How effective are oral hygiene measures for preventing pneumonia in critically ill people on ventilators?

Ventilator‐associated pneumonia (VAP) is a lung infection. It develops in patients who are on artificial breathing machines (ventilators) in hospitals for more than 48 hours. Often, these patients are very ill – they may have had a heart attack or stroke, a serious accident, or major surgery. They may be unable to breathe on their own because they are unconscious or sedated while they receive treatment. Ventilators supply patients with oxygen through a tube placed in the mouth or nose, or through a hole in the front of the neck. If germs enter through the tube and get into the patient’s lungs, this can lead to VAP. VAP is a potentially very serious complication in patients who are already very ill. It can cause worsening health and increases patients’ risk of dying.

Keeping a patient’s mouth clean and free of disease could help to prevent VAP. Oral hygiene care includes mouthwash, antiseptics, using swabs to clean the mouth, toothbrushing and tools like suction devices, which suck away fluid from the mouth. These measures can be used on their own or combined.

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Chlorhexidine may reduce the risk of ventilator-associated pneumonia in patients treated in intensive care units

CCUCritically ill people, who may be unconscious or sedated while they are treated in ICUs, often need to have machines to help them breathe (ventilators). The use of these machines for more than 48 hours may result in ventilator-associated pneumonia (VAP). VAP is a potentially serious complication in these patients who are already critically ill. Oral hygiene care, using a mouthrinse, gel, toothbrush, or combination, together with breathing-in of secretions, may reduce the risk of VAP in these patients. Continue reading

Review of the month: critically ill patients can benefit from improved oral health

vap

C Cambridge University Hospitals NHS Foundation Trust

Critically ill people who need machines to help them breathe are at high risk for developing chest infections and pneumonia. This is known as ventilator-associated pneumonia, or VAP. Can a programme of oral care (such as mouthwashes, toothbrushing) help to prevent this life-threatening condition?

What was the research?

A systematic review of the evidence to find out whether oral health care can reduce the likelihood of a patient in intensive care on a ventilator developing pneumonia.

Who conducted the research?

The research was conducted by a team led by Zongdao Shi on behalf of the Cochrane Oral Health Group. Huixu Xie, Ping Wang, Qi Zhang, Yan Wu, E Chen, Linda Ng, Helen V Worthington, Ian Needleman and Susan Furness were also on the team.

What evidence was included in the review?

Data was extracted from 35 randomised controlled trials. A total of 5,374 patients participated in the trials. The trials looked at:

  1. Chlorhexidine antiseptic mouthrinse or gel compared with a placebo or usual care.
  2. Toothbrushing compared with no toothbrushing
  3. Powered compared with manual toothbrushing
  4. Oral care with other solutions.

Participants were all critically ill and needed assistance from hospital staff, who administered the oral care.

What did the evidence say?

The review found that chlorhexidine administered as a mouthrinse or gel reduces the odds of VAP by 40%. For every 15 people in hospital in intensive care, use of oral hygiene including chlorhexidine will prevent one person developing VAP. There was no evidence that chlorhexidine makes a difference to the numbers of patients who die in intensive care, or the length of their stay in the intensive care unit. There was no evidence that toothbrushing or oral care without toothbrushing affected the risk of developing VAP. Two studies showed some evidence of a reduction in VAP with povidine iodine antiseptic mouthrinse. There was not enough evidence of the effects of other oral care solutions, such as water, saline or triclosan.

How good was the evidence?

Only 14% of the studies included in this review were well conducted and described. Almost half of the included studies were at high risk of bias.

What are the implications for intensive care staff and the general public?

Effective oral hygiene care is important for ventilated patients in intensive care to reduce ventilator-associated pneumonia. There is evidence from this review that oral hygiene care incorporating chlorhexidine mouthrinse or gel is effective in reducing the development of ventilator-associated pneumonia in adult patients in intensive care. The definition of oral hygiene care varied among the studies included in this review but common elements include cleaning of the teeth and gums with a swab or gauze, removing secretions using suction and rinsing the mouth.

What should researchers look at in the future?

Although the included studies provided some evidence of the benefits of oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia, incomplete reporting of studies is a major limitation. Further trials of oral hygiene care (including use of manual or powered toothbrushes, or swabs) should report both measures of effectiveness of plaque removal and prevention of ventilator-associated pneumonia.

Link

Shi Z, Xie H, Wang P, Zhang Q, Wu Y, Chen E, Ng L, Worthington HV, Needleman I, Furness S. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD008367. DOI: 10.1002/14651858.CD008367.pub2.

New publications from the Cochrane Oral Health Group

CCUIssue 8 of the Cochrane Library for 2013 has been published, and features two new reviews and one new protocol from the Cochrane Oral Health Group.

Follow the links for more information!

New review
Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia
by Zongdao Shi, Huixu Xie, Ping Wang, Qi Zhang, Yan Wu, E Chen, Linda Ng, Helen V Worthington, Ian Needleman, Susan Furness

Ventilator associated pneumonia is a potentially serious complication in patients who are already critically ill. This new systematic review looks at whether keeping the mouth and teeth clean and preventing the build up of plaque on the teeth helps to reduce the risks. 35 randomized controlled trials were included, involving 5,374 participants. The review found that chlorhexidine mouthrinses or gels reduces the risk of ventilator-associated pneumonia by 40% but there was not enough research information available to provide evidence of the effects of other mouth care rinses such as water, saline or triclosan.

New review
Interventions for the management of dry mouth: non-pharmacological interventions
by Susan Furness, Gemma Bryan, Roddy McMillan, Helen V Worthington

This new review looks at non-drug treatments used to stimulate saliva production for the relief of dry mouth. Nine clinical trials were included in the review, and they covered treatments including acupuncture, electrostimulation and powered toothbrushes. 366 people participated in the trials. The review found that the evidence was generally of poor quality.

New protocol
Hypnosis for alleviation of anxiety in adults undergoing dental treatment
by Catherine Potter, Paul Coulthard, Richard Brown, Tanya Walsh

This is a protocol for a new Cochrane Oral Health Group review, which will consider the effects of hypnosis (with or without conscious sedation) in reducing anxiety in dental treatment.

Other highlights of the Cochrane Library, Issue 8, 2013 include:

Three new editorials:

Highlighted reviews: