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The Effect of Using Chlorhexidine Mouthwash as an Oral Care Protocol Compared Routine Oral Care when Managing Ventilator-Associated Pneumonia: Annotated Bibliography

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The Effect of Using Chlorhexidine Mouthwash as an Oral Care Protocol Compared Routine Oral Care when Managing Ventilator-Associated Pneumonia: Annotated Bibliography

Introduction

In current healthcare management processes, there are unique methods involved in managing pneumonia infections that, if not avoided, would cause diverse outcomes on the well-being of patients. The patient population being studied is patients in the ICU who constantly require ventilation to support their treatment processes (Rak et al., 2020). Prolonged ventilation is a crucial requirement for the population as they experience subtle types of critical illnesses, leading to improvements in pain management, mobilization, and ventilator care that profoundly impact reducing more infections for the patient population (Rak et al., 2020). Improvement of patient treatment methods is needed to facilitate a proper health management process.

Background

The current problem of ventilator-associated pneumonia (VAP) affects patients in the ICU who get placed on mechanical ventilation (MV). Issues related to patient treatment progress make it hard for them to attain complete well-being when they do not receive the expected health improvement. VAP usually occurs within 48 hours when a patient gets intubated and receives mechanical ventilation (Singh et al., 2022). Prolonged mechanical ventilation is needed for different patients exposed to more susceptibility to infections when the healthcare providers do not implement proper measures (Rak et al., 2019). An adverse impact on patients’ lives occurs instead of receiving appropriate health improvement. The practice that needs to change is using oral care protocols immediately after a patient starts receiving MV so that they do not risk infection.

Infections for patients receiving mechanical ventilation are common, as discovered by a comprehensive review of how the life-saving process causes ventilator-associated lung damage, prolonged hospitalization, death, and ventilator-associated pneumonia (VAP) (Vali et al., 2023). Improvement of patient care is possible while implementing measures to address the inevitable use of mechanical ventilation. Currently, mouthwashes are used to reduce the possibility of patient infections, but the practice has not been entirely appropriate, resulting in the need to implement mechanical cleaning (Pinto et al., 2021).

The target population is patients receiving mechanical ventilation due to severe chronic or acute respiratory insufficiency. The treatment process cost is usually higher than other oral care processes due to its advanced technique instead of a simplified process. An adverse impact of the increase in healthcare costs occurs when patients get infected with pneumonia at the ICU, as they usually get treated for other health conditions and then get newly infected (Blot et al., 2022). Policy statements related to the problem are related to high in-hospital mortality and lengthy ICU stays that can be avoided. The PICOT question guiding this study is “In mechanically ventilated patients in the ICU (P), does an oral care protocol using chlorhexidine mouthwash (I) compared to routine oral care (C) reduce the incidence of ventilator-associated pneumonia (O) over six months (T)?”

Research

Pinto, A. C. da S., Silva, B. M. da, Santiago-Junior, J. F., & Sales-Peres, S. H. de C. (2021). Efficiency of different protocols for oral hygiene combined with the use of chlorhexidine in the prevention of ventilator-associated pneumonia.
Jornal Brasileiro de Pneumologia: Publicacao Oficial Da Sociedade Brasileira de Pneumologia E Tisilogia,
47(1), e20190286.
https://doi.org/10.36416/1806-3756/e20190286.

The authors used a mixed methods research design, specifically document analysis of different databases to find articles that had studied ventilator-associated pneumonia among patients in the ICU and meta-analysis of data in the studies. Using keywords like intensive care units and ventilator-associated pneumonia allowed the study to be performed effectively. The sample size was 6 studies that were used for qualitative review and meta-analysis. There was no independent & dependent variable in the article since the authors focused on a review of existing research documents. Two reviewers analyzed the research articles, which was valid since it addressed methods of assessing how lack of advanced oral care for patients caused them to get infected with pneumonia. Some eligibility criteria for the article included studies that evaluated patients with VAP and those that studied adults aged 18 and above in the ICU.

Research findings of the articles indicated that performing oral hygiene routines a minimum of three times a day using chlorhexidine was more effective than regular tooth brushing techniques. Normal toothbrushing techniques included brushing with an electric toothbrush and brushing with distilled water. The study accurately proved that reducing VAP was possible using advanced oral hygiene protocols that relied on chlorhexidine. Threats to the reliability of the intervention are related to the fact that there is no scientific evidence to indicate how the use of chlorhexidine can reduce VAP. Even though the study found that the reduction can occur from 25% to approximately 19%, there is no scientific data to strengthen that finding. Further, no scientific data indicates how mechanical removal of biofilm using manual brushing or brushing with an electric toothbrush will impact the reduction in infection.

Singh, P., Arshad, Z., Srivastava, V. K., Singh, G. P., & Gangwar, R. S. (2022). Efficacy of Oral Care Protocols in the Prevention of Ventilator-Associated Pneumonia in Mechanically Ventilated Patients.
Cureus,
14(4).
https://doi.org/10.7759/cureus.23750.

The research design was quantitative research that integrated randomized clinical trials to determine how improvement of oral hygiene impacted mortality and VAP. The sample used was 220 ICU patients between 18-65 years of age and receiving less than 48 hours of mechanical ventilation. The study did not have particular independent & dependent variables, but the focus was on the ventilator-associated pneumonia rate before using various intervention types. The intervention included immediate implementation of the techniques when patients were admitted to the ICU. Analysis of the patients was performed in conformity to group S, a study group that integrated interventions like chlorhexidine wash, tooth brushing, or moisturizing gel over gums, buccal mucosa, and lips, while group C, as the control group, integrated intervention using chlorhexidine wash only.

The study’s findings indicated that comorbidities were higher for patients in group C in comparison to patients in group S. Infection rates of patients in group S were relatively higher in comparison to group C patients, which indicates how VAP was an adverse reaction to patients in the ICU if they did not get provided with many interventions. Group C patients had to be provided with more mechanical ventilation requirements and stayed longer in the ICU, indicating how an unreliable treatment process affected their well-being. When patients in group C continued with the intervention, rates of mortality were higher even though such rates were lower in group S. Threats to the reliability of the study are related to the fact that it was conducted at a single ICU, yet results can be different if the same study got implemented at different ICUs.

Conclusion

The study by Singh et al. (2022) revealed that an oral care protocol using chlorhexidine mouthwash is effective when reducing VAP but only when the intervention gets done alongside known interventions like tooth brushing or moisturizing gel over gums, buccal mucosa, and lips. The study by Pinto et al. (2022) offered a valid outcome of using chlorhexidine mouthwash frequently to reduce VAP. All the studies have provided different reviews of the intervention presented in the PICOT questions. Improving healthcare accuracy is possible while assessing how interventions proved to produce results create a proper outcome when implemented at different healthcare facilities.

References

Blot, S., Ruppé, E., Harbarth, S., Asehnoune, K., Poulakou, G., Luyt, E., Rello, J., Klompas, M., Depuydt, P., Eckmann, C., Martin-Loeches, I., Povoa, P., Bouadma, L., Timsit, F., & Zahar, R. (2022). Healthcare-associated infections in adult intensive care unit patients: Changes in epidemiology, diagnosis, prevention and contributions of new technologies.
Intensive & Critical Care Nursing,
70, 103227.
https://doi.org/10.1016/j.iccn.2022.103227.

Pinto, A. C. da S., Silva, B. M. da, Santiago-Junior, J. F., & Sales-Peres, S. H. de C. (2021). Efficiency of different protocols for oral hygiene combined with the use of chlorhexidine in the prevention of ventilator-associated pneumonia.
Jornal Brasileiro de Pneumologia: Publicacao Oficial Da Sociedade Brasileira de Pneumologia E Tisilogia,
47(1), e20190286.
https://doi.org/10.36416/1806-3756/e20190286.

Rak, K. J., Ashcraft, L. E., Kuza, C. C., Fleck, J. C., DePaoli, L. C., Angus, D. C., Barnato, A. E., Castle, N. G., Hershey, T. B., & Kahn, J. M. (2020). Effective Care Practices in Patients Receiving Prolonged Mechanical Ventilation. An Ethnographic Study.
American Journal of Respiratory and Critical Care Medicine,
201(7), 823–831.
https://doi.org/10.1164/rccm.201910-2006oc.

Singh, P., Arshad, Z., Srivastava, V. K., Singh, G. P., & Gangwar, R. S. (2022). Efficacy of Oral Care Protocols in the Prevention of Ventilator-Associated Pneumonia in Mechanically Ventilated Patients.
Cureus,
14(4).
https://doi.org/10.7759/cureus.23750.

Vali, M., Paydar, S., Seif, M., Sabetian, G., Abujaber, A., & Ghaem, H. (2023). Prediction prolonged mechanical ventilation in trauma patients of the intensive care unit according to initial medical factors: A machine learning approach.
Scientific Reports,
13(1), 1-14.
https://doi.org/10.1038/s41598-023-33159-2.