The review of literature was conducted using the following databases CINAHL, PubMed and Medline using the keywords oral care, mouth care, ventilator-associated pneumonia, ventilator, critical care and hygiene. Of the articles retrieved there were randomized, nonrandomized and quasi experimental. Location of the studies included single centers to university hospital settings in multiple critical care units. Results of the studies were difficult to compare due to the different methodologies, interventions and protocols used in each study. Standard oral protocols were used and revised and new protocols were added to the ventilator bundle.
The main themes identified were oral care with chlorahexadine, chlorahexadine with other product and other products. The findings are discussed in the following sections that follow. Grap et al and Cuccio et al both used CHX and a rinse in their studies in the prevention of VAP. Grap et al (2011) used a single rinse dose of 5ml (0.12%) chlorhexidine to the oral cavity areas for their intervention with specimens obtained at 48 and 72 hours. Cuccio et al (2012) also use a 0.12% CHX rinses with a rigorous oral care protocol including tooth brushing during a 6 month pre-implementation and 12 months after implementation.
However, neither study discussed the frequency of oral care needed in VAP prevention. Sona et al (2009), Kausahara et al (2012) and Munro et al (2009) used a combination of swabs, toothbrushing, CHX and sodium monoflurophosphate when performing oral care. Sona et al approach initiated a pre-intervention, post-intervention study comparing cleaning teeth with sodium monoflurophosphate 0.7% paste every 12 hours and brush, rinsing with tap water, and application of 0.12% chlorhexidine gluconate swab twice daily. Kusahara et al tested the effectiveness on the intervention group of tooth brushing and an antiseptic gel of 0.12% chlorhexidine twice daily and control group received tooth brushing with a non-antiseptic gel. Munro et al compared 4 oral care application methods and products.
One group received 0.12% chlorhexidine swab twice a day, another used tooth brushing alone three times daily, the third group had a combination of both tooth brushing three times daily with CHX swabs every 12 hours, and the control group used standard unspecified protocol. Oral care protocol used in Munro et al (2006) involved using standard oral protocol that was not specified to determine the relationship between oral health status and the development of ventilator-associated pneumonia (VAP) with changes in oral health status during the first seven days of ventilation.
Standard oral protocol followed evidenced based practice of keeping the HOB elevated, changing circuit, removal of subglottic secretions and washing of hands prior to contact of patient. Koeman, et al (2006) compared three different oral treatment groups. The three group treatments included 2% chlorhexidine in petroleum jelly, 2% chlorhexidine, and 2 % colistin in petroleum jelly and the placebo group which received on the petroleum jelly.
The topical oral decontamination with CHX or CHX/COL reduced the incidence of VAP with chlorhexidine alone reduced gram-positive microorganisms whereas CHX/COL reduced both gram-positive and gram-negative microorganisms Garcia et al (2009) compared a pre-intervention or control group received oral cleaning every 4hours or as needed, and tooth brushing twice per day using Cetypyridiniun CHL and hydrogen peroxide swabs. There was no agreement on the studies reviewed on oral care practice.
The practice of oral care with or without application of other products was not consistent. Chlorhexidine was the choice product; however the frequency and the effect of tooth brushing whether manual, electric or spongettes was inconclusive. Many of the studies discussed the importance of education for nurses in reducing ventilator-associated pneumonia in all the studies reviewed. In studies performed by Grap et al, Sona et al, Garcia et al, and Cuccio et al the focus of the study was on pre-intervention and post-intervention of revised protocols. Educational enhancement included education sessions, pictorials, visual posters, in-service training and self-learning. The education of nurses was done through an on-the-job training rather than formal education.
Cuccio L, Cerullo. E., Paradis, Hl, Padula, C., Rivet, C., Steeves, S., &
Lynch, J. (2012). An evidence-based oral care protocol to decrease ventilator-associated pneumonia. Dimensions of Critical Care Nursing, 31, 5, , 301-308.
Garcia, R., Jendresky, L., Colbert, L., Bailey, A., Zaman, M., & Majumder, M. (2009). Reducing ventilator-associated pneumonia through advanced oral-dental care: A 48-month study. American Journal of Critical Care, 18(6), 523-532.
Grap M.J., Munro, C. L., Hamilton, V. a., Elswick Jr, R., Sessler, C. N., & Ward, K. R. (2011). Early, single chlorhexidine application reduces ventilator-associated pneumonia in trauma patients. Heart & Lung 40 (5), e115-e122.
Koeman, M., van der Ven, Andre JAM, Hak, E., Joore, H. C., Kaasjager, K., de Smet, A. G., . . . de Bel, E. E. (2006). Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. American Journal of Respiratory and Critical Care Medicine, 173(12), 1348-1355.
Kusahara DM, P. M. (2012). Oral care with 0.12% chlorhexidine for the prevention of ventilator-associated pneumonia in critically ill children: Randomised, controlled and double blind trial. International Journal of Nursing Studies 49, 1354-1363.
Munro, C. L., Grap, M. J., Elswick, R., McKinney, J., Sessler, C. N., & Hummel, R. S. (2006). Oral health status and development of ventilator-associated pneumonia: A descriptive study. American Journal of Critical Care, 15(5), 453-460.
Munro, C. L., Grap, M. J., Jones, D. J., McClish, D. K., & Sessler, C. N. (2009). Chlorhexidine, toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults. American Journal of Critical Care, 18(5), 428-437
Sona C., Zack, J., Schallom, M., McSweeney, M., McMullen, K., Thomas, J., & … Schuerer, D. (2009). The impact of a simple, low-cost oral care protocol on ventilator-associated pneumonia rates in a surgical intensive care unit. Journal of Intensive Care Medicine,24(1), 54-62.