Effect of oral care on bacterial colonization and ventilator-associated pneumonia

Exploring the complex relationship between the lung microbiome and ventilator-associated pneumonia

INTRODUCTION

Understanding the presence and function of a diverse lung microbiome in acute lung infections, particularly ventilator-associated pneumonia (VAP), is still limited, evidencing significant gaps in our knowledge.

AREAS COVERED

In this comprehensive narrative review, we aim to elucidate the contribution of the respiratory microbiome in the development of VAP by examining the current knowledge on the interactions among microorganisms. By exploring these intricate connections, we endeavor to enhance our understanding of the disease's pathophysiology and pave the way for novel ideas and interventions in studying the respiratory tract microbiome.

EXPERT OPINION

The conventional perception of lungs as sterile is deprecated since it is currently recognized the existence of a diverse microbial community within them. However, despite extensive research on the role of the respiratory microbiome in healthy lungs, respiratory chronic diseases and acute lung infections such as pneumonia are not fully understood. It is crucial to investigate further the relationship between the pathophysiology of VAP and the pulmonary microbiome, elucidating the mechanisms underlying the interactions between the microbiome, host immune response and mechanical ventilation for the development of VAP.

Community pharmacists' knowledge, attitudes and practices towards oral healthcare and its management: A systematic review

BACKGROUND

Community pharmacists play a significant part in providing oral healthcare advice as there are significant connections between oral healthcare and body system healthcare.

OBJECTIVE

To systematically review the literature regarding the knowledge, attitudes and practice of community pharmacists in managing oral healthcare problems.

METHODS

A systematic review was conducted through Scopus, PubMed and Google Scholar databases. Studies regarding knowledge, attitudes and practice of management of dental care by community pharmacists between 1990 and 2019 were included.

RESULTS

Forest plot was performed to access knowledge, attitudes and practice of community pharmacist on oral healthcare. The results showed there were 44% of community pharmacists have a lack of knowledge on oral healthcare to provide an appropriate recommendation to patients with dental problems. Eighty-eight per cent of community pharmacists were willing to improve their knowledge of oral healthcare. There were 86% of them recognised that their role was significant in oral health. However, there were 59% of community pharmacists who had poor attitude in providing oral health information.

CONCLUSIONS

Community pharmacists were lacking knowledge on oral health mainly because of paucity in providing appropriate training courses. This has led to poor practices towards oral healthcare as they were unable to provide suitable products recommendations to the patients. This has led the community pharmacists into lack of attitudes in providing oral health information. However, most of the community pharmacists were conscious of their role in the oral healthcare system and were willing to improve their knowledge of oral healthcare.

Systematic review: Effectiveness of herbal oral care products on ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) resulting from bacterial infection is a prevalent medical problem in intensive care units (ICUs). The purpose of this study was to systematically review available studies on oral products employed to control and reduce VAP in patients undergoing tracheal intubation. This study was based on a systematic review of clinical trial data from science databases such as PubMed, Cochrane, Scopus, and Web of science. Articles were reviewed and selected according to defined criteria and assessed by the primary evaluation checklist. After a critical review of 3,143 search hits, only 18 relevant articles were finally selected for discussion. Our assessment revealed that chlorhexidine and some other oral herbal medications are beneficial in preventing VAP. Chlorhexidine oral dosage forms provide a remarkable role in oral health and prevention of VAP by decreasing the microbial flora in the mouth. Because of similar benefits and comparable effects, some herbal medicines can be suggested as a practical alternative to chlorhexidine.

Technology for maintaining oral care after stroke: considerations for patient-centered practice

PURPOSE

Activities of daily living including oral care may be challenging after stroke. Some stroke survivors are not able to complete oral care independently and need assistance from healthcare professionals and care partners. Poor oral hygiene may impact stroke recovery and rehabilitation possibly incurring issues such as aspiration pneumonia, malnutrition, and social isolation. The objective of this paper is to outline practical ways to apply oral care technology in daily use for stroke survivors.

MATERIALS AND METHODS

We reviewed the literature on i) stroke-related impairments impacting oral care, ii) oral hygiene dental devices, and iii) technology for oral care education.

RESULTS

Oral care activities involve integrated skills in the areas of motivation, energy, planning, body movement and sensation, and mental acuity and health. Post-stroke impairments such as fatigue, hemiparesis, and mental impairments may impact oral care activities. Technology may help survivors and caregivers overcome some barriers. Three types of technologies are available for facilitating post-stroke oral care: i) non-powered tools and adaptations; ii) powered oral care tools, and; iii) electronic aids to guide oral care activities. Particular choices should maximise patient safety and autonomy while ensuring accessibility and comfort during oral care tasks.

CONCLUSION

The available device and technologies may help substantially with the accommodations needed for post-stroke oral care, improving the oral health of stroke survivors. Good oral health confers benefit to overall health and well-being and could enhance recovery and rehabilitation outcomes. Nonetheless, more research is necessary to demonstrate the feasibility and effectiveness of technology in stroke contexts.IMPLICATIONS FOR REHABILITATIONOral care may be challenging after stroke due to patient fatigue, hemiparesis, cognitive impairments, and other impaired body functions.Poor oral hygiene may impact stroke recovery and rehabilitation due to risk of aspiration pneumonia, malnutrition, and social isolation.Powered oral care tools, non-powered tools, and adaptations to non-powered tools are some of the technology available to help overcome post-stroke barriers for oral care.Computer programs and online resources for education and guidance for oral care activities may help improve recommendation uptake and compliance.

Impact of oral hygiene in patients undergoing mechanical ventilation in the COVID-19 pandemic

COVID-19, caused by SARS-CoV-2, can present respiratory complications that often lead patients to depend on mechanical ventilation (MV) for several days. It is known that Pneumonia Associated with Mechanical Ventilation (PAMV) is frequent in patients who use this equipment for a long time. As a consequence of COVID-19, its prolonged use can lead to a worse prognosis for the patients. For this reason, in addition to the insufficiency of devices for mechanical ventilation to meet the current demand, it is necessary to adopt measures aimed at preventing complications that may aggravate the patient's clinical condition and, consequently, increase the average hospital stay and the respective hospital care costs. Therefore, the objective of this study was to discuss, in a concise and practical way, and based on the available literature, the importance of adopting adequate oral hygiene protocols for patients on mechanical ventilation. Based on the data obtained, it was identified that the adoption of effective oral hygiene measures, especially under the supervision of dental professionals, can contribute to the reduction of morbidity and mortality associated with MV, resulting in greater availability of mechanical ventilation equipment. Since such equipment is in great demand during the COVID-19 pandemic, the knowledge and implementation of effective oral hygiene measures will undoubtedly have an impact on improving the quality of care offered to patients, therefore benefiting all those in critical health conditions and assisted in ICUs.

Misperception of Oral Health among Adults in Rural Areas: A Fundamental but Neglected Issue in Primary Healthcare

Background: Poor oral hygiene is associated with metabolic syndrome, systemic diseases, mortality and many chronic diseases. Misperception means a wrong or incorrect understanding or interpretation. Few studies have examined the subjective perception and objective condition of oral health among community adults in rural areas. Methods: This was a cross-sectional, community-based study. Participants were recruited via convenience samples from December 2015 to July 2016. One thousand six (1006) community residents participated in the project, of which 973 fulfilled the inclusion criteria. The average age was 42.8 (SD = 12.3) years, range 20–64, selected from a collaboration local hospital. Results: Most of the participants reported brushing their teeth every day, however, 72% reported seldom brushing their teeth after meals, 54% seldom used dental floss, 64% seldom received dental scaling, 29.5% had experienced a toothache within 6 months, and 30.5% demonstrated significant tooth loss. However, most of them perceived their oral health as good. Misperception of oral health was common, 21.5% among whose number of remaining teeth <25 under-assess their actual oral health. The more number of remaining teeth (p < 0.001) and regular dental check-up (p < 0.01) were positively associated with feeling good about their oral health. After adjusting for potential confounders, clinically significant findings indicated that number of remaining teeth (OR = 3.03, p < 0.001), age (OR = 0.99, p < 0.001), regular dental check-ups/scaling (OR = 1.85, p < 0.001), education (OR = 1.45, p < 0.05), and water consumption (OR = 1.38, p < 0.05) were independently associated with good perceived oral health. Conclusions: The findings showed that subjective self-perception of oral health was not matched with their objective oral condition. Excluding the unmodifiable factors, the clinical implications indicated that oral health promotion programs, particularly for adopting regular dental check-up, healthy diet and oral hygiene habits are urgent in rural areas.

Enteral Access Devices: Types, Function, Care, and Challenges

Enteral access feeding devices are placed in patients who have a functional and accessible gastrointestinal (GI) tract but are not able to consume or absorb enough nutrients to sustain adequate nutrition and hydration. For many individuals, enteral nutrition support is a lifesaving modality to prevent or treat a depleted nutrient state that can lead to tissue breakdown, compromised immune function, and poor wound healing. Psychological well-being is also affected with malnutrition and dehydration, triggering feelings of apathy, depression, fatigue, and loss of morale, negatively impacting a patient's ability for self-care. A variety of existing devices can be placed through the nares, mouth, stomach or small intestine to provide liquid nutrition, fluids, and medications directly to the GI tract. If indicated, some of the larger-bore devices may be used for gastric decompression and drainage. These enteral access devices need to be cared for properly to avert patient discomfort, mechanical device-related complications, and interruptions in the delivery of needed nutrients, hydration, and medications. Clinicians who seek knowledge about enteral access devices and actively participate in the selection and care of these devices will be an invaluable resource to any healthcare team. This article will review the types, care, proper positioning, and replacement schedules of the various enteral access devices, along with the prevention and troubleshooting of potential problems.

Impact of oral hygiene involving toothbrushing versus chlorhexidine in the prevention of ventilator-associated pneumonia: a randomized study

BACKGROUND

Nosocomial pneumonia has correlated to dental plaque and to oropharynx colonization in patients receiving mechanical ventilation. The interruption of this process, by preventing colonization of pathogenic bacteria, represents a potential procedure for the prevention of ventilator-associated pneumonia (VAP).

METHODS

The study design was a prospective, randomized trial to verify if oral hygiene through toothbrushing plus chlorhexidine in gel at 0.12% reduces the incidence of ventilatior-associated pneumonia, the duration of mechanical ventilation, the length of hospital stay and the mortality rate in ICUs, when compared to oral hygiene only with chlorhexidine, solution of 0.12%, without toothbrushing, in adult individuals under mechanical ventilation, hospitalized in Clinical/Surgical and Cardiology Intensive Care Units (ICU). The study protocol was approved by the Ethical Committee of Research of the Health Sciences Center of the Federal University of Pernambuco - Certificate of Ethical Committee Approval (CAAE) 04300012500005208. Because it was a randomized trial, the research used CONSORT 2010 checklist criteria.

RESULTS

Seven hundred sixteen patients were admitted into the ICU; 219 fulfilled the criteria for inclusion and 213 patients were included; 108 were randomized to control group and 105 to intervention group. Toothbrushing plus 0.12% chlorhexidine gel demonstrated a lower incidence of VAP throughout the follow up period, although the difference was not statistically significant (p = 0.084). There was a significant reduction of the mean time of mechanical ventilation in the toothbrushing group (p = 0.018). Regarding the length of hospital stay in the ICU and mortality rates, the difference was not statistically significant (p = 0.064).

CONCLUSIONS

The results obtained showed that, among patients undergoing toothbrushing there was a significant reduction in duration of mechanical ventilation, and a tendency to reduce the incidence of VAP and length of ICU stay, although without statistical significance.

TRIAL REGISTRATION

Retrospectively registered in the Brazilian Clinical Trials Registry (Registro Brasileiro de Ensaios Clínicos) - RBR-4TWH4M (4 September 2016).

ASPEN Safe Practices for Enteral Nutrition Therapy [Formula: see text]

Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors. The latter can occur at any step from patient assessment, prescribing, and order review, to product selection, labeling, and administration. To maximize the benefits of EN while minimizing adverse events requires that a systematic approach of care be in place. This includes open communication, standardization, and incorporation of best practices into the EN process. This document provides recommendations based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring for patients receiving EN.

Oral care practices for patients in Intensive Care Units: A pilot survey

OBJECTIVE

To assess the level of knowledge and difficulties concerning hospitalized patients regarding preventive oral health measures among professionals working in Intensive Care Units (ICUs).

STUDY POPULATION AND METHODS

A cross-sectional survey was conducted among 71 health professionals working in the ICU. A self-administered questionnaire was used to determine the methods used, frequency, and attitude toward oral care provided to patients in Brazilian ICUs. The variables were analyzed using descriptive statistics (percentages). A one-sample t-test between proportions was used to assess significant differences between percentages. t-statistics were considered statistically significant for P < 0.05. Bonferroni correction was applied to account for multiple testing.

RESULTS

Most participants were nursing professionals (80.3%) working 12-h shifts in the ICU (70.4%); about 87.3% and 66.2% reported having knowledge about coated tongue and nosocomial pneumonia, respectively (P < 0.05). Most reported using spatulas, gauze, and toothbrushes (49.3%) or only toothbrushes (28.2%) with 0.12% chlorhexidine (49.3%) to sanitize the oral cavity of ICU patients (P < 0.01). Most professionals felt that adequate time was available to provide oral care to ICU patients and that oral care was a priority for mechanically ventilated patients (80.3% and 83.1%, respectively, P < 0.05). However, most professionals (56.4%) reported feeling that the oral cavity was difficult to clean (P < 0.05).

CONCLUSION

The survey results suggest that additional education is necessary to increase awareness among ICU professionals of the association between dental plaque and systemic conditions of patients, to standardize oral care protocols, and to promote the oral health of patients in ICUs.

[Methods for endotracheal tube fixation. Results of a survey of intensive care nurses]

There are a wide variety of strategies and methods used in securing and managing the oral endotracheal tube and mouth and oral care in German clinical intensive care nursing for mechanically ventilated patients. There are no nationally recognized guidelines or recommendations on this topic. A survey among intensive care nurses identified the most widely used nursing strategies and methods. Regarding the results of the survey and international literature findings, the commonly used strategies and methods are discussed. Following these discussions, there are recommendations for improving nursing care of orally intubated patients in intensive care, including the aspects of evidence identified, currently used methods and patient needs. Also included are aspects of patient safety, potential complications and quality-orientated nursing care within a system having limited overall nursing care resources.

Oral care education in the prevention of ventilator-associated pneumonia: quality patient outcomes in the intensive care unit

BACKGROUND

Ventilator-associated pneumonia (VAP) is associated with high morbidity and mortality rates in mechanically ventilated patients in the United States. Routine oral care has been shown to have a direct effect on reducing VAP rates.

METHODS

Intensive care unit registered nurses attended educational sessions about oral care and also used online education modules. Nursing care involving 180 intubated patients was observed, and changes were noted in practices related to oral care.

RESULTS

After the education intervention, the frequency of oral care increased significantly (p = .001) to tooth brushing every 4 hours and swabbing every 12 hours with 0.12% chlorhexidine solution. The evidence-based practice education intervention decreased VAP rates by 62.5%.

CONCLUSION

Significant reductions in VAP rates may be achieved through improved education and implementation of oral care protocols with 0.12% chlorhexidine solution.

Mouth care for orally intubated patients: a critical ethnographic review of the nursing literature

OBJECTIVES

The aim of this critical ethnographic literature review was to explore the evolution of nursing discourse in oral hygiene for intubated and mechanically ventilated patients.

METHODS

The online databases CINAHL and MEDLINE were searched for nurse-authored English language articles published between 1960 and 2011 in peer-reviewed journals. Articles that did not discuss oral problems or related care for intubated adult patients were excluded. Articles that met the inclusion criteria were chronologically reviewed to trace changes in language and focus over time.

RESULTS

A total of 469 articles were identified, and 84 papers met all of the inclusion criteria. These articles presented an increasingly scientific and evaluative nursing discourse. Oral care originally focused on patient comfort within the literature; now it is emphasized as an infection control practice for the prevention of ventilator-associated pneumonia (VAP). Despite concern for its neglected application, the literature does not sufficiently address mouth care's practical accomplishment.

CONCLUSIONS

Mouth care for orally intubated patients is both a science and practice. However, the nursing literature now emphasises a scientific discourse of infection prevention. Inattention to the social and technical complexities of practice may inhibit how nurses learn, discuss and effectively perform this critical aspect of patient care.

The oral health of critically ill children: an observational cohort study

AIMS AND OBJECTIVES

This study will describe the oral health status of critically ill children over time spent in the paediatric intensive care unit, examine influences on the development of poor oral health and explore the relationship between dysfunctional oral health and healthcare-associated infections.

BACKGROUND

The treatment modalities used to support children experiencing critical illness and the progression of critical illness may result in dysfunction in the oral cavity. In adults, oral health has been shown to worsen during critical illness as well as influence systemic health.

DESIGN

A prospective observational cohort design was used.

METHOD

The study was undertaken at a single tertiary-referral Paediatric Intensive Care Unit. Oral health status was measured using the Oral Assessment Scale and culturing oropharyngeal flora. Information was also collected surrounding the use of supportive therapies, clinical characteristics of the children and the occurrence of healthcare-associated infections.

RESULTS

Of the 46 participants, 63% (n = 32) had oral dysfunction and 41% (n = 19) demonstrated pathogenic oropharyngeal colonisation during their critical illness. The potential systemic pathogens isolated from the oropharynx and included Candida sp., Staphylococcus aureus, Haemophilus influenzae, Enterococcus sp. and Pseudomonas aeruginosa. The severity of critical illness had a significant positive relationship (p < 0·05) with pathogenic and absent colonisation of the oropharynx. Sixty-three percent of healthcare-associated infections involved the preceding or simultaneous colonisation of the oropharynx by the causative pathogen.

CONCLUSIONS

This study suggests paediatric oral health to be frequently dysfunctional and the oropharynx to repeatedly harbour potential systemic pathogens during childhood critical illness.

RELEVANCE TO CLINICAL PRACTICE

Given the frequency of poor oral health during childhood critical illness in this study and the subsequent potential systemic consequences, evidence based oral hygiene practices should be developed and validated to guide clinicians when nursing critically ill children.

Chlorhexidine and tooth-brushing as prevention strategies in reducing ventilator-associated pneumonia rates

BACKGROUND

Ventilator-associated pneumonia (VAP) is a common complication of mechanical ventilation after endotracheal intubation. The role of chlorhexidine and tooth-brushing has been considered as a clinical intervention to reduce infection rates, however, evidence to inform this needs appraising.

AIM

This paper presents a critical review on the effect of chlorhexidine gluconate (CHX) and tooth-brushing in decreasing rates of VAP in mechanically ventilated adult patients cared for in intensive care settings.

METHODS

A literature search was conducted using a number of bibliographic databases (n = 6). A number of parameters were used to exclude irrelevant papers. A total n = 17 papers were located and accessed, which were directly related to the field. Eight studies that met the criteria and addressed the study aims were reviewed.

FINDINGS

CHX was successful in reducing the rate of VAP and using a combination of CHX and colistine resulted in better oropharyngeal decontamination which reduced and delayed VAP. Chlorhexidine was also effective in reducing dental plaque in patients cared for in intensive care and had the potential to reduce nosocomial infections. Results of studies investigating the use of tooth-brushing in reducing VAP incidence proved inconsistent, although all recommend tooth-brushing as important in maintaining good oral hygiene.

CONCLUSIONS

The use of chlorhexidine has been proven to be of some value in reducing VAP, although may be more effective when used with a solution which targets gram-negative bacteria. Tooth-brushing is recommended in providing a higher standard of oral care to mechanically ventilated patients and reducing VAP when used with chlorhexidine. However, limitations in study design and inconsistency in results suggest that further research is required into the effects of tooth-brushing.

The effects of different oral care protocols on mucosal change in orally intubated patients from an intensive care unit

AIM

To compare the effectiveness of three different oral care protocols in intubated patients.

BACKGROUND

Although oral care is important to improve the oral mucosa integrity in intubated patients, there are few evidence-based nursing protocols to deal with this problem in critical care units.

DESIGN

A quasi-experimental design was employed for this study.

METHODS

Eighty-one orally intubated patients recruited from the intensive care unit of a medical centre in northern Taiwan were employed in this study. Patients were divided into three treatment groups: a control group (n = 27), green tea group (n = 29) and boiled water group (n = 25). Oral mucosal status was monitored using a rating scale for 14 days. All data were analysed by the sas software (version 8.2; SAS Institute, Cary, NC, USA) using descriptive statistics, the Kruskal-Wallis H test and generalised estimating equation regression models.

RESULTS

Severity of mucosal change was significantly less on six subscales (labial mucosa, tongue mucosa, gingival colour, gingivitis, salivary status and amount of dental plaque) in the boiled water group than the control group (p < 0·05). In addition, severity was significantly less on two subscales (salivary status and amount of dental plaque) in the green tea group than the control group (p < 0·05).

CONCLUSIONS

Both boiled water and green tea oral care protocols may improve mucosal status of orally intubated patients. Mucosal status was significantly more improved by oral care with boiled water than by oral care with green tea.

RELEVANCE TO CLINICAL PRACTICE

Because oral care plays an important role in improving mucosal status, nurses are urged to find new effective oral care methods to further reduce the occurrence of oropharyngeal colonisation and ventilator-associated pneumonia in intubated patients.