Running head: ORAL CARE IN INTUBATED PATIENTS 1

The Use of Oral Care in Intubated Patients To Reduce Ventilator-Associated Pneumonia

Stefany A. Ramirez

James Madison University

ORAL CARE IN INTUBATED PATIENTS 2

Abstract

Ventilator-associated pneumonia (VAP) is one of the biggest leading causes of mortality in

critical care units (CCU). Research has shown that providing oral care in intubated patients can

help prevent VAP. The aim of this research paper is to determine what it the best way to perform

oral care. Toothbrushing with the use of chlorhexidine 0.12% and suctioning has proven to be

effective in the prevention of VAP.

Key Words: Ventilator-associated pneumonia (VAP), oral care, chlorhexidine, critical care unit

(CCU)
ORAL CARE IN INTUBATED PATIENTS 3

The Use of Oral Care in Intubated Patients To Reduce Ventilator-Associated Pneumonia

Ventilator-associated pneumonias (VAP) are a huge risk in the vented population. Every

time a patient gets intubated, there is a risk of them developing pneumonia. In many cases,

intubation cannot be prevented in a patient. However, VAP can be prevented if the patient gets

the proper care by staff. Every facility has its own protocols when it comes to preventing VAP.

Oral care in the vented population has been researched a lot. There are researchers that suggest

using chlorhexidine toothbrushing and suction to be the most effective way to prevent VAP. The

problem is that different hospitals perform oral care differently. There should be one universal

protocol in order to reduce VAP.

The question is what is the best way to provide oral care in patients that are intubated.

Working in a Critical Care Unit (CCU) at least half of the patients are ventilated making oral

care a critical task to reduce the incidence of VAP. This nursing problem is very interesting to

me because I work with a lot of patients that are intubated. I want to research what is the best

way to prevent VAP. I believe it is a very important topic because there is a lot of research that

contradicts itself regarding how oral care should be done.

Through evidence-based practice research, nurses can come together and create a

universal protocol to prevent VAP. This will increase the proper patient care and decrease the

risk of developing VAP in critical care units. According to researchers, VAP is the leading cause

of death in critical patients (Warren, Medei, Wood & Schutte, 2019). Not only does it affect the

patients care, it also affects the cost of the treatment (Warren et al., 2019). “The researchers

estimated that the average case of VAP costs more than $40,000,” (Warren et al., 2019). A

protocol will create an overall improvement in the hospitals therefore create better patient

satisfaction.
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Oral Health

Oral health is important in every human being. The oral cavity harbors an estimated

amount of seven hundred to 1000 different kinds of microorganisms (Munro, 2014). It is

believed that two hundred to 300 organisms are stable (Munro, 2014). However, there is

microbial flora that is very condensed in plaque (Munro, 2014). “Dental plaque is a biofilm

found on tooth surfaces, and plaque accumulation is enhanced by bacterial aggregation between

and among species,” (Munro, 2014). When a patient is intubated, there is a small amount of

saliva that is present. Since there isn’t enough saliva, the normal self-cleansing does not happen

and plaque thickens (Ory et al., 2017). The main pathogens that are present in VAP are

Staphylococcus aureus and Pseudomonas aeruginosa (Haghighi et al., 2016). It is important to

perform oral care because they can only be removed by using antimicrobial mouthwash and

brushing (Haghighi et al., 2016).

Risks

Patients are at risk of developing VAP due to having an “endotracheal tube, altered

sensorium, dry and open mouth, alteration in oro-pharyngeal flora, oral inflammation, impaired

mucociliary clearance, inhibition of cough response and micro aspiration of secretions,” (Chacko

et al., 2017). Having an endotracheal tube (ETT) present can affect the way oral care is

performed (Rabello, Araujo & Magalhaes, 2018). The environment that ETT presents, it is easier

for biofilm to be colonized (Rabello et al., 2018). It is important to decontaminate the oral cavity

in order to prevent the colonization of pathogens by decontaminating with an antiseptic or topical

antibiotic (Rabello et al., 2018). However, it is important to realize that antibiotics can induce
ORAL CARE IN INTUBATED PATIENTS 5

bacterial resistance (Rabello et al., 2018). Another risk of VAP is having an ETT be placed under

emergencies (Rabello et al., 2018). Since there is no prophylaxis before intubation, it causes

bacteria in the upper respiratory tract to be aspirated which can cause the development of VAP

(Rabello et al., 2018).

Chlorhexidine And Suction

The studies about using chlorhexidine in oral care are still being studied. The Centers for

Disease Control (CDC) suggests using chlorhexidine with a concentration of 0.12% for oral care

to prevent pneumonia (Rabello et al., 2018). “Tracheal suctioning is one of the most common

invasive procedures performed by nurses on ICU patients and is crucial to reducing the risk of

VAP,” (Letchford & Bench, 2018). Suctioning can through an ETT will get the secretions in the

lower respiratory tract that may have bacterial pathogens that can cause VAP (Letchford &

Bench, 2018).

Nursing Interventions

Although VAP cannot be completely prevented, there are a few nursing interventions that

nurses can do in order to prevent it. Nurses can work together with the doctors and respiratory

therapists to prevent VAP. One of the biggest interventions done by nurses is performing oral

care. Although oral care is still being studied it is important to prevent plaque buildup in order to

prevent bacteria to harbor in the oral cavity. Another intervention that nurses are able to perform

is how to position a patient. It is important to position a patient in the “semi-recumbent position

and have the head of the bed elevated,” (Khezri et al., 2014). This intervention prevents the

patient from aspiration. Nurses can also perform constant subglottic suctioning in order to

suction out any extra saliva that may contain bacteria to prevent it from being aspirated and

causing VAP (Khezri et al., 2014).

ORAL CARE IN INTUBATED PATIENTS 6

Analysis

The patients preferred in this study were intubated patients in CCU. The most common

information in the 8 articles reviewed, were that oral care played a huge role in the prevention of

VAP. Although the research done doesn’t come to a clear conclusion of how oral care affects

VAP, the researchers believe oral care is better than no care. All of the research reviewed

followed good ethical guidelines. They all got the proper consent from the patients and the

nurses to study this issue. Nurses are a great clinical expertise in this problem. Nurses in CCU

are the ones that are constantly taking care of intubated patients. They are the ones that see if

other nurses are performing the proper oral care and if the VAP interventions work.

Implications and Recommendations

There is an unfortunate amount of evidence-based practice that does not know whether

toothbrushing and suction is a better way of preventing VAP in intubated patients. “Significant

opportunities remain for development of strategies that improve nurses’ performance in

toothbrushing,” (Munro, 2014). It is unclear what policy and protocol is the best in order to

prevent VAP. Although there are a lot of policies to prevent VAP, only a few have been

confirmed to work (Khezri et al., 2014). “Many others must be further evaluated in large clinical

trials before definite recommendations can be made,” (Khezri et al., 2014). The overall

recommendation from evidence-based practice is to keep performing oral care based on the

individual protocols CCU provide (Khezri et al., 2014).

Conclusion
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Oral care is important in all patients whether they are intubated or not. The mouth harbors

a lot of bacteria that needs to be removed in order to prevent any of it to be aspirated. It is clear

that VAP is a very dangerous infection. “VAP is the most common nosocomial infection in ICU

and one of the leading causes of ICU mortality,” (Letchford & Bench, 2018). CCU patients

benefit from using oral chlorhexidine 0.12% to prevent VAP (Rabello et al., 2018). Research has

shown that using an oral antiseptic can help reduce the risk of VAP (Chacko et al., 2017).

Research has also shown that suctioning subglottic secretions is recommended to prevent VAP

(Letchford & Bench, 2018). Suctioning these secretions can help prevent them from being

aspirated and causing VAP. In conclusion, toothbrushing with chlorhexidine and suctioning

helps prevent VAP in the CCU setting.

ORAL CARE IN INTUBATED PATIENTS 8

References

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Haghighi, A., Shafipour, V., Bagheri-Nesami, M., Baradari, A. G., & Charati, J. Y. (2016). The

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Khezri, H. D., Zeydi, A. E., Firouzian, A., Baradari, A. G., Kiabi, F. H., & Moghaddasifar, I.

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