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Closed-circuit endotracheal suctioning (CES) is advocated for preventing hypoxemia caused by the loss of lung volume resulting from open endotracheal suctioning (OES). However, the efficiency of CES and OES on tracheal secretion removal has never been compared in patients with acute lung injury. The authors designed a two-part study aimed at comparing gas exchange and efficiency between OES and CES performed at two levels of negative pressure.Among 18 patients with acute lung injury, 9 underwent CES and OES at 3-h intervals in a random order using a negative pressure of −200 mmHg. Nine other patients underwent CES twice using two levels of negative pressure (−200 and −400 mmHg) applied in a random order. After each CES, a recruitment maneuver was performed using 20 consecutive hyperinflations. Tracheal aspirates were weighed after each suctioning procedure. Arterial blood gases were continuously recorded using an intravascular sensor.Open endotracheal suctioning induced a significant 18% decrease in arterial oxygen tension (Pao2) (range, +13 to −71%) and an 8% increase in arterial carbon dioxide tension (Paco2) (range, −2 to +16%) that persisted 15 min after the end of the procedure. CES using −200 cm H2O did not change Pao2, but tracheal aspirate mass was lower compared with OES (0.6 ± 1.0 vs. 3.2 ± 5.1 g; P = 0.03). Increasing negative pressure to −400 cm H2O during CES did not change Pao2 but increased the tracheal aspirate mass (1.7 ± 1.6 vs. 1.0 ± 1.3 g; P = 0.02).Closed-circuit endotracheal suctioning followed by a recruitment maneuver prevents hypoxemia resulting from OES but decreases secretion removal. Increasing suctioning pressure enhances suctioning efficiency without impairing gas exchange.