Running head: VENTILATOR-ASSOCIATED PNEUMONIA

Ventilator-Associated Pneumonia:

Prevention in the Mechanically Ventilated Patient

Rebecca Netjes

University of South Florida

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Abstract

Clinical Problem: Patients who require mechanical ventilation are at a high risk of acquiring

ventilator-associated pneumonia (VAP), which corresponds to an increased length of

hospitalization and increase in mortality rate.

Objective: Determine if chlorhexidine (CHX) oral care decreases the incidence of VAP in

mechanically ventilated patients admitted to the intensive care unit (ICU). PubMed and CINAHL

were accessed to locate randomized controlled trials (RCT) and guidelines regarding prevention

of VAP. The key search terms were ventilator-associated pneumonia, prevention, chlorhexidine

oral care, chlorhexidine, mechanically ventilated patient, and clinical guideline.

Results: Muscedere et al. (2008) developed a clinical practice guideline that encourages the

consideration of oral CHX care as it may decrease the incidence of VAP. The literature indicated

a decrease in the prevalence of VAP in mechanically ventilated patients during ICU admission

with the use of CHX oral care.

Conclusion: Patients who require mechanical ventilation that received a form of CHX oral care

had a reduced incidence of VAP. The incidence of VAP and effectiveness of CHX was also

closely associated with baseline pulmonary status, at time of intubation. Further research is

indicated to assess what protocol of CHX oral care will prevent VAP in patients reliant on

mechanical ventilation.
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Ventilator-associated Pneumonia: Prevention in the Mechanically Ventilated Patient

According to current clinical guidelines, VAP correlates with an increase in length of

time patients require ventilator support, an increase in mortality by 65%, and an increase in the

overall cost of hospitalization (Muscedere et al., 2008). Risk factors associated with VAP are

poor hand hygiene, insertion of a nasogastric tube, a lowered head of bed, and

immunosuppression (Munro, Grap, Jones, McClish, & Sessler 2009). VAP is considered to be

gram-positive or gram-negative bacterial colonization of the oropharynx within 48 hours of

intubation. There are currently several recommendations for clinical practice that seek to prevent

or decrease the incidence of VAP. Examples of these recommendations are ensuring each patient

receives a new ventilator, the units are cleaned on a schedule in addition to as clinically

indicated, endotracheal suctioning, and a head of bed elevated to at least 45 degrees (Muscedere

et al., 2008). These clinical guidelines are often collectively referred to as the ventilator-

associated pneumonia bundle, or “VAP bundle”. This paper seeks to evaluate the effect of daily

CHX oral care on mechanically ventilated patients to decrease the incidence of VAP, decrease

morbidity, and decrease length of hospitalization. In mechanically ventilated, ICU patients, does

the use of CHX oral care agents compared to standard non-CHX oral care reduce the incidence

of ventilator-associated pneumonia during their admission to the ICU?

Literature Search

PubMed and CINAHL were accessed to locate RCTs and clinical guidelines regarding

prevention of VAP. The key search terms were ventilator-associated pneumonia, prevention,

chlorhexidine oral care, chlorhexidine, mechanically ventilated patient, clinical guideline.

Literature Review
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Three RCTs and one current clinical practice guidelines were utilized to assess the

effectiveness of CHX oral care on VAP incidence. Through the means of a RCT, Koeman et al.

(2006) analyzed the effect of CHX oral care and CHX and a colistin mixture were at preventing

VAP, when compared to a placebo. Random assignment included 385 adult patients in need of

mechanical ventilation for greater than or equal to 48 hours. Participants were randomly placed

in a placebo group (n=130), the CHX intervention group (n=127), or the CHX and colistin

intervention group (n=128). When compared to the placebo, CHX and the CHX clositin mixture

were found to be statistically significant at reducing the risk of ventilator associated pneumonia

(p=0.012 and p=0.030, respectively). A weakness of this study was that the similarity between

participants was not explicitly addressed in the literature. The strengths of this study included

random, double blind assignment into the intervention or control group, valid and reliable

measurement methods, and the length of assessment was long enough to fully analyze the results

of the study. Also, if any participants did not participate in the trial, or were excluded during the

trial, a thorough explanation was provided.

Munro, Grap, Jones, McClish, and Sessler (2009) conducted a RCT to assess the

effectiveness of CHX (n=44), standard toothbrushing (n=49), and a combination of the two

(n=48) at preventing the occurrence of VAP in ventilated patients in the ICU when compared to

a control group (n=51). The trial consisted of 192 adult patients that did not have a previous

intubation, were not edentulous, and were free from a pre-existing diagnosis of pneumonia who

were randomly assigned to a control group or an intervention group. The results showed that

CHX oral care was significant in preventing VAP in those patients without a baseline Clinical

Pulmonary Infection Score (CPIS) score of at least six (p=0.006). A weakness of this study was

that there were patients that had a CPIS greater than or equal to six, which was indicative of
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pneumonia, but lacked a formal diagnosis. Also, because of the nature of the intervention, the

health care providers giving oral care could not be blind to the assignment. However, the health

care providers analyzing the results of the interventions were kept blind to assignment. The

strengths of this study included random assignment to the control and intervention groups and

the instruments that measured the incidence of VAP were valid and reliable.

Through a RCT, Grap et al. (2011) evaluated the effectiveness of a single dose of CHX

prior to intubation in reducing cases of VAP, when compared to no dose of CHX prior to

intubation. 60 patients who were intubated less than 12 hours prior to the start of the study, that

were free from pneumonia or a burn injury and were not edentulous, were randomly assigned to

the control (n=24) or intervention group (n=36). The results of this study showed that a single

one-time dose of CHX prior to intubation was effective in preventing ventilator-associated

pneumonia, as evidenced by CPIS scores, at 48 and 72 hours post intubation (p=0.02 and

p=0.027, respectively). Weaknesses of this study include that it utilized a small sample size and

that the data on the incidence of VAP was collected up to 72 hours post intubation. It would be

preferable that data be collected and analyzed until extubation. The strengths of this study

included that health care providers analyzing data were blind to the assignments of the

participants, and if patients left or were excluded from the study, there was an explanation

provided.

The guidelines for clinical practice provided by Muscedere et al. (2008) indicate that oral

care with a form of CHX should be considered as it is associated with a decrease in the

prevalence of VAP. The guideline does not list a specific technique of administration or type of

CHX. Rather, it suggests that further research on the best practice for administration of CHX is

warranted.
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Synthesis

Koeman et al. (2006) identified a decrease in the number of cases of VAP when oral care

was provided with CHX or a CHX clositin mixture (p=0.012 and p=0.030, respectively) to

mechanically ventilated patients. Furthermore, Munro et al. (2009) a significant decrease

(p=0.006) in occurrence of VAP in patients that did not have underlying respiratory disease

processes at play, as evidenced by a CPIS score of less than six, when CHX oral was provided.

Grap et al. (2011) also reported that a single one-time dose of CHX prior to intubation was

statistically significant in preventing ventilator-associated pneumonia at 48 and 72 hours post

intubation (p=0.02 and p=0.027, respectively). Finally, Muscedere et al. (2008) set forth

guidelines stating that CHX oral care interventions should be considered in the prevention of

VAP.

Research supports the implementation of CHX oral care in preventing VAP in patients

admitted to ICUs that require mechanical ventilation. This reduction in hospital-acquired

infection will correlate with improved patient outcomes and decreased length of hospitalization.

However, the research does not indicate a single approach to CHX, as there are several types (i.e.

CHX and colistin mixture) that can be utilized in various forms of administration. Further

investigation is necessary to unify the research in identifying the most effective means of

administration and form of CHX. Also, research is indicated to assess clinicians’ knowledge of

CHX, appropriate oral care, and attitudes towards preventing VAP.

Clinical Recommendations

The guidelines reported by Muscedere et al. (2008) state that patients who are

mechanically ventilated should have oral care with CHX considered as an intervention to prevent

the occurrence of VAP. CHX oral care can be implemented as an adjunctive intervention to
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traditional preventative measures such as universal precautions and hand hygiene, sterilization of

all components to the ventilator and endotracheal tube, endotracheal suctioning, and an elevated

head of bed. Research has also confirmed that CHX oral care can be effective in prevention of

VAP in patients reliant on mechanical ventilation, but further research is indicated to assess for

the most effective form and administration. CHX oral care will contribute to the prevention of

VAP, but most importantly, high quality patient care and the full recovery of the patient.
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References

Grap, M. J., Munro, C. L., Hamilton, V. A., Elswick Jr, R. K., Sessler, C. N., & Ward, K. R.

(2011). Early, single chlorhexidine application reduces ventilator-associated pneumonia

in trauma patients. Heart and Lung, 20, e115-e122. doi: 10.1016/j.hrtlng.2011.01.006

Koeman, M., Van Der Ven, A. J., Hak, E., Joore, H. C., Kaasjager, K., De Smet, A. G., …

Nonten, M. J. (2006). Oral decontamination with chlorhexidine reduces the incidence of

ventilator-associated pneumonia. American Journal of Respiratory and Critical Care

Medicine, 173(12), 1348-1355. doi: 10.1164/rccm.200505-820OC

Munro, C. L., Grap, M. J., Jones, D. J., McClish, D. K., & Sessler, C. N. (2009). Chlorhexidine,

toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults.

American Journal of Critical Care, 18(5), 428-439. doi: 10.4037/ajcc2009792

Muscedere, J., Dodek, P., Keenan, S., Fowler R., Cook, D., & Heyland, D. (2008).

Comprehensive evidenced-based clinical practice guidelines for ventilator-associated

pneumonia: prevention. Journal of Critical Care, 23(1), 126-137. doi:

10.1016/j.jcrc.2007.11.014