Efficacy of Oral Care Protocols in the Prevention of Ventilator-Associated Pneumonia in Mechanically Ventilated Patients

Abstract

Background: Ventilator-associated pneumonia (VAP) is one of the most common infections in intubated intensive care unit (ICU) patients. Oral care with chlorhexidine is a conventional method for maintaining hygiene. Recently, adjuvant methods have been introduced into routine oral care, including teeth brushing and the application of moisturizing lotion. The objective of this study was to compare the incidence of VAP in critical care patients receiving oral care with and without manual teeth brushing and the application of moisturizers to the mouth.Methods: We conducted a prospective randomized control study comprised of 220 ICU patients between 18 and 65 years of age, and of either sex. The patients were divided into two groups of 110 each. Care for the study group (group S) consisted of chlorhexidine wash, tooth brushing, and moisturizing gel over gums, buccal mucosa, and lips. The control group (group C) was treated with chlorhexidine wash only. The oral assessment was done at 4, 6, 8, and 12 hours using the Beck Oral Assessment Scale (BOAS). Pneumonia was assessed based on abnormal chest x-rays, fever, chest auscultation, endotracheal culture report, and the incidence of VAP, and mortality was observed Results: Abnormal chest x-rays, positive auscultatory findings, fevers, and positive culture reports were significantly reduced in group S compared to these measurements in group C. The incidences of VAP and mortality were also significantly lower in group S compared with the incidences in group C.Conclusions: Oral care with chlorhexidine mouth wash and the adjuvant measures reduced VAP and, consequently mortality and hospital stays. Tooth brushing along with standard oral care provides an additional advantage in the prevention of VAP in mechanically ventilated patients. Compulsory tooth brushing, if included in regular oral care yields better results in terms of decreased incidence of VAP, length of ICU stay, and mortality.

Association Between Daily Toothbrushing and Hospital-Acquired Pneumonia

“…Three studies were conducted in Iran, 3 in Brazil, 2 in India, 2 in Spain, 2 in China, and 1 each in the US, Malaysia, and Taiwan . Most studies were in English, 1 was translated from Portuguese, 2 from Chinese, and 2 from Persian . Study publication dates spanned 2009 to 2022.…”

“…For the outcomes of hospital length of stay and use of antibiotics, the strength of the recommendation was very low due to individual study limitations, imprecision, and possible publication bias. Singh et al, 43 2022 Subtotal Total Heterogeneity: τ 2 = 0.00; χ 2 = 12 (P = .72); I 2 = 0% Test for overall effect: z = 2.37 (P = .02) Heterogeneity: τ 2 = 0.00; χ 2 = 2.16 (P = .83); I 2 = 0% Test for overall effect: z = 2.66 (P = .008) Test for subgroup differences: χ 2 = 0.89 (P = .34); I 2 = 0% Data were synthesized using inverse-variance random-effects models, with effect sizes expressed as risk ratios (RR). Size of markers indicates the relative weight of each study within the meta-analysis.…”

“…Chlorhexidine gluconate was used in both the toothbrushing and the control groups in 11 studies. 32,[39][40][41][42][43][44][45][46]49,51 The remaining studies used plaque-removing toothpaste, 47 saline, 31 povidone-iodine, 50 or purified water 48 in both study groups.…”

“…None of the studies reported on hospital mortality, but 6 studies reported on ICU mortality (n = 1331 patients). [41][42][43]45,46,50 Toothbrushing was associated with significantly lower ICU mortality (RR, 0.81 [95% CI, 0.69-0.95]; I 2 = 0%) (Figure 4). The target frequency of toothbrushing 4 times/d was not met in any of the intervention units but was significantly higher than on any of the control units.…”

“…Six studies (n = 1284) reported on ICU length of stay. [41][42][43]45,46,48 Toothbrushing was associated with significantly shorter ICU length of stay (MD, −1.78 [95% CI, −2.85 to −0.70] days; I 2 = 0%). Limiting to the 5 studies at low risk of bias, 41,42,45,46,48 toothbrushing remained associated with significantly shorter ICU length of stay (MD, [95% CI, −2.58 to −0.14] days; I 2 = 0%).…”