Does Brushing Every Day Keep VAP Away? The Impact of Oral Care on Patients in the ICU
By Ruth M. Kleinpell, PhD, RN, Director, Center for Clinical Research and Scholarship, Rush University Medical Center; Professor, Rush University College of Nursing, Chicago, is Associate Editor for Critical Care Alert.
Dr. Kleinpell reports no financial relationship to this field of study.
Prevention of ventilator associated pneumonia (VAP) is a key area of focus for promoting quality of care in the intensive care unit (ICU) and best patient outcomes. Use of oral care protocols in the ICU for patients receiving mechanical ventilation has become a standard of care in ICUs based in part on the results of research that have demonstrated decreased oral colonization rates and studies that suggest a potential relationship between poor oral care and increased risk of VAP.
Implications of a New Study Including Electric Toothbrushing
A recently released study from Spain has focused attention on this issue by questioning the assumption that better oral care would improve infection-related outcomes.1 Pobo et al conducted a randomized clinical trial with 147 patients in a single medical-surgical ICU to assess the impact of the use of 0.12% chlorhexidine every 8 hours (standard group) compared to standard oral care plus the use of electric toothbrushing (toothbrushing group). The results of the study did not demonstrate a significant difference between groups in rates of VAP, mortality, antibiotic-free days, duration of mechanical ventilation, or length of stay.
In the Pobo study, consecutive intubated adult patients were randomized within 12 hours of intubation to oral care with either the 0.12% chlorhexidine oral rinse every 8 hours or oral rinse with the addition of tooth and tongue brushing every 8 hours with an electronic toothbrush. While the general study methods are described and it is indicated that nurses received training for oral care, the duration of toothbrushing is not addressed and the specific oral care protocol is not described, leaving the reader unclear as to the specific components of the toothbrushing intervention. The results of the study must therefore be interpreted with caution, especially as the study was conducted over a 30-month period and fidelity of the intervention or compliance may also have been impacted. The authors acknowledge the study limitations and cite that more frequent or intensive implementation of the intervention may have been more effective.
Effect of Oral Care on Bacterial Colonization
Dental plaque and oral flora have been implicated in the risk of colonization of the oropharynx and the development of VAP. Changes in oral health status have been demonstrated during the first several days of intubation with a decrease in salivary volume, increase in dental plaque, and changes in salivary lactoferrin.2 Implementation of oral care protocols has been advocated as a strategy to target removal of dental plaque and minimize colonization and micro-aspiration of microbially rich biofilm. A number of oral care interventions have been examined, including mechanical (toothbrushing) and pharmacological measures (chlorhexidine 0.12%-2%, 2% colistin, or a combination of the two) delivered via rinse, swab, gel, or paste at intervals ranging from every 2 hours to 2, 3, or 4 times a day.3 A systematic literature review of oral hygiene practices for ICU patients receiving mechanical ventilation identified 11 prospective controlled trials, 20 observational studies, and 24 descriptive reports addressing the topic, highlighting the increased focus on oral care in the ICU.4
Several studies have demonstrated a benefit of implementing oral care protocols incorporating tooth brushing and oral suctioning, including several randomized clinical trials.5-10 Toothbrushing was found to significantly reduce plaque colonization, but 0.12% chlorhexidine swab had no effect in one study,11 while in two other studies, 0.2% chlorhexidine demonstrated reduced positive dental plaque cultures.5,12 A meta-analysis of four studies examining the impact of chlorhexidine found beneficial effects on VAP that approached statistical significance (P = 0.07).8 Additional study on the impact of oral care on oropharyngeal colonization has demonstrated the efficacy of 2% chlorhexidine/2% colistin in reducing both gram-positive and gram-negative bacteria compared to 2% chlorhexidine in reducing gram-positive bacteria.6
Effect of Oral Care on VAP Reduction
Several studies have demonstrated reduced rates of VAP with the use of oral care protocols, some in combination with additional focused measures such as head of bed positioning, use of specific endotracheal tubes to minimize aspiration or supraglottic secretions, and aggressive antibiotic stewardship. A randomized controlled trial in 345 neurologic ICU patients using a standardized protocol that included specified durations of toothbrushing every 8 hours, the use of laminated cards with oral care instructions along with oral assessments every 12 hours, replacement of oral Yankauer suction catheters every 24 hours, and the use of audit sheets to track compliance resulted in a significant decrease in VAP rates from 1.72% to 0.62% per 1000 ventilator-days over a 6-month period.10 A focused performance improvement project that incorporated standardized ventilator weaning, focused attention to head of bed positioning at 30° position, a standard oral care protocol, use of special endotracheal tubes with subglottic suctioning, and use of altered antibiograms resulted in a significant reduction in VAP from 2.7 per 1000 patient-days to 1 per 1000 patient-days.13
In addition to reduction in VAP rates, the use of oral care protocols has been linked to cost savings during ICU hospitalization due to decreased incidence rates of VAP. Implementation of a standardized oral care protocol to assist in prevention of bacterial growth of plaque by using toothbrushing with sodium monofluorophosphate 0.7% paste and brush and subsequent application of a 0.12% chlorhexidine gluconate solution every 12 hours resulted in a 46% reduction in a surgical ICU and an associated cost savings of up to $560,000 based on the estimated cost per VAP of $10,000-$40,000.14
Interpreting Evidence Related to Oral Care in the ICU
It becomes evident that the use of oral care protocols has been demonstrated to be beneficial in reducing oropharyngeal colonization. While several studies have demonstrated a relationship between oral care and reduction in VAP, additional research is needed,15 especially in terms of key factors including optimal duration of toothbrushing, frequency of oral care, and measures to ensure standardization of technique. Future studies exploring oral care interventions need to report on the specific measures incorporated, and education and training considerations in order to maximize clinical application and replication of strategies that prove to be efficacious. Targeting reduction in VAP is a recognized area of priority care for ICU patients. Interventions to improve oral care practices can improve patient safety and promote best outcomes for mechanically ventilated patients.
- Pobo A, et al. A randomized trial of dental brushing for reventing ventilator-associated pneumonia. Chest 2009;136:433-439.
- Munro CL, et al. Oral health status and development of ventilator-associated pneumonia: A descriptive study. Am J Crit Care 2006;15:453-460.
- Halm MA, Armola R. Effect of oral care on bacterial colonization and ventilator-associated pneumonia. Am J Crit Care 2009;18:275-278.
- Berry AM, et al. Systematic literature review of oral hygiene practices for intensive care patients receiving mechanical ventilation. Am J Crit Care 2007;16:552-562.
- Fourrier F, et al; PIRAD Study Group. Effect of gingival and dental plaque antiseptic decontamination on nosocomial infections acquired in the intensive care unit: A double-blind placebo-controlled multicenter study. Crit Care Med 2005;33:1728-1735.
- Koeman M, et al. Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med 2006;173:1348-1355.
- Mori H, et al. Oral care reduces incidence of ventilator associated pneumonia in ICU populations. Intensive Care Med 2006;32:230-236.
- Pineda LA, et al. Effect of oral decontamination with chlorhexidine on the incidence of nosocomial pneumonia: A meta-analysis. Crit Care 2006;10:R35.
- Houston S, et al. Effectiveness of 0.12% chlorhexidine gluconate oral rinse in reducing prevalence of nosocomial pneumonia in patients undergoing heart surgery. Am J Crit Care 2002;11:567-570.
- Fields LB. Oral care intervention to reduce incidence of ventilator-associated pneumonia in the neurologic intensive care unit. J Neurosci Nurs 2008;40:291-298.
- Munro CL, et al. Chlorhexidine, toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults. Am J Crit Care 2009;18:428-437.
- Fourrier F, et al. Effects of dental plaque antiseptic decontamination on bacterial colonization and nosocomial infections in critically ill patients. Intensive Care Med 2000;26:1239-1247.
- Weireter LJ, et al. Impact of a monitored program of care on incidence of ventilator-associated pneumonia: Results of a long-term performance-improvement project. J Am Coll Surg 2009;208:700-705.
- Sona CS, et al. The impact of a simple, low-cost oral care protocol on ventilator-associated pneumonia rates in a surgical intensive care unit. J Intensive Care Med 2009;24:54-62.
- Munro CL, Grap MJ. Oral health and care in the intensive care unit: State of the science. Am J Crit Care 2004;13:25-34.