Chlorhexidine, Toothbrushing, and Preventing Ventilator-Associated Pneumonia in Critically Ill Adults

Abstract

Background Ventilator-associated pneumonia is associated with increased morbidity and mortality. Objective To examine the effects of mechanical (toothbrushing), pharmacological (topical oral chlorhexidine), and combination (toothbrushing plus chlorhexidine) oral care on the development of ventilator-associated pneumonia in critically ill patients receiving mechanical ventilation. Methods Critically ill adults in 3 intensive care units were enrolled within 24 hours of intubation in a randomized controlled clinical trial with a 2 × 2 factorial design. Patients with a clinical diagnosis of pneumonia at the time of intubation and edentulous patients were excluded. Patients (n = 547) were randomly assigned to 1 of 4 treatments: 0.12% solution chlorhexidine oral swab twice daily, toothbrushing thrice daily, both toothbrushing and chlorhexidine, or control (usual care). Ventilator-associated pneumonia was determined by using the Clinical Pulmonary Infection Score (CPIS). Results The 4 groups did not differ significantly in clinical characteristics. At day 3 analysis, 249 patients remained in the study. Among patients without pneumonia at baseline, pneumonia developed in 24% (CPIS ≥6) by day 3 in those treated with chlorhexidine. When data on all patients were analyzed together, mixed models analysis indicated no effect of either chlorhexidine (P = .29) or toothbrushing (P = .95). However, chlorhexidine significantly reduced the incidence of pneumonia on day 3 (CPIS ≥6) among patients who had CPIS <6 at baseline (P = .006). Toothbrushing had no effect on CPIS and did not enhance the effect of chlorhexidine. Conclusions Chlorhexidine, but not toothbrushing, reduced early ventilator-associated pneumonia in patients without pneumonia at baseline.

Ethnographic Investigation of Oral Care in the Intensive Care Unit

“…In accordance with recommendations 17,18 to prevent VAP, care providers on the unit used an oral care protocol that included an oral chlorhexidine gluconate rinse. [19][20][21] Hospital and university institutional review boards approved the study.…”

“…Instances in which nurses demonstrated or spoke concretely about oral care problems were written up and circulated to the study team. 21 Then important gaps between standardized ways of speaking or documenting oral care and the unscripted problems encountered by nurses were analyzed. 23 The final analysis involved identifying technical issues and contextual work-arounds to consider opportunities for innovation.…”

Valuation and Records of Oral Hygiene of Intubated Patients in Intensive Care Units

“…A escovação dentária do paciente com IOT tem sido objeto de inúmeras pesquisas. 16,17 Estudos têm demonstrado que a utilização de clorexidine é mais importante do que a escovação 17 . Entretanto, sabe-se que a ação dos enxaguantes bucais pode ser comprometida diante de placas de biofilme bucal que são mais bem removidas com as escovas dentárias.…”

Electric Versus Manual Tooth Brushing among Neuroscience ICU Patients: Is it Safe?

“…[8][9][10] The American Association of Critical-Care Nurses has recommended tooth brushing twice daily with a pediatric toothbrush, 11 but clinical evidence that such interventions are well tolerated by patients is lacking. Early studies reported transient but significant increases in ICP of 3-10 mm Hg during unspecified oral care.…”