Oral Health and Mechanically Ventilated Critically Ill Adults

Deborah J. Jones PhD, MSN, RNJune M. Sadowsky, DDS, MPH

Donna Warren-Morris, RDH, MedBela Patel, MD, DABSM, FCCP

OutcomesDefine components of oral health in

mechanically ventilated adultsRecognize complications from poor oral healthPromote good oral health through the delivery

of appropriate oral hygieneDescribe the state of the science regarding oral

care practices in mechanically ventilated adults Assess and deliver evidence-based oral careRecognize triggers to consult other healthcare

providers

Oral and Systemic Health LinkDiabetesCardiovascular diseaseRespiratory disease StrokePremature birth

Mechanically Ventilated PatientsCharacteristics:

Vulnerable to systemic infections due to disruption in host defenses like mucociliary clearance, cytokine production and salivary volume

Dependent on healthcare providers to provide oral care

Have the potential for bacterial load to be increased due to lack of consistent oral care regimen

Develop oropharyngeal colonization with pathogenic organisms within the first 24 hours of intubation

Reasons for Lack of Oral Care RegimenNurses receive little to no formal trainingLack of priority, perceived need or timePatient’s inability to participate or request Medical conditions and equipment interfereFear of endotracheal tube dislodgementLack of published randomized controlled

trials examining the best practices for oral care in critically ill patients

Complications of Poor Oral HygieneOropharyngeal colonization linked to the

development of ventilator-associated pneumonia (VAP)Remains the most deadly hospital acquired

infection in intensive care units (8-15% estimated mortality rate)

Increased dental plaque accumulation and oral inflammation

Disruption of tissue integrity Further complication of pre-existing oral conditions

Rationale for Good Oral HygieneOral care protocols (usually included in VAP

bundles) show decrease in incidence of VAPOral care reflects preventive measures aimed

at reducing pathogenic organisms, and promoting holistic patient care

Patient comfortPrevention of halitosis

Although…to dateNo gold standard oral care protocol with

optimal frequency or products have been well established; several organizations have published recommendations to guide oral care of the mechanically ventilated patientInstitute for Healthcare Improvement (IHI)American Association of Critical-Care Nurses

(AACN)Centers for Disease Control and Prevention

(CDC)

Institute for Healthcare Improvement (IHI) Recommendation

Daily oral care with 0.12% chlorhexidine• Develop a comprehensive oral care process that

includes the use of 0.12% chlorhexidine oral rinse

• Schedule chlorhexidine as a medication, which then provides a reminder for the RN and triggers oral care process delivery

Educate the RN staff about the rationale supporting good oral hygiene and its potential benefit in reducing ventilator-associated pneumonia

American Association of Critical-Care Nurses (AACN) Recommendation

Develop and implement a comprehensive oral hygiene program for patients in critical care and acute care settings

who are at high risk for ventilator-associated pneumonia (VAP)

Brush teeth, gums and tongue at least twice a day using a soft pediatric or adult toothbrush

Provide oral moisturizing to oral mucosa and lips every 2 to 4 hours

Use an oral chlorhexidine gluconate (0.12%) rinse twice a day during the perioperative period for adult patients who undergo cardiac surgery

Routine use of oral chlorhexidine gluconate (0.12%) in other populations is not recommended at this time

Centers for Disease Control and Prevention(CDC) Recommendation

Perform regular oral care with an antiseptic solution

The optimal frequency for oral care is unresolved

Oral Care Protocol for Intubated PatientsFollow standard precautions and infection

prevention procedures including asepsis, gloves, a mask, and eye protection (as needed)

Obtain all necessary equipment prior to beginning oral care

Explain to the patient what you are planning to do so they are not startled

Note the position and placement of the endotracheal tube prior to oral care

Assessment and Oral Cancer ScreeningAssess all areas of the mouth for any signs of

trauma, inflammation, bleeding, ulcerations or suppurationRedness, swelling, exudate, tenderness and

ulcerations are signs of infections that should be further assessed to rule out oral cancer.

AssessmentSlight bleeding of the gums is

common if homecare has been deficient. With good oral hygiene, bleeding will cease in a few days of adequate care

Xerostomia (dry mouth)Common in intubated patients

Assessment Assessment of the oral cavity should include

all surfaces of the mouth, carefully inspecting for abnormalities.

When inspecting the intubated patient be careful to observe the position and placement of the endotracheal tube.

SuctioningPrior to beginning the oral care

protocol and immediately following oral care it is important to suction the patients mouth and the subglottic space in order to prevent aspiration of pooled secretions Suctioning should be repeated as needed during oral care

Tooth BrushingThe teeth and mouth should be cleaned at

least twice a dayUse a soft bristle toothbrush with a small

head (pediatric size) for better access A smear of a sodium fluoride toothpaste Do not use a sodium monofluorophosphate

fluoride if chlorhexidine gluconate is to be used since the two are not compatible

Tooth Brushing TechniqueUse a systematic sequence

Angle the bristles toward the gumline and brush with gentle pressure in small circular strokes on each tooth. The bristles of the toothbrush will extend underneath the gumline if adapted correctly

Facial surfaces of all maxillary teeth, then linguals, then repeat on the mandibular teeth. Brush the occlusal or biting/chewing surfaces last with a scrub stroke

Brush the tongue with long outward sweeping strokes Gently move the tube from side to side as necessary for access

Tooth BrushingTeeth should be brushed in a circular motion.Teeth of mechanically ventilated adults should be

brushed using the same technique with the exception of the following modifications:

observe the placement of the endotracheal tube by the markings on the tube before and during oral care, suction the oral cavity frequently and suction the subglottic space following oral care to prevent aspiration .

A mouth prop, tongue blade or bite block may be used to hold the mouth open for unresponsive patients

Antiseptic/microbial applicationAntimicrobial

Chlorhexidine gluconate (0.12%) Recommended with little side effects (tooth

staining)Swab the endotracheal tube as well to prevent

bacterial biofilm formationSwab twice a day with no rinsing afterward for

a minimum of 30 minutes

Moisturizing the MouthEvery two hours, moisturize the lips,

mucosa, tongue and corners of the mouth with a water-based moisturizer

Petroleum based products should be avoided as they can dry tissues and are harmful if aspirated

Detrimental Practices.Foam Swabs do not

remove plaque bacteria as well as a toothbrush and should not be substituted

Hydrogen peroxide is acidic and can burn soft tissues if not diluted enough and may also cause black hairy tongue

Lemon glycerin swabs are very acidic and can cause soft tissue burns and decalcify the teeth

Petroleum jelly dries out oral tissues and can also degrade latex gloves

Special ConsiderationsNeuroscience patients

Intracranial pressureEdentulous patients

Brush the gums gentlyFacial trauma patients

Modify tooth brushing

Role of Healthcare ProvidersNurses

Patient and other healthcare provider education

Daily assessment of oral cavity Delivery and documentation of oral careConsultation as needed

Respiratory TherapistsFurther assessment around endotracheal tube

holdersMaintenance of closed ventilation circuit

Role of Healthcare ProvidersPhysicians/Nurse Practitioners/Physician

AssistantsOral assessmentsRoutine/standard order of antimicrobial rinseCollaboration with dental professionals Patient education

Dental Hygienists/DentistsReferral follow-upCollaboration with critical care clinicians

References Berra L, Sampson J, Wiener-Kronish J. Pseudomonas aeruginosa:

Acute lung injury or ventilator-associated pneumonia? Minerva Anestesiol. 2010;76(10):824-832.

Nseir S, Di Pompeo C, Pronnier P, et al. Nosocomial tracheobronchitis in mechanically ventilated patients: Incidence, aetiology and outcome. Eur Respir J. 2002;20(6):1483-1489.

Craven DE, Driks MR. Nosocomial pneumonia in the intubated patient. Semin Respir Infect. 1987;2(1):20-33.

Torres A, El-Ebiary M, Gonzalez J, et al. Gastric and pharyngeal flora in nosocomial pneumonia acquired during mechanical ventilation. Am Rev Respir Dis. 1993;148(2):352-357.

Greene R, Thompson S, Jantsch HS, et al. Detection of pooled secretions above endotracheal-tube cuffs: Value of plain radiographs in sheep cadavers and patients. Am J Roentgenol. 1994;163(6):1333-1337.

References Jones DJ, Munro CL, Grap MJ. Natural history of dental plaque

accumulation in mechanically ventilated adults: A descriptive correlational study. Intensive Crit Care Nurs. 2011;27(6):299-304. doi: 10.1016/j.iccn.2011.08.005.

Munro CL, Grap MJ, Jones DJ, McClish DK, Sessler CN. Chlorhexidine, toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults. American Journal of Critical Care. 2009;18(5):428-437. Accessed 25 February 2011.

Fourrier F, Duvivier B, Boutigny H, Roussel-Delvallez M, Chopin C. Colonization of dental plaque: A source of nosocomial infections in intensive care unit patients. Crit Care Med. 1998;26(2):301-308.

Barkvoll P, Rölla G, Bellagamba S. Interaction between chlorhexidine digluconate and sodium monofluorophosphate in vitro. Scand J Dent Res. 1988 Feb;96(1):30-3.

Abidia RF. Oral Care in the Intensive Care Unit: A Review. J Contemp Dent Pract 2007 January;(8)1:076-082. http://vilarmoreiranunes.files.wordpress.com/2009/11/abidia.pdf

References MDCT Evaluation of Foreign Bodies and Liquid Aspiration Pneumonia

in Adults. http://www.ajronline.org/content/190/4/907.full.pdf+html Garrouste-Orgeas M, Chevret S, Arlet G, et al. Oropharyngeal or

gastric colonization and nosocomial pneumonia in adult intensive care unit patients. A prospective study based on genomic DNA analysis. Am J Respir Crit Care Med. 1997;156(5):1647-1655.

Chastre J. Ventilator-associated pneumonia: What is new? Surg Infect (Larchmt). 2006;7 Suppl 2:S81-5. doi: 10.1089/sur.2006.7.s2-81.

Albertos R, Caralt B, Rello J. Ventilator-associated pneumonia management in critical illness. Curr Opin Gastroenterol. 2011;27(2):160-166. doi: 10.1097/MOG.0b013e32834373b1.

Ashraf M, Ostrosky-Zeichner L. Ventilator-associated pneumonia: A review. Hosp Pract (Minneap). 2012;40(1):93-105. doi: 10.3810/hp.2012.02.950

References Martin B. AACN practice alert: Oral care for patients at risk for

ventilator-associated pneumonia. http://www.aacn.org/WD/Practice/Docs/PracticeAlerts/oral%20care%2004-2010%20final.pdf. Updated 2010.

Chan EY, Ruest A, Meade MO, Cook DJ. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: Systematic review and meta-analysis. Br Med J. 2007;334(7599):889-893. Accessed 9 March 2011.

Institute for Healthcare Improvement. http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/IndividualChanges/DailyOralCarewithChlorhexidine.htm. Updated Implement the ventilator bundle: Daily oral care with Chlorhexidine.