Synthesis on the Oral Care Intervention on Reducing Pneumonia - Literature review Example

Research Synthesis on the Oral Care Intervention on Reducing Pneumonia Research Synthesis on the Oral Care Intervention on Reducing Pneumonia A. Reason and Purpose of this Review In the recent decade, oral care interventions have been found to help reduce the incidence of pneumonia. However, up to now, many stakeholders observed that no data have yet been published from large, well-controlled clinical trials of oral care interventions in critical care patients. There are limited clinical reports of infection rates before and after changes in oral care procedures. The role of oral care in reducing nosocomial pneumonia is yet clearly established by previous researches conducted. Hence, a review of the available literature will be conducted to synthesize recent researches on the impacts of providing oral care intervention to patients suffering from pneumonia. It is aimed that after a conduct of thorough review of the recent advances in oral care interventions in the reduction of pneumonia, consolidated findings will lead to conclusive evidences of the effects of oral care intervention on minimizing the occurrence of pneumonia. B. Description of Search and Review Process Used Search and review process is the strategy used to select documents. In this study, only relevant and recent literature will be used for review. For a literature to be considered relevant, it has to have direct bearing on the problem/issue – in this case, the reduction of pneumonia cases through oral care intervention. For a literature to be considered current, it has to have been published from the year 2004 onwards. The exclusion criteria was adapted to ensure that the latest findings that are directly-related are focused on this study. The databases searched included journal articles, books and online material containing the terms oral care, oral care intervention, pneumonia and pneumonia reduction. Tabulated meta-analysis of six selected articles was conducted. In this way, ease in comparison was successfully achieved. The selected studies were efficiently synthesized since tabulated information can easily be compared and contrasted. Likewise, in the matrix form, all significant items can be completely filled up and analyzed. C. Critical Analyses of the Reviewed Studies Selected a. Reliability To determine the reliability of the peer-reviewed researches, studies and meta-analysis, six literatures were selected and analyzed. Selection standards are based on the criteria of being the most recent and most relevant literatures. The information and data quality of each of the literatures were assessed. The content type of each literature indicates the reliability of the literatures. The large samples from sixty-six patients in the study by Munro, et al. (2006) on the oral health status and development of ventilator-associated pneumonia make findings reliable. The same is true with the paper by Pesola (2004) on the ventilator-associated pneumonia in institutionalized elders which makes use of big samples of literatures, making the study reliable. Reliability of the research conducted by El-Solh, et al. (2004) on the colonization of dental plaques is high. This is because the researchers were able to establish the relationship concerning dental plaque colonization and lower respiratory tract disease in hospitalized institutionalized elders through molecular genotyping. On the other hand, the meta-analysis by Pineda, et al. (2006) on the effect of oral decontamination with chlorhexidine on the incidence of nosocomial pneumonia makes use of randomized controlled trials – inferences can be generated about whether incidence of pneumonia dropped after oral decontamination with chlorhexidine. The large samples used in this study makes findings reliable. Ohrui (2005) suggests preventive strategies for aspiration pneumonia in disabled persons as a result of his study where nothing can be inferred about whether or not the provision of oral care results in decreased incidence of pneumonia. The degree of Rate of Incidence of pneumonia was not mentioned, hence, reliability is low. The same can be said in the case of Varela (2006) whose paper dealt with the role of oral care in preventing pneumonia. This was a cross-sectional study where nothing can be inferred yet about whether provision of oral care dropped pneumonia incidence. Specific indicator on the reduced incidence of pneumonia was not clear. Degree of decrease in pneumonia incidence is not clear. All of these, aside from the fact that small sample was used, makes the findings of Varela (2006) not very reliable. b. Validity The construct and content of each of the literature are indicative of its validity. Each study was reviewed in terms of its quality as well as its contribution to knowledge regarding oral care intervention on reducing pneumonia. The findings presented confirmed the validity of each. With regards to analysis of each literature, there are evidences found that support their validity. The observational studies demonstrated good external and internal validity. Although the data collection tool used by El-Solh et. al. (2004) contributed to their study's validity, the small sample size affected the information garnered. Validity was observed in the study by Pesola (2004), who made use of an overall study design that was appropriate to the study and contributed to its relevance. It also meta-analyzed big samples of literature which made the findings not only reliable, but valid as well. Pineda et. al. (2006) conducted a meta-analysis of randomized controlled trials, generating inferrences about whether or not the incidence of pneumonia can be decreased after oral decontamination with chlorhexidine. The study made use of a large sample size and came up with relevant information contributing to knowledge of the issue being discussed, making it a valid study. The study conducted by Munro et. al. (2006) made use of a small sample size consisting of only 66 patients which decreased the impact of its findings and conclusion; validity was compromised. Varela's (2007) study is very much relevant to the question/problem, but not much can be inferred from the study design used. c. Scientific Rigor The meta-analysis of Munro et al. (2006) shows how dental plaque provides a microhabitat for organisms and an opportunity for adherence of the organisms to either the tooth surface or other microorganisms. The authors explain that several researches proved that in critically ill patients, potential pathogens can be cultured from the oral cavity. These microorganisms in the mouth can be translocated and colonize the lung, thus resulting in ventilator-associated pneumonia. The importance of oral care in the intensive care unit has been noted in the literature, but little research is available on mechanical or pharmacological approaches to reducing oral microbial flora via oral care in critically ill adults. Most researches in oral care, according to Munro et al. (2006), have been directed toward patients’ comfort. However, the microbiological and physiological effects of tooth brushing in the intensive care unit have not been reported. Although two studies analyzed by Munro et al. (2006) indicated reductions in the rates of ventilator-associated pneumonia in cardiac surgery patients who received chlorhexidine before intubation and postoperatively, the effects of chlorhexidine in reducing ventilator-associated pneumonia in other populations of critically ill patients or its effect when treatment with the agent initiated after intubation have not been reported. In addition, no evaluation of the effectiveness of pharmacological and mechanical interventions relative to each other or in combination has been published, observes Munro et al. (2006). Pesola (2004) is another author who conducted a meta-analysis of existing literatures on the ventilator-associated pneumonia in institutionalized elders. Pesola’s meta-analysis specifically boils down to the results of the research conducted by El Solh et al (2004), since according to Pesola (2004) have added another piece to the pathophysiologic puzzle of how pneumonia develops by demonstrating that ventilator-associated pneumonia can originate from organisms in dental plaque. The meta-analysis gave the study scientific rigor by providing a study design that was appropriate to the study and the kind of data being analyzed. Meta-analysis is a procedure that makes use of output from different studies in one study. This process allows one to gauge the strength of the results of different studies, and then use these to determine the variability and similarity of the results. The findings by El-Solh, et al. (2004) suggest that aerobic respiratory pathogens colonizing DPs may be an important reservoir for HAP in institutionalized elders. Future studies are needed to delineate whether daily oral hygiene in hospitalized elders would reduce the risk of nosocomial pneumonia in this frail population. Results of the study by Pineda et al. (2006) revealed that the use of oral decontamination with chlorhexidine did not result in significant reduction in the incidence of nosocomial pneumonia in patients who received mechanical ventilation, nor altered the mortality rate. The lack of benefit may reflect the few studies conducted in this area. According to Ohrui (2005), pneumonia is the fourth leading cause of death despite the availability of potent new antimicrobials in Japan. Aspiration of oropharyngeal bacterial pathogens to the lower respiratory tract is one of the most important risk factors for pneumonia. Impairments in swallowing and cough reflexes among disabled older persons, e.g., related to cerebrovascular disease, increase the risk of pneumonia. Thus, strategies to reduce the volumes and pathogenicity of aspirated material should be pursued. Based on the paper by Ohrui (2005), both swallowing and cough reflexes are mediated by endogenous substance P contained in the vagal and glossopharyngeal nerves. Hence, pharmacologic therapy using angiotensin-converting enzyme inhibitors which decrease substance P catabolism can improve both reflexes. It can also result in the lowering of the risk of pneumonia. Similarly, since the production of substance P is regulated by dopaminergic neurons in the cerebral basal ganglia, treatment with dopamine analogs or potentiating drugs such as amantadine can reduce the incidence of pneumonia. Furthermore, Ohrui (2005) suggested that since mortality from infections correlates with cutaneous anergy, interventions that reverse these age-associated changes in the immune system are also effective. Varela (2006) published an article which mentions oral care as helping to prevent pneumonia. Varela mentions that providing oral care to ventilated patients should be considered a high priority. This study indicates that health care-associated pneumonia increases a patient’s length of stay in the Intensive Care Unit by approximately 6.1 days. However, ventilator-associated pneumonia accounts for sixty percent of all deaths due to hospital-associated infections. The CDC also suggests considering methods of non-invasive ventilation to reduce the risk of ventilator-associated pneumonia. Using oro-tracheal tubes rather than naso-tracheal tubes in patients who are mechanically ventilated has been found to reduce ventilator-associated pneumonia. d. Comparison of the studies’ strengths and limitations or weaknesses Strengths The strength of the study by Munro, et al (2006) on the oral health status and development of ventilator-associated pneumonia is that large samples are used. Having large samples such as this would result to more accurate outcomes. The same is the case with the research conducted by Pesola (2004) on the ventilator-associated pneumonia in institutionalized elders which reveals that big samples of literature used makes his findings reliable. The study by El-Solh, et al. (2004) on the colonization of dental plaques by examining the relationship concerning dental plaque colonization and lower respiratory tract disease in hospitalized institutionalized elders via molecular genotyping is strong. Advances in technology such as that in molecular genotyping add credibility to the study. The study may pave the path for forthcoming research to determine whether or not everyday oral sanitation in institutionalized aged would decrease danger of nosocomial pneumonia in hospitalized elders. The strength of the paper by Pineda, et al. (2006) on the effect of oral deconta- mination with chlorhexidine on the incidence of nosocomial pneumonia is that it makes use of randomized controlled trials. These facilitate for inferences that can be made. Likewise, the large sample size used in this study is one of its strengths. Large samples give ample amount of observations. The preventive strategies for aspiration pneumonia in disabled persons suggested by Ohrui (2005) makes this study strong. The same holds true in the case of the paper by Varela (2006) on oral care that helps prevent pneumonia. The sound recommendation given by Varela (2006) is that providing oral care for the ventilated patient can actually keep them from developing pneumonia. Weaknesses and Limitations The weakness of the study by Munro, et al. (2006) on oral health status and development of ventilator-associated pneumonia is that the relationship of oral health status with the degree of incidence of ventilator-associated pneumonia was not clearly discussed. Similarly, the weakness of the study by Pesola (2003) on ventilator-associated pneumonia in institutionalized elders is that it does not back up the study with sufficient quantitative analysis. El-Solh, et al. (2004) studied the colonization of dental plaques. The advancement of technology on molecular genotyping enhances the credibility of the study; however, this methodology does not define whether everyday oral sanitation in institutionalized aged would decrease danger of nosocomial pneumonia in hospitalized elders. The meta-analysis by Pineda, et al. (2006) adopts randomized controlled trials. One weakness of the study is that it employed only a single outcome measure. Future study related to that will include additional outcome data that will give more credible results. It is also a weakness that the randomized trial was limited to a relatively short time. Ohrui (2005) recommended preventive strategies for aspiration pneumonia in disabled persons. However, there is a weakness in terms of backing the recommendations with previously conducted experiments which resulted to significant quantitative data. This was a cross sectional study, however, so nothing can be inferred about whether provision of oral care result can decrease the incidence of pneumonia. The degree of rate of incidence of pneumonia was not mentioned. Varela (2006) concludes that oral care helps prevent pneumonia. This was a cross sectional study, therefore, nothing can be inferred yet about whether provision of oral care dropped pneumonia incidence. Specific indicator on the reduced incidence of pneumonia was not clear. Since small sample was used, this makes findings unreliable. The degree of decrease in pneumonia incidence is not clear as well. e. Relevance of the findings to the original problem The findings by Munro et al. (2006) on the oral health status and development of ventilator-associated pneumonia is relevant in this study since from their outcomes inferences can be generated whether it will result to low or high Clinical Pulmonary Infection Score after provision of oral health measures. These inferences are relevant to the current problem/issue. These can be a good support to the current study since large samples from sixty-six patients generated reliable findings by Munro et al. (2006). On the other hand, the results of Pesola's (2004) study on the ventilator-associated pneumonia in institutionalized elders strengthened the current study since the meta-analysis conducted by this researcher generated reliable findings. The outcomes of the study by El-Solh, et al. (2004) have strong relevance to the current study. This research by El-Sohl et al. (2004) also pave the way for forthcoming research like this current study to define whether everyday oral sanitation in institutionalized aged would decrease danger of nosocomial pneumonia in hospitalized elders. Likewise, Pineda, et al. (2006) give strength to the current study since the meta-analysis of randomized controlled trials conducted by Pineda et al. (2006) gives rise to inferences about whether incidence of pneumonia dropped after oral decontamination with chlorhexidine. Degree on the incidence of nosocomial pneumonia, mortality rate and the population of microorganisms found in pneumonia-inflicted patients were measured and duration of mechanical ventilation and intensive care unit length of stay controlled for. The cross-sectional study conducted by Ohrui (2005) resulted to an in-depth analysis on the development of pneumonia in disabled older people and suggestion that preventive strategies that may reduce the incidence of pneumonia among these subjects. Relevance to the problem/issue is strong. Another relevant cross-sectional research was facilitated by Varela (2006). Literature Review However, despite the extensive contributions of the above literatures on oral care intervention on reducing pneumonia, there are additional knowledge that are still needed in order to more comprehensively address the problem/issue. Discussed below are the relevant topics to be considered in this study for a broader literature search. These studies could also shed light on the problem/issue. Grap and Munro (2003) found that despite evidence that they are ineffective for plaque removal, sponge toothettes remain the primary tool for oral care, especially in intubated patients in intensive care units. This study will support the preventive strategies mentioned by Ohrui (2005). As a result of the findings by Grap and Munro (2003), the preventive strategy to support the suggestions of Ohrui (2005) should be to use the effective tool in plaque removal to better decrease the pneumonia incidence. Another study is by Schleder, et al. (2002) on the effect of a comprehensive oral care protocol on patients at risk for ventilator-associated pneumonia. Since other relevant studies were notably conducted below 2004, the year range of the publications to be considered in the current study will be adjusted to 2002 to present. D. Conclusions a. Conclusions that are supported about the problem Munro et al. (2006) conducted a meta-analysis of the literatures on oral health status and development of ventilator associated pneumonia. Based on the vast examination of literatures, Munro et al. (2006) concluded that oral health is influenced by oral microbial flora, which are concentrated in dental plaque. Pesola specifically notes that El Solh et al (2004) have added another piece to the pathophysiologic puzzle of how pneumonia develops by demonstrating that ventilator-associated pneumonia can originate from organisms in dental plaque. The findings by El-Solh, et al. (2004) suggest that aerobic respiratory pathogens colonizing DPs may be an important reservoir for HAP in institutionalized elders. Results of the study by Pineda et al. (2006) revealed that the use of oral decontamination with chlorhexidine did not result in significant reduction in the incidence of nosocomial pneumonia in patients who received mechanical ventilation, nor altered the mortality rate. Impairments in swallowing and cough reflexes among disabled older persons, increase the risk of pneumonia, hence, strategies to reduce the volumes and pathogenicity of aspirated material should be pursued, according to Ohrui (2005). One strategy is pharmacologic therapy. That is, both swallowing and cough reflexes are mediated by endogenous substance P contained in the vagal and glossopharyngeal nerves. Hence, pharmacologic therapy using angiotensin-converting enzyme inhibitors which decrease substance P catabolism can improve both reflexes and lowering the risk of pneumonia. Another strategy is treatment with dopamine analogs or potentiating drugs such as amantadine that can reduce the incidence of pneumonia. This can prove to be a sound strategy since the production of substance P is regulated by dopaminergic neurons in the cerebral basal ganglia. And since mortality from infections correlates with cutaneous anergy, interventions that reverse these age-associated changes in the immune system are also effective, recommends Ohrui (2005). In the paper by Varela (2006), the author concludes that oral care helps prevent pneumonia as indicated by studies revealing that health care-associated pneumonia increases a patient’s length of stay in the Intensive Care Unit by approximately 6.1 days. Varela (2006) further specifies that using oro-tracheal tubes rather than naso-tracheal tubes in patients who are mechanically ventilated has been found to reduce ventilator-associated pneumonia. b. Knowledge or information that is still needed to fully address the problem Future study should focus on several strategies of mechanical and pharmacological interventions. Additional studies are needed to develop and test best practices for oral care in critically-ill patients. c. Suggestions for further literature search to gain additional knowledge or information The next studies to be conducted are essential to delineate whether daily oral hygiene in hospitalized elderly would reduce the risk of nosocomial pneumonia in this frail population. Bibliography El-Solh, A.A., Pietrantoni, C., Bhat, A., Okada, M., Zambon, J., Aquilina, A. & Berbary, E. (2004). Colonization of dental plaques: a reservoir of respiratory pathogens for hospital-acquired pneumonia in institutionalized elders. Chest, 126, 1575-1582. Grap, M.J. & Munro, C. L. (2003). Oral Care Interventions in Critical Care: Frequency and Documentation. American Journal of Critical Care, 12: 113-118 Munro, C. L., Elswick, R.K., McKinney, J., Sessler, C.N. & Hummel, R.S. (2006). Oral health status and development of ventilator associated pneumonia. American Journal of Critical Care, 15, 453-460. Ohrui, T. (2005). Preventive strategies for aspiration pneumonia in disabled persons. Exp Med, 207, 3-12. Pesola, G.R. (2004). Ventilator-associated pneumonia in Institutionalized elders. Chest, 126: 1401-1403. Pineda, L.A., Saliba, R.G. & El Solh, A.A. (2006). Effect of oral decontamination with chlorhexidine on the incidence of nosocomial pneumonia: a meta-analysis. American Journal of Critical Care, 10, R35. Schleder, B., Stott, K & Lloyd, R.C. (2002). The effect of a comprehensive oral care protocol on patients at risk for ventilator-associated pneumonia. Journal of Advocate Health Care, Spr/Sum, 4(1):27-30. Varela, R. (2006). Oral care helps prevent pneumonia. RN.com., AMN Healthcare, Inc. Read More