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Abstract

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Introduction

Background Information

Critically ill patients in the intensive care units, ICU, are often in need of mechanical ventilation due to their inability to breathe unassisted due to trauma, medical conditions or surgeries (Shi, 2013). Further, these critically ill patients are usually dependent on caregivers to meet their basic life sustaining need and hygiene. Oral health that is an essential part of overall body hygiene deteriorates the following admission to a critical care unit (Shi, 2013). Intubation and illness also work in reducing one’s immunity as they result in mechanical injury of the mouth or respiratory tract; increase the likelihood of dry mouth. Dental plaques accumulate rapidly in the mouth leading to increased buccal colonization by microbial pathogens (Shi, 2013). This accumulation of pathogens may be intensified, according to Shi (2013), by the lack of adequate oral hygiene care and drying of the buccal cavity due to prolonged mouth opening reducing antiseptic effects of saliva. One serious complication that may develop as a result such an inadequate oral hygiene care is ventilator-associated pneumonia, VAP.

VAP has been defined as the occurrence of pneumonia in mechanically ventilated patients in the ICU after 48 hours of endotracheal intubation. VAP is considered the leading cause of nosocomial infection and is contributing to the highest number of mortality and morbidity in critical care units. It is estimated to affect 10-30% of mechanically ventilated patients (Li, 2015). VAP is also associated with increased medical care costs, prolonged hospital stays, lengthened care in the ICU and a ‘two-fold’ risk of mortality, (Li, 2015). Together with other nosocomial infections, VAP accounts for 15% of all hospital-associated infections and represents second most common hospital-related infection after urinary tract infection (Fields, 2008). It is therefore quite essential to consider the effects, prevention and control of VAP to militate against its occurrence.Studies have determined aspiration of the oropharyngeal followed by bacterial proliferation and parenchymal invasion as the most agreeable cause to the development of VAP. Bacteria associated with VAP are believed to exist freely in the oropharynx and gastrointestinal track, and so reducing oral bacteria may help in preventing VAP by keeping these potential reservoirs bacteria free (Li, 2015). To make a diagnosis of pneumonia, one has to make at least one of the following findings; identify a new or persistent infiltrate to a chest x-ray, identify an associated organism from sputum or pleural fluid and, or a positive bronchoalveolar lavage (Fields, 2008).

Problem Statement

The use of antibiotics administered either intra-orally s topical pastes or systematically have proven very effective in preventing VAP and have traditionally been used. The risk awareness of developing antibiotic resistant organisms or multidrug resistant pathogens has intensified lately, calling for an exploration of other approaches to preventing VAP. One notable alternative is the oral care with antiseptics such as chlorhexi¬dine and povidone-iodine. Though there is still a lot of questions concerning potential factors such as the type of antiseptics, frequency of use and for which kind of patients, that have not been answered conclusively. This study is therefore designed to examine the effectiveness of oral care with antiseptics on the prevalence of VAP against other clinical outcomes in patients undergoing mechanical ventilation in random controlled trials.

Objectives

To compare effectiveness of oral care with an antiseptic, to a placebo or usual standards of care at reducing the prevalence of VAP in Intensive care unit patients in a 3 year period of time.

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Significance and Justification

The significance of this study is to provide conclusive evidence for the effectiveness of using antiseptics, particularly the use of chlorhexidine and povidone-iodine in mitigation of VAP against other traditional methods or placebo. There has been systematic review evaluating the uses of topical antibiotics, use of probiotics and systematic antibiotics to prevent VAP or even the use of the above-listed antiseptics but with insufficient evidence providing the details of such critical cares (Shi, 2013). The researcher plan to give a brief summary of a few available studies in this discipline that meets required criteria so as to provide evidence-based care for vulnerable patients (Shi, 2013).

Intervention

In this study, the research seeks to conduct a systematic review of the different types of oral hygiene care as possible measures to reducing the incidence of VAP in mechanically ventilated patients. In clinical care, oral hygiene has been emphasized as a means of preventing VAP though there is still insufficient evidence to this effect (Shi, 2013). The use of mouth rinses: water, saline, antiseptics and gel, applied as either spray, liquids or with a swab, with or without toothbrushing and toothpaste, to remove debris and microbial from the oral cavity are considered basic oral hygiene care. Suction to remove excess fluids, tooth-brushing to remove debris and application of antiseptic gel may also be considered. While antiseptics are widely accepted to include saline, cetylpyxidium, chlorhexidine, povidone and others, antibiotics should not be included in this category (Koeman, 2006). Much as the use of such antiseptics is hypothesized to reduce bacterial load; caution should be taken to avoid aspiration of contaminated fluids into the respiratory tract. This can be achieved by raising the head, according to Shi (2013). And the careful use of well-maintained closed aspirates fitted with a cuff around the endotracheal tube.

Methodology

Search Strategy

The search for literature was conducted on systematically on Pro-Quest Health and Cochrane databases. The search terms consisted of VAP and ICU patients, prevention with oral care, Pneumonia, nosocomial infections, usual standards of care. MeSH terms used were ventilated associated pneumonia, healthcare-associated infections, infection control, oral care ventilated patients, intensive care units, quality improvements guidelines. This search was limited to randomized controlled trials, systematic reviews, multi-center studies and meta-analyses conducted on human subjects and published within the last five years. For the duration, Pro-quest had only two publications that met the researcher’s criterion and none from Cochrane, prompting an extension to include ten years. This adjustment brought in two other results from Pro-quest and just a single outcome from Cochrane.

Selection Criteria

In our previous searches, several search outcomes popped out, so we had to refine our selection criteria to ensure that the study addresses our PICOT question. For instance, articles that compared oral hygiene care to placebo normal standards of care for mechanically ventilated patients in intensive care units, neurologic or 24-bed stroke, aiming at preventing VAT over a duration of 3 years or thereabout, were included. The articles had also met the standards of a meta-analysis, random-controlled trials, systematic review of oral care against common strategic treatments and must have been published in the past ten years in The English language. Any article that did not meet such requirements and any that only focuses on prevention of central line infections in patients that are in ICU were excluded.

Selected articles involved human participants, critically ill in intensive care units without any ventilator-associated pneumonia or respiratory infections at the start. The participants must have stayed in the ICU for a minimum period of 48 hours and received no antibacterial treatment before the trial. The trial also included a group of intervention participants were a clearly defined oral hygiene care was administered such as caregiver-assisted tooth-brushing, decontamination of oropharyngeal cavities and pharyngeal cavity rinse with antiseptics. Studies with control groups who received no treatment, placebo, traditional care or used different specified oral hygienic care procedures were considered. Similarly, trials with aspiration systems or variations in methodology and timing were excluded.

Outcome Measures

The primary outcome measure in the study was the reduction in the rate at which ventilated intensive care unit patients catch VAP or VAP incidences and mortality. Secondary outcome measures included the duration of ICU stay, colonization of dental plaque, adverse effects of the intervention, economic data and caregivers’ preference to oral hygiene care (Shi, 2013).

Data Extraction

Some of the attributes considered for the data collected were the year of publication, study design including population and settings, the researchers’ inclusion and exclusion criteria, VAP diagnosis approaches, intervention and the control groups and VAP prevalence (Labeau et al. 2011). The concentration and type of antiseptic used in the study were also noted.

Quality Assessment

The researcher used a Jada scale with scale of 0 to 2 as a quality measure indicator to help in eliminating the risk of bias. Randomization of sequence generation to avoid selection bias was highly emphasized, blinding of participants and personnel to reduce performance bias through masking, blinding of assessment outcomes to reduce detection bias and incomplete data outcome analysis to avoid attrition bias were also considered. Further, the risk of drop-outs or withdrawals and selective reporting were also graded. The applicability of the trials was evaluated in regards to the uniformity of the groups at the start of the trials, loss-to-follow-up, intention-to-treat analysis, comparability of treatment, and patient-caregivers’ compliance with the treatment. The researcher also considered the assessment of the sample size and definitions of inclusion and exclusion criteria by the individual studies as the basis of quality checks (Labeau, 2011).

Results

Search outcomes

The electronic search conducted on Cochrane and pro-quest databases brought forth the following articles that met the researcher’s inclusion standards:

i. Shi et al., (2013). Oral hygiene cares for critically ill patients to prevent ventilator-associated pneumonia (Review) The study by Shi et al. (2013) was designed to assess the effects of oral care on the incidence of VAP in ICU patients. The selected patients were receiving mechanical ventilation in intensive care units (ICUs) in various hospitals. The study that involved 5374 participants and 35 random-controlled trials involved treatment with a chlorhexidine mouth rinse or gel. The outcome revealed a 40% reduction in the incidence of VAP. The article was extracted from Cochrane review of randomized control trials. ii. Labeau, S. et al., (2011). Prevention of ventilator –associated pneumonia with oral antiseptics: a systematic review and meta-analysis The article by Labeau et al. (2011) involved a review of 14 studies, where a total of 2481 patients were considered. Twelve of these studies considered treatment with chlorhexidine while two used povidone-iodine as an intervention. These treatments were monitored against normal or placebo treatments. These investigations that were intended to assess the effects of oral care with chlorhexidine or povidone-iodine on the prevalence of VAP against other oral care treatments without antiseptics revealed a 21% reduction in VAP prevalence while the effects of povidone-iodine remained unclear. The research conducted a systematic review and meta-analysis of randomized control trials. iii. Longti, L et al., (2015). Can routine oral care with antiseptics prevent VAP in patients receiving mechanical ventilation? An updated meta-analysis from 17 randomized controlled trials. A meta-analysis of 17 randomized controlled trials aimed at assessing the effect of oral care with antiseptics on the prevalence of VAP in critically ill patients. In the study, 4,249 participants were treated with chlorhexidine or povidone –iodine and observed against a control group who used normal treatments or placebo. The study noted a significant reduction in the VAP incidence in the intervention group administered with chlorhexidine while povidone-iodine was not as successful. iv. Koeman, M et al., (2005). Oral cleansing with Chlorhexidine Reduces the incidence of Ventilator- Associated Pneumonia Randomized control trials involving 385 patients and three groups were included in the study. Effects of Chlorhexidine were compared against placebo, Chlorhexidine, and colistin at preventing VAP. 130 patients received the placebo, 127 patients received the Chlorhexidine, and 128 patients received both Chlorhexidine and collection. A combination of chlorhexidine and colistin resulted in a significant risk reduction of VAP. v. Fields, L., (2008). Oral Care to Reduce the Incidence of Ventilator-Associated Pneumonia in the Neurologic Intensive Care Unit

The study involved randomized control trial that compared the intervention group whose teeth were brushed every 8 hours using a suction toothbrush and a control group whose care involve daily mouth swabbing with a toothette swab, at preventing VAP. A single RCT was conducted 200 patients on a 24 bed ICU stroke unit. The study recorded a reduction in VAP prevalence.

Review of Evidence

From the five studies reviewed in this paper, there seems to be a universal agreement concerning the effectiveness of antiseptics, such as chlorhexidine, in reducing the incidence of VAP. However, none of them seems to provide any evidence in support for the effectiveness of povidone-iodine in preventing VAP against other traditional treatments. When a study to compare the effectiveness of normal treatments, such as the use of chlorhexidine, and a combination of chlorhexidine and colistin; chlorhexidine in conjunction with colistin was found to be a more effective treatment. The last article reviewed by Fields et al. (2008) gave comparative analyzes between tooth-brushing and mouth swabbing as alternative oral hygiene care and determined assisted tooth-brushing to reduce the risk of VAP effectively.

Validity

The studies reviewed in this paper made substantial efforts to guarantee the validity of the outcomes recorded. For instance, the researchers analyzed the association between their variables at 95% confidence interval, thereby reducing the range of error in their statistical outputs. Further, Probability value less than 0.05 reduces the chances of committing type II error their investigations, save for the last two studies that did not mention any such measures.

These trials were also controlled and all sources of possible variations other than the ones being investigated taken care of. The time for each trial was limited to 3 years and various sources of biases such as selection, reporting, performance and attrition covered for by randomizing selection, masking and ensuring there was uniformity in health status at baseline. Some of the above studies, however, did not go to great lengths in heightening the validity of their studies like their counterparts. For instance, the first three studies conducted heterogeneity and the Mantel-Hazel method test to ensure that there was compliance no biases while the last two did not make such efforts, compromising the validity of their outcomes.

Reliability

Reliability in statistical research implies the degree to which the tools used in the evaluation produces accurate, stable and consistent results. The studies went to great lengths to ensure that their results were reliable (Longti et al. 2015). First, some studies involved a separate independent review of the data collected by teams of experts, the sample size used were also large enough to guarantee sufficient effect size and up to fourfold screening for RCTs. Further, a jada score was employed by some of the studies as a quality assessment tool and gave no room for exception in exclusion from studies that did not meet the stipulated criteria. Data collection and analysis strategies were, however, omitted in the last two studies making reliability questionable.

Applicability

The studies provide a positive answer to the PICOT question. This condition implies that the use of antiseptics such as chlorhexidine reduces the incidence of VAP, reduce associated morbidity and mortality. Most importantly, the study by Shi (2015), proved that using antiseptics in oral hygiene care significantly reduces the cost health care for patients in the ICU and reduces their length of stay too. These benefits alone make these approaches to dental care very helpful in curbing VAP, and besides, it is easy to administer.

The sample size used in the investigation and the conditions gives typical health facility environment and generalizing this treatment to everyday medical care poses no unforeseeable challenges.

Implications for Future Research

It is agreeable that effective oral care is vital for mechanically ventilated patients in ICU and helps reduce the incidence of pneumonia. There is also enough evidence in the literature that oral hygiene with antiseptics is quite effective in reducing the risk of VAP in intensive care units. Though, the definition of what entails oral hygiene care varied among the studies used in this research but common elements such as cleaning teeth and gums and removing secretions using aspirates and mouth rinsing stood out.

According to Shi (2013), although studies provided beneficial evidence of antiseptics in critically ill patients to prevent VAP, limitation of incomplete reporting was clearly notable. He further recommends the use of the CONSORT statement for reporting of RCTs in improving the value and quality of future research. Some studies also used usual care instead of placebo as a control group; Shi (2013) recommends a preference for placebo to enable blinding. Full reporting of methods used to diagnose VAP, since it was determined that varied methods were used, and this could have compromised the reliability and validity of these studies. The studies did not also provide reports on the adverse effects of treatments.

Application to Practice

This study has conclusively determined the effectiveness of using antiseptics and tooth-brushing in ventilated patients at reducing the VAP prevalence. Though, in practice, placebo controls have been recognized to be more effective than normal standard treatments as it encourages masking of the caregiver as to which patients are part of active or control groups. This improvement is likely to reduce performance bias significantly and give more genuine results. All the shortcomings aside, these studies prove to be very helpful general practice. The substantial amount can be saved in hospital care for patients in the ICU using this relatively cheaper method of controlling the development of VAP. None of the studies used above, however, measured the cost associated with the different treatments used in their investigations to validate this opinion, and further research is needed to substantiate this assumption.

`EBP Model

The evidence-based practice model used to guide this study was highly inclined at addressing the PICOT question. In ventilated ICU patients (P), does the use of oral care with an antiseptic (I) as compared placebo and usual care (C) help reduce the risk of getting VAP (O) during a three-year period (T)? The researcher then determined the significance of conducting an investigation on this subject by addressing the questions of prevalence and the societal impact of the malady.

Being that VAP was determined to be a widespread and common problem in practice, 10 to 30% prevalence with high morbidity and mortality impacts, the researcher was the justified in conducting a review and meta-analyses of previous research on the prevention and control of this disease. The best approaches identified to prevent the incidence of VAP significantly were; the use of antiseptics, the use of antibiotics, mouth-rinsing and gel pastes. Though, antibiotics have been highly discouraged in practice as a result of the secondary effects associated with overusing them in treatments. Having established the beneficial effects of this treatment, the researcher recommends the application of his model in daily health care practice (Appendix C). The model, however, appears, like many other studies done before, to give a proper definition of oral care and details of administering such treatments. Further, there are varied approaches to making VAP diagnosis in practice, specifically stating the approach used may help in settling discrepancies in an outcome known by other researchers.

References

Fields, L. B. (2008, October). Oral Care Intervention to Reduce the Incidence of Ventilator-Associated Pneumonia in the Neurologic Intensive Care Unit.Journal of Neuroscience Nursing, 40(5). Retrieved from: www.proquest.com

Koeman, M., Van der Ven, A. J., Hak, E., Joore, H. C., Kassjager, K., De Smet, A. G., ... De Bel, E. E. (2006, March 31). Oral Decontamination with Chlorhexidine Reduces the Incidence of Ventilator-associated Pneumonia. American Journal of Respiratory Critical Care Medicine, 173(5), 1348-1355. Retrieved from: www.proquest.com http://dx.doi.org/10.1164/rccm.200505-820OC

Labeau, S. O., Van de Vyver, K., Brusselaers, N., Vogelaers, D., & Blot, S. I. (2011). Prevention of ventilator-associated pneumonia with oral antiseptics: a systematic review and meta-analysis. Lancet of Infectious Disease, 11, 845-854. Retrieved from: www.proquest.comhttp://dx.doi.org/10.1016/S14733099(11)70127-X

Li, L., Ai, Z., Zheng, X., &Jie, L. (2015, February 15, 2015). Can routine oral care with antiseptics prevent ventilator-associated pneumonia in patients receiving mechanical ventilation? An update meta-analysis from 17 randomized controlled trials. International Journal of Clinicalclinical and experimentalMedicine, 8(2), 1645-1657. Retrieved from:www.proquest.com

Shi, Z., Xie, H., Wang, P., Zhang, Q., Wu, Y., Chang, E., ... Furness, S. (2013). Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia (Review).Cochrane review, Issue 8, 1-127. Retrieved from:www.Cochranereview.com http://dx.doi.org/DOI: 10.1002/14651858.CD008367

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