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Effect of Chlorhexidine Oral Spray Versus Mechanical Toothbrushing and Chlorhexidine Rinse in Decreasing Ventilator Asso...

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Material Information

Title: Effect of Chlorhexidine Oral Spray Versus Mechanical Toothbrushing and Chlorhexidine Rinse in Decreasing Ventilator Associated Pneumonia in Critically Ill Adults
Physical Description: 1 online resource (91 p.)
Language: english
Creator: Mccartt, Peggy
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2010

Subjects

Subjects / Keywords: chlorhexidine, hygiene, nursing, oral, pneumonia, protocols, ventilator
Nursing -- Dissertations, Academic -- UF
Genre: Nursing Sciences thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Ventilator associated pneumonia (VAP) is the most frequently occurring nosocomial infection associated with increased morbidity and mortality of patients in intensive care units. Although oral decontamination with chlorhexidine has been shown in some studies to reduce the risk of VAP, there have been few randomized controlled trials evaluating its efficacy. This study addressed two research questions: Is there a difference in the three study groups related to oral pH, oral culture scores and CPIS scores at 24 and 72 hours compared to baseline, and Do the number of decayed, missing and filled teeth, being edentulous and the presence of periodontal disease have an association with the development of ventilator associated pneumonia in critically ill adult patients? Eighty-five patients were randomized and assigned into three groups, group 1(n=29) received chlorhexidine spray 0.12%, group 2 (n=31) received chlorhexidine 0.12% and toothbrushing and group 3 (n=25) received standard or usual oral care using foam swabs (toothettes) with a variety of oral rinses. No statistically significant differences in oral pH values occurred between the three groups. Statistically significant decreased oral culture scores occurred at 24 hours and 72 hours compared to baseline in the intervention groups indicating a possible benefit in the prevention of VAP using chlorhexidine spray 0.12% or chlorhexidine 0.12% and toothbrushing, group 1 (p=0.045, p=0.0082) and group 2 (p=0.0092, p= 0.0047). No statistically significant differences in CPIS scores occurred in group 1 at 24 hours and 72 hours compared to baseline (p=0.7868, p=0.8462) or group 3 (p=0.6017, p=0.3151) but group 2 (p=0.545, p=0.0428) was significant at 72 hours compared to baseline, again indicating a possible benefit in preventing VAP in the chlorhexidine 0.12% and toothbrushing group. When using poor oral health and tooth condition as a risk factor for the development of VAP, subjects with periodontal disease, greater than 4 missing, decayed or filled teeth, and those who were edentulous were at higher risk (p=0.0057) to develop VAP. This study demonstrates that in patients in critical care units in Northeast Florida, the use of chlorhexidine 0.12% and toothbrushing is effective in preventing ventilator associated pneumonia.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Peggy Mccartt.
Thesis: Thesis (Ph.D.)--University of Florida, 2010.
Local: Adviser: Stechmiller, Joyce K.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2011-02-28

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2010
System ID: UFE0042151:00001

Permanent Link: http://ufdc.ufl.edu/UFE0042151/00001

Material Information

Title: Effect of Chlorhexidine Oral Spray Versus Mechanical Toothbrushing and Chlorhexidine Rinse in Decreasing Ventilator Associated Pneumonia in Critically Ill Adults
Physical Description: 1 online resource (91 p.)
Language: english
Creator: Mccartt, Peggy
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2010

Subjects

Subjects / Keywords: chlorhexidine, hygiene, nursing, oral, pneumonia, protocols, ventilator
Nursing -- Dissertations, Academic -- UF
Genre: Nursing Sciences thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Ventilator associated pneumonia (VAP) is the most frequently occurring nosocomial infection associated with increased morbidity and mortality of patients in intensive care units. Although oral decontamination with chlorhexidine has been shown in some studies to reduce the risk of VAP, there have been few randomized controlled trials evaluating its efficacy. This study addressed two research questions: Is there a difference in the three study groups related to oral pH, oral culture scores and CPIS scores at 24 and 72 hours compared to baseline, and Do the number of decayed, missing and filled teeth, being edentulous and the presence of periodontal disease have an association with the development of ventilator associated pneumonia in critically ill adult patients? Eighty-five patients were randomized and assigned into three groups, group 1(n=29) received chlorhexidine spray 0.12%, group 2 (n=31) received chlorhexidine 0.12% and toothbrushing and group 3 (n=25) received standard or usual oral care using foam swabs (toothettes) with a variety of oral rinses. No statistically significant differences in oral pH values occurred between the three groups. Statistically significant decreased oral culture scores occurred at 24 hours and 72 hours compared to baseline in the intervention groups indicating a possible benefit in the prevention of VAP using chlorhexidine spray 0.12% or chlorhexidine 0.12% and toothbrushing, group 1 (p=0.045, p=0.0082) and group 2 (p=0.0092, p= 0.0047). No statistically significant differences in CPIS scores occurred in group 1 at 24 hours and 72 hours compared to baseline (p=0.7868, p=0.8462) or group 3 (p=0.6017, p=0.3151) but group 2 (p=0.545, p=0.0428) was significant at 72 hours compared to baseline, again indicating a possible benefit in preventing VAP in the chlorhexidine 0.12% and toothbrushing group. When using poor oral health and tooth condition as a risk factor for the development of VAP, subjects with periodontal disease, greater than 4 missing, decayed or filled teeth, and those who were edentulous were at higher risk (p=0.0057) to develop VAP. This study demonstrates that in patients in critical care units in Northeast Florida, the use of chlorhexidine 0.12% and toothbrushing is effective in preventing ventilator associated pneumonia.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Peggy Mccartt.
Thesis: Thesis (Ph.D.)--University of Florida, 2010.
Local: Adviser: Stechmiller, Joyce K.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2011-02-28

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2010
System ID: UFE0042151:00001


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EFFECT OF CHLORHEXIDINE ORAL SPRAY VERSUS MECHANICAL
TOOTHBRUSHING AND CHLORHEXINDINE RINSE IN DECREASING VENTILATOR
ASSOCIATED PNEUMONIA IN CRITICALLY ILL ADULTS




















By

PEGGY ALICE MULLIGAN MCCARTT


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA
2010




































2010 Peggy Alice Mulligan McCartt
































To my husband, Gerry, for all his support; my children; Chris and Beth, for understanding when
mom could not go somewhere with them because of finishing a paper; and my parents, especially
my mother, who if still alive, would be so proud













ACKNOWLEDGMENTS


I would like to thank Dr. Stechmiller who has stood beside me every step of the way
during my journey to obtain my PhD. She is an excellent nurse researcher and has taught me
more than she is probably aware.

I would also like to thank Dr. Jo Snider who has known me from my first classes at the
University of Florida to obtain my BSN and always remains a source of encouragement.

I would also like to thank all the nurses at each facility, Dr. Koch and Dr. Laos for helping
me to complete this work. I also appreciate the work my other committee members Dr. Figueroa-
Haas and Dr. Heft provided.












TABLE OF CONTENTS

page

A C K N O W L E D G M E N T S ......... ....... ............................. ................................................................. 4

LIST OF TABLES ............. ....... ... ......... .. ......... .............. 6

A B STR A C T ....................................................................................... 7

CHAPTER

1 IN T R O D U C T IO N ..................................................................................... ....................... 9

B background of the P problem ........................................................................................ ........... 9
Statem ent of th e P rob lem ................................................................................. ..................... 10
P urpo se of th e Stu dy .................................................................. 15
Hypotheses.. ..................................................... ............... 16
Sig nifican ce o f th e Stu dy ................................................................ ...................................... 16

2 REVIEW OF THE LITERATURE..................................................... ............................ 20

N orm al O ral F lora ................................................................................................. ............. 2 0
R isk Factors C contributing to V A P ....................... ............................. ......................................... 30

3 M E T H O D O L O G Y .......................................................................................... ...................... 5 1

Sample ............................... 51

4 RESULTS ........................... .................... 60

5 D IS C U S S IO N ...................................................................................................... ..................... 6 7

D A T A C O LLE C TIO N TO O L ............................................................................... 76

LIST O F R E FER EN CE S .................................................................. 77

BIOGRAPHICAL SKETCH .................................................... 91









LIST OF TABLES


Table page

3-1 Descriptive Statistics of Study Participants.................................................. 53

3-2 M modified Oral Assessment Tool ........................................................... ................ 54

4-1 Oral pH means and standard deviations at baseline, 24 hours and 72 hours................. 60

4-2 Oral pH differences between groups at baseline, 24 hours, and 72 hours..................... 61

4-3 Oral culture score means and standard deviations for each group at baseline, 24
hours and 72 hours. ........................................................................... 61

4-4 Differences in Oral Culture Scores between groups at 24 hours and 72 hours
co m p ared to b aselin e................................................................................. ......................... 6 2

4-5 A Description of Pathogens Present at Baseline according to CPIS Score and Actual
Development of VAP at 72 hrs. ........................................................................... 63

4-6 CPIS score means and standard deviations between groups at baseline, 24 hours and
72 hours ................... ............................. ..... 64

4-7 Oral culture pathogens present and CPIS score Means/SD scores at baseline, 24
h ou rs a n d at 7 2 h ou rs ........................................................ ............................................... 6 4

4-8 CPIS Scores for each group at 24 and 72 hours compared to baseline. ...........................65

4-9 Oral assessment scores for high and low risk for poor oral health for each group on
a d m issio n ................... ........................................................... ................ 6 5

4-10 The relationship of tooth condition and oral assessment with CPIS score to determine
risk of VAP at 72 hours compared to baseline .................... ...............................66









Abstract of Dissertation Presented to the Graduate School
of The University of Florida in Partial Fulfillment of the
Requirements for the Degree Of Doctor Of Philosophy

EFFECT OF CHLORHEXIDINE ORAL SPRAY VERSUS MECHANICAL
TOOTHBRUSHING AND CHLORHEXINDINE RINSE IN DECREASING VENTILATOR
ASSOCIATED PNEUMONIA IN CRITICALLY ILL ADULTS

By

Peggy Alice Mulligan McCartt

August 2010

Chair: Joyce Stechmiller
Major: Nursing Sciences

Ventilator associated pneumonia (VAP) is the most frequently occurring nosocomial

infection associated with increased morbidity and mortality of patients in intensive care units.

Although oral decontamination with chlorhexidine has been shown in some studies to reduce the

risk of VAP, there have been few randomized controlled trials evaluating its efficacy. This study

addressed two research questions: Is there a difference in the three study groups related to oral

pH, oral culture scores and CPIS scores at 24 and 72 hours compared to baseline, and Do the

number of decayed, missing and filled teeth, being edentulous and the presence of periodontal

disease have an association with the development of ventilator associated pneumonia in critically

ill adult patients? Eighty-five patients were randomized and assigned into three groups, group

1(n=29) received chlorhexidine spray 0.12%, group 2 (n=31) received chlorhexidine 0.12% and

toothbrushing and group 3 (n=25) received standard or usual oral care using foam swabs

(toothettes) with a variety of oral rinses.

No statistically significant differences in oral pH values occurred between the three groups.

Statistically significant decreased oral culture scores occurred at 24 hours and 72 hours

compared to baseline in the intervention groups indicating a possible benefit in the prevention of









VAP using chlorhexidine spray 0.12% or chlorhexidine 0.12% and toothbrushing, group 1

(p=0.045, p=0.0082) and group 2 (p=0.0092, p= 0.0047). No statistically significant differences

in CPIS scores occurred in group 1 at 24 hours and 72 hours compared to baseline (p=0.7868,

p=0.8462) or group 3 (p=0.6017, p=0.3151) but group 2 (p=0.545, p=0.0428) was significant at

72 hours compared to baseline, again indicating a possible benefit in preventing VAP in the

chlorhexidine 0.12% and toothbrushing group. When using poor oral health and tooth condition

as a risk factor for the development of VAP, subjects with periodontal disease, greater than 4

missing, decayed or filled teeth, and those who were edentulous were at higher risk (p=0.0057)

to develop VAP. This study demonstrates that in patients in critical care units in Northeast

Florida, the use of chlorhexidine 0.12% and toothbrushing is effective in preventing ventilator

associated pneumonia.









CHAPTER 1
INTRODUCTION

Background of the Problem

Historically, nosocomial pneumonia is the second most common infection in patients in

all healthcare settings in the United States (Cunha, 2009; Centers for Disease Control, 2004;

Lode, Raffenberg, Erbes, Geerdes-Fengea & Mauch, 2000). In 2004, it was the leading cause of

death from all infections, with mortality rates of 13-65% according to the Centers for Disease

Control (CDC), (CDC, 2004). According to the CDC, pneumonia occurs in 25-30% of

mechanically ventilated patients and increases hospital costs and patients' lengths of stays

(Cunha, 2009; Munro, Grap, Sessler & Carter, 2003). The international incidence and prevalence

of nosocomial pneumonia is similar to that in the United States, with 300,000 cases annually,

with an associated mortality rate of 30-70% (Cunha, 2009).

Ventilator associated pneumonia (VAP) is a frequent complication of intensive care

patients (Depuydt, Myny, & Blot, 2006; Salahuddin, Zafar, et al., 2004). A risk factor for the

development of ventilator associated pneumonia includes oral bacterial colonization (Chulay,

2008; Rumbak, 2000; Kollef, 1999; Johanson, Pierce, Sanford & Thomas, 1972). The normal

oral flora of humans may harm a debilitated host since some of these bacteria are opportunistic

pathogens. These pathogens may grow and multiply in the host, and may invade tissues for

example, lung tissue, that is not normally accessible to them and cause infectious disease. One of

these diseases is aspiration pneumonia, or specifically ventilator associated pneumonia (Cao,

Progulski-Fox, Hillman & Handfield, 2004). Surveillance data on 500,000 patients in combined

medical-surgical intensive care units (ICU) showed that 68% of nosocomial infections were

respiratory-related; with pneumonia as the primary diagnosis (Richards, et al., 2000).

Furthermore, an intubated patient has 6-21 times the risk of developing hospital-









acquired/nosocomial pneumonia when compared to a non-ventilated patient (Ranes, Gordon &

Arroliga, 2006; Tantipong, Morkchareonpong, Jaiyindee & Thamlikitkul, 2008; CDC, 2004;

Scannapieco, Stuart, & Mylotte, 1992; Sole, Poalillo, Byers & Judy, 2002; Bauer, Torres, Ferrer,

Heyer, Schultze-Werninghaus & Rasche, 2002). Therefore, because of these associations and the

increased risk of poor patient outcomes, nursing interventions that could decrease ventilator

associated pneumonia are an important healthcare issue.

Statement of the Problem

Ventilator associated pneumonia as defined by the CDC (2004), is the development of

pneumonia after 48 hours of mechanical ventilation. This may be linked to decreased immune

capacity and change in bacterial proliferation. Changes in the oropharyngeal environment can

occur as a result of hospitalization related to diet, systemic disease, medications and oral diseases

(Steifel, Damron, Sowers & Velez, 2000). Organisms that reside in the mouth of healthy

individuals consist primarily of gram positive strains; with severe illness, bacterial strains shift

and anaerobic gram-negative strains predominate (Myrianthefs, Kalafati, Samara, &

Baltopoulos, 2004; Kite & Pearson, 1995, Rumbak, 2000). In a healthy subject, the respiratory

tract is able to defend against aspirated bacteria. Mechanically ventilated patients in ICUs with

no ability to clear oral secretions by swallowing or coughing are at high risk for VAP, especially

if the ventilation lasts for more than 48 hours (Paju & Scannapieco, 2007).

Research data has shown a correlation of oropharyngeal bacterial colonization to the

incidence of (VAP) in critically ill adults (Chulay, 2008). Dental plaque, a film of bacteria, acid,

food and saliva deposited on the teeth that encourage the development of dental caries and

gingivitis, accumulate along with poor oral hygiene starting a cascade of physiological

oropharyngeal contamination in the critically ill patient (Heo, 2007; Munro, Grap, Elswick,

McKinney, Sessler & Hummel, III, 2006; Marsh, 1999). Oropharyngeal changes can occur









rapidly as a result of medications, or disease related lower saliva production, epithelial injuries

imposed by nasogastric and endotracheal intubation, the start of an antibiotic regimen, as well as,

immunosuppression therapy (Munro, et al., 2006; Tantipong et al., 2008; Kaplan & Baum, 1993;

Lamkin & Oppenheim, 1993; Rodriguez, Gibbons, Bitzer, Dechert, Steinberg & Flint, 1991;

Daschner, Kappstein, Engels, Reuschenbach, Pfisterer, Krieg & Vogel 1988). For VAP to occur,

a significant number of organisms must enter the patient's lower respiratory tract and infect

susceptible tissues. In addition, oral bacterial colonization increases with poor oral health

(Munro, Grap, Elswick, McKinney, Sessler, & Hummel, III, 2006; Genco, Offenbacher & Beck,

2002). Patients with poor oral health, for example, those with dental caries and periodontal

disease, are at high risk of developing nosocomial pneumonia when mechanically ventilated

(Koeman, et al., 2006; Scannapieco, et al., 1992; Sole, Poalillo, Byers & Judy, 2002; Bauer,

Torres, Ferrer, Heyer, Schultze-Werninghaus & Rasche, 2002). Therefore, measures that could

alter oropharyngeal colonization may help decrease this event (Koeman, et al., 2006; Craven &

Driks, 1987).

Secondary pneumonia, related to mechanical ventilation, has a high mortality and

morbidity rate (CDC, 2004; Pugin, Auckenthaler, Lew & Sutter, 1991). Patients with VAP have

a 2.2 to 4.3 times higher risk of death when compared to patients in the ICU without pneumonia

(Chastre & Fagon, 2002). In Pugin's study (1991), the researchers stated that diagnosis of VAP

was difficult and treatment failures were common and therefore, preventive measures should be

important. In a double-blind, placebo, case controlled trial, selective decontamination of the

oropharynx with polymyxin B sulfate, neomycin sulfate, and vancomycin hydrochloride (PNV)

in fifty-two patients requiring mechanical ventilation for 3-34 days (mean=10 days) was studied.

Either PNV or placebo was administered six times daily in the oropharynx. During the first 12









days of intubation, tracheobronchial colonization by gram-negative bacteria and staphylococcus

aureus, as well as pneumonia, occurred less frequently in the PNV than in the placebo group. At

the conclusion of the study, hospital mortality was not different, but systemic antibiotics were

prescribed less often and no resistant microorganisms emerged. Ventilator associated pneumonia

was decreased by a factor of 5, the researchers reported, by interrupting the stomach-to-tracheal

route of infection (Pugin, et al., 1991). This was one of the first studies linking oral antibiotic

decontamination and a possible decrease in the development of VAP. It used common oral

antibiotics at that time which did not include chlorhexidine.

In 1997, Abele-Horn, Dauber, Bauemfeind, Russwurum, Seyfarth-Metzger, Gleich &

Ruckdeschel randomized eighty-eight patients admitted as emergencies and intubated within less

than 24 hours. Study participants received systemic cefotaxime as a prophylaxis and were

prospectively randomized into one of three groups receiving either amphotericin B, colistin

sulfate or tobramycin which was applied to the ororpharynx. The primary pathogen identified in

this study was staphylococcus aureus. The purpose of the study was to determine the influence of

selective oropharyngeal decontamination on the rate of colonization and infection of the

respiratory tract in intensive care patients, while also performing a financial assessment. The

results of this study demonstrated a reduced colonization and pneumonia rate, but ICU stay, and

duration of ventilation and mortality were similar to the control group (Abele-Horn, et al., 1997).

At the end of their study, they recommended larger studies to evaluate the effect of prophylaxis

oral decontamination on overall cost and prognosis of critically ill patients who are at risk of

developing ventilator associated pneumonia.

Houston, Hougland, Anderson, LeRocco, Kennedy & Gentry (2002), compared phenolic

mixture (Listerine) (Pfizer, New York, New York) oral mouth rinse as a control and









chlorhexidine 0.12% mouth rinse in postoperative cardiac patients in a prospective randomized

controlled trial. Five hundred sixty-one cardiac surgical patients were in the study. The overall

rate of nosocomial pneumonia was reduced by 52% in the chlorhexidine 0.12% mouth rinse

group. These patients were generally healthier than those in the Abele-Horn, Dauber,

Bauernfeind, Russwurum, Seyfarth-Metzger, Gleich & Ruckdeschel study since they were

elective surgical patients. Among patients intubated for greater than 24 hours who had cultures

that showed microbial growth, the pneumonia rate was reduced by 58%. In patients at highest

risk for pneumonia; those intubated greater than 24 hours, with cultures showing the most

growth, the rate was 71% lower in the chlorhexidine group than in the phenolic mixture group.

They concluded that although the rates of nosocomial pneumonia were lower in patients treated

with chlorhexidine than in the phenolic mixture group, the difference was significant only in

those patients intubated greater than 24 hours who had the highest degree of bacterial

colonization.

Fourrier, Cau-Pottier, Boutigny, Roussel-Delvallez, Jourdain & Chopin (2000),

performed a single-blinded randomized comparative study of sixty patients to document the

effect of dental plaque antiseptic decontamination versus control on the occurrence of plaque

colonization by aerobic nosocomial pathogens and nosocomial infection in ICU patients. The

treatment group received dental plaque decontamination with 0.2% chlorhexidine gel, three

times a day during their ICU stay. The standard group received routine oral care which consisted

of mouth rinsing with bicarbonate isotonic serum followed by a gentle oropharyngeal sterile

aspiration four times daily. At the conclusion of the study, the treatment group had a decrease in

dental bacterial colonization. Although there was a trend for reduction in mortality, length of stay

and duration of mechanical ventilation, the results were not statistically significant. The study









objective was to document the effect of dental plaque antiseptic decontamination on the

occurrence of plaque colonization by aerobic nosocomial pathogens and nosocomial infections,

including VAP. Limitations of the study included the researchers who did not check the quality

of the application of chlorhexidine gel at the bedside; therefore, patients having a prolonged

length of stay may not have properly received the antiseptic gel application as described in the

study.

Genuit, Bochicchio, Napolitano, McCarter & Roghman (2001) added the administration

of an oral rinse of chlorhexidine gluconate 0.12% twice daily to their rapid ventilator weaning

protocol for surgical patients. The addition of chlorhexidine gluconate 0.12% significantly

reduced VAP, (37% overall, p<0.05) in comparison to rapid ventilator weaning alone. A

limitation in the study design was that the researchers did not look at the incidence of VAP

related to mechanically ventilated patients who were not on a rapid weaning protocol.

Chlorhexidine gluconate is a broad spectrum antibacterial agent that has been used

extensively in healthy populations as a daily oral rinse to control plaque and to treat periodontal

disease (Iacono, Aldredge, Luck & Schwartzstein, 1998; Eldridge, Finnie, Stephens, Mauad,

Munoz & Kettering, 1998; Newman, et al., 1997; DeRiso, Ladowski, Dillon, Justic & Peterson,

1996). In a study by Grap, Munro, Ellswick, Sessler & Ward (2004), an early single post-

intubation oral application ofchlorhexidine gluconate 0.12% was administered immediately

following intubation. Thirty-four subjects were randomly assigned to chlorhexidine gluconate

spray 0.12% or swab 0.12% or to a control group. Oral cultures were obtained at baseline, 12,

24, 48 and 72 hours. At the end of the study, statistically significant reductions in oral culture

scores were only found in the chlorhexidine treatment groups. The results of these three studies:









Grap, 2004; Houston, et al., 2002; and Fourier, et al., 2000 demonstrate that the use of

chlorhexidine gluconate in critically ill adults may be beneficial in reducing VAP.

To enhance oral health and hygiene in hospitalized patients, nurses need to be

knowledgeable about risk factors that may contribute to poor oral health, facilitate best practice

and ultimately improve oral hygiene management to decrease the risk of developing ventilator

associated pneumonia in critically ill adult patients. Furthermore, few randomized controlled

trials have been performed that examined the effectiveness of oral hygiene protocols in the orally

intubated patient. In the absence of evidence-based guidelines, nurses often perform oral care

according to individual preferences or historical patterns (Munro, Grap, Jones, McClister &

Sessler, 2009). These preferences are often based on a combination of availability of a product,

or the nurses' knowledge and experience at the time. Therefore, a research gap exists regarding

evidenced based oral hygiene protocols and the role they could play in reducing VAP in the

critically ill adult patient.

Purpose of the Study

The purpose of this randomized controlled trial was to determine if there is a difference

in the occurrence of ventilator associated pneumonia in three oral hygiene protocol groups at 24

hours and 72 hours compared to baseline following implementation of the following nursing oral

hygiene study protocols:

The protocol groups included:

1. Group 1 consisted of the application of chlorhexidine gluconate spray 0.12% provided by
the nursing staff twice daily at twelve hour intervals on the teeth, gums and oral cavity.

2. Group 2 consisted of the application of chlorhexidine gluconate 0.12% and mechanical
toothbrushing provided by the nursing staff twice daily at twelve hour intervals on the
teeth, gums and oral cavity.

3. Group 3 consisted of the utilization of standard nursing oral hygiene protocols. Standard
oral hygiene was the hospital's policy and procedure, or the critical care unit's standard. In









most instances this was the utilization oftoothette foam swabs with or without
chlorhexidine 0.12% provided by the nursing staff twice daily at twelve hour intervals.

This study addressed two research questions: 1) Is there a difference in the three study

groups related to oral pH, oral culture scores and CPIS scores at 24 and 72 hours compared to

baseline, and 2) Do the number of decayed, missing and filled teeth, being edentulous and the

presence of periodontal disease have an association with the development of ventilator associated

pneumonia in critically ill adult patients?

Hypotheses

Hol: There will be no differences at 24 hours and at 72 hours compared to baseline in the

three study groups related to oral culture scores, oral pH, and CPIS scores.

Ho2: There will be no association between the number of decayed, missing and filled

teeth, being edentulous, the presence of periodontal disease and the development of ventilator

associated pneumonia in critically ill adult patients.

Significance of the Study

There is a lack of evidence-based nursing hygiene protocols for the prevention of

ventilator associated pneumonia. Most nursing practices are not research based, especially those

surrounding oral care (Berry, et al., 2007; Grap & Munro, 2004; Moore, 1995). Nursing

interventions lack empirical validity. Nursing approaches are guided by past experiences of the

caretakers (Walsh, 1990). Although use of an oral hygiene program is recommended, evidence to

guide specific oral care practices is limited (Berry, Davidson, Masters & Royle, 2007).

Evidence-based strategies will likely improve outcomes. Ventilator associated pneumonia (VAP)

remains an important cause of morbidity and mortality despite advances in antimicrobial therapy,

better supportive care modalities, and the use of a wide-range of preventive measures (Berry,

Davidson, Masters & Royle, 2007; Tablan, Anderson, Besser, Bridges & Hajjeh, 2004;









Niederman, 1996; Craven, Kunches, Kilinisky, Lichtenberg, Make & McGabe, 1986).

Endotracheal intubation and mechanical ventilation predispose a patient to VAP by interfering

with the normal defense mechanisms that keep microorganisms out of the lungs. Endotracheal

tubes interfere with the mucociliary transport system that helps clear airway secretions. These

secretions pool below and above the endotracheal tube cuff and are an ideal growth medium for

pathogens. The endotracheal tube also prevents normal closure of the epiglottis which results in

an incomplete seal of the laryngeal structures that normally protect the lungs. This tube

placement contributes to the aspiration of oral pathogens that can lead to the development of

VAP (Pruitt & Jacobs, 2006). Ultimately, providing guidelines to decrease the incidence of VAP

should be an important nursing goal.

Ventilator associated pneumonia is also significant in relation to healthcare costs. VAP

has been shown to prolong hospitalization by 7-9 days and a conservative estimate of the cost for

treatment of all nosocomial pneumonias in the United States is more than $2.5 billion dollars

annually (Cunha, 2009; Brooks, 2001; Leu, Kaiser, Mori, Woolman & Wenzel, 1989). One

example of cost savings to decrease VAP was a performance improvement project implemented

at St. Joseph's Hospital in Atlanta, Georgia in 1999. It resulted in a decrease of 318 Intensive

Care Unit days for an approximate savings of $349,164 (Keith, Garrett, Hickox, Echols &

Comeau, 2004). Since the conclusion of the performance improvement initiative, the hospital has

implemented the most recent CDC guidelines, a new ventilator assessment flow sheet and the

use of an antibacterial mouth care product that utilizes chlorhexidine 0.12% and mechanical

tooth brushing (Keith, et al., 2004).

At the Allegheny General Hospital in Pittsburgh, Pennsylvania in 2004, senior

leadership and the hospital board of directors introduced a strong support for a culture of safety









and set a goal of zero VAP in their intensive care units (Laux & Herbert, 2006). Interventions

included securing the patient's resuscitation bag in one location, maintaining the head of bed

elevation to more than 30 degrees, if not contraindicated, Yankauer suction tip care, and the use

of chlorhexidine 0.12% mouth rinse, resulting in the decreased incidence of VAP by 43% within

a six month period (Laux & Herbert, 2006).

Another healthcare system in Indiana and Kansas, utilized a performance improvement

strategy to reduce VAP by implementing standardized patient positioning, oral care, nutrition,

and management of comfort drugs across their healthcare system. Standardization of these

essential care practices reduced VAP in seven of their ten intensive care units, with two of them

maintaining zero VAP for two years (Murray & Goodyear-Bruch, 2007).

In March 2004, the CDC presented the Guidelines for Preventing Health Care-Associated

Pneumonia. In recent years, demand for protocols which may help to decrease or prevent

hospital acquired ventilator associated pneumonia has been desired. In response to this, the CDC

produced guidelines from the Healthcare Infection Control Practice Advisory Committee

(HICPAC). The committee's guidelines for prevention of VAP, however, did not include

guidelines for the prevention or modulation of oropharyngeal colonization. The guidelines

distributed in March of 2004 did not provide any recommendation regarding antimicrobial

agents, specifically chlorhexidine rinses or other oral decontamination agents for the prevention

of healthcare associated pneumonia in any health care setting. Therefore, the purpose of this

study was to identify if a nursing oral hygiene protocol consisting of application of chlorhexidine

gluconate spray 0.12% or chlorhexidine gluconate rinse 0.12% in conjunction with mechanical

toothbrushing would result in a decrease in VAP. If effective, this could translate to a decreased









length of stay, decreased hospital costs and ultimately a decrease in morbidity and mortality of

ventilator associated pneumonia in the hospital setting for critically ill adults.










CHAPTER 2
REVIEW OF THE LITERATURE

Recent studies provide evidence that the condition of the oropharynx may contribute to

the progression of ventilator associated pneumonia in critically ill adults. This chapter reviews

human normal oral flora, pathogenesis of gingivitis leading to periodontal disease, oral

colonization, definition and development of ventilator associated pneumonia in the ICU setting,

risk factors for developing VAP and strategies to reduce its development in the critically ill adult.

Normal Oral Flora

The normal oral flora is very intricate and consists of more than 200 species of bacteria;

although other microbes exist, bacteria are the most numerous microbial component of the

normal flora (Todar, 2008). Developmental changes in humans such as the eruption of teeth,

invariably affect the composition of the flora in the oral cavity; it has been calculated that the

normal oral cavity houses about 10 to the 10th power of bacteria (Todar, 2008).

Very little is known about the nature of the association between humans and their normal

oral flora, but they are thought to be dynamic interactions rather than associations of mutual

indifference (Todar, 2008). Both host and bacteria are thought to derive benefit from each other,

and the associations are, for the most part, mutually supported. The normal oral flora derives

from the host a supply of nutrients, a stable environment and constant temperature, protection,

and transport. The host obtains from the normal oral flora certain nutritional benefits, stimulation

of the immune system, and colonization strategies that exclude potential pathogens at the site.

The normal oral flora adapts to their host probably by biochemical interactions between bacterial

surface components ligandss and adhesions) and host cell molecular receptors (Merritt, Kreth,

Qi, Sullivan & Shi, 2005).









In general, there are three explanations for why the normal oral bacteria are located at

particular anatomical sites in the oral cavity. First, the normal oral flora exhibits a tissue

preference or predilection for colonization. Certain species of oral bacteria are invariably in one

locale and never in the other. This is sometimes referred to as tissue tropism. One explanation for

tissue tropism is that the host provides an essential growth factor needed by the bacterium. An

explanation of why an oral bacterium is not located at an alternative site is because the host

inherently provides a hostile environment for the bacterium by the production of such substances

as stomach acids, bile salts, and lysozymes. A second explanation is that normal oral flora

specifically colonizes a particular tissue or surface using their own surface components

(capsules, fimbriae, cell wall component) as specific ligands that are used for attachment to

specific receptors located at the colonization site in the oral cavity. Third, indigenous bacteria are

able to construct bacterial biofilm on a tissue surface; in other terms, they are able to colonize a

biofilm built by another bacterial biofilm on a tissue surface. Many biofilms are a mixture of

microbes, although one member is responsible for maintaining the biofilm and may predominate

(Merritt, Kreth, Qi, Sullivan & Shi, 2005).

The presence of nutrients, epithelial cells and debris, as well as secretions makes the

mouth a favorable habitat for colonization, disrupting the normal flora. The bacteria commonly

found in the oral cavity are staphylococci, streptococci, pseudomonas aeruginosa and

corynebacteria with a great number of anaerobes, especially bacteriodes. Many of the normal

oral floras are either pathogens or opportunistic pathogens; of these, the ones considered

potential pathogens for causing respiratory infections include: 1) staphylococcus aureus, 2)

streptococcus mutans, 3) streptococcus pneumoniae, 4) pseudomonas aeruginosa, 5)









corynebacteria with bacteriodes, and 6) actinomyctes (Merritt, Kreth, Qi, Sullivan & Shi, 2005;

Mayhall, 1997; Rumbak, 2000).

Staphylococci and corynebacteria normally occur in the oral cavity via the nares.

Staphylococcus aureus, a potential virulent pathogen, is the leading cause of all bacterial disease

in humans. It can be transmitted from the nasal membranes of an asymptomatic carrier to a

susceptible host, such as a mechanically ventilated patient (Koleff, 2004; Scannapieco &

Rethman, 2003).

Streptococcus mutans is the primary bacterium involved in plaque formation and

initiation of dental caries. Dental plaque, which is material adhering to the teeth, consists of

bacterial cells (60-70% the volume of the plaque), salivary polymers, and bacterial extracellular

products. Plaque is a naturally-constructed biofilm, in which the consortia of bacteria may reach

a thickness of 300-500 cells on the surfaces of the teeth. These accumulations subject the teeth

and gingival tissues to high concentrations of bacterial metabolites, which result in dental

disease. Viewed as an opportunistic infection, dental disease is one of the most prevalent and

costly infectious diseases in the United States. After initial weakening of the enamel, various oral

bacteria gain access to interior regions of the tooth. Lactobacilli and Actinomyces are commonly

found in human caries (Todar, 2008), which would suggest that they are secondary invaders that

contribute to the progression of lesions which can then be aspirated into the lungs and produce

VAP (Kollef, 2004).

Respiratory pathogens isolated from the lung are often genetically indistinguishable from

strains of the same species isolated from the oral cavity in patients who receive mechanical

ventilation and are admitted to the hospital from the community (Heo, Haase, Lesse, Gill &









Scannapieco, 2008). Thus, dental plaque serves as an important reservoir for respiratory

pathogens in patients who undergo mechanical ventilation.

Streptococcus pneumoniae is present in the oral and upper respiratory tract of about half

the population. If it invades the lower respiratory tract it can cause VAP. Streptococcus

pneumoniae causes 95 percent of all bacterial pneumonia. Streptococcus pyogenes refers to the

Group A Beta-hemolytic streptococci. Streptococcus pneumonia is a leading cause of VAP

(Todar, 2008; Kollef, 2004).

Gingivitis Leading to Periodontal Disease

Gingivitis is widespread with 54 percent of the population 13 years or older having

bleeding on probing. The most common type of gingivitis is caused by dental plaque. Plaque in

subgingival bacterial biofilm (plaque) initiates gingival inflammation (gingivitis). This in some

patients may extend apically to become periodontitis (Miyasaki, 2010). Periodontitis is clinically

differentiated from gingivitis by the loss of the connective tissue attachment to the teeth in the

presence of concurrent gingival inflammation (Cunha, 2009).

The causes of infections related to this condition are both exotoxins and endotoxins.

Exotoxins are proteins released by living cells. They secrete many gram positive and gram

negative bacteria. Endotoxins, a lipopolysacharide in the cell wall of gram negative organisms,

are released at cell death. They are gram negative bacteria. This process inhibits healing and

allows tissues to spread bacteria (Cunha, 2009).

Bacterial exotoxins such as hyaluronidase destroy the intercellular connections between

epithelial cells lining the gingival sulcus. The barrier effect of epithelial cells is reduced by a

widening of intercellular spaces. This is one of the first stages in the initiation of gingivitis. This

allows the penetration of other bacterial products through the epithelium to the underlying









gingival connective tissue. Other bacterial exotoxins such as collagenase can now penetrate

through the epithelial cell barrier of the gingival sulcus. This results in the destruction of the

basement membrane and areas of loss of the epithelial cell layer with ulcer formation. Epithelial

ulceration provides a portal for subgingival bacteria and their products to the gingival connective

tissue (Masada, 2006; Page, 2006). Bacteria may then enter blood vessels and cause a

bacteremia. Most subgingival bacteria that penetrate into connective tissue in gingivitis do not

proliferate in the tissue. This is because they are anaerobic and the tissues are aerobic. Bacterial

products that contact gingival connective tissue initiate an acute inflammatory response with

vasodilatation, edema and polymorphonuclear leukocyte (PMN) activation. Gingivitis is seen

clinically as acute inflammation with redness and edema of tissues and exudates of inflammatory

fluid from the gingival sulcus. One of the first effects of bacterial contact with gingival tissue is

activation of mast cells. Mast cells are inflammatory cells of the basophil series of granular

leukocytes. Mast cells have receptors which initiate production ofvasoactive substances such as

histamine which induce vascular permeability and vasodilatation. This vasodilatation and

increased permeability of capillaries are associated with edema and diapedesis of leukocytes

from the blood vessels into the connective tissue of the gingiva. Mast cells produce other

inflammatory mediators such as slow-reacting substance of anaphylaxis, leukotriene C4, tumor

necrosis factor alpha (TNF) and IL6. These activate the acute inflammatory response (Masada,

2006; Page, 2006).

As gingivitis develops the initial acute inflammatory response continues and a chronic

inflammatory response is added. Lymphocytes and capillary proliferation characterize this

chronic inflammation. B cells are lymphocytes derived from bone marrow and produce

antibodies to bacterial antigens. T cells are lymphocytes derived from the thymus and initiate cell









mediated immunity by producing lymphokines. B cells interact with macrophages in gingival

tissue and become plasma cells which produce antibodies. There are also B cell series that carry

the memory of a particular antigen and can quickly produce antibodies. This memory is

dependent on interactions with T cells. Plasma cells (B cells) produce immunoglobulins within

gingival tissue which bind to and inactivate bacterial antigens including exotoxins. The antibody

- antigen complexes also activate complement (Page, 2006; Masada, 2006; Miyasaki, 2010).

With chronic inflammation, gingival blood vessels and inflammatory cells proliferate into

the areas of destroyed connective tissue. Acute inflammatory changes are superimposed on

chronic inflammation. The combined acute and chronic inflammation seen in gingivitis and

periodontitis is destructive of bacteria. It also causes damage to the connective tissue of gingival

and the periodontal tissues. Another mechanism of breakdown of connective tissue in

periodontal disease involves matrix metalloproteinases (MMP). These are produced by PMNs,

macrophages, fibroblasts and epithelial cells. MMP8 comes from PMNs; and MMP1 comes from

resident cells (Page, 2006; Masada, 2006; Miyasaki, 2010).

The bacterial induced inflammation of gingivitis can spread apically and involves the

destruction of connective tissue of the periodontium including bone. This is periodontitis. The

damaged epithelium of the gingival sulcus proliferates apically. As loss of attachment of

connective tissue fibers to cementum occurs, the pocket epithelium migrates to line the root

surface. Bone destruction is a result of osteoblasts or inflammatory cells signaling osteoclasts

activation via cytokines such as IL-1 and TNF and prostaglandins (PGE). Activated osteoclasts

destroy the inorganic bone components by release of acid hydrolases. MMPs from osteoblasts

destroy the organic collagenous components. Possible mechanisms of bone loss in periodontitis

include: 1-suppression of osteoblasts by inflammation with lowered bone production, 2- loss of









collagen attachment with reduction of tensile forces on bone, and 3-direct bacterial toxicity on

osteoblasts and collagen. Other mechanisms of bone loss include: 1-regulation of cytokine and

PGE secretion by inflammatory cells and 2-osteoblasts regulation ofMMPs from inflammatory

and connective tissue cells (Page, 2006; Masada, 2006; Miyasaki, 2010). The role of oral

colonization of VAP-associated pathogens, which are atypical bacteria for the oral cavity,

therefore appear to have an association in the development of hospital acquired pneumonia in

patients who are mechanically ventilated (Grap & Munro, 2004).

Oral Colonization

Colonization of normal oral flora begins at birth and is of two types: 1) permanent

colonization by bacteria that are expected to be a part of the normal flora at all times; and 2)

transient colonization by potential pathogens. Colonization is by no means a haphazard event.

Changes in normal oral flora, a shift to colonization related to diet, medications and disease may

lead to biofilms on the tooth surfaces. Microorganisms have on their surfaces specialized

molecules called adhesions that bind with specific receptors on host epithelial cells or with

extracellular matrix materials. In respiratory infections such as VAP, viral infections facilitate

invasion by colonizing bacteria, which in turn facilitates superinfection by "normal flora" species

(Bryan, 2003). The primary cause then of most oropharyngeal colonization is plaque bacteria. It

is this disease process that appears to contribute to orally intubated patients being at an increased

risk for the development of ventilator associated pneumonia (Bryan, 2003).

Oral colonization has been reported to be the second most frequent principal diagnosis

among hospitalized Medicare patients (Baine, Yu & Summe, 2001). While aspiration pneumonia

doubled over the period from 1991-1998, aspiration pneumonia is still reported between 9 to

28% in hospitalized patients ( Shanratzadeh, Huang, & Marrte, 2006). Risk factors for the









development of ventilator associated pneumonia include oral bacterial colonization (Tantipong,

et al., 2008).

Aspiration of oropharyngeal contents with its high concentrations of anaerobic bacteria

has been implicated in the pathogenesis of aspiration pneumonia (Myrianthefs, et al., 2004). The

association between oral health and respiratory diseases has been suggested by a number of

microbiologic and epidemiologic studies (Hayes, Sparrow, Cohen, Vokonas & Garcia, 1998;

Scannapieco, Papandonatos & Dunford, 1998). It is quite possible that poor oral hygiene results

in an increase in dental plaque. The result of poor oral health may promote colonization by

anaerobic and gram-negative organisms. Pseudomonas aeruginosa is the quintessential

opportunity pathogen of humans that can invade virtually any tissue. Oral colonization of

pseudomonas aeruginosa is a leading cause of hospital acquired (nosocomial) gram-negative

infections, but its source is often exogenous (from outside the host) (Kollef, 2004). One source

may be the ventilator circuits and humidifiers that are connected to patients who are

mechanically ventilated (Kollef, 2004). Once aspirated, it is not uncommon for the anaerobic

bacteria to acquire virulence leading to pneumonia. Pharmacologic agents have shown promise

in reducing aspiration pneumonia, but their efficacy has not been established in large randomized

clinical trials (El Solh & Saliba, 2007; Donskey, et al., 2000).

The stomach can harbor organisms that cause nosocomial pneumonia as well. Patients on

antacids and other H-2 receptor antagonists may experience bacterial overgrowth (Berry, et al.,

2007; Valles, et.al., 2004; Bonten, et.al., 1996). Although colonization/infection with

pseudomonas aeruginosa in intubated patients tends to be endogenous, exogenous sources should

not be ruled out (Valles, et al., 2004). Bonten, et al., (1996) reported that length of ventilation

also increased the risk of stomach colonization. Patient conditions that increase the risk of









aspiration of stomach contents include: repeated endotracheal intubations, presence of a

nasogastric tube, supine positioning, neurological impairment, and an increased number of

invasive procedures (Kollef, 2004). Several interventions have been suggested to decrease

oropharyngeal and stomach colonization; one intervention includes the use of chlorhexidine as

an antimicrobial agent (Koeman, et al., 2009; Leone, Delliaux, Bourgoin, Albanese, Garnier,

Boyadjiev, Antonini & Martin, 2005; Kollef, 2004; DeRiso, Ladowski, Dillon, Justice &

Peterson, 1996).

Development of Ventilator Associated Pneumonia in the ICU

Pneumonia is an acute inflammation of the lung parenchyma that is caused by an

infectious agent that can lead to alveolar consolidation. Pneumonia can be classified as

community acquired (CAP) or hospital acquired (HAP or nosocomial). Patients who develop

ventilator associated pneumonia have fatality rates that exceed 50% and are more than two-fold

higher than intubated patients without pneumonia (Tejerina, Frutos-Vivar, Restrepo, et al., 2006;

Markowicz, Wolff, Djedini, et al., 2000; Craven & Driks, 1987). VAP continues to complicate

the course of 8 to 28% of patients receiving mechanical ventilation. In contrast to infections of

more frequently involved organs, such as the urinary tract and skin for which mortality is low,

ranging from 1 to 4%, the mortality for VAP ranges from 24-50% and can reach as high as 76%

in some specific settings or when lung infection is caused by high-risk pathogens (Tejerina, et

al., 2006; Chastre & Fagon, 2002). Pathogens that can cause severe HAP include Streptococcus

pneumoniae, Legionella, Klebsiella pneumoniae, Haemophilus influenza, Staphylococcus areas,

Mycloplasma pneumoniae, respiratory viruses, bacteriodes and Pseudomonas aeruginosa (May,

Kelly, Mendlein & Garbe, 1991). A number of factors determine the severity of HAP. Bacterial

factors include the size of the pathogen inoculum and the virulence of the organism. Pulmonary









factors include multi-lobar involvement and the presence of underlying lung disease and

pulmonary neoplasms. Systemic factors include advanced age, compromised host, and the

presence of congestive heart failure and hepatic/renal insufficiency (Tejerina, et al., 2006; May,

Kelly, Mendlein & Garbe, 1991).

By definition, hospital acquired pneumonia includes any case of pneumonia that starts

greater than 48 hours after hospital admission. Among intubated and mechanically ventilated

patients, the development of VAP occurring 48 hours after admission or later is known as

ventilator associated pneumonia (Kollef, 2004). Development of acute VAP implies a defect in

host defenses, particularly virulent organisms, or an overwhelming inoculation event. A number

of conditions predispose a patient to developing VAP. Bacterial invasion of the lower respiratory

tract can occur by aspiration of organisms colonizing the oropharynx. While other factors such as

spread of infections through the bloodstream, direct inoculation of organisms or spread of

infection to the lungs from adjacent structures are also causes; it appears that the most common

mechanism is aspiration of oropharyngeal organisms (Azarpazhooh & Leake, 2006).

Colonization of the patient's oropharynyx with infectious organisms is a major

contributor to the development of VAP. Oropharyngeal colonization with pathogenic organisms

contributes to the development of VAP in ICUs (Berry, Davidson, Masters & Rolls, 2007).

Normally, the oropharynx has a stable population of resident flora that may be anaerobic or

aerobic. When stress occurs, such as with illness, surgery, or infection, pathogenic and

opportunistic organisms from the oral cavity invade the lower respiratory tract causing

pneumonia. Disruption of the gag and cough reflex, altered consciousness, abnormal swallowing,

and artificial airways all predispose the patient to aspiration and colonization of the lungs and

subsequent infection (Kollef, 2004).









Previous antibiotic therapy may also affect the resident flora population, making

replacement by pathogenic organisms likely. The pathogens are then able to invade the sterile

lower respiratory tract (Kollef, 2004). Histamine blockers, antacids, and enteral feedings also

contribute to this problem because they raise the pH of the stomach and promote bacterial

overgrowth (Kollef, 2004).

Oral and systemic disease, as well as medication use, may be contributing factor to VAP

by altering the levels of oral bacteria in saliva and/or by changing the composition of the salivary

flow. Aspiration of the oropharyngeal secretions and contaminants likely provide the origin of

many of the anaerobic bacteria that have been cultured from aspiration pneumonia patients

(Azarpazhooh & Leake, 2006). The Infectious Diseases Society of America and the recent

Thoracic Society guidelines have recommended anaerobic coverage for patients with pneumonia

with poor dentition who are at risk for aspiration (Diaz, Ulldemolins, Lisboa & Rello, 2009;

Bouza & Burillo, 2009; Bartlett, Breiman, Mandell & File, 1998). Recent research, therefore,

suggests the relative importance of oropharyngeal colonization in the development of VAP;

additionally convincing evidence exists to suggest other risk factors for VAP and interventions

that can be employed to reduce its occurrence (O'Keefe,Carthy, Santiago & Lau 2009; Kollef,

2004).

Risk Factors Contributing to VAP


A review of the literature by this author regarding oral health identifies at least ten actual

or potential risk factors which can contribute to the colonization of the oropharyngeal area; these

include 1) tooth loss 2) dental plaque 3) dental caries 4) periodontal disease 5) stomatitis 6) oral

pH 7) dry mouth/xerostomia 8) conditions favoring reflux 9) prolonged use of ventilator

support/potential exposure to contaminates and 10) host factors such as extremes in age,









malnutrition and severe underlying condition. Nursing knowledge regarding each of these risk

factors and implementing best practice interventions can improve patient outcomes.

Tooth Loss. Most tooth loss is caused by two preventable diseases: dental caries (tooth

decay) and periodontal disease (Coleman, 2002). Loss of teeth alters food selection, resulting in

a carbohydrate-rich diet lacking in fiber and protein, putting the patient at risk for malnutrition.

Identification of tooth loss and implementing procedures to provide replacement can help

alleviate this problem. Kressin, Boehmer, Nunn and Spiro (2003) studied 735 men in the

Veterans Affairs Dental Longitudinal Study utilizing a cross sectional and longitudinal self-

report regarding tooth brushing, dental floss use, annual prophylaxis, and combinations of such

behaviors. It was significant for the prevention of tooth loss. To examine the association

between childhood dental visits and attitudes and beliefs about dental care and oral health, data

from the Florida Dental Care Study (FDCS) was reviewed. The data suggests that the

socialization associated with early dental visits may occur even though the experience may have

been painful or frightening. Although this study design precluded direct inference about

causation, these findings do support the utility of further investigations into possible causative

linkages between childhood dental experiences and adult attitudinal and dental health outcomes

(Riley & Gilbert, 2005).

Vitamin D and calcium are associated with increasing bone density. Increasing the intake

of both has shown to reduce the rate of tooth loss. Currently one longitudinal study has found a

correlation between these factors (Wactawski-Wende, Grossi & Trevisan, 1996). Nordenram &

Ljunggren in 2002 studied 192 nursing home residents and determined that cognitive function

influences the retention of teeth. Being dentate but having loss of cognitive functional capacity is

predictive of oral treatment need among nursing home residents.









Dental Plaque. Dental plaque is material adhering to the teeth, consisting of bacteria,

salivary polymers, and bacterial extra cellular products. Plaque is a naturally constructed biofilm,

in which the consortia of bacteria may reach a thickness of 300-500 cells on the surfaces of the

teeth. These accumulations subject the teeth and gingival tissues to high concentrations of

bacterial metabolites, which result in dental disease (Azarpazhooh & Leake, 2006).

Plaque formation is initiated by a weak attachment of the streptococcal cells to salivary

glycoprotein from a pellicle on the surface of the teeth. This is followed by a stronger attachment

by means of extra cellular sticky polymers of glucose which is synthesized by the bacteria from

dietary sugars. An enzyme on the cell surface of streptococcus mutans, glycosol transferease, is

apparently involved in initial attachment of the bacterial cells to the tooth surface and in the

conversion of sucrose to dextran and levan polymers which form the extra cellular matrix of

plaque. Attachment of S. mutans and the formation ofglucans are mediated by glycosyl

transferase. The specificity of the adhesion has been proven by the fact that the attachment can

be prevented by specific antibody to the enzyme (Azarpazhooh & Leake, 2006).

Nine patients at the University of Buffalo Hospital who were suspected of having VAP

had samples of dental plague removed for DNA analysis. Results showed that genetic profiles of

bacteria from tracheal and bronchial samples of the nine patients with pneumonia were identical

to profiles of bacteria from their dental plague. Heo (2007) stated that the results suggest that the

teeth likely serve as an important reservoir of infection in these high risk patients. He further

stated that to prevent possible hospital acquired ventilator associated pneumonia, taking care of

teeth and gums while hospitalized might be important.

Munro, Grap, Elswick, McKinney, Sessler & Hummel (2006) enrolled 66 patients within

24 hours ofintubation and were followed for seven days. Patients with higher dental plaque









scores and oral organisms at baseline increased over time during the seven days of observation

and showed a greater risk for ventilator-associated pneumonia, particularly for patients with a

greater severity of illness.

Dental Caries. Dental caries is an infectious disease in which the destruction of the

enamel, dentin or cementum of teeth is due to bacterial activities. Caries are initiated by direct

demineralization of the teeth enamel due to lactic acid and other organic acids which accumulate

in dental plaque. Lactic acid bacteria in the plaque produce lactic acid from the fermentation of

sugars and other carbohydrates in the diet of the host. Streptococcus mutans has most

consistently been associated with the initiation of dental caries, but other lactic acid bacteria are

probably involved as well. These organisms normally colonize the occlusal surface and contact

points between teeth and this increases the incidence of decay on these surfaces (Azarpazhooh &

Leake, 2007). Dental biofilms are implicated in the formation of caries and periodontal disease.

A major constituent is Streptococcus mutans, which produce lactic acid from sucrose

fermentation, enhancing enamel demineralization and eventual caries development. Increasing

the delivery of anticariogenic agents such as flouride into the plaque biofilm may be a useful

strategy for enhancing the anticaries effects in areas of the mouth where complete biofilm

removal is not possible with routine daily cleaning techniques (Aspiras, Stoodley, Nistico,

Longwell & deJager, 2010).

Dental caries can result in pain, tooth loss, abscess formation and bacteremia. Lapses in

oral hygiene can contribute to dental caries and ultimately risk the development of tooth loss.

Hase, Attstrom, Edwardsson, Kelly & Kisch (1998) compared the use of 0.2% delmonipinol

hydrochloride versus 0.2% chlorhexidine digluconate and placebo. The study demonstrated that

rinsing twice daily for 60 seconds for 6 months resulted in less plaque formation and gingivitis









than with a placebo. Pearson (1996) compared foam swabs and toothbrushes to prevent dental

plaque. The sample size of two participants reported no significance. Dental caries increase

bacteria residing in plaque. Older adults form plaque more rapidly than younger individuals and

because lapses in oral care can occur in the elderly, an increased risk of developing new and

recurrent tooth decay has been seen (Terpenning, 2005).

Periodontal Disease. Periodontal disease is an inflammatory disease of the gingival

structure and supporting tissues caused by bacteria residing in dental plaque. Increased

populations of Actinomyces and Streptococci, as well as, gram-negative organisms have been

suggested as the cause. Diseases of the gum may lead to tooth loss, diffuse progression may

produce hydrolytic enzymes, endotoxins, and other toxic bacterial metabolites. Periodontal

disease increases the elderly's susceptibility to pneumonia. Genult, Bochicchio, Napolitano,

McCarter & Roghman (2001) performed a prospective study over ten months in surgical

intensive care patients. The first 5 months no interventions were performed in the surgical

intensive care unit; the second 5 months chlorhexidine 0.12% oral rinses were performed twice

daily for the duration of mechanical ventilation, on a matched sample of critically ill subjects.

There was no significant difference in the overall hospital or ICU length of stay between groups.

Improved oral hygiene via topical chlorhexidine application in conjunction with the use of a

weaning protocol was effective in reducing the incidence of VAP and the duration of mechanical

ventilation in surgical ICU patients.

In 1997, Mojon, Budtz-Jorgensen, Michel & Limeback examined 302 frail elderly

acutely ill patients. They reported that poor oral hygiene presents potential risk factors for

respiratory tract infections in frail elderly clients. Implementing oral health protocols may be

effective in reducing the risk of aspiration pneumonia, which was studied by Taylor, Loesche &









Terpenning in 2000. In their study, eighteen outpatients had oral health protocols implemented

using chlorhexidine 0.12% rinses. A statistically significant reduction in bacterial plaque was

noted, thereby preventing aspiration pneumonia in this study population.

Seymour, Ford, Cullinan, Leishman & Yamazaki (2007) wrote that despite 3,000 years of

medical dental history demonstrating the influence of oral status on general health, it is only in

recent decades that the association between periodontal disease and systemic conditions such as

respiratory conditions have been realized. They stated that it is clear that oral infections may

represent a significant risk factor for systemic disease and hence the control of oral disease is

essential in the prevention and management of these conditions.

Stomatitis. Stomatitis is a chronic inflammation of the mucous membranes. Prevalent in

surveys of institutionalized patients, it is usually due to denture wearing (Coleman, 2002).

Stomatitis is also present during broad-spectrum antibiotic use, impaired salivary flow,

corticosteroid therapy and immunocompromised states (Coleman, 2002). Thirty-three

participants were randomized using micronized sucralfate versus salt and soda mouthwashes in a

study by Dodd, et al., (1996). They utilized a randomized, double-blind, placebo controlled

clinical trial for prevention of oral mucositis in patients receiving chemotherapy. Results showed

there was no significant difference between the two mouthwashes, but there was a reduction in

the incidence ofmucositis in all clients compared to earlier studies. This may indicate that

increased nursing attention to oral health in and of itself may lead to improve oral outcomes for

clients.

Oral pH. Oral pH should be maintained between 6 and 7 (Coleman, 2002). Products that

alter the pH, such as hydrogen peroxide, sodium bicarbonate, mouthwashes containing alcohol,

as well as many medications may increase the alkalinity of the oral pH. This change in pH may









contribute to periodontal disease. Bacteria, saliva, minerals and foods eaten all play a role in

helping or hindering the progress of dental caries. Cariogenic bacteria are at the heart of

periodontal disease and dental caries formation. The decaying action of the bacteria depends on

their ability to adhere to tooth surfaces, the degree to which they colonize and how the food

residues influence the amount of acid produced by the bacteria. Acid conditions below a pH of

5.5 cause dissolution of calcium and phosphate from tooth enamel. When this occurs, tooth

dimeralization exceeds the ability of recovery or remineralization.

Dry Mouth/Xerostomia. Saliva is important for the health of both soft and hard oral tissues

(Defabianis & Re, 2003). Dry mouth/xerostomia may be caused by systemic disease,

medications or radiation. The health of teeth, gums and soft tissues of the mouth are at risk when

patients have gingivitis, which may lead to periodontal disease. Dry mouth also increases a

person's risk of tooth decay and mouth infections, such as thrush. Conditions that lead to

dehydration, such as fever, excessive sweating, vomiting, diarrhea, blood loss, and bums can

cause dry mouth. These conditions are often seen in critically ill adult intensive care patients. In

addition, we require saliva to moisten and cleanse our mouths and digest food. Saliva also

prevents infection by controlling bacteria and fungi in the mouth. When adequate saliva is not

produced, the mouth gets dry and uncomfortable. The placement of an endotracheal tube may

alter saliva production while patients are mechanically intubated, increasing the chance of

developing ventilator associated pneumonia because of the changes in the oral cavity (Liena-

Puy, 2006; Hicks, Garcia-Godoy & Flaitz, 2003).

Medications used to treat psychotropic disorders such as depression and anxiety, in

addition to medications to treat pain, allergies and colds (antihistamines and decongestants),

obesity, acne, epilepsy, hypertension (diuretics), diarrhea, nausea, urinary incontinence, asthma









(certain bronchodilators), and Parkinson's disease have been shown to produce xerostomia. The

use of muscle relaxants and sedatives also contribute to this situation. Most mechanically

ventilated patients receive some type of sedation while intubated.

In addition, a side effect of the patient's medical conditions may contribute to decreased

production of saliva, including Sjogren's syndrome, HIV/AIDS, Alzheimer's disease, diabetes,

anemia, cystic fibrosis, rheumatoid arthritis, hypertension, Parkinson's disease, stroke, and

mumps. Reduction in salivary flow is attributed to systemic conditions and medications rather

than the aging process itself. More than 500 drugs contribute to xerostomia. In addition, other

causes are oxygen therapy, oral suctioning and NPO status (Henshaw & Calabrese, 2001).

Damage to the salivary glands, the glands that produce saliva, for example, from radiation to

the head and neck and chemotherapy treatments for cancer, can also reduce the amount of saliva

produced. Nerve damage to the head and neck area from an injury or surgery or personal health

habits such as smoking or chewing tobacco can affect saliva production and aggravate dry

mouth. Continuously breathing with the mouth open contributes to the problem. The placement

of an endotracheal tube artificially produces this effect in patients on mechanical ventilation

(Defabianis & Re, 2003).

In a study by Dennesen et al., in 2003, twenty-four ventilated ICU patients and 20

coronary artery bypass grafting patients were included in a study to ascertain salivary flow.

Absence of salivary flow in the ICU patients caused severe xerostomia which may have

contributed to the development of oropharyngeal colonization with gram-negative bacteria,

which has been shown to increase the risk for the development of VAP (Dennesen, et al., 2003).

Munro, et al. (2006) in their descriptive study of 66 critically ill patients, attributed a decrease in

salivary volume as a possible contributor to patients developing VAP.









Conditions Favoring Reflux. Supine positioning has been shown to be an independent

risk factor for the development of VAP (Kollef, 2004; Sole, 2003). Aspiration of stomach

contents is increased when patients are in the supine position. In one trial, there was a three-fold

reduction in the incidence of nosocomial pneumonia when a semi-erect position was maintained

(Drakulovic, et.al., 1999). Positioning affects the volume of gastric aspirate. The semi-Fowler's

position (elevating the head of the bed by 30 degrees) decreases the volume of gastric juices and

thereby reduces the aspiration risk (Tablan, Anderson, Besser, Bridges & Hajjeh, 2004).

Aspiration of Gastric Contents. Several studies have found an association between

aspiration of gastric contents and VAP. The avoidance of gastric over-distension may reduce

this complication (Torres, et al., 1996; McClave, DeMeo, DeLegge, et al., 2002). Currently

available measures at avoiding gastric over-distension include reducing the use of narcotics and

anti-cholinergic agents, monitoring gastric residuals, using gastrointestinal motility drugs,

supplying enteral nutrition with small bore feeding tubes and administering feeding solutions

directly into the small bowel instead of the stomach (Berry, et al., 2007; Kollef, 1999).

Prolonged Use of Ventilator Support/Potential Exposure to Contamination. Length

of ventilation. Several studies have shown a direct relationship to the length of mechanical

ventilation and the development of VAP (Cunha, 2009; Brooks, 2001). In addition, the use of the

naso-pharyngeal route increases patients' risk of developing VAP (Koleff, 2004). The incidence

of VAP increases with the length of stay in intensive care and the number of days mechanically

ventilated (Cunha, 2009). Cook et al., (1998) reported a 3% increase in VAP per day during the

first week of mechanical ventilation for every intensive care unit patient. Decreasing the time the

patient is on the ventilator could help reduce the incidence of VAP Strategies that may reduce

the number of ventilated days include limiting sedation and utilizing mechanical ventilator









weaning protocols aimed at early attempts to extubate the patient by allowing them spontaneous

breathing (Kollef, 2004).

In a randomized control trial in a California trauma ICU, a protocol designed to assist

nurses and respiratory therapists initiating a weaning process was effective in reducing the

duration of mechanical ventilation without any adverse effects on patient outcomes (Marelich, et

al., 2000). Six percent of the patients receiving the protocol-directed weaning developed VAP,

whereas 15% of the patients in the control group developed VAP. Therefore, the evidence

suggests that a weaning protocol may help to decrease ventilated days in patients in ICU and

decrease their chance of developing VAP (Marelich, et al., 2000).

Potential exposure to contaminants. Secretions are common in the upper airways of

intubated patients. Secretions pool above the endotracheal tube cuff allowing for leakage of

contaminated secretions into the lower airway. In four studies, the effect of using an endotracheal

tube that has a separate dorsal lumen, which allows continuous aspiration of the subglottic

secretions, was compared with that of a conventional endotracheal tube (Smulders, van der

Hoeven, Weers-Pothoff & Vandenbroucke-Granulus, 2002; Mahul, et al., 1992; Valles et al.,

1995; Kollef, Nikolaos & Thoralf, 1999). Although the four randomized controlled studies

showed a beneficial effect of continuous suctioning of subglottic secretions on the incidence of

VAP, none of these studies showed a corresponding effect on mortality rate, length of stay in the

intensive care unit, or duration of mechanical ventilation (Kollef, 2004).

Subglottic secretion drainage systems appear effective in preventing early onset of VAP

in a meta-analysis review of 5 studies and 896 patients. The revised CDC guidelines suggest this

specially designed endotracheal tube should be used when feasible (Fletcher, Ruffell & Young,

2009; Tablan, et al., 2004).









Nasal intubation has been identified as a risk factor promoting the development of VAP

and sinusitis (Holzapfel, Chastang, Deminogeon, et al., 1999; Bert & Lambert-Zechovsky,

1996). Nasal obstruction with an endotracheal tube or feeding tube prevents the clearance of

secretions from the sinuses, which plays a role in the development of sinusitis. Aspiration of

infected secretions from the sinuses into the lower respiratory tract can overwhelm local host

defense mechanisms allowing VAP to occur (Holzapfel, Chastang, Deminogeon, et al., 1999).

Available investigations and experiences suggest that the preferred route of tracheal and gastric

intubation is via the oropharynx and not the nasopharynx to prevent both hospital acquired

sinusitis and VAP (Kollef, 2004).

Host Factor Extremes: Age, Malnutrition, Underlying Conditions

Nosocomial pneumonia represents the third most frequent hospital diagnosis among

patients aged 65 years or older (May, Kelly, Mendlein, & Garbe, 1991). Systemic factors

contributing to VAP include advanced age, compromised host, and the presence of congestive

heart failure and hepatic/renal insufficiency.

Poor nutritional status is an independent risk factor for poor outcomes in ventilator

associated patients. Malnutrition has been correlated with increased incidence of sepsis,

prolonged ventilator dependence and increased mortality. Given that nutritional deficits have

been reported in 35% of the elderly population, it is not surprising that nutritional modulation of

immune function acting in concert with coexistent chronic diseases predisposes those for a worse

prognosis (Reinhardt, Myscofski, Wilkens, Dobrin, Mangan, & Stannard, 1980).

Ford (2008) found that although the provision of mouth care has gained momentum,

oropharyngeal morbidity can cause pain and disordered swallowing leading to reluctance in









commencing or maintaining an adequate dietary intake. The neglect of oral care, he found, can

be detrimental to surgical outcomes.

The number of decayed teeth and the frequency of brushing teeth in conjunction with

functional dependency for oral care have been significantly associated with VAP. Poor oral

hygiene is common in the elderly population. Patients needing assistance in tooth brushing were

found by Jette (2003) to have more plaque and gingivitis than those who brushed their own teeth.

Similarly, Nakayama, Washio, & Mori (2004) found a high correlation between oral disease and

dependence for activities of daily living, including self-care among older persons. Others have

documented that a relatively large proportion of the independent and institutionalized, older adult

population has dental disease and that they rarely seek dental services (Samaranayake,

Wilkieson, Lamey & MacFarlane, 1995; Ettinger, Warren, Levy, Hand, Merchant, & Stromquist,

2004). Patients needing assistance with tooth brushing or oral care have been shown to have an

increase in poor nutrition and malnutrition.

Bacterial flora in the oropharynx can be altered by severe underlying disease, inactivity,

or malnutrition (Marshall, Warren, Hand, Xie, & Stumbo, 2002). A more direct cause of altered

colonization in the oropharynx is the presence of oral or dental disease. The shedding of bacteria

from the buccal mucosa, tongue dorsum, gingival sulcus, and the teeth is about tenth to eleventh

power for bacteria per day. Plaque, gingivitis, periodontal disease and tooth decay will alter the

flora within the mouth and could change the bacterial composition of saliva. Reduced salivary

flow, a common side effect of many medications increase the concentration of bacteria in the

saliva and if the saliva is aspirated or mixed with food or liquid, it changes to 100,000,000

bacteria/ml saliva that could enter the lungs. The saliva can then become problematic if it

contains bacterial pathogens (Marshall, et al., 2002).









Strategies to Decrease Ventilator Associated Pneumonia

Critically ill adults have many needs related to physiological stability while hospitalized

in an ICU. Intensive care unit nurses prioritize care related to immediate medical problems

(Berry, et al., 2007; Fitch, et al., 1999). However, in addition to planning and delivering nursing

care related to the medical reasons for admission, nurses have a responsibility to keep patients

comfortable, prevent complications and maintain patients' functions at the highest level possible.

Providing evidence-based strategies to prevent VAP should be a nursing goal. This includes

providing the best oral care possible to patients.

Oral Assessment Tools. In 1977, Maurer wrote that the assessment tool for evaluating

the general oral health of patients should state concisely the areas to be evaluated and the

descriptive criteria to be used to show the changes from normalcy to deterioration that can occur

if proper oral care is not provided. Twenty five years later, there is not a routine oral assessment

tool utilized in most healthcare settings. Several studies have cited the ability to decrease VAP

when oral assessment tools were implemented (Fitch, 1999; Moore, 1995; Fitch, Munro, Glass &

Pelligrini, 1997). Developing an improved assessment tool for intubated patients was the purpose

of Steifel, Damron, Sowers & Velez (2000) work.

A pilot study adapted Eller' s (1988) oral assessment tool in order to improve oral hygiene and

standardize procedures for intubated clients. The study was significant, although the sample size

consisted of only eight patients. Treloar and Stechmiller (1995) developed an assessment tool

for orally intubated clients. The sample size in their study was 16 and demonstrated that

oropharyngeal cultures of 37.5% of orally intubated critical care patients grew nosocomial

bacterial fungal pathogens and those same pathogens were cultured from sputum specimens.

Thus, more serious nosocomial infections, such as VAP might be avoided by preventing









pathogen colonization of the oropharynx by better oral assessments. Kayser-Jones' oral

assessment instrument was designed to for use in nursing home patients to improve oral

assessments by nurses and nursing assistants. Utilization of the Kayser-Jones' (1995) oral

assessment instrument in nursing home patients has shown to decrease the development of

community acquired aspiration pneumonia.

An accepted oral health assessment tool or related instrument for use at the bedside is an

important consideration (Binkley, Furr, Carrico & McCurren, 2004). Such an instrument reminds

the bedside nurse to remember the issue of oral care, provides critical thinking cues as to who is

at high risk for problems related to oral contamination, and provides a method for monitoring the

effectiveness of interventions. The researchers surveyed 102 intensive care units within the

United States with 556 respondents; 97% registered nurses. The participants in the study reported

that despite efforts to perform oral care, the oral status of their patients continued to decline. The

use of an oral assessment tool might avoid this problem (Binkley, Furr, Carrico & McCurren,

2004). Research has demonstrated that utilizing an oral assessment tool improves oral hygiene of

patients; therefore, systemic oropharyngeal assessments in critically ill ventilated adult patients

may prevent more serious infections such as VAP.

Chlorhexidine Use. Preventive strategies to reduce oral respiratory colonization and

respiratory infections include selective oropharyngeal decontamination with topically applied

antibiotics (Hutchins, et al., 2009; Munro, Grap, Jones, McClister & S essler, 2009; Grap,

Munro,Elswick, Sessler, & Ward, K. 2004. Bergman, Bonten, Gaillard, Paling, van der Geest,

Van Tiel, et al., 2001; Abele-Horn, Dauber, Bauerfeind, Russwurm, Seyfarth-Metzger, Gleich et

al., 1997; Pugin, Auckenthlaer, Lew & Suter, 1991), application of the antimicrobial agent

chlorhexidine gluconate (DeRsio, Ladowski, Dillon, Justice & Peterson, 1996; Fourrier, Cau-









Pottier, Boutigny, Roussel-Delvaliez, Jourdain & Chopin, 2000; Genuit, Bochicchio, Napolitano,

McCarter & Roghman, 2001) and toothbrushing combined with dental prophylaxis (Yoshida,

Yoneyama & Aagawa, 2001; Coleman, 2002; Steifel, Damron, Sowers & Velez, 2000). Oral

decontamination of mechanically ventilated adults using antiseptics was associated with a lower

risk of VAP, although in Chan, Ruest, Meade & Cooke's (2007) literature review there was no

reduction in mortality, duration of mechanical ventilation or stay in the intensive care unit. The

use of topically-applied antibiotics has not been widely accepted because of concerns about the

development of antibiotic resistance. Chlorhexidine is an easily applied and relatively

inexpensive preventive measure with minimal side effects.

Studies have investigated the use of chlorhexidine gluconate as an adjunct to reducing

nosocomial ventilator associated pneumonia (Berry, et al., 2007: Koeman, et al., 2006; DeRiso,

et al., 1996; Houston, Hougland, Anderson, LaRocco, Kennedy & Gentry, 2002). In addition, the

use of chlorhexidine has also been utilized in the elderly and to decrease the risk of developing

pneumonia in the community (Clavero, Baca, Junco, & Gonzalez, 2003). Although there is

concern regarding increasing antibiotic resistance, the most recent studies demonstrate improved

outcomes with its use if the duration is limited (Berry, et al., 2007: Koeman, et al., 2006; Kollef,

2004).

Several clinical trials have utilized chlorhexidine in the following areas. Two studies in

cardiovascular patients demonstrated a reduction in respiratory tract infections with the use of

chlorhexidine gluconate before elective coronary artery bypass grafting procedures (DeRiso,

Ladowski, Dillon, Justice & Peterson, 1996; Houston, Hougland, Anderson, LaRocco, Kennedy

& Gentry, 2002). These researchers randomized ICU patients into one hundred and eighty

treatment patients and one hundred and seventy three control patients. Patients rinsed with 0.12%









chlorhexidine twice daily in the treatment group and the control group received standard oral

care. Results of the study demonstrated a 69% reduction in incidence of respiratory infection

and a 43% reduction in intravenous antibiotic use.

In the Genuit, et al. study (2000), a prospective randomized intervention trial using

chlorhexidine and a rapid weaning protocol was performed. There were 30 control subjects who

received rapid weaning protocol intervention alone, and then 56 patients received rapid weaning

and chlorhexidine 0.12% that was swabbed in the posterior oropharynx. A 75% reduction in late

onset (5 days or greater) VAP developing after intubation was reported with a 43% reduction in

mortality.

Ercole, et al. (2009) used chlorhexidine 0.12% with fifteen subjects compared to ten

subjects in a control group which did not receive chlorhexidine after dental implant. Results

showed that chlorhexidine appears to be an effective method for the reduction of bacterial

colonization of the implant cavity and improves the health status of the peri-implant tissue. In a

study by Heitz, Heitz-Mayfield & Lang (2004) post-surgical peri-implant patients were assigned

to one of two groups. One group rinsed twice daily for 1 minute with 0.12% of chlorhexidine for

4 weeks and one group rinsed in addition to applying chlorhexidine gluconate locally using a

special soft toothbrush. Both groups resulted in successful wound healing and optimal closure

suggesting that the introduction of mechanical toothbrushing in addition to chlorhexidine

gluconate may be recommended for decreasing post surgical infections and increasing wound

healing. In another study of implant surgical patients, Francetti, Del Fabbro, Basso, Testori,

Taschieri, & Weinstein (2004) indicated that chlorhexidine spray or mouth rinse significantly

lowered dental plaque and improved dental wound healing.









In a study by Tantipong, Morkchareonpong, Jaiyindee, & Thamlikitkul (2008) conducted

in Thailand; oral decontamination with 0.2% chlorhexidine solution was an effective and safe

method for preventing VAP in patients who received mechanical ventilation. Of the 102 treated

subjects, oropharyngeal colonization with gram negative bacilli was either reduced or delayed in

the chlorhexidine treatment group. Chlebicki and Safdar's (2007) article on the use of

chlorhexidine for prevention of VAP, which was a meta analysis review; stated that Koeman, et

al., (2005) study was conducted in the Netherlands using a 0.2% chlorhexidine concentration.

The higher chlorhexidine concentration in both these studies may have partially explained the

benefit of reducing VAP that was reported in both these studies.

In a randomized, double blind, placebo-controlled trial with three arms: chlorhexidine

0.12%, chlorhexidine 0.12% with colistin and a placebo conducted by Koeman, et al. (2006), 127

of the chlorhexidine treated patients and 128 of the chlorhexidine and colistin treated patients

compared to the placebo group demonstrated a significant decrease in the development of VAP

in both treatment groups compared to the control group. Hutchins, et al. (2009) conducted a

quality improvement project in their facility between 2004 and 2007. Oral care was provided

every four hours and the teeth were brushed with cetylpyridium chloride during the years 2004

and 2005. In 2007, the procedure was changed and they started using chlorhexidine 0.12% and a

suction toothbrush to cleanse the oral cavity and applied mouth moisturizers as needed. In

addition, deep oropharyngeal suctioning was performed and suction catheters were used to

control secretions routinely. At the conclusion of their quality improvement project, VAP had

been reduced 89.7% in their patient population following the addition of chlorhexidine 0.12%.

Chlorhexidine appears to be the most effective agent for the reduction of both plaque and

gingivitis (Ciancio, 1991). Chlorhexidine is sold in the United States by prescription in a 0.12%









concentration as a mouth rinse, Peridex, which is approved by the Council on Dental

Therapeutics of the American Dental Association (ADA). In Europe and other countries,

chlorhexidine is available in a variety of concentrations, with 0.2% being most often used and is

available as a mouth rinse and gel. Due to the availability of 0.12% chlorhexidine, which would

not need FDA approval, the decision to use the ADA approved chlorhexidine concentration for

this study was deemed the most appropriate.

Toothbrushing. Toothbrushing at least twice per day has been shown to reduce

pneumonia in dependent nursing home patients and is also more cost-effective than routine use

of foam swabs (Steifel, Damron, Sowers & Velez, 2000). Fitch (1999) performed a longitudinal

intervention evaluation and observational study utilizing thirty patients in the treatment and

control groups. Pediatric toothbrushes, toothpaste, ethyl alcohol-free antibacterial mouthwash,

moisturizing gel to mucous membranes and petroleum jelly to the lips were applied every 12

hours. Results of the study showed decreased gingival inflammation and the nurses preferred the

oral protocol to their previous standard routine.

The toothbrush has been shown to perform substantially better than foam swabs or

toothettes in the ability to remove dental plaque and an electric toothbrush reduces plaque

significantly better than manual toothbrushes (Pearson, 1996; Day, Martin & Chin, 1998).

Electric or powered toothbrushes have also been shown to improve the quality of care and are

easier to use than manual brushes when health care workers provide care for dependent patients

(Day, Martin & Chin, 1998). In these studies, frequency of oral care ranged from 2 to 12 hours

(Binkley, et al., 2004). Although some evidence-based oral care protocols and oral preventive

care measures for VAP have been published, there is little information on current practices, oral

care training, time, frequency, product and nurse's attitudes. In a systematic literature review by









Azarpazhooh and Leake (2006), they found good evidence (I, grade A recommendations) that

improved oral hygiene reduces the progression or occurrence of respiratory diseases among high

risk elderly adults in the ICUs.

Nursing Knowledge. A survey of oral care practices in the United States in intensive

care units was conducted by Binkley, Furr, Carrico & McCurren (2004). Oral care methods were

not consistent with current research and oral care protocols. The authors concluded that

translation of oral care research into practice in the ICUs may improve the quality of care and

decrease the incidence of VAP.

Wardth, Hallberg, Berggren, Anderson & Sorensen (2000) interviewed 22 nurses and

reported that increasing nurses knowledge on oral hygiene was important to decreasing bacterial

colonization. Paulsson, Soderfeldt, Nederfors & Fridlund (2002) reported that nurses did not

consider oral hygiene an important aspect of nursing care. Furr, Binkley, McCurren & Carrico

(2004) reviewed factors that affect the quality of oral care in ICUs. They concluded that

improving the quality of oral care in intensive care units is a multi-layered task. Reinforcing

proper oral care in education programs, de-sensitizing nurses to the often-perceived

unpleasantness of cleaning oral cavities, and working with hospital managers to allow sufficient

time to attend to oral care was recommended to decrease VAP and other respiratory infections.

At the Aga Khan University Hospital, six hundred and seventy-seven adult patients were

included in the study that introduced evidence-based practice guidelines for preventive oral care

practices at the bedside. VAP rates were reduced by 51% from a mean of 13.2 +/-1.2 in the pre-

intervention period to 6.5+/-1.5/1000 device days in the post intervention period. The authors felt

that a multidisciplinary education program geared towards ICU staff can successfully reduce the

incidence rates of VAP (Salahuddin, et al., 2004).









Ross and Crumpler (2007) found that despite strong evidence in the literature on the role

of oral care in the prevention of VAP, nurses continue to view oral care as a comfort measure

with low priority and utilize foam swabs rather than toothbrushes. Additionally, Cason, et al.

(2007) provided a 29-item questionnaire about the type and frequency of oral care provided to

nurses attending education seminars in the United States. Twelve hundred nurses completed the

questionnaire. The study found that nurses in hospitals with oral care protocols reported better

compliance with hand washing, maintaining head-ofbed elevation, were more likely to provide

oral care, were more familiar with rates of ventilator-associated pneumonia and the organisms

involved than were nurses working in hospitals without such protocols.

Therefore, a focused education intervention can dramatically decrease the incidence of

VAP. Education programs should be more widely employed for infection control in the

intensive care unit setting and could lead to substantial decreases in cost and patient morbidity

attributed to hospital acquired VAP (Zack, et al., 2002).

Questionnaires were distributed and collected during the annual congress of the Flemish

Society of Critical Care Nurses (Labeau, Vandijck, Blaes, VanAken & Blot, 2007). There were

855 registered participants, of which 638 completed the questionnaire. The results demonstrated

that nurses valued non evidence based practice as much as they did evidence based nursing

protocols. Therefore, nurses' lack of knowledge may be a barrier to adherence to evidence-based

guidelines for preventing ventilator associated pneumonia.

Conclusion

Reducing the risk of bacterial colonization and ultimately aspiration into the lungs can

help reduce aspiration pneumonia. Despite the importance of providing oral hygiene to intensive

care patients receiving mechanical ventilation, high-level evidence from rigorous randomized









controlled trials or high quality systematic reviews that could inform clinical practice is scarce

(Berry, et al., 2007). As stated, the limited number of randomized controlled trials conducted to

reduce VAP. The effectiveness of oral hygiene and the use of antimicrobial agents appear to be

promising; therefore, research in the area should be conducted. In addition, increasing nurses

knowledge in these areas may help reduce the incidence. The CDC reports that aspiration of oral

pharyngeal pathogens places patients at high risk for developing aspiration pneumonia and VAP.

Interventions aimed at preventing bacterial colonization have not been well studied. Improving

clinical knowledge and procedures may help establish education programs, oral assessment tools

and procedures that will decrease the incidence of VAP. Integrating knowledge of best practices

may also help to contribute standards for oral care of patients at risk of developing ventilator

associated pneumonia.

Summary

This chapter has reviewed the current literature related to ventilator associated

pneumonia, factors contributing to the incidence, recommendations from the Centers for Disease

Control, the research gaps and the significance to nursing. Aspiration of contaminated secretions

is the most likely cause of transmission of bacteria into the lungs, resulting in VAP in

mechanically ventilated patients. The predominant use of foam swabs and no current evidence

based oral protocols or oral assessment tools may indicate that the current oral care efforts are

ineffective and should be studied further.









CHAPTER 3
METHODOLOGY

This study was designed to determine if there is a difference in the occurrence of ventilator

associated pneumonia at 24 hours and 72 hours compared to baseline following implementation

of three different nursing hygiene protocols. This study addressed two research questions: 1) Is

there a difference in the three study groups related to oral pH, oral culture scores and CPIS

scores at 24 and 72 hours compared to baseline, and 2) Do the number of decayed, missing and

filled teeth, being edentulous and the presence of periodontal disease have an association with

the development of ventilator associated pneumonia in critically ill adult patients?

The Clinical Pulmonary Infection Score (CPIS) includes: white blood cell count,

temperature, tracheal secretions, oxygenation (calculated by PaO2/FiO2), chest radiograph and

tracheal aspirates). The CPIS is a risk assessment and diagnostic tool developed by Pugin (1991)

to identify patients at risk to develop VAP. This chapter is divided into four sections. In the first

section, the sample of respondents is described. The study design and procedures used to collect

the data are included in the second section of the chapter. The instrumentation section is

described in the third section. The fourth section includes a description of the statistical analysis

of the research questions used to guide the study.

Sample

Selection of research participants

Permission to conduct the study was first obtained through the Institutional Review

Board of the University of Florida Health Science Center, Gainesville and Jacksonville.

Following approval, a convenience sample of 109 patients was selected. A total of 85 critical

care patients were enrolled in the study.









The sample consisted of 85 patients obtained from acute care not-for-profit facilities in

the Northeast Florida area. Sample size was calculated using the correlation coefficient with an

effect size estimated at 0.50, two-tailed alpha 0.05, and a beta of 0.20, power .80. This was

chosen since the data collected was in a continuous format and a moderate effect size, 20%,

would be observable. The effect size selected was to observe a decrease in CPIS < 6, indicating

no VAP.

Inclusion criteria for the recruitment of participants included those who were anticipated

to be orally intubated for greater than 72 hours and over the age of 18. This age group was

chosen as those representing adults that would be admitted to an adult critical care unit. Subjects

of any ethnic group or sex were included. Methods of recruitment included physician and

nursing referrals. Exclusion criteria included the following: 1) admitting diagnosis of pneumonia,

2) nasally intubated patients, and 3) patients who were expected to be extubated in less than 24

hours such as those undergoing coronary artery bypass surgery. Attrition for statistical analysis

were patients who were not orally intubated for 72 hours. The attrition rate for this study was

10%.

Characteristics of the Sample

Table 1 displays the admitting diagnosis for the study participants in each group. The

effectiveness of chlorhexidine 0.12% to reduce the development of VAP and oral colonization

has been documented in several research studies within limited patient populations, those being

cardiovascular and surgical (Koeman, et al., 2006). The majority of subjects recruited for this

study were from combined medical/surgical units. Patients in these units had high Apache II

scores > 24, defining them as high risk. This is a typical ICU patient population in mixed

medical/surgical units.









A total of 85 adults orally intubated, without an admitting diagnosis of pneumonia

participated in the study. Forty-six were female and thirty-nine were male. They ranged in age

from 22 to 92, with 44 (approximately 50%) between the ages of 39-68. Mean age was 57, with

a standard deviation of 17.51. An additional 21 subjects were 69 years of age and over with three

over the age of 85; one 87 years of age, one 88 years of age and one 92 years of age respectively.

Fifteen subjects were 43 years of age or younger, the youngest being 22.years of age (Table 1).

The subject's admitting diagnoses included cardiovascular, pulmonary, neurologic, gastroenteric,

trauma, and general medical/surgical problems. In general there are eight categories of diseases

and disorders that are regarded as justification for admission to an ICU, of which the above are

listed (Lott, et al., 2009). (Table 3-1)

Additionally, over fifty-percent of the subjects had co-morbidities including a history of

hypertension, diabetes mellitus, and coronary artery disease. Subjects in Group 1 and 2 had

greater than fifty-percent of these co-morbidities, while the control group had twenty-percent.

Table 3-1. Descriptive Statistics of Study Participants
Group 1 Group 2 Group 3 Mean SD
Age, yr (mean) 63 60 57 57.11 17.51
Male sex 11(29) 16(31) 11(25)
Cardiovascular (MI, CABG, HTN) 8 2 3
S/P Cardiac Arrest 2
Pulmonary (Asthma, COPD) 7 5 5
Neurologic (Altered mental status, CVA, 5 2 2
S/P neurological surgery/interventional
procedures
Gastro enteric 1
Trauma 1 1
General Post Operative 2 12 4
Sepsis 1
Renal 1 1
Metaboloic 1
Hematologic (DIC, sickle cell crisis) 2 1
Post Partum 1 1
Mental Health 1
Periodontal Dx 1
Other 1 5 6









Risk factors for development of VAP include changes in the oral cavity and dental health.

Table 3-2 displays the modified oral assessment tool used to capture the subjects baseline oral

and dental health related to decayed, missing or filled teeth, periodontal disease, dentures,

edentulous, mucous membranes and lips.

Table 3-2. Modified Oral Assessment Tool
Teeth or Dentures Mucous membranes Lips

Clean 1 Pink and moist 1 Smooth/moist 1
Plaque/debris in localized areas 2 Reddened/coated 2 Dry/cracked 2
Plaque/debris along gum line 3 White areas 3 Bleeding 3
11 fitting dentures/caries/missing teeth/ Ulcerated/bleeding 4 Ulcerated 4
edentulous/ periodontal disease 4


Study Design and Procedures

A quasi experimental randomized controlled clinical trial was performed. The study was

prospective and longitudinal. Subjects were randomly assigned to one of three oral care hygiene

groups; Group 1- chlorhexidine gluconate spray 0.12% twice daily at twelve hour intervals,

Group 2- chlorhexidine gluconate 0.12% with toothbrushing twice daily at twelve hour intervals

and Group 3 standard oral hygiene care with toothette foam swabs. Subjects were randomized

utilizing a random tables generated by the Office of Research and Development in the

Department of Nursing at the University of Florida.

The dependent variables were: oral pH, oral cultures, Clinical Pulmonary Infection Score

(CPIS), which includes 1- white blood cell count, 2- temperature, 3- cultures of oral secretions,

4- oxygenation (calculated by PaO2/FiO2), 5- chest radiograph, and 6- tracheal aspirate culture.

Additionally, the descriptive variable of number of decayed, missing, and filled teeth, (DMF

scores) being edentulous and the presence of periodontal disease was assessed at baseline prior to

the implementation of the study protocol. Other demographic variables collected included age,

sex, and admitting diagnosis.









Measures

Oral pH. Actual oral pH was charted at baseline, 24 and 72 hours after implementation

of study protocol. pH paper was used to document the oral pH in the right or left buccal area of

the mouth. The primary investigator performed all measures. Confirmation of pH was done with

the primary nurse assigned to the patient at the time of measurement.

Oral Culture. Utilizing Grap, Munro, Elswick, Sessler & Ward's (2004) analysis for

oral cultures, oral cultures were assigned a (0-3) ranking, 0=no growth, 1= few, 2=moderate or

3=many/large. The analysis was performed by the microbiology department at the facilities.

Each oral culture was observed by the same microbiologists to assure inter-rater reliability.

These values were assigned by the microbiologists participating in the study.

Clinical Pulmonary Infection Score (CPIS). Each variable in the CPIS (temperature,

white blood cell count, chest radiograph (radiologist's interpretation), tracheal secretions,

oxygenation (calculated by PaO2/FiO2), and tracheal aspirate culture) was assigned points, and a

total CPIS was calculated, with a final score ranging from 0-12. A score of 6 or more was

considered to indicate risk for or diagnosis of pneumonia. The investigator assigned the CPIS

score based on review of the medical record, attending physician and infectious disease

physician chart notations and daily rounding.

Oral Assessment Tool. An oral assessment tool derived from Kayser-Jones (1995) and

Treloar and Stechmiller (1995) was utilized to determine tooth loss, periodontal disease,

moisture and dental caries on admission to the study. These oral assessment tools have shown a

high rate of inter-rater reliability and validity in previous studies, 80% inter-rater reliability for

both with p<.001. Validity for both instruments is from literature review and construct and face

validity by dentists, nurses, and dental hygienists.









Assumptions of the Study

VAP risk and diagnosis is a condition that has been measured with the CPIS score. The

clinical assessment of VAP is usually based on the presence of fever (core temperature of more

than 38.3 C), blood leukocytosis (more than 10,000 per mm3), or leukopenia (less than 4,000per

mm3), purulent tracheal secretions, and the presence of a new and/or persistent radiographic

infiltrate. However, these parameters taken separately have limited diagnostic value (Fartoukh, et

al., 2003). Pugin and colleagues (1991) combined body temperature, white blood cells count,

volume and appearance of tracheal sections, oxygenation (PaO2/FiO2), chest X-ray, and tracheal

aspirate cultures into a clinical pulmonary infection score (CPIS) as a diagnostic tool for

pneumonia. They found that a CPIS of more than six was associated with a high likelihood of

pneumonia with a sensitivity of 93% and a specificity of 100%. VAP risk in this study was

diagnosed utilizing the CPIS score and the determination of the development of VAP was by

independent infectious disease physicians' consults.

Demographic Variables. Demographic data was obtained from chart review and placed

in a collection data format which included: age, gender and admitting diagnosis. Charts were

reviewed for presence of illness or conditions that might contribute to poor oral health including

DMF (decayed, missing or filled) teeth, being edentulous and presence ofperiodontal disease.

Procedures

After receiving approval from the Institutional Review Board of the hospital and the

University of Florida, the investigator met with nursing staff and physicians from the facilities to

inform them of the purpose of the study and data collection activities. The nursing staff received

in-service training on how to perform the oral hygiene protocols, the use of the oral assessment

instrument and utilization of the data collection tool. The researcher performed all the oral









assessments. To ensure consistency in nursing oral hygiene protocol interventions, the researcher

observed the nurses performing the oral care interventions ensuring inter-rater reliability and

consistency of application of chlorhexidine 0.12% via spray and rinse with toothbrushing.

Documentation of oral care was placed on the medication administration record. A data

collection tool was provided for the nursing staff to record initiation of the protocol and

collection of descriptive data. Informed consent was obtained by the principal investigator when

appropriate patients were identified. Once consent was obtained, a medical chart review was

performed by the researcher to screen for inclusion and exclusion criteria. If the patient was

eligible then the patient was randomized to a group, with baseline data obtained at that time by

the researcher. The procedure for the oral assessment consisted of using an oral assessment tool

adapted by the principal investigator derived from previous assessment tools noted in the

literature (Treloar & Stechmiller, 1995; Kayser-Jones, Bird, Long & Schnell,1995). Oral

assessments were performed by the researcher after randomization and before the initial oral

hygiene intervention was performed. Table 3-2.

The inservice training of the nursing staff included the following:

1. Review of the oral assessment tool
2. Instruction for the oral hygiene protocols

Group 1 Procedure:

1. Set up suction equipment.
2. Position patient's head to the side and maintain in semi-fowler's position.
3. Don gloves.
4. Provide deep suction, as needed.
5. Assess oral cavity and document on oral assessment instrument (baseline, 24, and 72 hours).
6. Obtain oral pH with litmus paper placed on inside of right or left cheek (baseline, 24 and 72
hours).
7. Obtain oral and sputum cultures (baseline, 24 and at 72 hours).
8. Suction oral cavity as necessary.
9. Apply chlorhexidine spray 0.12% inside mouth applying to all teeth and gum surfaces.
10. Apply lip moisturizer if needed.









11. Document on data collection form.

Group 2 Procedure

1. Set up suction equipment.
2. Position patient's head to the side and maintain in semi-fowler's position.
3. Don gloves.
4. Provide deep suction, as needed. Assess oral cavity and document on oral assessment
instrument (baseline, 24 and 72 hours).
5. Obtain oral pH with litmus paper placed on inside of right or left cheek (baseline, 24 and 72
hours).
6. Obtain oral and sputum cultures (baseline, 24 and at 72 hours).
7. Suction oral cavity as necessary.
8. Apply chlorhexidine 0.12% to pediatric toothbrush.
9. Brush teeth using a small, soft pediatric toothbrush.
10. Brush teeth for approximately 1-2 minutes, using gentle pressure in short horizontal and
circular strokes and brushing all teeth and gum areas.
11. Gently brush tongue.
12. Apply lip moisturizer if needed.
13. Document on data collection form.

Group 3 Procedure

1. Follow hospital policy and procedure or unit protocol for oral hygiene.
2. Assess oral cavity and document on oral assessment instrument (baseline, 24 and at 72
hours).
3. Obtain oral pH with litmus paper placed on inside of right or left cheek (baseline, 24 and 72
hours).
4. Obtain oral and sputum cultures (baseline, 24 and at 72 hours).
5. Document on data collection form.

3- Review of Protection of Human Subjects

Patients charts were identified through a color coded protocol driven sheet so all staff were

aware that the patient was involved in a research study and which protocol to use. The principal

investigator, along with the nurse managers of each unit, ensured that the protocols were

followed. In addition, the principal investigator rounded daily to ensure that protocols as defined

were being followed.

Statistics

Data obtained from the daily assessments were transcribed onto a data collection form

formulated specifically for this study. See appendix. All participant data, forms, study results and









informed consents were kept confidential and secured in a locked file during every phase of the

study. An informed consent was placed in the medical record and a copy was provided to the

patient and/or party authorized to provide consent, usually a family member. No participant or

their family requested that they be removed from the study. Data was entered onto an excel

spreadsheet and then statistical software (SPSS) for analysis using standard procedures was used.

There were three serious adverse events reported to the IRB, none were deemed associated with

the research study.

Descriptive analyses were done on the demographic data to determine number and

characteristics of the sample that were evaluated at baseline and on the study variables including

oral pH, oral culture scores, and CPIS scores. Analysis of variance was used to determine if the

observed differences among the groups' set of means would be greater than expected by chance

alone. Continuous data analysis and repeated measures analysis was used for categorical data.

Descriptive statistics to define group characteristics is provided.









CHAPTER 4
RESULTS

This study was designed to determine if there is a difference in the occurrence of

ventilator associated pneumonia at 24 hours and 72 hours compared to baseline following

implementation of three different nursing oral hygiene protocols. The first research question was

to determine if there were no differences at 24 and 72 hours compared to baseline in the three

study groups related to oral pH, oral culture scores and CPIS. The hypothesis; Hol: There will be

no differences at 24 hours and at 72 hours compared to baseline in the three study groups related

to oral culture scores, oral pH, and CPIS scores.

The secondary research question was to determine if the number of decayed, missing and

filled teeth, being edentulous and having periodontal disease have an association with the

development of ventilator associated pneumonia in critically ill adult patients. The hypothesis

Ho2: There will be no association between the number of decayed, missing and filled teeth,

being edentulous, the presence of periodontal disease and the development of ventilator

associated pneumonia in critically ill adult patients.

A description of the oral pH scores with means and standard deviations for the three groups

at baseline, 24 hours and 72 hours are presented in Table 4-1.


Table 4-1. Oral pH means and standard deviations at baseline, 24 hours and 72 hours
Oral pH Mean /SD Oral pH Mean /SD Oral pH Mean /SD
at baseline at 24 hours at 72 hours
Group 6.48/0.602 6.48/0.607 6.47/0.597

Group 2 6.53/0.618 6.56/0.495 6.51/0.564

Group 3 6.60/0.612 6.50/0.661 6.56/0.557









Oral pH levels at baseline and differences at 24 hours and 72 hours compared to baseline

after intubation were comparable in all 3 groups and differences were not statistically significant.

(Table 4-2).

Table 4-2. Oral pH differences between groups at baseline, 24 hours, and 72 hours.
Oral pH baseline to 24 Oral pH baseline to 72 hours
hours between groups between groups
Group 1 p=0.589 p= 0.713
Group 2 p=0.3392 p=0.3256
Group 3 p=0.7514 p=0.3067
Oral pH df Sum of Squares Mean Squares F value Significance
between groups 2 0.446 0.223 0.72 p=0.4904


Oral Cultures scores were performed utilizing Grap, et al. (2004) analysis for oral

cultures. Oral cultures were assigned a (0-3) ranking, 0=no growth, 1= few, 2=moderate or

3=many/large. Mean and standard deviation results for the three groups at baseline, 24 hours and

72 hours are shown in Table 4-3.

Table 4-3. Oral culture score means and standard deviations for each group at baseline, 24 hours
and 72 hours.
Oral culture scores at Oral culture scores at Oral culture scores at
baseline Mean/SD 24 hours Mean/SD 72 hours Mean/SD
Group 1 1.862/1.381 1.172/1.255 1.480/1.194
Group 2 1.516/1.287 1.419/1.232 1.375/1.209
Group 3 1.480/1.194 1.225/1.175 1.208/1.120

Overall differences in oral culture scores between the three groups at 24 and 72 hours

compared to baseline were analyzed and found to be statistically significant at 24 hours

(p=0.0001) and 72 hours (p=0.0005). Statistically significant oral culture scores occurred at 24

hours and 72 hours compared to baseline in the intervention groups indicating a possible benefit

in the prevention of VAP with chlorhexidine spray 0.12% and chlorhexidine 0.12% and

toothbrushing (group 1 (p=0.045, p=0.0082) and (group 2 (p=0.0082, p= 0/0047). The control









group's differences in oral culture scores were not statistically significant at 24 hours and 72

hours compared to baseline (p=0.1797, p=0.1028) (see Table 4-4).


Table 4-4. Differences in Oral Culture Scores between groups at 24 hours and 72 hours
compared to baseline
Oral culture scores at Oral culture scores at Oral culture scores at
baseline 24 hours 72 hours
Group 1 10 of 29 6 of 29 1 of 24
(34.5%) (20.7%) (4.2%)
Comparison to S = 4 S = 7
baseline p =0.0455* p =0.0082*
Group 2 13 of 31 4 of 28 2 of 24
(41.9%) (14.3%) (8.3%)
Comparison to S = 7 S = 8
baseline p= 0.0082* p =0.0047*
Group 3 10 of 25 7 of 23 5 of 21
(40%) (30.4%) (23.8%)
Comparisonto S= 1.8 S = 2.67
baseline p= 0.1797 p= 0.1025
Overall 33 of 85 17 of 80 8 of 69
(38.8%) (21.2%) (11.6%)
Comparison to S = 17.19 S = 12.25
baseline p < 0.0001" p =0.0005*


Oral cultures were performed and results indicated that potential VAP pathogens were

found in 13 of the 85 subjects either in oral or endotracheal cultures at baseline (Table 4-5). Of

the 13 positive oral cultures for potential VAP pathogens at baseline, the same pathogen was

found in both oral and endotracheal cultures consistently across subjects. The potential VAP

pathogens that were found at baseline included, methicillin-resistant Staphylococcus aureus

(MRSA), Pseudomonas aeruginosa, Staphylococcus aureus, Streptococcus pneumoniae,

Moraxella catarrhalis, and Acinetobacter baumanii. Of these 13 positive cultures, six subjects

were considered by the CPIS score as having VAP (CPIS >6), but clinical correlation by

radiograph and infectious diseases consultation concluded that the patients were not considered

to have clinically developed VAP. The 13 subjects with VAP pathogens at baseline, (six in

group 1, three in group 2 and four in group 3) did not have these pathogens present at 24 and 72









hours, demonstrating a possible correlation of the intervention to prevention of VAP.

Differences in oral culture scores demonstrated an apparent trend for the percentages in each

group to decline over time, and this trend seemed stronger in the intervention groups than in the

control group. A description of the oral culture pathogens present and CPIS scores with means

and standard deviations for the three groups at baseline, 24 hours and 72 hours are presented in

Table 4-5.

Table 4-5. A Description of Pathogens Present at Baseline according to CPIS Score and Actual
Development of VAP at 72 hrs.
Virulent Pathogens CPIS Score at Actual Development of VAP at
Present at Baseline Baseline 72 hours
Group 1 1-Pseudonomas 10 No
2- MRSA 9 No
3- Staph Aureus 9,6 No, No
4- Strep Pneumonia 3 No
5- Acinobacter 2 No

Group 2 1- Moraxella 7 No
Catarrhais 7 No
2- Staph Aureus 5 No
3-MRSA

Group 3 1-Staph Aureus 7 No
2- MRSA 5,4, 3 No, No, No

A description of the CPIS scores with means and standard deviations for the three groups

at baseline, 24 hours and 72 hours are presented in Table 4.6. No statistically significant

differences in CPIS scores occurred in group 1 at 24 hours and 72 hours compared to baseline

(p= 0.7868, p=0.8462) or for group 3 (p=0.6017, p=0.3151); but group 2 (p=0.545, p=0.0428)

was statistically significant at 72 hours, indicating a possible benefit in preventing VAP in the

chlorhexidine 0.12% and toothbrushing group (Table 4-7 and 4-8).












Table 4-6. CPIS score means and standard deviations between groups at baseline, 24 hours and
72 hours
CPIS score Mean /SD CPIS Mean /SD at 24 CPIS Mean /SD at 72
at baseline hours hours

Group 1 5.137/2.35 5.172/2.17 4.880/2.14
Group 2 5.129/1.70 5.172/2.17 5.00/1.84
Group 3 5.120/1.39 5.227/1.47 5.190/1.56


Table 4-7. Oral culture pathogens present and CPIS score
and at 72 hours
CPIS Mean Pathogens CPIS Mean
/SD baseline Present /SD at
24 hours
Group 1 5.137/2.35 1- Staph 5.172/2.17
Aureus
2- Strep
Pneumonia
3-
Pseudomonas
4- Staph
Aureus
5-
Acinetobacter
6-MRSA
Group 2 5.129/1.70 1- MRSA 5.172/2.17
2- Moraxella
Catarrhais
3- Staph
Aureus
Group 3 5.120/1.39 1-Staph Aureus 5.227/1.47
2- MRSA
3- MRSA
4- MRSA


Means/SD scores at baseline, 24 hours

Pathogens CPIS Mean Pathogens
Present /SD at Present
72 hours
none 4.880/2.14 none


none


5.00/1.84


none


5.190/1.56


none




none


Considering using tooth condition, the number of decayed, missing and filled teeth, and

the relationship to developing VAP was also analyzed. A score on the oral assessment tool of 12

or below was considered low risk and a score greater than 12 was considered high risk. Group 1

had 13 subjects in the low risk group and 16 in the high risk group, group 2 had 19 subjects in

the low risk group and 12 subjects in the high risk group, and group 3 had 13 subjects in the low










risk group and 12 subjects in the high risk group (Table 4-9). Based on the relationship of tooth

condition and oral assessment to determine VAP, patients in the high risk group had a 19.51%

greater chance of developing VAP than the low risk group. Subjects who were considered at high

risk were those subjects with periodontal disease, greater than four missing teeth, decayed or

filled teeth, and those who were edentulous. These patients were compared to those with less

than four missing, decayed, or filled and who were not edentulous and who did not display

periodontal disease; this was shown to be statistically significant (p=.0057) (Table 4-10).



Table 4-8. CPIS Scores for each group at 24 and 72 hours compared to baseline.
CPIS score at 24 hours compared to CPIS score at 72 hours compared to
baseline baseline
F(2,77)=0.26 F(2,67)=1.00
p value=0.7700 p value=0.3743

Group 1 n = 29, M = 0.035 n= 25, M= -0.04
S = 0.681, t = 0.27 S = 1.020, t = -0.20
p value = 0.7868 p value = 0.8462

Group 2 n = 29, M= -0.086 n = 24, M= -0.500
S = 0.7567, t = -0.61 S = 1.142, t = -2.14
p value = 0.545 p value = 0.0428*

Group 3 n= 22, M= -0.136 n= 21, M= -0.286
S = 1.2069, t = -0.53 S = 1.271, t = -1.03
p value 0.6017 p value = 0.3151

Between Groups F(2,77) = 0.26, F(2,67) = 1.0
p value = 0.77 p value = 0.374



Table 4-9. Oral assessment scores for high and low risk for poor oral health for each group on
admission
Low Risk Poor Oral Health Patients on High Risk Poor Oral Health Patients
Admission: on Admission:
No periodontal disease, less than 5 missing, Presence of periodontal disease, greater
decayed or filled teeth and not edentulous than 4 missing, decayed or filled teeth,
edentulous
Group 1 n=13 n=16
Group 2 n=10 n=12
Group 3 n=13 n=12










Table 4-10. The relationship of tooth condition and oral assessment with CPIS score to
determine risk of VAP at 72 hours compared to baseline
N CPIS VAP at 72 hours
Group 1 (good oral 37 0.0%


health)
Group 2 (bad oral health)

Chi-Square
P<= 0.0057


Value
8.0466


19.51%
Probability
0.0046









CHAPTER 5
DISCUSSION

Ventilator associated pneumonia (VAP) is the most frequently occurring nosocomial

infection associated with increased morbidity and mortality of patients in intensive care units.

(Koeman, et al., 2006). Although oral decontamination with chlorhexidine has been shown in

some studies to reduce the risk of VAP, there have been few randomized controlled trials to

support its effectiveness. VAP is a condition that has been measured with the clinical pulmonary

infection score (CPIS) risk tool developed by Pugin and colleagues (1991) which combines body

temperature, white blood cells count, volume and appearance of tracheal sections, oxygenation

(PaO2/FiO2), chest X-ray, and tracheal aspirate cultures as a diagnostic tool for pneumonia.

They report that a CPIS score of six or more was associated with a high likelihood of ventilator

associated pneumonia. This study was designed to determine if there is a difference in the

occurrence of ventilator associated pneumonia at 24 hours and 72 hours compared to baseline

following implementation of three different nursing oral assessment and hygiene protocols

including chlorhexidine spray 0.12%, chlorhexidine 0.12% and toothbrushing and standard or

usual oral care using foam swabs (toothettes) with a variety of oral rinses.

This study addressed two research questions: Is there a difference in the three study

groups related to oral pH, oral culture scores and CPIS scores at 24 and 72 hours compared to

baseline, and Do the number of decayed, missing and filled teeth, being edentulous and the

presence of periodontal disease have an association with the development of ventilator associated

pneumonia in critically ill adult patients? Eighty-five patients were randomized and assigned into

three groups, group 1(n=29) received chlorhexidine spray 0.12%, group 2 (n=31) received

chlorhexidine 0.12% and toothbrushing and group 3 (n=25) received standard or usual oral care

using foam swabs (toothettes) with a variety of oral rinses.









No statistically significant differences in oral pH values occurred between the three groups.

Statistically significant decreased oral culture scores occurred at 24 hours and 72 hours

compared to baseline in the intervention groups indicating a possible benefit in the prevention of

VAP using chlorhexidine spray 0.12% or chlorhexidine 0.12% and toothbrushing, group 1

(p=0.045, p=0.0082) and group 2 (p=0.0092, p= 0.0047). No statistically significant differences

in CPIS scores occurred in group 1 at 24 hours and 72 hours compared to baseline (p=0.7868,

p=0.8462) or group 3 (p=0.6017, p=0.3151) but group 2 (p=0.545, p=0.0428) was significant at

72 hours compared to baseline, again indicating a possible benefit in preventing VAP in the

chlorhexidine 0.12% and toothbrushing group. Chlorhexidine appears to have an excellent

antibacterial effect on gram negative oral pathogens (Koeman, et al., 2006). While chlorhexidine

has been used in healthy patients as a daily oral rinse to control plaque and to prevent gingivitis,

studies to determine its effectiveness on critically ill subjects has been limited. In addition,

although studies in other populations have compared chlorhexidine rinses with swab

administration and found equal efficacy, there has not been a published study comparing two

different modes of applications of chlorhexidine 0.12% and its effectiveness to prevent or

decrease VAP.

This study showed that thirteen subjects admitted to ICUs in the Northeast Florida area had

virulent oral pathogens present at baseline (less than 24 hours after hospital admission and oral

intubation) and were identified as high risk for development of VAP. These oral pathogens

included methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa,

Staphylococcus aureus, Streptococcus pneumoniae, Moraxella catarrhalis, and Acinetobacter

baumanii. Additionally, risk for VAP using the modified oral assessment tool (Kayser-Jones,

Bird, Long & Schnell, 1995; Treloar & Stechmiller, 1995) was statistically significant for









subjects with periodontal disease, greater than 4 missing, decayed or filled teeth and those who

were edentulous at baseline. When using poor oral health and tooth condition as a risk factor for

the development of VAP, subjects with periodontal disease, greater than 4 missing, decayed or

filled teeth, and those who were edentulous were at higher risk (p=0.0057) to develop VAP.

There is a firm body of evidence that oropharyngeal colonization is pivotal in the pathogenesis of

VAP. More than 25 years ago, Johanson, et al., (1972) described the association between

increasing severity of illness, higher occurrence of oropharyngeal colonization and the increased

risk to developing VAP. This study demonstrated that VAP pathogens were present on admission

especially in patients with poor oral health. Earlier studies, (Horan, et al., 1986; Johanson, et al.,

1988) had shown a change in the oropharyngeal flora within 48 hours of admission to the

intensive care units; however, this study data supports that of Grap, Munro, Elswick Sessler &

Ward's (2004) that virulent VAP pathogens may be present in the oral cavity earlier than

previously documented.

Considerable evidence exists to support a relationship between poor oral health, the oral

microflora and bacterial pneumonia, especially ventilator-associated pneumonia. Teeth or

dentures have nonshedding surfaces on which oral biofilms (that is, dental plaque) form that are

susceptible to colonization by respiratory pathogens. Subsequent aspiration of respiratory

pathogens shed from oral biofilms into the lower airway increases the risk of developing a lung

infection. In addition, patients may aspirate inflammatory products from inflamed periodontal

tissues into the lower airway, contributing to lung insult (Scannapieco & Rathman, 2003). This

study supports these previous findings and suggests that identification of high risk patients and

early oral care interventions may prove to decrease VAP.









Oral care assessment tools are also not routinely utilized in critical care. While some

mention of the mouth may be documented on nursing flow sheets, a routine oral assessment is

not common practice. As this study indicates, patients on admission with poor oral health were at

higher risk to developing VAP. The use of a routine oral assessment tool on admission may help

to direct nurses to identify and intervene earlier in the prevention of VAP in high risk patients.

Clinicians should use oral health assessment tools to determine individual treatment and

approaches to promote oral health. Garcia, et al. (2009) implemented a comprehensive oral and

dental care system and protocol in their facility. Patients whose oral cavity was assessed, along

with other interventions such as toothbrushing, had a reduction in the development of VAP and a

decrease in mechanical ventilation and length of stay in the ICU. In addition, mortality was

decreased. Therefore, the use of a valid oral assessment tool in coordination with an effective

oral hygiene protocol could significantly reduce costs and decrease mortality in critically ill

adults in the ICU.

Interestingly, study findings indicated that none of the patients in groups 1, 2 & 3

developed a documented VAP during the study duration (years 2006-2009). The determination

of VAP was independently validated by board certified infectious disease physicians employed

by the critical care medicine service at the study sites. This finding may be due to the increased

attention to oral care as a result of the implementation of this study. Contamination of the

control group was unpreventable and the nursing staff became more aware of oral assessment

and oral care using chlorhexidine 0.12%. During the study, all subjects were provided the

preventive strategies recommended by the Institute for Healthcare Improvement (IHI) for VAP

prevention (the VAP Bundle). These included: semi recumbent positioning (not less than 300),

daily "sedation vacations," an assessment of readiness to be extubated, deep vein thrombosis









prevention, and peptic ulcer disease prophylaxis. Additionally, all subjects were orally intubated,

had a gastric tube (placed orally) to help prevent aspiration of gastric contents, and the majority

had endotracheal tubes with a sideport for continuous oral secretion evacuation.

Study Limitations

This study was conducted in two not for profit facilities in Northeast Florida and cannot

be generalized to other populations. While the aim was to include all consecutive subjects

identified for inclusion, actual recruitment depended on the willingness of physicians, patients

and patient families' informed consent; therefore, the sample size was small. Additionally, the

prediction of whether a patient was expected to remain intubated for more than 48 hours was left

to the discretion of the responsible physician.

The development of documented VAP was consistently documented in both facilities by

independent infectious disease physician consultants. While several patients would have been

considered to be positive for VAP, according to Pugin's criterion, no patients in the study were

documented as developing VAP. Others reviewing this data may consider this a conflict of

interest, but since VAP had been previously recorded in these intensive care units by the same

physicians and reported through their infectious disease divisions, this was considered

appropriate for this study. Although the CPIS has good reliability and acceptable sensitivity and

specificity, articles by Rea-Neto, et al., (2006) and Swoboda, Dixon & Lipsett, (2006) both state

that better strategies should be developed for identification of pneumonia in the ICU than just

using CPIS. The authors stated that an integrated approach should be followed in diagnosing and

treating patients with the risk for and diagnosis of VAP and should include clinical response and

results of bacteriologic cultures. Swoboda, Dixon, & Lipsett (2006) stated that a pneumonia









review committee of physicians resulted in fewer patients believed to have had pneumonia than

was identified using the CPIS. This also supports the results of this study.

This study only examined the first four days of intensive care and the development of

VAP. There is an increasing desire to determine whether present strategies to prevent VAP are

effective in the prevention of late onset VAP.

Daily notation of the maintenance of the Institute for Healthcare Improvements (MII)

VAP Bundle was recorded. The IHI bundle included daily breaks from sedation if stable, daily

assessment of readiness to extubate, prophylaxis for peptic ulcer disease, deep vein thrombosis

prophylaxis and elevation of the head of the bed at or equal to 30 degrees. In addition, whether

an endotracheal tube with a subglottic side port for continuous low suction was in place was

recorded. These two unit protocols were already established in the units to prevent the

development of VAP prior to the start of the study and continued through the study's

implementation. Most subjects in the study had a dual lumen side port endotracheal tube in place

for continuous low suction. It should also be noted that during the last months of the study, the

majority of subjects were recruited from the medical/surgical intensive care unit, which had a

previously documented VAP rate of 7.09 using rates per 1,000 patient days and ventilated days.

During the study and for the next three months after subject recruitment was closed, the VAP

rate remained at zero.

Another limitation of the study could have been this researcher's daily presence in the

intensive care units involved in the study and interaction with the multidisciplinary teams

involved in patient care. Nurses, physicians, respiratory therapists and any other direct caregivers

were instructed on the study design and its study aims. A recent article by Ross and Crumpler

(2007) discussed the impact of an evidence-based practice education program on the role of oral









care in the prevention of VAP. The study suggested that although an evidence-based oral care

protocol existed prior to the study start and best practice oral care tools were available, the VAP

rates had not significantly decreased even though nurses reported providing oral care. The

nursing staff received an educational inservice program prior to implementation of the study

regarding the importance of oral care and all protocol interventions that would be investigated.

The direct care nurses were involved in data documentation and received monthly quality

improvement reports on the unit's VAP incidence at staff meetings. After the first month of no

patients developing VAP, the unit-based nursing staff became even more engaged in the study

and were excited to see the difference in patient outcomes. This may have made them more

vested in the positive patient outcomes observed and reported. This may be evident by the results

of the patients in the standard unit protocol group who also did not develop VAP during the

study.

Recommendations for Further Research and Education

Links continue to be made between oral health and the development of VAP, although

establishing cause and effect can be complex and confounded by a myriad of variables.

Additionally, even in the reported randomized controlled trials, different products, different

strengths of chlorhexidine, different applications and different timing intervals are noted.

Therefore, to continue to build the scientific evidence necessary to determine best oral care

interventions, additional randomized controlled trials must be conducted, with large sample sizes

and replicating previous study designs.

The lack of published protocols for oral care in intubated patients has been noted in the

clinical nursing literature (Anderson & Lester, 1999). During the first 24 to 48 hours of

admission to critical care units, nurses' attention is usually focused on physiological stability and









oral care may not be seen as a priority. Therefore, evidence-based education regarding the

importance of oral care and its relationship to the reduction of VAP in critically ill patients is

clinically significant.

Research should proceed on the implementation and evaluation of effectiveness of oral

care assessment tools. A cost/benefit ratio may be obtained if patients' oral cavities are routinely

assessed on admission and patients at high risk have evidence based oral hygiene protocols

implemented quickly. A reduction in mortality, length of ventilation and morbidity should be

evaluated using a validated tool. Presently, there are no consistent oral assessment tools being

utilized in acute critical care units. All assessment tools reviewed have guides using a three or

four-point numerical and descriptive scale, with low scores representing best oral cavity health.

Information obtained from studies using oral assessment tools could further guide nursing

practice.

Oral care is usually documented in the nursing notes of most patients. During this study,

with the help of the pharmacists at both facilities, oral care intervention with chlorhexidine

0.12% and the appropriate protocol was documented on the medication administration record.

All nurses commented on this as a positive reinforcement and they felt this also improved

compliance in providing oral care at the appropriate timed intervals.

Conclusions

Although colonization of dental plaque with respiratory pathogens correlates with

occurrence of ventilator associated pneumonia, nursing oral care protocols based on research

studies for best practice are limited. Therefore, oral care is often performed according to

individual preferences, unit protocols and historical patterns. It is important then that nurses

continue to research this clinical issue. In addition, only a few studies have addressed nurses'









perceptions of the importance of oral hygiene and the barriers that prevent adherence to evidence

based protocols so further research in this area is also needed.

Therefore, ongoing research should address the following: 1) well designed clinical trials

to determine the most effective product, time interval and solution strength for patients receiving

mechanical ventilation, 2) development of a standardized oral assessment tool not only for

research but also for assessing patients, evaluating practice and improving the quality of care,

and 3) assessment of nurses' perceptions and knowledge about the importance and possible

benefits related to oral care and the development of VAP in critically ill adult patients.









APPENDIX
DATA COLLECTION TOOL

Questions? Call Peggy McCartt, RN, PhD (c), CCRN, ARNP (904) 501-3364

Apply Patient Label

Group 2 Protocol Initial after X in Baseline 24 hours 72 hours Yes/No/
box when complete _Comments

Date:

a) Verify/obtain consent from
family/patient before starting X


b) Set up suction equipment
c) Position patient' s head to the
side or in semi-fowler's position

d) Suction as needed
e) Obtain oral pH inside right or
left cheek- document once daily X X X

f) Obtain oral culture/swab and
sputum culture via ET tube- send X X X
lab research slips with specimen
once daily

g) Brush teeth/tongue with
pediatric toothbrush and X X X
chlorhexidine rinse 0.12% for
approximately 1-2 minutes, using
gentle pressure in short horizontal
and circular strokes twice a day X X X
(twelve hours apart) for the next
three days- chart on Medication
Administration Record and this
form
h) Apply lip moisturizer if
necessary

i) Mark on this form as completed









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BIOGRAPHICAL SKETCH

The author received her BSN, MN and PhD from the University of Florida, Gainesville,

Florida. She is presently a Senior Consultant for Clinical Practice at Baptist Health in

Jacksonville, Florida.





PAGE 9

Background of the Problem

PAGE 10

Statement of the Problem

PAGE 15

Purpose of the Study

PAGE 16

Hypotheses Significance of the Study

PAGE 20

Normal Oral Flora

PAGE 23

Gingivitis Leading to Periodontal Disease

PAGE 26

Oral Colonization

PAGE 28

Development of Ventilator Associated Pneumonia in the ICU

PAGE 30

Risk Factors Contributing to VAP

PAGE 31

Tooth Loss

PAGE 32

Dental Plaque

PAGE 33

Dental Caries

PAGE 34

Periodontal Disease

PAGE 35

Stomatitis Oral pH

PAGE 36

Dry Mouth/ Xerost omia.

PAGE 38

Conditions Favoring Reflux Aspiration of Gastric Contents Prolonged Use of Ventilator Support/Potential Exposure to Contamination

PAGE 39

Potential e xposure to c ontamina nts

PAGE 40

Host Factor Extremes: Age, Malnutrition, Underlying Conditions

PAGE 42

Strategies to Decrease Ventilator Associated Pneumonia Oral Assessment Tools.

PAGE 43

Ch lorhexidine Use.

PAGE 47

Toothbrushing

PAGE 48

Nursing Knowledge

PAGE 49

Conclusion

PAGE 50

Summary

PAGE 51

Sample Selection of research participants

PAGE 52

Characteristics of the Sample

PAGE 54

Study Design and Procedures

PAGE 55

Measures Oral pH Oral Culture C linical P ulmonary I nfection S core (CPIS) Oral Assessment Tool

PAGE 56

Assumptions of the Study Demographic V ariables Procedure s

PAGE 58

Statistics

PAGE 71

Study Limitations

PAGE 73

Recommendations for Further Research and Education

PAGE 74

Conclusions

PAGE 76

Questions? Call Peggy McCartt, RN, PhD (c), CCRN, ARNP (904) 501-3364 Apply Patient Label

PAGE 77

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PAGE 78

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PAGE 79

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PAGE 81

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PAGE 82

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PAGE 83

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PAGE 85

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PAGE 87

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PAGE 88

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PAGE 89

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PAGE 90

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