Oral Care: State of the Science

Vicki J. Spuhler RN MS

Nurse Manager RICU

LDS Hospital

Ventilator Associated Pneumonia

• In the US nosocomial pneumonia ranks 2nd in morbidity and 1st in mortality among nosocomial infections.

• Adds 5-7 days to a hospital stay

• Occurs in 9-24% of patients who are on ventilators

• Reported mortality of 54-71%

Impact of Oral Health

• Oropharyngeal colonization impacts– Cardiovascular disease– COPD– Endocarditis– Bacteremia– Important risk factor for Ventilator Associated

Pneumonia

“Bacterial colonization of the oropharynx with S aureus, S pneumoniae, or gram-negative rods is positiviely associated with the occurance of nosocomial pneumonia”

Craven,DE, Driks MR, Semin in Resp. Infect. 1987.

Saliva- What’s that got to do with it anyway?

• Role of Saliva– Provides significant antimicrobial activity for

the oropharynx– Contains a variety of specific innate and

specific immune components– Saliva flow is stimulated by eating- chewing

• Unstimulated flow .25-.35 ml/min• Stimulated flow increases 4-6 ml/ min

Role of Saliva

• Decrease flow or lack of salivary secretion can lead to changes in oropharyngeal colonization– Teeth become more adherent to bacteria– Antimicrobial effects of saliva are absent– Oropharyngeal colonization takes place

Impact of ICU Environment

• Xerostomia- chronic dry mouth

• Reduces the mouths defense mechanism– Cause by tubes that transverse the oral cavity– Stress and anxiety reduces slaivary

stimulation– Dehydration

Impact of ICU Environment

• Within 48 hours of hospital admission oropharyngeal flora of critically ill patients undergoes a change to predominantly gram negative organisms.

• High colonization of MRSA and Pseudomonas on dental plaque of patients in the ICU.

A reduction of microorganisms in the mouth decreases the pool of organisms available for translocation to and colonization of the lungs.

Improving Health Care Performance

• Know what works

• Use what works

• Do well what works

Don Berwick President CEO Institute for Healthcare Improvement

Evidence in Literature

• Definitive scientific studies relating oral care interventions to VAP have not yet been published

• Evidence based protocols are not available in the literature

Do we know what works?

• Two ways exists to remove dental plaque and associated microbes:– Mechanical interventions

– Pharmacological interventions with antimicrobial agents

Mechanical Interventions

• Oral care practices are poorly defined in the literature

• Rarely defines a mechanical component

• Generally targeted at comfort

• Surveys of nurses suggest that where practice is defined it is inconsistent at best

“ICU nurses mean rating of the priority of oral care was 53.9 on a 100 point scale” Johnson WG etal American Rev. of

Resp. Dis. 1988

Impact on Nursing

Barriers to providing oral care:– Concern about tube dislodgement– Limited access to oral cavity- tubes– Potential for the development of Bacteremia– Low priority– Time consuming– Requires little skill- “I didn’t go into the ICU to

do oral care”

• In a study of 66 patients receiving mechanical ventilation the routine oral comfort care provided by nurses was not associated with a reduction in either dental plaque or VAP.

Munro C. Am J of Critical Care 2002

Oral Care Practices

Foam swabs- stimulates mucosal tissue but is ineffective in removing plaque- used for intubated patients 91.5% of the time

H202- removes debris but unless diluted can cause superficial burns to the mucosa

Lemon-glycerin swabs- stimulates saliva initially but are acidic and cause irritation and decalcification of teeth causing rebound xerostomia

Oral Care Practices

• Toothbrush- best mechanical intervention for removal of plaque– Currently no literature that demonstrates the

relationship of the intervention to quantity or type of oropharyngeal flora or to the development of VAP.

• Not without risk- potential to increase translocation of organisms from the oral cavity to trachea or blood if not effectively removed from the oral cavity.

Pharmacologic Interventions

• Removal of microorganisms via oral topical bactericidal agents.– Tobramyacin study-1997- Abele-Horn et al

• 58 of 88 mechanically ventilated patients treated with topical tobramyacin

• Decreased incidence of VAP from gram-negative pathogens

– Overgrowth of S aureus occurred– No incidence of resistance developed

Pharmacologic Interventions

– Selective decontamination with polymixinB sulfate, neomyacin and vancomycin in double blind, placebo controlled trial on 52 mechanical ventilated patients (Pugin et al)• Decreased tracheobronchial colonization

by microorganisms that can cause VAP• No change in mortality

Pharmacologic Interventions

• Chlorhexidine .12% (Peridex)– Broad spectrum antibacterial agent– Bactericidal for gram-positive and gram-

negative organisms– Used for patient suffering from gingivitis– No known microbial resistance has ever been

demonstrated– Not absorbed through skin or mucous

membranes

Chlorhexidine

• Rare allergic reactions

• Side effects minimal– Discoloration of teeth and tongue– Transient alterations in taste

Evidence for use of Chlorhexidine

• 2 studies in elective cardiac surgery patients– DeRiso- double blind, placebo controlled

• “rate of respiratory tract infections was lower in patients who received chlorhexidine than in those who received placebo” 17 of 180 vs 5 of 173 p=.05

• CHEST 1996

Evidence for use of Chlorhexidine

– Houston et al- randomized placebo controlled study of same population of patients

• “number of patients who had nosocomial pneumonia was lower in patients who received Chlorhexidine than in patients who received placebo.”

• 4 of 270 vs 9 of 291 p=.21• Subset of patients- those on mechanical ventilation

for greater than 24 hours– 2 of 10 developed VAP vs 7 of 10 in placebo group

Limitations

• Application to other ICU settings

• In both studies treatment started prior to intubation

• Long term effects of Chlorhexidine is unknown

Sub-glottic suctioning as adjunct to Oral care

• Et tubes – VAP connection– Impair cough reflex– Alter normal flora of oropharynx– Pooling of secretions above the cuff of ET tube

• Valles J- et al Annals of Int. Med 1995- • Kollef MH- et al CHEST 1999• Mahul P, et al 1992 Intensive Care Medicine

– demonstrated a reduction in VAP related to continuous sub-glottic suctioning

Sub-glottic suctioning as adjunct to Oral care

• ET tubes designed for sub-glottic suctioning were developed.– Clogging of tube– Cost– Frequent adjustment of tube required

• Use of CSS-ET tubes has been limited

• Further studies required to demonstrate effectiveness

Summary

• Oral care- significant intervention for ventilator patients• Best performed in the form of a protocol or clearly

defined standard• Must include a mechanical component such as use of

toothbrush to assure elimination of dental plaque- recommendation is Q12 hours

• Oropharynx cleansing and mouth moisturizers should be applied Q4 hours

• Use of topical antimicrobial should be considered• More evidence needed to support CSS-ET tubes

– Effectiveness– Tube design– Cost