Reducing Ventilator-Associated Pneumonia Through Advanced Oral-Dental Care: A 48-Month Study

Abstract

Objective To determine the effect of implementing a comprehensive oral and dental care system and protocol on the rate of ventilator-associated pneumonia. Methods Patients more than 18 years old receiving mechanical ventilation for more than 48 hours in a medical intensive care unit at a university-affiliated medical center were studied in 2 consecutive 24-month periods. Patients in the group studied before the intervention (n = 779) had no oral assessments, no suctioning of the subglottic space, no toothbrushing, and suctioning of secretions in the oral cavity as needed. The group studied during the intervention (n = 759) included patients treated under a protocol whereby the oral cavity was assessed, deep suctioning was done every 6 hours, oral tissue cleansing was done every 4 hours or as needed, and toothbrushing was done twice daily. Results Compliance with protocol components exceeded 80%. The groups did not differ significantly in age, sex, or severity of illness. The rate of ventilator-associated pneumonia was 12.0 per 1000 ventilator days before the intervention and decreased to 8.0 per 1000 ventilator days during the intervention (P = .06). Duration of mechanical ventilation and length of stay in the intensive care unit differed significantly between groups, as did mortality. Conclusion Our findings suggest that use of advanced tools, a comprehensive oral care protocol, and staff compliance with the protocol can significantly reduce rates of ventilatorassociated pneumonia and associated costs. (American Journal of Critical Care.

Influence of Institutional Guidelines on Oral Hygiene Practices in Intensive Care Units

“…[7][8][9][10][11] For intubated patients, endotracheal tube placement provides a direct pathway for bacteria to enter the body, reduces the cough reflex, and decreases salivary flow, which inhibits mechanical removal of plaque by saliva.…”

“…[3][4][5][6] Maintaining oral hygiene is one of the key components of VAP prevention. [7][8][9][10][11] For intubated patients, endotracheal tube placement provides a direct pathway for bacteria to enter the body, reduces the cough reflex, and decreases salivary flow, which inhibits mechanical removal of plaque by saliva. 9 Ideally, oral hygiene care of patients receiving mechanical ventilation should consist of oral cavity assessment, swabbing the oral cavity using an oral swab or "toothette," toothbrushing, suctioning, oral rinse, and providing moisture.…”

Mechanical Ventilation and Cytopathological Changes in the Oral Mucosa

“…3,4 Despite some differences, research indicates a correlation between the decreased incidence of respiratory infections and routine oral care in ICU patients. 4,[6][7][8][9][10] Specifically, dental studies indicate relevant alterations in the oral cavity of ICU patients, such as lesions in the oral mucosa, periodontal disease, 11 lip and mucosal dryness, fungal infections, 12 and increased biofilm on dental surfaces. 13,14 These alterations may be associated with several variables in routine ICU care, such as the use of specific drugs that reduce salivary flow and consequently worsen oral health.…”

“…[1][2][3][4][5] In this context, endotracheal intubation for mechanical ventilation plays an important part because of the risk for ventilator-associated pneumonia. 3,4 Despite some differences, research indicates a correlation between the decreased incidence of respiratory infections and routine oral care in ICU patients.…”

“…[1][2][3][4][5] In this context, endotracheal intubation for mechanical ventilation plays an important part because of the risk for ventilator-associated pneumonia. 3,4 Despite some differences, research indicates a correlation between the decreased incidence of respiratory infections and routine oral care in ICU patients. 4,[6][7][8][9][10] Specifically, dental studies indicate relevant alterations in the oral cavity of ICU patients, such as lesions in the oral mucosa, periodontal disease, 11 lip and mucosal dryness, fungal infections, 12 and increased biofilm on dental surfaces.…”