Ventilator Acquired Pneumonia

How effective is oral care in the prevention of Ventilator Acquired Pneumonia in
Intubated mechanically ventilated patients admitted in the intensive care unit?
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

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
Cochrane Library
Other sources NHS evidence website
Hand search reference lists in “Intensive and Critical Care
Nursing” journal
Terms Used Ventilait* OR Respirator
Oral Care OR Mouth Care
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
Table 2 summarizes the articles that were included in this review.
Table 2: Table of Evidence

Author/Date Topic/Focus/Question Paradigm/
Findings/ Outcomes
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
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.
Combination of ventilator care
bundle and regular oral care with
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%.
Comparing variation in oral health
during intubation to changes in oral
and respiratory nosocomial
colonization among intubated
control trail,
47 Adult ICU
There was an association between
comprehensive oral care procedure (Tongue
scrapper, power toothbrush, non-foam
toothpaste and oral moisturizers) and reduction
of nosocomial colonization.
Oral care practices performed by
critical care nurses for orally
intubated critically ill patients
design with a
347 critical care
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/
Findings/ Outcomes
Implementation of specific VAP
bundle in conjunction with staff
A 24months
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.,
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
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,, 2015
Identifying the level of nurses
knowledge about nursing
interventions designed to prevent
A prospective
study of a
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.
Effect of Oral care program on
prevention of VAP in ICU pateints
RCT included
admitted in to
the ICUs less
than 24hours
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.,
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
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
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 ………
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