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Research paper on ventilator associated pneumonia. Featured

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Research paper on ventilator associated pneumonia.

PICO QUESTION: What best practices would be necessary to prevent ventilator associated Pneumonia in patients under mechanically ventilated adult ICUs using oral care (teeth brushing and toothetes) or antiseptic agents (chlorhexidien gluconate).



Title and date


Design and research methods

Setting and sample

Measurements and Outcome


Level of evidence

Dallas, J., & Kollef, M., (2010)

Oral decontamination to prevent ventilator-Associated Pneumonia. Is it sound strategy?

Determination of whether or not  using oral decontamination is an effective strategy in the prevention of Ventilator associated Pneumonia


SDD comparison using cross over design, randomized. placebo


Research design

Using selective

Digestive decontamination:

Antimicrobial paste application on oropharynx, non absorbed oral antibiotics decontamination gastrically and gram-negative organisms use on parenteral antibiotics


ICU patients


Sample:152 patients in randomized samples


Examination of oral decontamination in VAP patients



Chlorhexidine is effective in VAP prevention when the patient is in cardiothoracic ICU

For non cardiothoracic patients, the effectiveness of chlorhexidine requires higher concentrations

Ventilator associated Pneumonia is dependent on the presence of microbial pathogens to gain access to the lower respiratory tract


Preventing VAP occurs with the interception of such pathogen colonization


Ideal VAP prevention measure must be cost effective and safe while limiting the promotion of resistance to microbial resistance


Fields, L., (2008).



Oral care intervention to reduce incidence of ventilator associated pneumonia in the neurologic intensive care unit

Supporting the fact that a combination of oral care with timed tooth brushing combined with VAP bundle can mitigate and prevent VAP occurrence in  ICUS.


Randomized control groups


Research method:

Tooth brushing done after every eight hours for a sample of about 200 patients



Patient found in medical ICU with 24 beds


Sample: 200



Tracking VAP episodes by infection control nurse

Ventilator day listing for respiratory therapy

VAP is preventable with interventions by nursing intervention evidence alone not forthcoming



Using oral care involving tooth brushing with toothetes and tooth paste saved not only lives but also money


Koe6man, M.,  et al. (2006)


Oral decontamination with Chlorhexidiene reduces the incidence of VAP






Determination of oral decontamination with CHX on VAP establishment

randomized, double-blind, placebo-controlled trial


three arms of the oral care: CHX, CHX/COL, and placebo (PLAC).

Each group received one of the treatments:

130 patients received PLAC, 127 patients received CHX 128 patients received CHX/ COL


385 patients observed.

No patient in need o consecutive mechanical ventilation within 48 hours was included



Patients used were those with VAP and were randomized from February to March in 2003


All patients had comparable baseline characteristics




Of the 385 patients, six were discontinue; five cases: one  in placebo, two in CHX and two in CHX/COL patients were also discontinued for patients’ refusal to use oral paste.

Due to tongue edema one patient was also withdraw from the study

373 patients pushed through the study

VAP occurs is linked to patients increased morbidity and mortality


Basically, using CHX or CHX/COL for oral decontamination reduces VAP instances


Munro, C., et al (2009)


Chlorhexidie Tooth brushing, and preventing ventilator associated pneumonia in critically ill adults



Examination of the effects of tooth brushing or mechanical pharmacological topical oral plus tooth brushing and chlorhexidine oral care

Three ICUS

Randomized controlled


Adults 547assigned 1-4 treatments

0.12% solution chlorhexidine oral swab twice daily, tooth brushing thrice daily, both tooth

brushing and chlorhexidine, or control (usual care).


No specific setting


Sample 547 adult patients


VAP determined using CPIS


249 patients remained on day three

Chlorhexidine patients were without pneumonia

Chlorhexidene minimized early instances of VAP for patient  with no baseline pneumonia


One risk factor or VAP was invasion of orypharynx by potential pathogens like staphylococcus aureus



Munro, C., & Grap, M., ()2004)



Oral health and care in intensive care Unit: state of science


Description of oral health in critically ill patients reviewing existing research that relates oral health with nosocomial pneumonia in ICUs


Review of existing research on oral care interventions


Research methods:

Article reviews

Sample : VAP patients in ICUs


Setting: not specialized but include patients in hospitals and at home


Effects of using antibiotics during interventions

Pharmacological oral interventions


Outcomes: health of critically ill patients is greatly improved by proper oral hygiene which reduces incidents of VAP occurrence

Oral hygiene in critically ill patients does not only improve their conditions but also increase their comfort as they live with no fear of VAP




Scannapieco, F., (2006).



Pneumonia in non-ambulatory patients

Determination of the role played by bacteria and oral hygiene to the spread of pneumonia


Randomized review of articles


Research method:

Review of laboratory studies, clinical trials and article reviews

Setting: no specific setting as information was included from different resource in order to compile the truth in the relationship between oral hygiene and pneumonia



Included articles of clinical trials, review articles and laboratory studies


Colonization of respiratory pathogens on biofilm. Colonization of respiratory pathogens as a result of antibiotic use



Interventions to colonization include chlorhexidine rinse

Chlorhexidine gel, and tooth brushing, tropical disinfectants,

Evidence demonstrates there being a relationship between poor oral health and bacterial pneumonia as well as oral microflora for institutionalized VAP patients


Adequacy of oral disinfection using chemotherapeutic agents only is not determined




Summary and conclusion
In this paper, the discussion focuses on investigating the best way one as a nurse or medical practitioner can use in order to prevent the spread of ventilator associated pneumonia for patients under mechanical ventilator in the ICUs. The paper explores how using oral care through tooth brushing, to such patients is of greater effect compared to the use of antiseptic agents like Chlorhexidien gluconate.


The article by Dallas and Kollef  (2010) is set to identify whether or not the use of oral decontamination is necessary in the prevention of the ventilator associated pneumonia. In the article, ventilator associated pneumonia develops as a result of the presence of microbial pathogens which have the access to the lower respiratory tract. For the intubated patients such pathogens originate from the upper respiratory tract. The main aim of decontamination as argued by Dallas and Kollef is the fact that method used must be cheap, safe and one that limits the development of resistance by the microbial. The most common method to meet those needs is the oral decontamination although silver coated endotracheal tubes is just one of the available alternatives although it is expensive.

From Koeman et all (2008), the article points out that the use of chlorhexidiene in oral decontamination is the best way to prevent the occurrence of ventilator associated pneumonia or VAP using a randomized placebo controlled trial. As a matter of fact, from the 385 patients, observed three divisions were made. Out of these three groups, only the one where the patients used CHX or CHX/COL was observed to have a significant reduction in the occurrence of incident VAP. This paper begins by identifying VAP as the most common infections through the nosocomial just after the UTI or the Urinary track infection. Since patients under such conditions require the use of antibiotics and this incurs measurable costs. The best oral care method in this article has been identified as use of antiseptic like chloehexidine.

Munro et all (2009) on the other hand recommends that critically ill mechanically ventilated patients need oral care using tooth brushing or using chlorhexidine. In this article the objective that comes out is the comparison of tooth brushing, using pharmacological antiseptics and finally the combination of the two. For the clinically ill patients, the use of chlorhexidine was the only one capable of reducing incidents of ventilator associated pneumonia. Munro et all (2009) identified that VAP had very many risk factors with the list including the failure of staff to wash hands, previous therapy using antibiotics, and spine positioning with no elevation of the backrest.

From Munro and Grap, the act of orally taking care of mechanically ventilated patients in ICUs is an issue that has received much care and attention by several researchers. From all of the resources observed each of the researchers independently identifies that there is an association between oral health and the presence of nosocomial pneumonia in ICUs.

Scannapieco (2006) investigates the role played by oral bacteria and oral hygiene by investigating different articles by different authors concerning the relationship between low level oral health persons and the oral pathogenic pneumonia. In this paper, the group of patients analyzed is one that is under care in a health institution.

In this article, tooth first dentures leaving some surfaces exposed to oral biofilms which in return allow the respiratory pathogens to colonize the teeth causing the mechanically ill patient to remain prone to VAP. Despite viewing a variety of laboratory studies, review of articles and clinical trials, all findings indicated that there was a relationship that existed between oral care and the prevention of VAP in mechanically ventilated patients in ICUs. However, in stead of having this patients use or depend on antibiotics to avoid the spread of VAP, the articles unanimously agree that by using the oral care like teeth brushing and antiseptics like chlorhexidine were recommended by many making it possible to prevent VAP for ICU patients heard.


To conclude, there is need to point out that oral health care is a vital element of consideration for patients under the ICU management suffering from mechanically ventilated patients. This is because the failure to do so would mean that patients in the ICU may suffer from incidents of pneumonia arising from one person to the next. VAP is a leading cause of death from nosocomial infections. In the US, VAP is the most common nosocomial infection. When it comes to the risk factors in mechanically ventilated patients, VAP risk is increased by about six fold to 21 fold and at least 10 to 25 percent of all these patients are infected by this disease.

The reason why the disease should be looked at with lots of care and concern is because the presence of this disease increases costs, length of stay in hospital and rates mortality. Identifying a good, effective and cost reductive way of dealing with the problem is an idea openly welcome. There are many ways but taking oral health care more seriously is on good and effective way especially where oral care involves tooth brushing on an 8 hour interval. This means brushing teeth thrice a day for the mechanically ventilated patients in ICUs

Of the two oral cares on mechanically ill patients, it is clear that the best method in delaying or preventing VAP development is Chlorhexidine applied Q6H to buccal cavity. Ithis antiseptic was also identified as a cost effective strategy for VAP prevention. However, mechanical oral care where tooth brushing is concerned identified decreased risk and incidents of VAP in ICU patient. Tooth brushing set three times a day or once in every shift of nursing resulted to VAP onset delayment. This is because tooth brushing using Q8H regimen saw VAP rate drop to zero making it the most effective way to removing dental plaque that occurred as a result of dented teeth


Dallas, J., & Kollef, M., (2010). Oral decontamination to prevent VAP. Chest Journal. Vol. 135. Iss. 5 p. 1116-1118

Fields, L., (2008). Oral care intervention to reduce VAP incidents in ICUs. AACN journal.

Koeman, M. et all. (2006). Oral decontamination. Journal of respiratory and critical care medicine. Vol, 173. P. 1348-1355.

Munro, C., et all. (2009). Chlorhexidine tooth brushing and preventing VAP. AACN Journals. Vol. 18. Iss. 5 P. 428-437

Munro, C. & Glad, M., (2004). Oral Health and care in ICUs. American Journal of critical care. Vol. 13. Iss.1 P. 25-34

Scannnapieco, F., (2006). Pneumonia in non ambulatory Patients. Journal of American Dental association. Vol. 137. Iss. 2. P 215-255.


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