treatment effect. DerSimonian Laird estimator was used to ascertain the heterogeneity of treatment effects. Stata Released 8 was used to estimate the treatment effects obtained using quality scores. Q statistic was used to assess the extent of diagnosis. The meta-regression was used to assess the potential impact of percentage male patients, surgical and trauma patients and the average age. In Zeitoun, Diccini, and Barros (2003) study, Mann-Whitney U-test was used to analyze the quantitative variables alongside the distribution between groups. It is also noted that a Brand Chi square test were employed in testing the differences between dichotomous variables. The multiple regression technique was used to help form independent variables. However, it is unclear how validation was achieved in both cases since the two articles seem to recognize the lack of relevant previously published research and also if it achieved saturation of data, as per grounded theory approach. Recommendation for further Research Considering the detailed analysis of the two articles outlined above, it is clear that various shortcomings are evident in these two articles. Failures as witnessed right from the conception of the topic, the abstract, approach to the topic, approach to literature review, how best the article integrated the results into the discussion, the relevant of the methodology and design employed, clearly indicate that there is needed research to compensate for such weaknesses. It is also clear that the researchers in both cases, failed to demonstrate superiority of either OES or CES with respect to VAP. The many flaws as highlighted above signify the need for a research on these subject. This being the case, this paper, therefore, seeks to propose a research based on the topic “Closed endotracheal suction versus open endotracheal suction in the incident of ventilator-associated pneumonia in the intensive care unit” Part 2 Research Proposal: Closed Endotracheal Suction Versus Open Endotracheal Suction in the Incident of Ventilator-Associated Pneumonia in The Intensive Care Unit” Introduction Ventilator-associated pneumonia has been linked to increased mortality, and morbidity in the ICU (Intensive care Units), in Asia, Western countries, and in particular Malaysia. Studies have shown that ventilator-associated pneumonia incidences vary from 9 percent to 27 percent, with mortality rates ranging between 30 to 70 percent (Lasocki et al, 2006). This necessitated increased attention on Ventilator-associated pneumonia. This showed that VAP can be appropriately used as a benchmark of quality of care for patients in Malaysia. However, it was noted that VAP can cause the length of stay in the hospital, as well as costs to increase. This means that any strategy directed towards reducing the occurrence of VAP is worth impressing. Recent years have been marked by changes in trends in ICUs. The focus has been on transforming from the older open endotracheal suction to a newer and somewhat more costly closed suction system. The main reason for this change has been attributed to the associated benefits of CES. It has been shown through research that CES can help eliminate environmental contamination associated with the Catheter, which in effect help reduce the risk of VAP (Lasocki et al, 2006). The decision to move from the open endotracheal suction to closed suction system will be informed by the findings of this conclusive study that focuses on the two systems. This paper proposes a research that focuses on closed Endotracheal Suction Versus Open Endotracheal Suction in the Incident of Ventilator-Associated Pneumonia in the Intensive Care Unit, this research proposed will Rationale In closed endotracheal suctioning system, suctioning is performed while the respiratory circuit is connected i.e. disconnected. In this method, a multi-use in line catheters are often used in enclosing a sheath. The use of this mode of suctioning is meant to help minimize complications, which occur when the open suctioning is used. The potential merits of CES in comparison with OES has made researchers to carry out studies with a focus on comparing the CES to OES. However, it is worth noting that these studies did not show how one of these methods is superior to the other. Literature Search The internet was used as an important source. The information had to be obtained basing on the rules laid down. This involved carrying out a computerized literature search. Either topical or the use of the leading words such as suction, endotracheal suctioning, closed suctioning, open suctioning, endotracheal suctioning and controlled trials or randomized trials, or clinical trials. The websites include PubMed, and CINAHL. The abstracts of trails that were generated electronically were reviewed. The time frame was limited to 2000 to 2010. Limited to this research, the topic was related to tobacco smoking. This means using key words in the CINAHL, MEDLINE (EBSCO), and PUBMED databases would provide a hint to the required information. Literature Review A ten year review of literature was conducted on different studies in the first world countries. Many clinical trials were included in the meta-analysis. This literature was done in the first-world intensive care unit having sufficient resources, and adequate staffing. The suctioning choice was made in accordance with the preferences of the staff. This review failed to display any evidences that support CES hence there was no need for a change for the OES use. Studies conducted in the developing countries showed that there were some specific challenges that were faced in the intensive care unit. There were a number of issues reported such as those that result in nosocomial infections. Some of these issues included the overcrowding of patients, inadequate staffing, huge burdens of the diseases that are infectious, and limitation of resources. The use of CES system, though expensive could reduce the infection risk to patients and the staff shares. However, without the demonstration of the objective benefits in the clinic, the CES use may not be justified in the countries that are developing. In this case, developing nations are a major focus of a clinical trial that is well designed so that the suction type can be selected finally. Aim of the study. This study aims at verifying the VAP incidences in the extended and intubated mechanically ventilated patients with ETT suctioning through a closed versus the open method of suction aiming at reducing the nosocomial pneumonia. Methodology. This part of the research will be dedicated towards understanding the step by step approach, which is to be used by the researcher in order to arrive at the data collected. It is also for purposes of reflecting on the key steps taken to arrive at the purposes set for this research work. To this end, the following components have been discussed. Research design. The continuous prospective cohort study would be done using a validated form of surveillance in a medical surgery of an intensive care unit of adult patients. The study would be done by the first of January 2014 to the thirty first of December 2014 following an assessment baseline. The study will be done in three hospitals within Penang. The participants of this study will be made up of patients of ages above eighteen who would have taken part in mechanical ventilation for duration more than forty eight hours. The study will also exclude the evidences of infection in the chest before the intubation. In addition, the study will exclude the evidences of chest infection from the intubated patients that would be readmitted from a different hospital. Participants. In this study, RCTs that compared CES with OES among the mechanically ventilated patient will be considered for inclusion. Medical and surgical patients who are older than 13 years, who are in the process of undergoing mechanical ventilation for a time period of more than 48 hours will be included. Patients who would have undergone tracheostomy in another hospital will be excluded. Also, patients with pulmonary infection during admission, severe neutropenia, or early reintubation shall be excluded. The participants of this study would be divided into two groups. The first group will involve those patients who would be intubated on even dates. This group participants will receive an open system of suction. The second group will involve those patients intubated on odd dates. These patients would receive a closed suction system. Data on Chronic Health Evaluation (APACHE) 11 score and Acute Physiology would be collected from these patients. This data will help in the verification of differences in risk factors for developing VAP such as previous lung disease, renal failure, alcoholism, smoking, time of use of antibiotics, and illness severity. Criteria for diagnosis. In the diagnosis, the fever, and temperatures of the participants above 37.8 degrees, and the clinical manifestation would be recorded. The radiographic appearance of the progressive and new pulmonary infiltrate would be recorded. In addition, leucocytosis higher than 1000 per millimeter cubic would be recorded. Any changes in their characteristics or the purulent secretion of tracheobronchial together with the confirmation of the positive microbial cultures for the aspiration tracheal would be recorded. Sample size. The sample will be a handy percentage out of the population size to be built. The population, on the other hand, refers to all people who have some level of the possibility of becoming part of the sample size. In common terms, the sample size is referred to as respondents (Mok, Lee, & Kam-yuet, 2002). This means that they are people from whom the researcher shall collect data directly. It is always important to build a sample size for data collection when there is a very large population to deal with it. Presently, the population of the research comprises patients who would be intubated on even dates, and those patients intubated on odd dates. It would be seen that this population presents a very large number of people whom the researcher will have to deal with. With the sample size, the researcher will now be dealing with a number that is quite manageable and not out of the control of the researcher. The researcher shall use a sampling technique that will ensure a very high level of fairness in the representation of people in the sample size. In all, the sample size of the study will involve one hundred patients selected randomly from the best three hospitals of the year. The sampling technique shall involve the selection of candidates that are not based on any foreknowledge of who is going to be part of the sample size and who shall not be part of the sample size (Cherry, 2012). This will ensure very high levels of fairness in data collection. Instrumentation and validation. The instrumentation basically refers to the mechanism of collecting data. This study will be conducted using a number of instruments and apparatus. The verified and developed NI form of surveillance would be used in collecting data. This tool will be useful in measuring the risks and incidences of the VAP factors. The forum will address demographic data, illness history, illness severity, diagnosis during admission, status of nutrition, antibiotics, medication, laboratory tests, clinical infection evidence, and the microbiology results investigation and the findings of x-ray. It has to be emphasized that the selection of this research instrument is based on the need to obtain quantitative data for the study. This instrument will be the best help in collecting quantitative data. This is because it deals with data, which can be quantified on a given scale. Measurement of the validity and reliability of any study cannot be underestimated in any way. In any study, it is the level of validity and reliability that gives a research the needed credibility. Due to this, this study will put in place certain measures that will help ensure the findings of this study highly valid and reliable. Some of these factors include the assessment approach and selection approach. In the absence of such an appropriate assessment and selection mechanism, the data presented under any study cannot be trusted as valid and reliable because they will lack an empirical backing. In this study, the APACHE (Acute, chronic, and physiology health evaluation) III Score will be used in assessing the gender, age, disease severity, admission cause, and the dysfunction for the organ during admission. The treatment intensity will also be noted down using the TISS. By extension, the SAPS will be used to assess the physiological condition. The random sampling technique will also help ensure that the research is valid and reliable. In selecting, the participants random sampling will help avoid bias. With this technique, the implication is that the researcher shall have no control whatsoever over the results. Risk Factors. A patient who stays with an endotracheal tube for a period exceeding 48 hours is at higher risk of contracting Ventilator-associated Pneumonia. The risk factors for Ventilator-associated Pneumonia can be divided into three categories: device related, personal related and host related. The preexisting conditions such as chronic, acute respiratory distress syndrome, chronic obstructive lung diseases, the patient’s level of consciousness, medications, the number of intubations, patient’s body positioning, and immunosuppression, are some of the host-related risk factors. On the other hand, device-related risk factors include the ventilator circuit, the presence of the orogastric or nasogastric tube. Low cuff pressures and secretions pool in the cuff of the endotracheal tube may lead to leakage of bacteria into the trachea. In the Intensive care Unit, the predictors of VAP include the aspiration pneumonia, leucocytosis, cancer, and mechanical ventilation duration. Procedure. The occurrence of VAP (Ventilator-associated Pneumonia), together with the risk factors would be monitored daily through surveillance form from lab results, case notes, direct observations, and clinical findings of the researcher the duration when the patient stayed in the intensive care unit. Admissions data and the data during the discharge from ICU would be collected. A forty eight hour follow-up process would follow the discharge of the patients. The reason for the follow-up involves capturing the VAP that is displayed in the ward. The collected data would be recorded in a table under the results section of the analysis. Data analysis. Quantitative variables shall be analyzed using the SPSS software. The standard deviation and the mean of the data will be calculated as needed for the numerical variables. The NI incidence rate of density will be determined as needed number of NI cases in one thousand patient-days. The rate of the ventilator associated pneumonia will be determined as the VAP number of cases per one thousand patients on days of ventilator. Ethics It is a widely known that ethics should form the guiding principal in a researcher’s quest to avoid any violation of the participant’s rights when treating subjects in social related studies that involve the input of humans. This contributes towards the reduction of research bias. The informed consent should form part of the ethical principle. In this regard, before conducting the study permission will be obtained from the administration of the three hospitals. It is difficult to obtain informed consent for the clinical trials from the critically ill patients. In this regard, the researcher will obtain informed consent from the closest relatives of the patient. As such, the children, wife, parents, or husbands of the patients would be given consent before the onset of the study. Additionally, this study would consider issues such as privacy, confidentiality, anonymity, and complying with the principle of beneficence and non-malfeasance. This way, it will make sure rules of informed consent are adhered to strictly. This would provide a chance for the relatives of the participants to take part in the research voluntarily when they are well informed of the associated risks and benefits of the study. They would, therefore, be required to fill consent forms voluntarily. The researcher would also consider discussing confidentiality limits and assure participants about how their right to question and ensure the data they provide is kept private. Time plan of work. Duration: 1st Jan 2014 To 31st Dec 2014 Activities Training staff Getting Ethical approval from MOH Recruiting patients Gantt chart to be prepared References Cormack, D. 2008. The research process in nursing. Oxford, BlackwellScience. Cherry, Kendra. What is a dependable variable? 2012. Retrieved on 16th Nov, 2013 from Anton, G, Buiting, M. 2011. Effect of open and closed endotracheal suctioning on cross-transmission with Gram-negative bacteria: a prospective crossover study. Impact Factor: 6.37; 39(6):1313-21. Johnson KL, Kearney PA, Johnson SB, Niblett JB, MacMillan NL, McClain RE. 1994. “Closed versus open endotracheal suctioning: Costs and physiologic consequences.” Crit Care Med; 22:658-66. Lasocki S, Lu Q, Sartorius A, Fouillat D, Remerand F, Rouby J. 2006. “Open and closed-circuit endotracheal suctioning in acute lung injury: Efficiency and effects on gas exchange.” Anesthesiology; 104:39-47. Morgan, D. L. 2010. “Reconsidering the role of interaction in analyzing and reporting focus groups.” Qualitative health research, 20, 718-722. Maggiore, SM, Lellouche F, Pigeot J, Taille S, Deye N, Durrmeyer X, 2003. “Prevention of endotracheal suctioning-induced alveolar derecruitment in acute lung injury.” Am J Respir Crit Care Med; 167:1215-24. Moran, V, Chacko, B & Peter, J. 2007. “Comparison of closed endotracheal suction versus open endotracheal suction in the development of Ventilator-associated pneumonia in intensive care Patients: an evaluation using meta-analytic techniques.” Indian J Med Sci, Vol. 61, No. 4. Mok, E. Lee, W.M. & Kam-yuet , H, & Wang, F. 2002. “The issue of death and dying: employing problem – based learning in nursing education.” Nurse Education Today. Volume 22 (4): 319- 329. Polit, D. F., & Beck, C. 2004. Nursing research: principles and methods. Philadelphia, Lippincott Williams & Wilkins. Polit-O'Hara, D., Polit, D. F., & Hungler, B. P. 1999. Instructor's manual to accompany Nursing research: principles and methods. Philadelphia, Lippincott. Rumrill, K., Cook, Y., & Wiley, L. 2011. A guide to Nursing research: principles and methods. Philadelphia, Lippincott. Zeitoun, S, Diccini, S, & Barros, B., 2003. “A prospective, randomized study of ventilator-associated pneumonia in patients using a closed vs. open suction system.” Journal of Clinical Nursing; 12: 484–489. Read More