ORAL CARE AND VAP

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Emily Hazelton
Nursing 611
12/05/2013
Picot Paper

What is the effect of frequent oral care or suctioning in prevention of
Ventilation- Associated Pneumonia in ICU patients compared with
routine oral care?

Population: Adult Intensive Care Unit patients (aged 18 or older)
Intervention: Frequent, thorough oral care
Comparison: Routine oral care
Outcome: Ventilator-Associated Pneumonia
Background

Nosocomial pneumonia is a leading cause of mortality and morbidity from
hospital-acquired infections in developing countries. Pneumonia is the second most
common nosocomial infection, and increases a patients hospital stay by seven to nine
days. It can also can increase hospital/patient costs by thousands of dollars, and further
delay healing due to individual stress (Schleder 2003). Ventilator-associated Pneumonia
(VAP) is pneumonia that develops later than or at least 48 hours after mechanical
ventilation has began through tubes aimed to maintain ventilation (i.e. endotracheal tubes,
Tracheostomies, etc) (Amanulla 2013). The prevention of VAP is preferable over the
treatment of the infection. Hospitals are working toward improving adherence to oral
hygiene policies to boost prevention and diminish exacerbation of this illness.
Mechanically ventilated patients arent fed normally, but through a tube, so their
normal salivary secretions decrease. This significantly reduces the usual self-cleaning of
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the oral cavity, and hygiene deteriorates as a result. Amount of bacteria increases, which
considerably heightens risk for Pneumonia. Paired with the risk of aspiration of
orapharyngeal secretions, the likelihood of developing ventilator-associated pneumonia is
high (Mori 2006). Providing thorough oral care, including frequent suctioning of
secretions for patients with ventilation assistance should be a priority in nursing practice
to reduce the incidence of VAP (Goldie 2013). Frequent maintenance of the oral cavity
greatly decreases the likelihood of developing ventilator-associated pneumonia, with an
aim to increase patient outcomes, and lower hospital costs. VAP can become a huge
problem for an individual, and if something as simple as performing mouth care more
frequently can significantly lower risk, thats something health care professionals should
be paying attention to.
Search Methods and Studies

Primary sources were attained through several searches of CINAHL, Medscape,
and Google. A range of terms were used to identify sufficient research articles, including
the following: Ventilator-associated pneumonia, VAP, oral care, oral suctioning,
adults and ICU. Limits included English only, full text, and date published (within 10
years). Inclusion criteria included adults aged 18 or above, patients on mechanical
ventilation, and patients receiving care in an Intensive Care Unit. Exclusion criteria
included anyone under 18, and patients who were not in the ICU. The limits reduced
search results from 1,413 results to 52 results, and inclusion/exclusion criteria further
narrowed to 10 results. The search was then further narrowed down through lack of
availability or lack of pertinent data. Studies chosen included a two-group comparison
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study, a non-randomized historical control study, and a parallel-group randomized control
trial.
Critical Appraisal of Evidence
Each trial assessed the role of frequent oral care and/or suctioning in preventing
and decreasing cases of ventilator associated pneumonia. Through analysis and
comparison of three clinical trials, it was concluded that frequent or continuous suction of
orapharyngeal secretions and thorough completion of oral care plays an important role in
reducing VAP development. Further, it was shown to decrease time spent using
mechanical ventilation, and to shorten length of stay in the hospital. Generally, all the
articles explored the same question and anticipated similar outcomes. All trials compared
an experimental group with a control group throughout the study, and tested sputum
cultures to identify bacteria levels at the end of the study. Two trials focused more on
suctioning (one of them on suctioning before each position change, the other on
continuous suctioning) while the third focused mainly on oral care (removal of
secretions/bacteria-ridden plaque through mouthwash, tooth brushing, etc). Each study
aimed to show how increased oral cavity maintenance could decrease bacteria levels, and
in turn decrease VAP prevalence.
Chao, et al. used a two group comparison study to assess the effect of oral
secretion suction before any positional care. There were no significant differences in age,
gender, COPD/Diabetes Mellitus history, antibiotic use, or other demographics between
the two groups (experimental and control). The ratio of experimental participants and
control group participants was 102:159. Individuals in the experimental group received
oral suctioning in the same time frame as a change in position, allowing loosening of
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secretions and easier, more thorough removal. Aerosol therapy refers to the
administration of humidity to liquefy secretions and ease elimination. Aerosol therapy
was used in the study group. Members of the control group received standard, routine
oral care typically given to ICU patients. 24 individuals (out of 159) in the control group
developed ventilator associated pneumonia, and 8 of those 24 died from the infection. 5
out of the 102 experimental subjects developed VAP, and there were no deaths. Length of
hospital stay and average days receiving ventilator assistance was decreased more in the
study group than the control group (Chao, Yin Yin, Wang, Ru Pin, & Hweifar, 2009) The
study included sufficient data, and good detail. Although there were some differences in
background characteristics between patients, it was reported insignificant due to logistic
regression. There was a difference in the number of participants in each group, but it does
not seem that this affected the outcome of the study. Results, in the form of tables, were
available, but not easily understandable. It was also unclear what routine oral care
really included, and how often it was performed. In addition, there should have been
more clarity in how often (in time) suctioning was taking place in the study group. There
was no mention of participants or events that could have altered results, or who were
removed from the study. Although there did seem to be some flaws with the study, it is
presumed that they had little effect on the outcome.
Mori, et al. used a non-randomized trial with historical controls, conducted in the
medical-surgical Intensive Care Unit of a University hospital. Patients who entered the
ICU between a 7 year period (January 1995-December 2002) who were receiving
mechanical ventilation with tracheal intubation became part of the study as part of the
experimental group (1,248 patients). Individuals who were patients on mechanical
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ventilation previously (January 1995-December 1996) who had received no oral care
became part of the control group, known as the non-oral care group (637 patients).
There were no significant differences in age, sex, etc. The oral status of all patients was
assessed by a dentist or nurses within the ICU at the time of admission. Study group
participants were given oral care, including suctioning of secretions from the oral cavity
and upper portion of the trachea 3 times daily as compared to the routine once per day
oral care. The incidence of VAP, when onset occurred, duration of mechanical
ventilation, how long the patient stayed in the ICU, and tested/causative bacteria were
gathered from and compared between the two groups. Cumulative incidence of VAP
results indicated 2.32% of patients receiving oral care and 6.28% of non-receiving
patients. The study gave great detail regarding the types of organisms found in sputum
samples, and in describing the oral care routine used in the study group (Mori et al.
2006).
Chow, et al. used a parallel-group randomized controlled trial to get a better look
at the role of continuous oral suctioning in preventing the development of ventilator-
associated pneumonia. A main goal of the study was to test the effect of a device to aid in
continuous suction, although the format of the study as well as the results effectively
contribute to the research question at hand. The study was conduction in the ICU of a
public hospital, and used both experimental and control groups. Participants in both
groups had endotracheal tubes. The device tested was only used in the experimental
group. The device used was placed between the patients cheek and teeth to provide
continuous secretion suction. 14 patients were randomly assigned to the experimental
group and 13 were randomized to the control group. The control group received standard
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oral care. Besides this, measures were the same (same tracheal suction system, semi-
recumbent body position, hand hygiene). The groups had similar demographics,
including reasons for intubation, co-morbidity, and risk factors. Results showed VAP
found in 3 patients (23.1%) receiving continuous suction and found in 10 patients
(83.3%) in the control group. 2 participants were lost from the study because theyd been
on mechanical ventilation for under 24 hours. Data was more clearly presented and
understandable to the reader. Discrepancies that altered the number of participants was
explained (Chow, Kwok, Luk, Law, & Leung 2012).
According to the presented studies, frequent oral care/oral suctioning significantly
decreases the presence of ventilator-associated pneumonia in ICU patients. It can also
delay the onset of VAP, and avoid the stress associated with illness and paying for
hospital treatment. Of three separate studies conducted in different places, all came to the
same conclusion regarding pneumonia prevention. There were noteworthy differences in
the format of the three studies: alterations in focus (between suctioning, mouth care
use/duration), historical controls versus same-time testing, and presentation of data
(tables vs. graphs). All of the studies concluded that more frequent and complete oral care
positively benefitted patients receiving mechanical ventilation by decreasing the
likelihood of VAP incidence. Completing oral hygiene more than once per day, and
closer to three times daily is an extremely helpful tool in avoiding VAP. Completing
orapharyngeal/upper tracheal suctioning at the same time as position changes provides
extensive secretion removal, thus more bacteria elimination and less risk of developing
pneumonia. Patients with ventilator-associated pneumonia require more attention to oral
hygiene; the importance of frequent mouth care for these patients should be part of
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standard protocol in the Intensive Care Unit, or any unit with mechanically ventilated
patients. In every study, the patients receiving more regular oral care and secretion
suctioning always had less incidence of VAP at the end of the trial, and fewer or no
deaths from the illness in comparison to patients receiving standard, once per day or as
needed care. The truth is that this care is needed more often than it is actually done.
There should be significant alterations in hospital protocol, especially within the
Intensive Care Unit to decrease Ventilator Associated Pneumonia in ICU patients.
Protocol should require nurses to provide mouth care at least 3 times daily to patients
receiving mechanical ventilation, to reduce incidence of VAP and help lower hospital
costs. Medical costs are a huge problem for people with serious illness, especially in the
United States. With VAP still a problem however, its clear that necessary measures for
mouth care are not taken in all health care facilities. Implementing and monitoring this
standard of care would decrease the stress levels of patients as well, eliminating the fear
associated with serious illness and medical cost buildup, allowing for better recovery in
general.















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References Cited

Amanullah, S. (n.d.). Ventilator-Associated Pneumonia Overview of Nosocomial
Pneumonias. Ventilator-Associated Pneumonia. Retrieved December 6, 2013, from
http://emedicine.medscape.com/article/304836-overview

Chao, Y., Yin-Yin, C., Wang, K., Ru-Pin, L., & Hweifar, T. (2009). Removal of oral
secretion prior to position change can reduce the incidence of ventilator-associated
pneumonia for adult ICU patients: a clinical controlled trial study. Journal Of
Clinical Nursing, 18(1), 22-28. doi:10.1111/j.1365-2702.2007.02193.x

Chow, M. M., Kwok, S., Luk, H., Law, J. H., & Leung, B. K. (2012). Effect of
continuous oral suctioning on the development of ventilator-associated pneumonia:
A pilot randomized controlled trial. International Journal Of Nursing Studies,
49(11), 1333-1341. doi:10.1016/j.ijnurstu.2012.06.003

Goldie, M. P. (n.d.). Oral hygiene care for critically ill patients to prevent ventilator-
associated pneumonia (review). - DentistryIQ. Retrieved December 6, 2013, from
http://www.dentistryiq.com/articles/2013/10/ventilator-associated-pneumonia.html

Mori, H., Hirasawa, H., Oda, S., Shiga, H., Matsuda, K., & Nakamura, M. (2006). Oral
Care Reduces Incidence of Ventilator-Associated Pneumonia in ICU Populations.
Intensive Care Medicine, 32(2), 230-236. doi:10.1007/s00134-005-0014-4

Schleder, Bonnie J. Taking charge of ventilator-associated pneumonia. (2003). Nursing
Management, 34(8), 27.