Oral Care Intervention to Reduce Incidence of Ventilator-Associated Pneumo

Pathophysiology

In ventilated patients, the normal defense system of the body, including the cilia in the nose and protective mucus, are circumvented, allowing the patient's mouth to be colonized with pathogenic bacteria such as Pseudomonas, Acinetobacter, and Methicillin-resistant Staphylococcus aureus (MRSA) within 24 hours of admission to an ICU (El-Solh et al., 2004; Rello, 2005). Mechanically ventilated neurointensive care patients are at an increased risk for VAP due to factors such as decreased level of consciousness and inability to protect the airway (Cohn & Fulton, 2006; Kollef et al., 2006). Neurologic patients with decreased level of consciousness or low Glasgow Coma Scale scores are prone to aspiration due to an unprotected airway and inability to swallow properly. Interventions for lowering intracranial pressure (ICP), such as raising the head of the bed, are a positive influence on prevention of VAP, whereas limited mobility because of ICP monitors, ventriculostomies, and disease processes such as spinal cord injury, can negatively affect VAP-prevention techniques (Cocanour et al., 2005). In addition, because it is difficult to temporarily stop sedation in neurologic patients who have increased ICP, the cessation of daily sedation cannot be used to prevent VAP in these patients. Other risk factors include gastric distension, presence of gastric or duodenal tubes, and trauma or chronic obstructive pulmonary disease (Harris & Miller, 2000).

Meticulous mouth care is crucial for preventing VAP. Rincón-Ferrari and colleagues (2004) found that in head-injured patients, 40%–60% of the gram-negative bacilli found were due to endogenous lung colonization after aspiration of oropharyngeal secretions. Twenty percent to forty percent of these bacteria were Staphylococcus aureus, and more than half of the Staphylococcus aureus were methicillin-resistant. This type of staphylococcus is exogenous, usually originating from the hands (Mori et al., 2006).

Studies have shown that patients can become colonized with pathogenic bacteria within 24 hours of admission to a critical care unit (Garcia, Jendresky, & Colbert, 2004; Sole, Poalillo, Byers, & Ludy, 2002). The oral cavity and its components—especially dental plaque—are the perfect media in which bacteria can colonize (Garcia et al.).

The American Association of Critical-Care Nurses published an evidence-based practice alert in 2006 that offered guidelines for oral care of the mechanically ventilated patient. In addition, Grap and Munro (2004) and Collard and Saint (2004) recommended raising the head of the bed to an elevation of 30˚ to 40˚, using endotracheal tubes that have a dorsal lumen above the endotracheal cuff, and sporadically changing ventilator circuits.

Grap and Munro (2004) presented supporting evidence indicating that critically ill patients who are intubated for more than 24 hours are at higher risk for VAP, and therefore, mouth care and oral health should be an important part of nursing care. Current literature identified a problem with adequate oral care in the intubated patient that included the definition and quantification of oral care (Fourrier et al., 2000). Bergmans and colleagues (2001) provided evidence that prevention of bacterial colonization of the oropharynx is the key to preventing VAP. The Centers for Disease Control and Prevention guidelines (Tablan, Anderson, Besser, Bridges, & Hajjeh, 2004) determined that the primary route of bacterial entry into the lungs is through the oropharynx during episodes of microaspiration.

Several studies (El-Solh et al., 2004; Schleder et al., 2002; Shinn, 2004) have verified that removing bacteria from the oropharynx requires the removal of dental plaque, and the only way to remove the plaque is with toothbrushing. Pearson and Hutton (2002) and others found that the majority of nurses use a soft Toothette^® instead of toothbrushing and that the Toothettes do not remove plaque as effectively as toothbrushes; consequently, oral bacteria can proliferate (Baker, 2007; Binkley, Furr, Carrico, & McCurren, 2004).

Pearson and Hutton (2002) completed a controlled trial that compared the ability of foam swabs and toothbrushes to remove dental plaque and to quantify any differences. They concluded that toothbrushing skills must be taught to nurses and clinical support staff. Schleder (2003) reviewed the pathogenesis of bacteria; identified risk factors, including colonization of the oropharynx; and recommended the following approaches:

Use good oral hygiene, including toothbrushing, on all patients.
Implement oral-hygiene assessments and intervention strategies for all patients at risk for developing VAP.
Decontaminate devices that come into contact with the respiratory tract.
Implement the hand-hygiene guidelines released by the CDC in 2003. The guidelines include decontaminating hands by washing them with antimicrobial soap and water or by using an alcohol-based, waterless antiseptic agent if hands are not visibly contaminated. In addition, gloves should be worn when handling respiratory secretions or objects contaminated with the respiratory secretions of any patient (Schleder, 2003; Tablan et al., 2004).

Grap, Munro, Ashtiani, and Bryant (2003) have substantiated the need to standardize oral care for a variety of reasons, the most compelling of which is to prevent or lower VAP rates in mechanically ventilated patients. Oral care is not only part of a standard of care that lowers infection rates by removing plaque-harboring organisms, but is also a comfort care issue (Fourrier et al., 2000; Munro & Grap, 2004). Using evidence-based outcomes and research, the CDC and its Hospital Infection Control Practices Advisory Committee have developed a set of guidelines for VAP prevention that are beneficial for any institution. The guidelines include preferential use of orotracheal tubes over nasotracheal tubes, use of endotracheal tubes with a dorsal lumen to allow drainage, elevating the head of the bed to 30˚ or 40˚, routinely verifying placement of feeding tubes, and preventing or modulating oropharyngeal colonization with implementation of a comprehensive oral hygiene program (Dodek et al., 2004; Tablan et al., 2004).

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