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The oral cavity is a proven source of hospital-acquired pneumonias (HAPs), including ventilator-associated pneumonia (VAP).1,2 Bacteria that cause nosocomial respiratory disease colonize the oropharyngeal area, including dental plaque.3-5 These pathogens can be aspirated into the lungs and cause infection.5 Meanwhile, comprehensive oral hygiene addresses three VAP risk factors—bacterial colonization of the oropharyngeal area, aspiration of subglottic secretions, and colonization of dental plaque with respiratory pathogens.1
“One of the most critical risk factors for ventilator-associated pneumonia is microbial colonization of the oropharynx.”6
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CDC Guidelines for Preventing Healthcare-Associated Pneumonia2,*
“…Develop and implement a comprehensive oral-hygiene program (that might include use of an antiseptic agent) for patients in acute-care settings or residents in long-term--care facilities who are at risk for health-care--associated pneumonia (II).
* In addition to other interventions.
AACN Procedure Manualfor Critical Care – Oral Care Interventions, 200512,*
“Assess oral cavity and lips every 8 hours, and perform oral care every 2 to 4 hours and as needed.† With oral care, assess for buildup of plaque on teeth or potential infection related to oral abscess.”
“Perform oral hygiene, using pediatric or adult (soft) toothbrush, at least twice a day. Gently brush patient’s teeth to clean and remove plaque from teeth.”†
“In addition to brushing twice daily, use oral swabs with a 1.5% hydrogen peroxide solution to clean mouth every 2 to 4 hours.”†
“With each cleansing, apply a mouth moisturizer to the oral mucosa and lips to keep tissue moist.”†
“Suction oral cavity/pharynx frequently.”††
* In addition to other interventions. † Level IV: Limited clinical studies to support recommendations. †† Continuous suctioning: Level II: Theory based, no research data to support recommendations; recommendations from expert consensus group may exist. Intermittent suctioning: Level IV: Limited clinical studies to support recommendations.
IHI Success Stories Featuring Oral Care for VAP Prevention
In its Five Million Lives Campaign, the IHI includes preventing VAP as one of its recommendations.11
View their success stories at here.
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Costly Consequences of VAP
Mechanically ventilated patients are 6 to 21 times more likely to develop a hospital-acquired pneumonia than non-vent patients.2 In fact, VAP is the most common infectious complication among ICU patients, accounting for over 47% of all infections.5 It occurs in 10 to 65% of ventilated critical care patients, with mortality rates as high as 70%.6 |
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Time Consequences7
9.6 additional days on mechanical ventilation
6.1 extra days in ICU
11.5 more days in the hospital
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Time, Mortality and Monetary Consequences8
Mean Length of Stay: 23 days
Mortality rate: 29.3%
Mean Hospital Charges: $150,841
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Non-Vent Patients Also at Risk8
Non-ventilated patients suffering from conditions including dysphagia, stroke, COPD, malignancy, renal or liver disease and dementia are also at increased risk for aspiration pneumonia.9,10 Enteral feeding also increases the risk. Consequences of hospital-acquired pneumonias are severe. These patients have been shown to suffer a mortality rate of 18.8%, have a mean length of stay totaling 15.2 days and mean hospital charges of $65,292.8
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| REFERENCES: 1. Schleder B, et al., J Advocate Health Care. 2002 Spr/Sum; 4(1): 27-30. 2. Tablan OC, et al., Guidelines for preventing health-care-associated pneumonia, 2003, Recommendations of CDC and Healthcare Infection Control Practices Advisory Committee (HICPAC), 2003. 3. Scannapieco FA, J Periodontology. 1999 Jul; 70(7): 793-802. 4. Fourrier F, et al., Crit Care Med. 1998; 26: 301-8. 5. Cason, CL, et al., Am J Crit Care. 2007 Jan; 16 (1): 28-38. 6. Sole, ML, et al., Am J Crit Care. 2002 Mar; 11(2): 141-9. 7. Rello J, et al., Chest. 2002 Dec; 122(6): 2115-21. 8. Kollef MH, et al., Chest. 2005;128(6): 3854-62. 9. Marik PE, N Eng J Med. 2001;344(9):665-71. 10. Kozlow JH, et al., Crit Care Med. 2003;31(7): 1930-7. 11. Getting started kit: prevent Ventilator-Associated Pneumonia, how-to guide. Protecting 5 Million Lives From Harm Campaign, Institute for Healthcare Improvement. 2006 Dec. 12. Scott JM,Vollman KM, Endotracheal tube and oral care. In DJ Lynn-McHale Wiegand and KK Carlson (Eds.) AACN Procedure Manual for Critical Care, Fifth Ed., pp. 28-33., Elsevier Saunders, St. Louis, MO. 13. Merriam-Webster’s Medical Dictionary. Retrieved July 3, 2007, from http://dictionary.reference.com/browse/biofilm. 14. Immunology of Biofilms. Immunology and Immunotherapy Program, Center for Integrative Biology and Infectious Diseases, Natl. Institute of Dental and Craniofacial Research, NIH, Bethesda, MD, 2004. 15. Kuramitsu, H. “Oral Microbial Communities: Genetic Analysis of Oral Biofilms.” Strict and Facultative Anaerobes: Medical and Environmental Aspects. Ed. Nakano, M. Horizon Bioscience, 2004. 109-111. 16. Campbell DL, Ecklund MM. Development of a research-based oral care procedure for patients with artificial airways. NTI News (a publication of AACN’s National Teaching Institute). 7 May 2002. 17. Oral Health Care Drug Products for Over-the-Counter Human Use; Antigingivitis/Antiplaque Drug Products; Establishment of a Monograph; Federal Register, 68(103):32232-87. 18. Oral Health Care Drug Products for Over-the-Counter Human Use; Tentative Final Monograph; Federal Register, 53(17): 2436-61. |
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