We read with great interest the study by Yildirim et al. [1] comparing the effects of open and closed suction on end-expiratory lung volume in patients with acute respiratory distress syndrome. Their findings confirm what we have long suspected: closed suction systems offer significant advantages over open suction by minimizing alveolar collapse and preserving ventilatory parameters.

We were in the process of designing a similar study and fully agree with the authors that closed-circuit suctioning should be preferred in mechanically ventilated patients. However, we have since shifted our focus to a related research question. We believe that additional data from current clinical practice would be valuable. Specifically, determining the proportion of intensive care units (ICUs) using either closed suction circuits, Kobe connectors, or relying on open suction would be useful. Closed suction is the standard of care in our ICU; open suction is only used in specific situations, such as weekly pulmonary sampling for microbiological surveillance of the bacterial ecology of our ICU. The main alternative to closed suction used in other ICUs with which we collaborate is the Kobe connector.

Furthermore, exploring the potential benefits of performing recruitment maneuvers following suctioning would be interesting. The latest American Association for Respiratory Care (AARC) clinical practice guidelines on artificial airway suctioning do not recommend post-suction recruitment maneuvers [2]. However, we believe that this strategy could be beneficial in helping functional residual capacity (FRC) return more rapidly to baseline, potentially mitigating the effects of alveolar derecruitment.

Given the observed loss of lung volume after endotracheal aspiration, a systematic post-suction recruitment strategy may help mitigate alveolar derecruitment. We are planning a study that will compare the effects of closed suctioning with and without post-suction recruitment maneuvers using electrical impedance tomography and FRC measurements.

We commend the authors for their rigorous study and look forward to further research in this field. Standardizing best practices in airway management remains a priority in critical care, and such studies contribute significantly to the improvement of patient outcomes.