How effective is oral care in the prevention of Ventilator Acquired Pneumonia in
Intubated mechanically ventilated patients admitted in the intensive care unit?
Abstract
Aim: The aim of this literature review was to assess the effect of oral care in preventing
incidence of ventilated acquired pneumonia (VAP) in intubated patients admitted in intensive
care units (ICU).
Search Strategy: An extensive literature search of studies published was undertaken between
2009 and 2019 with thirteen articles meeting the inclusion criteria drawn from an initial
search which yielded 729 papers. The databases searched included PubMed, CINAHL and the
Cochrane library.
Results: VAP is most common nosocomial infection reported in critically ill patients receiving
mechanical ventilation in ICUs. Oral health can be compromised in critically ill and
mechanically ventilated (MV) patients; hence it is important to provide suitable oral care
strategy. This review found that oral care techniques such as toothbrushing, chlorhexidine
mouth rinse and other oral care protocol are effective in preventing VAP in mechanically
ventilated patients.
Discussion / Recommendations: The duration in which oral care can be administered has
been observed in past studies, with recommendation that oral care be administered between
twice and four times daily. Although some ICU nurses have demonstrated adequate level of
knowledge about preventive interventions of VAP. However, there is still need for health
service to update nursing staffs on oral care benefits for MV patients. It is recommended that
future studies investigate the exact oral care method that is most effective in preventing VAP
and the frequency of administration.
Keywords: Oral care, Intensive care Unit (ICU), Nursing intervention, Ventilator-acquired
pneumonia
Method
A search for published literature was undertaken through different databases. Table 1 shows
the databases and terms used for the search. Figure 1 then presents the search using the
flowchart advocated as the statement on Preferred Reporting Items for Systematic Reviews
and Meta-Analyses (PRISMA, 2009).
Table 1: Search Strategy
| Databases searched | CINAHL MEDLINE (PubMed) Cochrane Library |
| Other sources | NHS evidence website Hand search reference lists in “Intensive and Critical Care Nursing” journal |
| Terms Used | Ventilait* OR Respirator AND Oral Care OR Mouth Care AND Intensive care OR Intensive Therapy OR ICU OR ITU |
| Inclusion Criteria | Published between 2009 and 2019 English Language |
| Exclusion Criteria | Neonatal and Children’s ICUs Patients ventilated for < 24 hours |
Figure 1. PRISMA flow diagram
Result
Table 2 summarizes the articles that were included in this review.
Table 2: Table of Evidence
| Author/Date | Topic/Focus/Question | Paradigm/ Method |
Context/Setting/ Sample |
Findings/ Outcomes |
| Soh et.al., (2012) |
Oral care practice for the ventilated patients in intensive care units. This survey focused on the type and frequency of oral care provided to ventilated patients in the ICUs in a hospital |
cross-sectional survey |
Kuala Lumpur, Malaysia A total of 124 participants were included. |
The results showed that about 73.4% of the nurses preferred to use cotton forceps rather than tooth brushes to clean patient’s mouth. Some of the nurses were hesitant in using toothbrushes for intubated patients as they felt it will resulting in dislodging or displacing the tube. |
| Azab et.al., (2013) |
Combination of ventilator care bundle and regular oral care with chlorhexidine |
Quality improvement project |
992 MV patients received oral care with chlorhexidine every 8 hours. |
They found that combination of traditional oral hygiene with chlorhexidine 2% and strict adherence of ventilator care bundle significantly reduced VAP rate in mechanically ventilated ICU patients. Hospital length of stay was reduced from 9.7 to 6.5 days and mortality rate reduced from 23.4% to 19.1%. |
| Prendergast and Klienman, (2015) |
Comparing variation in oral health during intubation to changes in oral and respiratory nosocomial colonization among intubated patients. |
Randomised control trail, (RCT) |
47 Adult ICU neuroscience patients |
There was an association between comprehensive oral care procedure (Tongue scrapper, power toothbrush, non-foam toothpaste and oral moisturizers) and reduction of nosocomial colonization. |
| Feider, et.al., (2010) |
Oral care practices performed by critical care nurses for orally intubated critically ill patients |
Descriptive, cross-sectional design with a web-based survey |
347 critical care nurses |
92% of nurses reported providing oral care in a 2 or 4 hourly basis. The most commonly used oral care method was foam swabs (92%) whilst 30% of nurses reported brushing intubated patients with toothbrush and tooth paste twice a day. |
| Author/Date | Topic/Focus/Question | Paradigm/ Method |
Context/Setting/ Sample |
Findings/ Outcomes |
| Parisi, et.al., (2016) |
Implementation of specific VAP bundle in conjunction with staff education. |
A 24months before/after study |
362 participants | The finding shows an association between adherence to VAP bundle and reduced mechanical ventilator days from 26-21 days and ICU stay from 36-27 days |
| Ory et al., (2017) |
Effect of oral care protocol, which includes toothbrushing chlorhexidine and silicon sticks and aspiration in intubated patients |
Cohort study | 2030 intubated patients from 5 different ICUs were assessed over two periods. |
This study showed a significant improvement in patients’ oral health when toothbrushing was used alongside chlorhexidine and aspiration compared to oral care with chlorhexidine alone. |
| Wagner, et.al., 2015 |
Identifying the level of nurses knowledge about nursing interventions designed to prevent VAP |
A prospective study of a quantitative approach |
Brazil Nine nurses working in ICU |
The results showed that 81% of the participants recognise the priority nursing interventions for preventing pneumonia by demonstrating adequate knowledge of preventive interventions with VAP. |
| Atashi et.al., (2018) |
Effect of Oral care program on prevention of VAP in ICU pateints |
RCT included patients admitted in to the ICUs less than 24hours |
Iran 80 patients in both intervention and control group. |
This study reported, that oral care program did not affect the incidence of VAP; No statistically significant difference was found amongst the two groups regarding the incidence of VAP. However, the incidence of VAP was lower in the intervention group than that of the control group. |
| Khan et al., (2018) |
The effects of oral care with 0.2% chlorhexidine with toothbrushing to prevent in ICU |
RCT Method | Malaysia 63 MV patients were randomly assigned into two groups |
VAP was less likely to occur in the experimental group than in the control group, indicating that the incorporation of tooth brushing twice daily in addition to standard care of 0.2% chlorhexidine gluconate was effective in the prevention of VAP in MV patients |
Critical Appraisal of two studies
More than half of the studies reviewed in this assignment included tooth brushing as a
method of oral care and an association has been found between toothbrushing and reduction
of VAP in MV patients. In a recent study by Ory and Colleagues (2017) performed over two
consecutive periods on MV patients an association between toothbrushing and VAP
reduction. This study showed a significant improvement was found in patients’ oral health
when toothbrushing was used alongside chlorhexidine and aspiration compared to oral care
with chlorhexidine alone. Similarly, Yao and colleagues (2011) found that toothbrushing with
purified water significantly lowered VAP rates in the experimental group, (17%) compared to
control group where merely cotton swabs was administered (71%). They thereby suggest that
twice daily toothbrushing with purified water is effective in reducing VAP in intubated
patients.
Both studies can be considered to present reliable and valid results. Orly et al’s cohort study
had a large sample of over 2000 patients in five intensive care units and hence their results
are generalisable. Equally, Yao et al ………
References
American Association of Critical-Care Nurses. Oral Care in the Critically ill patients (2010)
Available at http://www.aacn.org/WD/Practice/Docs/PracticeAlerts/oral care 04-2010 final
.pdf) Lat accessed 1st September 2019
Ames N., (2011). Evidence to support tooth brushing in critically ill patients. American journal
of critical care:, 20(3), pp.242–250.
Atashi, V., Yousefi, H., Mahjobipoor, H., Bekhradi, R. and Yazdannik, A. (2018). Effect of oral
care program on prevention of ventilator associated pneumonia in intensive care unit
patients: A randomized controlled trial. Iranian J Nursing Midwifery Res;23: pp. 486-90.
Azab, S., Sayed, A., Abdelkarim, M., Mutairi, K., Saqabi, A. and Demerdash, S. (2013).
Combination of ventilator care bundle and regular oral care with chlorhexidine was associated
with reduction in ventilator-associated pneumonia. Egyptian Journal of Anaesthesia, 29(3),
pp. 273-277.
Boltey, E., Yakusheva, O. and Costa, D. (2017). 5 Nursing strategies to prevent ventilatorassociated pneumonia. American nurse today, 12(6), 42–43.
Cutler, R. and Sluman, P. (2014). Reducing ventilator associated pneumonia in adult patients
through high standards of oral care: a historical control study. Intensive and Critical Care
Nursing, 30(2), pp. 61-68.
DeKeyser Ganz, F., Fink, N., Raanan O, et al. ICU nurses’ oral-care practices and the current
best evidence. J Nurs Scholar. 2009;41(2):132-138
Field, A. (2018). Discovering Statistics using IBM SPSS STATISTICS. London: SAGE Publications
Ltd.
Feider, L., Mitchell, P., and Bridges, E. (2010). Oral care practices for orally intubated critically
ill adults. American Journal of Critical Care, 19(2), pp. 175-183.
Gallagher, J. (2012). Implementation of ventilator-associated pneumonia clinical guideline
(Bundle). Journal of Nursing practice, (8), pp. 377-382
Heale, R., and Twycross, A. (2015). Validity and reliability in quantitative studies. Evidencebased nursing, 18(3), pp.66-67.
Hillier, B., Wilson, C., Chamberlain, D. and King, L. (2013). Preventing ventilator‑associated
pneumonia through oral care, product selection, and application method. A literature review.
AACN Adv Crit Care, (24) pp. 38‑58.
Hua, F., Xie, H., Worthington, H., Furness, S., Zhang, Q. and Li, C. (2016). Oral hygiene care for
critically ill patients to prevent ventilator‐associated pneumonia. Cochrane Database of
Systematic Reviews, (10), pp. 1-140
Hutchins, K., Karras, G., Erwin, J. and Sullivan, K. (2009). Ventilator‑associated pneumonia and
oral care: A successful quality improvement project. Am J Infect Control.;37:590‑7. 6.
Kaya, H., Turan , Y., Tunalı, Y., Aydın, G., Yüce, N., Gürbüz Ş, et al. (2017). Effects of oral care
with glutamine in preventing ventilator‑associated pneumonia in neurosurgical intensive care
unit patients. Appl Nurs Res;33, pp. 10‑4
Khan, M., Mohamed, Z., Ali, S., Saddki, N., & Sukminingrum, N. (2018). The effects of oral care
with 0.2% chlorhexidine with toothbrushing to prevent ventilator associated pneumonia in
adults’ intensive care units. 52(62)
Malkin, B. (2009). The importance of patients’ oral health and nurses’ role in assessing and
maintaining it. Nursing Times; 105: 17, early online publication.
Munro, C., Grap, M., Jones, J., McClish, D., Sessler, C. and Chlorhexidine, S. (2009).
toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults. Am J
Crit Care; 18(5), pp. 428–437.
Miranda, A., de Paula, R., de Castro Piau, C., Costa. P. and Bezerra, A. (2016). Oral care
practices for patients in Intensive Care Units: A pilot survey. Indian J Crit Care Med;(20), pp.
267-73.
Nursing and Midwifery council, (2008). The Code: Standards of conduct, performance and
ethics for nurses and midwives available at:
https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-old-code-2008.pdf
Ory, J., Raybaud, E., Chabanne, R., Cosserant, B., Faure, J.S., Guérin, R., Calvet, L., Pereira, B.,
Mourgues, C., Guelon, D. and Traore, O. (2017). Comparative study of 2 oral care protocols in
intensive care units. American journal of infection control, 45(3), pp. 245-250.
Panchabhai, T. S., Dangayach, N. S., Krishnan, A., Kothari, V. M., & Karnad, D. R. (2015).
Oropharyngeal cleansing with 0.2% chlorhexidine for prevention of nosocomial pneumonia in
critically ill patients: an open-label randomized trial with 0.01% potassium permanganate as
control. Chest, 135(5), pp.1150-1156.
Parisi, M., Gerovasili, V., Dimopoulos, S., Kampisiouli, E., Goga, C., Perivolioti, E.,
Argyropoulou, A., Routsi, C., Tsiodras, S. and Nanas, S., (2016). Use of ventilator bundle and
staff education to decrease ventilator-associated pneumonia in intensive care
patients. Critical Care Nurse, 36(5), pp.1-7.
Prendergast, V. and Kleiman, C. (2015). Interprofessional practice: translating evidence-based
oral care to hospital care. American Dental Hygienists’ Association, 89( 1), pp. 33-35
Silva, S, Nascimento, E. and Salles, R., (2014). Ventilator-associated pneumonia: discourse of
professionals about prevention. Escola Anna Nery, 18(2), pp.290-295.
Soh, K., Ghazali, S., Soh, K., Raman, R., Abdullah, S. and Ong, S. (2012). Oral care practice for
the ventilated patients in intensive care units: a pilot survey. The Journal of Infection in
Developing Countries, 6(04), pp. 333-339.
Subramanian, P., Choy, K., Gobal, S., Mansor, M. and Ng, K., (2013). Impact of education on
ventilator-associated pneumonia in the intensive care unit. Singapore Med J, 54(5), pp.281-4.
Wagner, B.V., Alves, E.F., Brey, C., Waldrigues, M.C. and Caveião, C. (2015). Knowledge of
nurses about the intervention for the prevention of pneumonia associated with mechanical
ventilation. J Nurs UFPE on line, 9(5), pp. 7902-9.
Yao, L., Chang, C, Maa, S., Wang, C., & Chen, C. (2011). Brushing teeth with purified water to
reduce ventilator-associated pneumonia. Journal of Nursing Research, 19(4), pp.289-297.
Zand, F., Zahed, L., Mansouri, P., Dehghanrad, F., Bahrani, M. and Ghorbani, M. (2017). The
effects of oral rinse with 0.2% and 2% chlorhexidine on oropharyngeal colonization and
ventilator associated pneumonia in adults’ intensive care units. Journal of critical care, 40,