hat’s so important about oral care for ventilated patients? Seems like there are so many more important things to do than cleaning my patients’ mouths!! What’s the big deal?"

In the hectic daily activities of patient care in the ICU, it is incredibly difficult to perform even such simple tasks as routine oral hygiene. There are so many urgent, life-threatening events taking priority over everything else that making sure to get back to basic mouth cleaning often seems like just an unnecessary task. It can’t be that important—right? Truthfully, oral care is extremely important! It is far, far more critical for the ventilated ICU patient than for almost any other patient.

DNA studies have confirmed that up to 90% of ventilator-associated pneumonia (VAP) is caused by pathogens colonizing the mouth. Within hours of admission into the ICU, the oral physiology of the patient begins changing.

1. Saliva production decreases dramatically causing:

• gums, tongue and other oral tissues to become seriously dry (xerostomia)

• chapped lips, inflamed gums and oral lesions which provide protective havens within which pathogens can rapidly breed

2. Severe reduction in saliva results in the failed delivery of saliva-suspended anti-bacterial, anti-fungal, anti-viral and anti-inflammatory agents including lactoferin, neopterin, cortisol, lysozyme, peroxidases, histatins and immunoglobin A. 1

3. Saliva normally produces a higher than neutral pH environment, helping protect teeth and tissues from food and gastric acids. Less saliva means a fall back to more neutral pH creating a more hospitable environment for pathogen takeover and tissue/tooth enamel attack.

4. An over-production of oral protease commences. Excess protease digests fibronectin – the glycoprotein coating that covers cells lining the mouth and throat. Destruction of this protective coating exposes surface receptor sites, ready to receive respiratory pathogens.

Path to Ventilator-Associated Pneumonia In the ventilated and/or critically ill patient, saliva production decreases. The resulting environment can promote virulent bacterial colonization in the mouth and oropharyngeal secretions, which can quickly lead to the development of pneumonia.

Within 48 hours, the bacteria in the mouth shift from the normal inhabitants to those that are the usual suspects for causing pneumonia: Staphylococcus aureus, Streptococcus pneumonia, Pseudomonas aeruginosa, Haemophilus influenza and Acinetobacter baumannii. These pathogens exude substances in order to form a biofilm matrix, or plaque. Within these protective shelters, bacteria rapidly multiply and spread throughout the oral cavity. Many of these pathogenic bacteria make their way into the pool of secretions constantly accumulating above the endotracheal tube cuff (balloon). There, the pathogens are positioned to migrate around the cuff, or through cuff folds and gain access to the lungs. With the cough reflex and other normal respiratory defense mechanisms incapacitated in the ventilated patient, these "drop-in" bacteria rapidly take hold and initiate an infection: pneumonia.

And it all started because conditions in the mouth of the intubated ICU patient changed so dramatically; so rapidly.

Consequences in perspective: VAP occurs in as many as 28% of patients who receive mechanical ventilation. Incidence increases with the duration of mechanical ventilation. Estimated rates are 3% per day for days 1-5; 2% per day for days 6-10.2 After several days in the ICU, the intubated patient’s oral pathogen population shifts to a higher percentage of multi-drug resistant organisms (MDROs), increasing VAP, length of stay and mortality. VAP costs generally range from $12,000 to $40,000 per patient. Crude mortality rates range from 27-76%.3,4,5

Plaques forms as a protective biofilm for breeding bacteria. The CDC stated that up to 90% pathogens causing ventilator-associated pneumonia originates in the mouth of the patient - emphasizing the importance of frequent, quality oral care as a preventative.

That’s why oral care quality and routine compliance are absolutely essential! Correctly performed, standardized oral care will:

• significantly disrupt plaque

• reduce plaque reformation opportunities

• kill colonizing pathogens microorganisms despite exposed cell receptors

• prevent oral sores (lesions), inflamed gums and chapped lips, eliminating them as microbial breeding grounds and reducing patient pain

• effectively reduce the pool of bacteria above the cuff awaiting access to the lungs

• improve comfort and quality of life for non- and minimally sedated patients

So, understanding the consequences of poor oral care and the benefits of performing "it" every 4 hours, why is it so hard to get it done? Because of the:

• lack of time; feeling that other things are much more important

• lack of evidence based education explaining the strong causal link between poor oral condition and VAP

• absence of defined protocols/procedures

• staff shortages/staff turnover/replacement staff poor instructions

• inaccessibility of needed supplies—often required from dispersed locations

• lack of monitoring (when oral care was performed and what was done)

• lack of feedback or posted trending to display the success of staff compliance and VAP incidence reduction (motivate and celebrate!)

• lack of accountability/responsibility

Addressing barriers to performing VAP preventative oral care, products must:

• be easily accessible

• have all components necessary to do the job correctly (right tools for the job)

• be ergonomically correct making the task easier to perform, and safer for healthcare providers and their patients

• make it easy to confirm compliance to performing oral care frequently with correct instruments as recommended by guidelines and facility policies. This is readily accomplished with kit packaging systems making compliance easy to determine at a glance. The American Association of Critical Care Nurses (AACN) Practice Alert 6 specifies to:

• brush teeth, tongue and gums twice daily with toothbrush (oral rinse and suction as part of regimen)

• moisturize oral mucosa and use lip balm every 2 to 4 hours

• be accompanied by quality accredited education provided by manufacturers presenting in-depth explanations as to why oral care, when done appropriately in a timely manner, is so incredibly important for preventing VAP— Knowing why is essential for optimal patient outcomes and staff satisfaction.

Oral care performed frequently and correctly is essential in winning the war against VAP.

Zero VAP: Enable it!

References:

1. Nieuw Amerongen A. 2007. Implications for diagnostics in the biochemistry and physiology of saliva. Ann N. Y. Acad. Sci (10298): 1-6.

2. Cook DJ, Walter SD, Cook RJ, et al. 1998 Sep 15. Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Ann Intern Med 129(6):433-40.

3. Chastre J, Fagon JY. 2002. Ventilator-associated pneumonia. Am J Respir Crit Care Med 165:867-903.

4. NNIS. 2003 Aug. National Nosocomial Infections Surveillance (NNIS) system report: data summary from January 1992 through June 2003. Am J Infect Control 31:481-498.

5. Tablan OC, Anderson LJ, Besser R, et al. 2004 Mar. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of the CDC and the Healthcare Infection Control Practices Advisory Committee. Morb Mortal Wkly Rep 53(RR-3):1–36.

6. American Association of Critical Care Nurses. 2006 Aug. Practice Alert: Oral Care in the Critically Ill. Online: www.aacn.org. Accessed 3/31/09.