What Are the Effects of Oral Care on the Prevention of Ventilator-Associated Pneumonia - Literature review Example

Short Head: ORAL CARE/VAP Running Head: ORAL CARE AND VENTILATOR ASSOCIATED PNEUMONIA What are the effects of oral care on the prevention of ventilator associated pneumonia in mechanically ventilated patients? Student Name NURS 301 Research in Nursing Northern Illinois University 7 April 2006 Introduction Mori et al (2006) defined ventilator-associated pneumonia (VAP) as “hospital-acquired pneumonia occurring within 48 hours after the initiation of mechanical ventilation with tracheal intubation,” yet, paradoxically, they also recognized a distinction between early ventilator associated pneumonia (E-VAP) and late ventilator associated pneumonia (L-VAP). Bergmans et al, (2001) also recognized that distinction, though with different terminology. Common opinion attributes development of VAP to aspiration of existing oral or oropharyngeal microbes, rather than lower intestinal flora, and attributes increased mortality to VAP. Accordingly, prevention of VAP is an important goal. The most important means of preventing VAP consists in reducing counts of VAP-producing organisms in patients’ mouths by frequent cleansing decontamination. The nursing profession’s general commitment to close, personal care brings with it a particular commitment to performing such oral cleansing. The studies referenced varied in their authors’ understanding of the parameters of oral care, which variably included swabbing patients’ oral mucosa with antiseptic solution and teeth-brushing once (Grap et al, 2004), “three times daily or once in every nursing shift” (Mori et al, 2006); ranging from every 2 hours to every shift (8-12 hours) (Cutler, 2005); every 1–3 hours, every 4 hours, every 8 hours, every 12 hours, once a day or every two to 12 hours (Furr et al, 2004, Binkley et al, 2004); topical antimicrobial prophylaxis (gentamicin/ colistin/vancomycin 2% in Orabase, every 6 h) (Bergmans, 2001). Mori et al (2006) extended their inquiry into the effect of VAP on length of stay in hospital and length of ventilatory assistance and found no statistically significant improvement from oral care. Problem Statement What are the effects of oral care on the prevention of ventilator associated pneumonia in patients receiving mechanical ventilation? Literature Review Investigators have conducted very little research in the past ten years on the prevention of ventilator associated pneumonia in mechanically ventilated patients by means of oral care. A Boolean pubmed-search on “oral care and ventilator associated pneumonia” yielded 29 references, of which the earliest dates from 2001 and of which only 10 appear in prominent, readily available English-language journals. Some of those sources referred to earlier studies on similar issues but they may not have included those terms in their lists of key words. Pubmed listed Cutler (2005) as written by authoresses Cutler and Davis but the article itself lists only Cutler as the authoress. Accordingly, the reference appears here as Cutler (2005). Most of the little research that has appeared focuses on preventing aspiration of bacteria , through cleansing patients’ mouths and subsequent diminution of the incidence of VAP. Only one study (Mori et al, 2006) explores whether prevention or development of VAP influences patients’ length of hospital stay or duration of patients’ ventilator-assistance and it finds no such influence. The commonest studied medium for diminishing or eradicating oral colonization with causative agents of VAP from patients’ oral cavities is chorhexidine (Furr et al, 2004, Brinkley et al, Byers et al, 2003, Grap et al, 2004). Mori et al (2006) applied 20-fold diluted povidone iodine and Bergmans et al, (2001) applied topical gentamicin/colistin/vancomycin 2% in Orabase. Some research has recognized that enteral feeding (Bergmans, 2001) and antecedent injury and/or surgery of the head, neck, thorax, or abdomen (Grap et al, 2004), are factors of added risk, beyond that of oral contamination, that contribute to development of VAP. The other four studies (Furr et al, 2004; Brinkley et al, 2004, Cutler 2005 and Mori et al, 2006), focused as they are on oral nursing care, omitted mention of any additional risk-factors. Bergmans et al (2001) and Mori et al (2006) divided VAP into early-onset (diagnosed within four days after initiation of mechanical ventilation; E-VAP) and late-onset (diagnosed four days or more after initiation of mechanical ventilation; L-VAP). The first group found the causative organisms, in early-onset VAP, to be Streptococcus pneumoniae, Staphylococcus aureus, and haemophilus influenzae and, in late-onset VAP, to be enteric gram-negative bacteria and Pseudomonas species. In descending order, the Mori group found the incidence of causative organisms for all cases of VAP, in both oral-care and non-oral-care groups to be pseudomonas aeruginosa, methicillin-resistant staphylococcus aureus (MRSA), and candida species. Furr et al, Binkley et al, Grap et al and Cutler omit mention of the causative organisms of VAP, probably because of the preventive focus of nurses’ oral care, for performance of which identification of organisms is unnecessary. The Mori group found that the incidence of VAP was 0.37 as high as in the group that had oral care than in the group that did not (3.9 vs 10.4, p > 0.001). The same group found that the cumulative incidence of E-VAP was also lower in the group that had oral care than in the group that did not. The cumulative incidence of L-VAP was also lower in the group that had oral care than in the group that did not but the difference was not statistically significant. In the group that had oral care, the mean time between the beginning of mechanical ventilation and onset of VAP was 8 days and, in the non-oral care group, it was 6 days. The time from the beginning of mechanical ventilation until onset of VAP was statistically significantly longer in the group that had oral care than in the group that did not duration of mechanical ventilation and length of ICU stay, overall, was not statistically significantly different between the two groups. Grap et al tested the efficacy of chlorhexidine gluconate, broad spectrum antibacterial chemical (2 mL of 0.12%; as spray and swab). They did not find statistically significant differences among the groups they studied but they did find trends that suggested to them that chlorhexidine gluconate, applied in the early post-intubation period may delay onset of VAP. Only the treatment groups showed reduced oral bacterial growth. They used various volumes of chlorhexidine gluconate. They considered the standard dose to be 15 ml. They found a 2-ml dose sufficient but considered larger doses, such as 5 or 10 ml, probably more effective. The types of the studies are variable. Bergmans et al (2004) is a prospective, randomized, placebo-controlled, double-blind study, Mori et al (2006) is a non-randomized, experimental study with historical controls. Cutler (2005) was an “observational study that was part of a larger research study.” Binkley et al (2004) and Furr et al (2004) are ex post facto questionnaire-surveys by the same authors, though with different lead-authors, and differently worded texts describing the same matters in two journals. The authors of the two articles camouflaged the identical figures of the two articles by paraphrasing wording in corresponding sections in a manner possibly intended to confuse the reader and forestall discovery of their subterfuge. In neither study, do the authors investigate the efficacy of oral care; they merely survey the nurses who perform it. Binkley and Furr demonstrated the perils of editors’ permitting authors to omit raw data from their published articles. It seems rather likely that the similar and, in some cases, identical percentages they published would have revealed themselves as identical cohorts of nurses if editors and peer-reviewers had insisted that the authors disclose the actual numbers of nurses in each cohort. Summary Investigators have conducted and published little research in the last decade on preventing VAP by oral care and identifying risk factors that contribute to development of VAP among patients on mechanical ventilators. The results of these few studies, though, indicate that colonization of patients’ mouths, chiefly with pseudomonas aeruginosa, MRSA, candida and gram-negative bacteria, antecedent trauma and/or surgery of the head, neck, thorax, or abdomen are key risk factors. Researchers have applied several antiseptic and antibiotic solutions, primarily chlorhexidine, but also povidone iodine and topical antibiotics. Findings consistently indicate that oral care diminishes the incidence of VAP by reducing colonization of patients’ mouths by pathogenic bacteria and fungi, hence decreases also the mortality-rate of ICU-patients dependent on mechanical ventilators. More research is needed to delineate the parameters of oral care in preventing VAP. References Allen Furr L, Binkley CJ, Carrico R, McCurren C. (2004). Factors affecting quality of oral care in intensive care units. Journal of Advanced Nursing 48, 454-62 Bergmans DC, Beysens AJ, Bonten MJ, de Leeuw PW, Gaillard CA, Paling JC, Stobberingh EE, van der Geest S, van Tiel FH. (2001). Prevention of ventilator-associated pneumonia by oral decontamination: a prospective, randomized, double-blind, placebo-controlled study. American Journal of Respiratory and Critical Care Medicine 164, 382-8 Binkley C, Carrico R, Furr LA, McCurren C. (2004). Survey of oral care practices in US intensive care units. American Journal of Infection Control 32, 161-9 Cutler CJ. (2005) Improving oral care in patients receiving mechanical ventilation. American Journal of Critical Care 14, 389-94 Fletcher SW, Fletcher RH. (1994). Publish wisely or perish: quality rather than quantity in medical writing. Annals of the Academy of Medicine Singapore 23, 799-800 Grap MJ, Elswick RK Jr, Munro CL, Sessler CN, Ward KR. (2004). Duration of action of a single, early oral application of chlorhexidine on oral microbial flora in mechanically ventilated patients: a pilot study. Heart and Lung 33, 83-91 Mori H, Hirasawa H, Matsuda K, Nakamura M, Oda S, Shiga H. (2006). Oral care reduces incidence of ventilator-associated pneumonia in ICU populations. Intensive Care Medicine 32, 230-6 Read More