Oral Hygiene and Chlorhexidine in Ventilated ICU Patients Report

This report examines the critical role of oral hygiene in preventing ventilator-associated pneumonia (VAP) among patients in intensive care units (ICUs) who are on mechanical ventilation. The introduction highlights VAP's prevalence, mortality rates, and associated costs, emphasizing the significance of oropharyngeal colonization and aspiration. The report presents a PICO question to guide the investigation of the efficacy of chlorhexidine oral rinse in minimizing VAP. A literature review synthesizes research on VAP's epidemiology, risk factors, and the importance of oral decontamination. The report then critically appraises a randomized controlled trial investigating the effects of 0.2% and 2% chlorhexidine on oropharyngeal colonization and VAP in ICU patients. The study's methodology, including patient inclusion/exclusion criteria, intervention protocols, and outcome measures (CPIS score, oropharyngeal cultures, etc.), is detailed. The findings of the study, which is not fully included in the provided text, would be analyzed to determine the impact of chlorhexidine on VAP incidence and oropharyngeal colonization. The report concludes by discussing the implications of the research for clinical practice and future research directions in oral hygiene protocols for ventilated ICU patients.

Running head: 1 ORAL HYGIENE IN VENTILATED PATIENTS (ICU)
Oral Hygiene in Ventilated Patients (ICU)
Name
Institution

ORAL HYGIENE IN VENTILATED PATIENTS (ICU)
Oral Hygiene in Ventilated Patients (ICU)
Introduction
VAP is a subcategory of clinic-received pneumonia, which affects sick people under MV
by way of a tracheostomy or endotracheal tube for at minimum forty-eight to seventy-two hours.
This form of pneumonia affects nine to twenty-seven percent of patients in the ICUs. In the
USA, the expenditure is two billion dollars yearly and nearly thirty thousand to forty thousand
dollars per case (Berry et al. 2017). The rate of mortality for VAP varies from twenty to seventy
percent. VAP intensifies the duration of hospital stay and mechanical ventilation. It is also liable
for fifty percent of the antibiotics recommended in the ICUs.
The most significant method in VAP development is the unstopping micro-aspiration of
oropharyngeal colonization into the tract of respiration that is found at a lower level. A day
following a sick person’s entry to the ICU, common oropharyngeal flora adjusts into pathogens
that are gram negative that elevate the plaque of the teeth. Plaques are conducive conditions for
the accumulation together with the growth of pathogens. Moreover, the tracheal tube may
function as a channel for the pathogens of the oral cavity to the lungs (Woodrow. 2017).
Numerous research have demonstrated a relation between respiratory pathogens and dental
plaque colonization. The occurrence of VAP is minimized through improving prevention
methods and by identifying the risk factors. Currently, the rate of mortality of VAP has been
projected at about nine to thirteen percent.
My PICO
Population: Adult population in the ICU with a mechanical ventilator.
Intervention: Oral topical decontamination

ORAL HYGIENE IN VENTILATED PATIENTS (ICU)
Comparison: No standard oral care or solution.
Outcome: Minimize ventilated related pneumonia among adult patients in the ICU with a
mechanical ventilator.
Answerable Question
Answerable question: What is the efficacy of oral rinse with 0.2 percent and 2 percent
chlorhexidine on oropharyngeal in minimizing the prevalence of ventilator related pneumonia?
The answerable question was developed by first identifying the population who are adult
patients in ICU with a mechanical ventilator. Secondly, I came up with the intervention that is to
reduce the likelihood of contracting pneumonia amongst patients at the adult stage with a
mechanical ventilator. Then thirdly, a comparison is made, which is then followed by the
outcome of the intervention. Finally, an answerable question is formulated that comprises of the
above-stated parts.
Literature
VAP carries on to cause difficulties to the rate of eight to twenty-eight percent of patients
getting mechanical ventilation (Morris et al. 2017). In divergence to infections of more often
engaged organs (for instance urinary and skin tract), in which death is little, varying from one to
four percent, the level of mortality for VAP varies from twenty-four to fifty percent and can get
to seventy-six percent when infection of lung is caused by some pathogens of high risk or in
some specific settings. The leading organisms liable for infection are Staphylococcus aureus,
Enterobacteriaceae and Pseudomonas aeruginosa, though etiologic agents extensively vary in
accordance to the patient's population in an intensive care unit, prior antimicrobial therapy, and
duration of hospital stay (Heo et al. 2018). Since suitable antimicrobial therapy of a patient with

ORAL HYGIENE IN VENTILATED PATIENTS (ICU)
VAP substantially enhances results, more accurate selection of microbial agents and rapid
identification of infected patients represent crucial clinical targets. Notwithstanding the major
developments in strategies for the supervision of sick people who rely on a ventilator and the
regular utilization of useful methods to clean respiratory tools, VAP continues to set hurdles to
the course of eight to twenty-eight percent of the patients getting mechanical ventilation (Rello et
al. 2017). Pneumonia rates are noticeably greater among hospitalized patients in the ICU
contrasted with those in wards of the hospital, together with the threat of pneumonia is
intensified by three to tenfold for the patients who are intubated and are getting mechanical
ventilation.
The current review is based on an assessment of the literature, chosen through a
computerized MEDLINE search from the year 1980 to the year 2001. Consensus statements,
review articles, and the references cited were also contemplated in this attempt to revise the
present knowledge on the analysis, epidemiology, and therapy of VAP (Jones et al. 2014). Since
the Practice for Hospital Infection, Advisory Committee of the Centers for Disease Prevention
and Regulation published up-to-date and extensive suggestions for the deterrence of nosocomial
pneumonia in 1997 and other comprehensive reviews are also available.
Correct data on VAP epidemiology are constrained by the lack of harmonized criteria for
its diagnosis. Theoretically, VAP is described as the inflammation of the lung parenchyma
instigated by agents that are infectious incubating or absent at the time the MV initiation
(Fourrier et al. 2015). Notwithstanding the clearness of this conception, the last 3 decades have
seen the advent of several definitions of operation, which none is accepted universally. In focal
areas of the lobe, pneumonia may fail to be seen, microbiologic research may be negative
notwithstanding the existence of inflammation in the lung and practitioners may differ

ORAL HYGIENE IN VENTILATED PATIENTS (ICU)
concerning the discoveries. The nonexistence of a ‘gold standard’ remains to bring
disagreements concerning the relevance and adequacy of many studies in this field.
Persistent (greater than forty-eight hours) MV is the most significant element linked with
nosocomial pneumonia. Nevertheless, VAP may take place with the initial forty-eight hours after
intubation. Since the princeps research by coworkers and Langer, it is normal to differentiate
premature onset VAP that takes place all through the initial four days of MV, from delayed-onset
VAP, that advances 5 or more days after the start of MV (Sona et al. 2019). Not only are the
pathogens that cause the disease usually different, but the prognosis is ideal in premature-onset
than late-onset VAP and the disease is normally less severe.
Wide-Scale 1-point prevalence research of pneumonia beginning in the intensive care
unit was undertaken on April 29, 1992, in one thousand four thousand and seventeen intensive
care units. Accumulation of ten thousand and thirty-eight patients was examined: two thousand
and sixty-four (twenty-one percent) had intensive care unit gotten infections, including
pneumonia in nine hundred and sixty-seven (forty-seven percent) patients, for a general
nosocomial pneumonia prevalence of ten percent. In that research, regression analysis for the
logistic recognized MV as one of the seven factors of risk for the intensive care unit –acquired
infections (Dennesen et al. 2013). Another wide-scale research, undertaken in one hundred and
seven intensive care units showed a crude rate of pneumonia of nine percent, in that research,
Mechanical ventilator was linked with a three-fold greater threat of advancing VIP than that
examined by for non-ventilated patients. On the grounds of their assessments of general rates of
nosocomial pneumonia, ten-fold greater occurrences were reported.

ORAL HYGIENE IN VENTILATED PATIENTS (ICU)
Critical Appraisal
My selected article for this research is, Randomised Controlled Trial to critiquing
ORIGINAL research article: “The effects of oral rinse with 0.2% and 2% chlorhexidine on
oropharyngeal colonization and ventilator associated pneumonia in adults' intensive care units”.
The current randomized clinical trial was intended to implement and design a protocol for oral
care and contrast the results of two diverse intensities of chlorhexidine on minimizing VAP and
colonization of oropharyngeal in the midst of hospitalized people in hospital in the ICUs of
Shahid Rajaee together with Nemazee clinics. The criteria of inclusion for the research
comprised patients aged eighteen years or above, not paining from irritation of the trauma or oral
mucosa to the mouth and at the influence of MV for at merely forty-eight hours. Others include
not paining from burn damages, not possessing a narration of hypersensitivity towards
chlorhexidine, being let in to the ICU for once, not possessing disorders of immunity led by
illness or medication, not being pregnant and not paining from damages due to burns. Admission
of those who are sick was because of surgery, trauma, medical, neurological, or neurosurgical
challenges. The projected occurrence of VAP in the ICUs was about fifteen to twenty-two per
one thousand period of mechanical ventilation. Primarily, written enlightened agreement was
gotten from every sick person’s legal or relative guardian (due to the sick person consciousness,
which is at a low level). The sick persons were then erratically allocated to 2 groups of 0.2
percent and 0.2 percent chlorhexidine in accordance to a randomization, which is computer
generated. Sick persons, that had aspiration, which is noticeable, were identified with
thrombocytopenia together with the likelihood of blood loss because of oral care, or had globally
normalized ratios above two, were exempted from the research.

ORAL HYGIENE IN VENTILATED PATIENTS (ICU)
CPIS (Clinical Pneumonia Infection Score) examined the occurrence of VAP occurrence
of VAP. We also contemplate the adjustment in drug treatment by intensivists at ICUs. The Beck
of mucosal-plaque together with oral examination scale was utilized to examine the status of oral
cavity. Moreover, tracheal and oropharyngeal colonization were examined by partially
measurable culture APACHE 4 was utilized to examine the gravity of the infection at the time of
the initial twenty-four-hour of admission in ICUs. This experiment addressed a focused issue of
oral care ventilated sick persons in ICUs. The assignment of patients to treatments was
randomized. The practitioners conducted random patient treatment and the allocation sequence
was not hidden from patients and researchers. Sick persons, workers in the health section and
research staff were not blind to therapy. All the groups were involved in the treatment of the
disease. In the beginning, the researcher looked at all guidelines and protocols associated with
oral care from 2003 forward. Afterward, numerous gatherings of the team were arranged with an
intensivist, an expert in microbiology, two individuals of faculty from the Nursing School, a
specialist in periodontal infection, a specialist in communicable ailment, two ICU nurses, a
medical pharmacist, and ICU and control managers for infections.
In the subsequent phase, a dental practitioner coached the investigator in the utilization of
the tools for oral examination. In the presence of the assistant and the investigator for five
individuals that are sick upon reaching undertook oral care plus oral assessment. The patient’s
information on demography was gathered by means of consultations with the patient’s medical
and families’ records. The investigator finalized the checklist in accordance to the CPIS by
examining the flowsheets of the sick person with collaboration. In instances where the
accumulated CPIS monia, the sick persons’ outcomes of the tracheal culture were assessed, just
in case of constructive culture outcomes, the patient was exempted from the research. People that

ORAL HYGIENE IN VENTILATED PATIENTS (ICU)
are sick who are non-intubated allowed in the ICU who necessitated mechanical together with
intubation ventilation for more than forty-eight were also researched. As soon as entrance in the
ICU was undertaken, a culture of the oropharyngeal discharges was afterwards seized, the throat
suction utilizing an applicator that is sterile, which was retrieved from the examination room. A
culture of the tracheal tube was also gotten by means of tracheal tube aspiration and the BAL
tube. The two tests were sent to the laboratory and conserved in normal saline. The tests of the
tracheal were cultured on the EMB, Chocolate, Thioglycollate and Blood in the examination
room and were incubated for period of twenty-four hours under thirty-seven degrees centigrade.
In instances of growth of bacteria spotted with particular biochemical tests after twenty-four-
hour of incubation at thirty-seven degrees centigrade, the type of bacteria was ascertained. In the
event of development of bacteria, the tests were reincubated and the kind of the bacteria was
established utilizing a table.
The investigator gathered the information of the patient utilizing the checklist of CPIS
daily and for instance, their scores were above or equal to 0.6 an X ray of the chest was taken.
Furthermore, secretions from the tracheal tube culture were forwarded to the examination room
for a diagnosis, which is definite. Oral care examination and protocol of the sick persons for the
incidence of VAP were conducted until forty-eight hours after the exclusion of the tracheal tube,
detection of an aspiration that is common, the occurrence of pneumonia, discharge from the
hospital, allergic reactions to chlorhexidine solution, death or twenty-eight days. In the current
research, the result measures comprised of period of MV (days), timespan of ICU delay,
mortality rate in the ICU, ventilator free-days at day twenty eight, the consequence of oral rinse
with 0.2 percent and two percent chlorhexidine on the degree of VAP and oropharyngeal
colonization, and undesirable outcomes of chlorhexidine (Nieszkowska et al. 2015). The

ORAL HYGIENE IN VENTILATED PATIENTS (ICU)
information was inserted into SPSS, and examined utilizing the test of chi-square, Mann –
Whitney U test and the t-test. A figure of p less than 0.05 was contemplated to be significant
mathematically. The information was displayed as mean plus or minus Standard deviation or
interquartile range plus median. At the time of the 5-month research period, four hundred and
fourteen sick people were let in to the hospial under research; however, two hundred and ninety-
seven were exempted.
Discussion
Minimizing VAP via oral care is key to preventing the increase of bacteria that are
defiant to an antibiotic. In the current research, two percent chlorhexidine was selected since
prior research demonstrated that this intensity was greatly useful compared to other
concentrations in extreme threat sick individuals and demonstrated good action in opposition to
multi-drug defiant bacteria in the environment of the laboratory (Bigham et al. 2019). The
current research demonstrated that the greater intensity of chlorhexidine (two percent) was useful
in minimizing the occurrence of VAP. These results are constant with those of Koeman (2016),
and Tantipong (2018). Tantipong (2018) conveyed that the occurrence of VAP was 4.9 percent
in the chlorhexidine band and 11.4 percent in the saline band. Additionally, Koeman (2016)
stated that the occurrence of VAP in chlorhexidine, placebo, and chlorhexidine classes was ten
percent (n=13), eighteen percent (n = 23), and thirteen percent (n=16), correspondingly. The
outcomes demonstrated that two percent chlorhexidine was greatly efficient than 0.2
chlorhexidine contrary to both gram-negative together with gram-positive bacteria (Scannapieco.
2016). Nevertheless, two percent of chlorhexidine was less efficient in opposition to
Acinetobacter. This was ascribed to the organism’s drug resistance and prevalence. The

ORAL HYGIENE IN VENTILATED PATIENTS (ICU)
outcomes are similar to those of Tantipong and Koeman. The mixture of two percent
chlorhexidine and two percent chlorhexidine-colistin were similarly efficient in minimizing
oropharyngeal gram-positive colonies. Nevertheless, the mixture of chlorhexidine-colistin was
more efficient in gram-negative microorganism in contrast with chlorhexidine on its own. In the
research by Tantipong (2018), colonization of oropharyngeal with gram-negative bacilli was
either delayed or reduced in sick people who had gotten chlorhexidine two percent. In the
research, more than sixty percent of sick people who had gotten oropharyngeal colonization that
is gram-negative was associated with underneath patients and diseases preceding
hospitalizations. Correspondingly, Kusahara (2016) demonstrated that chlorhexidine did not
minimize the accumulated number of gram-negative microorganisms. The results of the current
research demonstrated that oropharyngeal pathogens were comparable to pulmonary pathogens
in VAP sick persons (Grap et al. 2017). Moreover, pathogens of VAP by this time was present in
the tract of oropharyngeal. Treloar stated that 37.5 percent of oropharyngeal tests from tracheal
tube sick individuals had comparable bacteria to samples of tracheal. However, disparities in the
forms of microorganisms segregated from tests in the research might consequence from
disparities in the forms of the stipulated antibiotic, periods, and concentration of antibiotics,
research methodologies and prevalence rates of bacteria.
The present research disclosed that reversible and mild oral mucosa irritation took place in the
two groups, and discoloration of the teeth took place in the 2 percent group of chlorhexidine
(Munro & Grap. 2014). Nevertheless, oral mucosa inflammation was minimized following the
gentle cleaning of the mucosa of the oropharyngeal. Therefore, appropriate cleaning of the teeth
before utilizing chlorhexidine could reduce its adverse effects and increase its effectiveness. In
the research by Tantipong (2018) reversible and mild inflammation of oral mucosa was detected

ORAL HYGIENE IN VENTILATED PATIENTS (ICU)
in ten patients which represent 9.8 percent of the chlorhexidine band and in one sick person 0.9
percent of the regular band that is saline. Nonetheless, this inflammation was minimized once the
practitioners were directed to moderately sterile the mucosa of the oropharyngeal. In the research
by Koeman (2016), tongue edema was witnessed in the chlorhexidine –colistin band on the 2nd
day. In divergence, it was reported by Firouzian (2014) that no stern effects are adverse, even
though 3 sick persons in the band of the experiment and 5 in the band of placebo protested
concerning the solution’s unfriendly taste.
Comparable to the research by Tantipong (2018), the present research demonstrated that
two percent of chlorhexidine did not result in more hostile consequences in comparison to 0.2
chlorhexidine. Thus, in prospective research, the unfavorable outcomes of two percent
chlorhexidine have to be examined under the supervision of the dentist. Even though both the
bands in the current research were not substantially diverse in form of timespan of the
conferment in ICU, period of MV, and the rate of mortality, all this results reduced in the two
percent band of chlorhexidine (Mori et al. 2016). This result conforms to those of most research
undertaken on the matter. The disparity between the outcome of the current research and those of
others might be credited to disparities in methods and protocols of VAP inhibition, populations
under scrutiny, place and time of intervention, therapy approaches, and procedures for the
clearance of the patients. In the present research, intensivists and laboratory experts endorsing
the analysis of VAP did not know concerning the intrusions. Furthermore, the researchers
undertook continuous oral care based on the protocol (Feider et al. 2010). This intensified the
research’ preciseness. Contrarily, even though uninformed of the assignments of the group, the
researcher was liable for finalizing the checklist for CPI, examining the mouths of the patients,
doing oral care and some bias might have taken place.

ORAL HYGIENE IN VENTILATED PATIENTS (ICU)
Based on the research by (Wallace et al, 2015) the description of the CDC should be
utilized for scrutiny, since it may miscalculate the occurrence of the VAP. CPIs can also over-
approximate the occurrence of the VAP. In the present research, tracheal and oropharyngeal
cultures were semi-quantitative. Due to the low costs and the convenience, semi-quantitative
reports of culture are usual in the VAP analysis, nevertheless, its specificity and sensitivity are
not as important as those of a culture report that are quantitative.
Conclusion
In the current research, there was also challenges disturbing appropriate oral care because
of the existence of oropharyngeal airways and tracheal tubes and some restlessness. As well,
numerous elements, for instance, diverse interventions and sample size that were out of control
of the investigator disturbed the VAP development. These could have led to the drawbacks in
assessing the benefits of oral care.
The outcomes of the present research depict that oral discontagion is greatly efficient
with two percent chlorhexidine than with 0.2 percent chlorhexidine in minimizing the occurrence
of VAP and the oropharyngeal colonization (Grap et al. 2014). These results may form the
ground for continued clinical use and trials of the two percent in such instances.

ORAL HYGIENE IN VENTILATED PATIENTS (ICU)
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