1

WHAT IS THE BEST FORM OF ORAL CARE FOR VENTILATED PATIENTS

Chlorhexidine Compared to Standard Care Reduce Risk for Pneumonia in Ventilated

Patients

Caton Espinola

College of Nursing, University of South Florida

2
WHAT IS THE BEST FORM OF ORAL CARE FOR VENTILATED PATIENTS

Abstract

Clinical Problem: Patients who are put on ventilation are at an increased risk for ventilator

associated pneumonia. This increases the chances of adverse effects while on ventilation, as well

as length of stay while being ventilated.

Objective: The objective of this synthesis was to discuss whether chlorohexidine mouth care

(CMC) was better in comparison to standard toothbrushing methods (STM) for patients that are

on ventilation and whether they reduce to the risk for ventilator associated pneumonia. PubMed

and CINAHL was used as a search tool to find randomized control studies (RCT) related to

patients on ventilation and methods used to reduce VAP. The key search terms that were used

were chlorohexidine, standard tooth brushing, ventilator associated pneumonia, ventilated

patients, reduce infection, hospital setting.

Results: In patients that are put on mechanical ventilation the use of chlorohexidine prior to

intubation and during intubation compared to just during intubation was not statistically

significant and didn’t demonstrate a decrease in the risk of ventilator associated pneumonia.

Another study showed the use of chlorohexidine by itself compared to with toothbrushing didn’t

decrease the risk for VAP. The results showed that in the study the results were not statically

significant in the reduction of VAP and that toothbrushing combined with chlorohexidine was

better. The third RCT that was used was also not statistically significant, but due to the reduced

number of patients that had VAP it showed that chlorohexidine was a good at preventing VAP in

intubated patients due to the use of oral care with chlorhexidine 4 times per day for 1000 days,

compared to normal saline solution. Chlorohexidine use does help decrease the risk of VAP but

when used in certain medical practices.

3
WHAT IS THE BEST FORM OF ORAL CARE FOR VENTILATED PATIENTS

Conclusion: Studies show different aspects of the use of chlorohexidine and its uses for

ventilated patients. With preintubation use it may not be the best choice for care, where when

combined with normal toothbrushing on already ventilated patients it decreased the number of

bacteria. When applied several times per day the use of chlorohexidine did help reduce VAP for

several days on ventilated patients. More research should be conducted regarding the use of

chlorohexidine rinses as well as standard toothbrushing protocol together compared to other uses

of standard care to test its effectiveness in reducing VAP.

Chlorhexidine Compared to Standard Care Reduce Risk for Pneumonia in Ventilated

Patients

Many patients are put on mechanical ventilation due to respiratory failure caused by

cardiovascular illness, to help relieve respiratory failure, and create a patent airway for a patient

when they can’t for themselves. When patients are put on ventilators their risk for infection

increases due to intubation. Within 48 hours patients can develop ventilator associated

pneumonia (Dai et al., 2022). This can be caused by several different diseases or other factors

that are present in the hospital and there are protocols put into effect to try and prevent these

cases of VAP. There are many methods in place at different hospitals as standards of care to

prevent patients from becoming infected from pneumonia when intubated, many patients still

experience this in the hospital setting. It is said that chlorhexidine has antibacterial properties and

can prevent infections in the mouth (Jouybary et al., 2016). This could potentially benefit

ventilated patients instead of just standard tooth brushing methods. Some facilities even have

daily chlorhexidine mouth care for ventilated patients as there standard for patients at risk for

VAP (Jouybary et al., 2016). This evaluation is to compare the effectiveness of multiple studies

with the use of chlorohexidine care to see which intervention is better for the patient.
4
WHAT IS THE BEST FORM OF ORAL CARE FOR VENTILATED PATIENTS

Literature Search

PubMed and CINAHL was used as a search tool to find randomized control studies

(RCT) related to patients on ventilation and methods used to reduce VAP. The key search terms

that were used were chlorohexidine, standard tooth brushing, ventilator associated pneumonia,

ventilated patients, reduce infection, hospital setting. The publication years used were from 2008

to 2022.

Literature Review

Four random clinical trials were used to assess the effectiveness of chlorohexidine oral

care on ventilated patients and the statistics of whether it reduced the level of VAP in intubated

patients. practice guidelines for hospitals and ventilated patients can all be different, and they

change depending on what is determined to be best practice. In an randomized controlled trial de

Lacerda Vidal et al. (2017) conducted a study that was used to test the effectiveness of

chlorhexidine by itself against VAP compared to standard care (toothbrushing) with

chlorhexidine solution. Based on suspected VAP was defined as new or progressive pulmonary

infiltrate on chest radiography, showing a minimum of two of three signs being a fever (axilar

temperature ≥37.8 °C), leukocytosis (>10 X 103 /mm3) or leukopenia (>3 X 103/mm3). There

was a total of 213 mechanically ventilated patients. In the control group there was 108 patients,

and the control group was just chlorhexidine solution by itself. The intervention group had 105

participants and was chlorhexidine application after toothbrushing. Each group received the

cleanings every 12 hours. VAP occurred in 45 out of 213 patients (21.1%), 28 being patients

from the control group and 17 from the intervention group. The use of toothbrushing plus 0.12%

chlorhexidine gel demonstrated a lower amount of VAP even though it wasn’t statistically

significant (p = 0.084). Strengths of the study include the subjects were randomly assigned to an
5
WHAT IS THE BEST FORM OF ORAL CARE FOR VENTILATED PATIENTS

experimental and control group, this assignment was concealed from the subjects and providers.

If patients were removed patients were told why, there were follow up assessments conducted,

instruments used were valid, and the subjects didn’t have statistically significant differences.

There were no weaknesses of this study it was completely unbiased.

On the other hand, in a randomized control trial Monro et al. (2015) conducted a study

and the purpose of this study was to evaluate the benefit of adding a CHX dose before intubation

to the known benefit of postintubation CHX to lower VAP. The secondary aim for this study was

to test the effects of oral application of CHX on early endotracheal tube (ETT) before intubation

colonization to see if it will lower the amount of the bacteria. The design of this study was a

random clinical trial and Groups were compared using a Clinical Pulmonary Infection Score

(CPIS) as the response variable. The subset of patients was categorized and there ETT was tested

at extubation. In the groups there were a total of 314 ventilated patients’ (N=314), the Control

group which had no CHX before intubation was 157 patients (n=157), The Intervention group,

which had oral application of 5 mL CHX 0.12% solution before intubation had a total of 157

patients in this group. In all groups in the study all demographics were similar. The study

concluded that preintubation application of CHX did not provide additional benefit in reducing

the risk of development of early-onset VAP when compared with daily administration of CHX

that began after intubation. Preintubation application of CHX also did not show any significant

improvement in patients with VAP. The strengths of this study were that subjects were randomly

assigned to experimental and control groups, that assignment was also concealed from the

subjects and providers. If the patient was excluded, they were told why, the instruments used

were valid for the study, and the subjects had no statistical differences. Weaknesses of the study

were the lack of a follow up meeting with the patients after the study.
6
WHAT IS THE BEST FORM OF ORAL CARE FOR VENTILATED PATIENTS

On the contrary, Tantipong et al. (2008) conducted a study to test the effectiveness

against VAP using oral decontamination with 2% chlorhexidine solution. The design of this

study was a random control trial with metanalysis. The study had a total of 207 participants and

the groups were organized by the control group receiving 2 % chlorohexidine solution 4 times

per day and had 107 total participants. The intervention group would receive saline solution oral

rinses 4 times per day and had 102 participants. Meta-analysis was used combining the results of

the current study and another randomized controlled trial that also used 2% chlorhexidine

solution for oral decontamination. VAP was caused by gram- negative bacilli and the patient was

tested for it after the clinical trial. The study’s results showed that only 4.9 percent patients (5 of

102) in the chlorohexidine group had tested positive for VAP and 11.4 percent (12 of 105) in the

normal saline group had tested positive for VAP. The P value for the number of patients who

developed VAP was 0.08. There were 7 episodes of VAP in 1000 days on ventilation for the

chlorohexidine group and 21 episodes of VAP in 1000 days on ventilation in the normal saline

group. The P value for the number of cases of VAP in 1000 ventilated days was 0.04. According

to the data, the characteristics of the group of patients was not statistically significant. This study

concluded that chlorhexidine is effective in preventing VAP in patients who are intubated. The

strengths of this study consisted of subjects that were randomly assigned to the experimental and

control groups, the patients were educated on why they were excluded if they were, they were

analyzed based off their specific groups, the control group was appropriate, the instruments used

in the study were valid, and there was no statistical difference in the groups. The weaknesses of

this study were that subjects did not have a follow up appointment after the study was conducted,

and the subjects and providers were not blind the study.
7
WHAT IS THE BEST FORM OF ORAL CARE FOR VENTILATED PATIENTS

The use of chlorohexidine to assess for reduction of VAP due to its use was by Kez et al.

(2021) and the purpose of the study was to assess the efficacy of chlorohexidine use with mouth

care for ventilated patients versus a placebo group as well assess oral health after uses from each

group. The design of this study was a randomized clinical trial. This study had a total of 57

patients, 29 in the chlorohexidine experimental group and 28 in the placebo control group. Oral

care was conducted three times per day in each group but in the placebo group they received

sodium bicarbonate as the mouth care solution. The study was a single blinded and randomized

control trial where the participants were randomly selected for there groups. The Barnason oral

assessment was used to evaluate the level of the patient’s oral mucosal health before oral care

began and before the patient was intubated. The patients were assessed with this scale on three

days, day 0, day 2, and day 3. Samples from the first and third day were collected, and the

patients were just assessed on the second day. The results of the study showed that there was no

statistical difference between either group at day 0 with each group starting with an incidence of

15 and 16 patients with ventilation associated diseases but as the days progressed the incidence

of Ventilator associated diseases increased in the placebo group by 5 patients totaling 20 on day

3 and the incidence of VAP decreased for the CHX group by 8 totaling 8 patients on day 3. The

differences between both groups P value at day 0 was 0.557 where in comparison to day 3 the P

value for the differences between groups was 0.001. This study showed that chlorohexidine is a

efficient method of oral care for patients with early onset VAP and VAT. The groups were not

statistically different, but the results showed a significant decrease in the chlorohexidine group

with several different ventilator associated diseases. The strengths of this study were that the

diseases associated with the study were diagnosed clinically and microbiologically. The study

was also a single blind, randomized, and included a placebo group. There was no statistical
8
WHAT IS THE BEST FORM OF ORAL CARE FOR VENTILATED PATIENTS

difference between each group and the instruments used were valid for the experiment. The

weaknesses of this study were that it was only conducted on early VAP not late onset. that it was

confined two only two ICUs and would be improved if the study could be conducted on a larger

scale to test its effectiveness as well as for both late and onset VAP and the providers were not

blind the study groups as well.

Synthesis

Most of these studies demonstrated that the use of chlorohexidine benefits patients that

are on mechanical ventilation and their risk for VAP and the prevention of VAP (p < 0.04)

Tantipong et al. (2008). Monro et al. (2015) on the other hand, study results stated that at pre-

intubation the use of chlorohexidine doesn’t benefit the patient in reducing VAP and the ETT

colonization at extubation was less than 20 percent in both groups, showing no statistical

difference. On the opposite end, De Lacerda Vidal et al. (2017) (p< 0.084) results showed that

chlorohexidine by itself isn’t as beneficial as the use of toothbrushing with chlorhexidine use.

Lastly, Kez et al. (2021) study showed (p < 0.001) a significant decrease of several different

ventilator associated diseases with the use of chlorohexidine.

There were several major weaknesses in some of these studies where others were well

rounded. One major weakness was that most of these studies were more on a smaller population

scale. Some of he studies also lacked a follow up meeting with these patients which is important

in finding if there is a continued issue. One study only tested early onset VAP instead of both

late and early onset VAP and was restricted to researching two ICUs. Further studies should be

conducted with a larger population to test the effectiveness of Chlorohexidine on ventilated

patients, as well as other studies with the use of chlorohexidine added to standard of practices

already in place.
9
WHAT IS THE BEST FORM OF ORAL CARE FOR VENTILATED PATIENTS

Clinical Recommendations

From the research assessed in the 4 random clinical trials, most suggest that the use of

chlorohexidine by itself is not efficient but when included with oral mouth care procedures it

reduces patients with VAP. Several trials also address potential bias in the research of ventilated

patients regarding chlorohexidine use and recommend remaking the research and testing the use

of it individually in comparison to other mouth care methods (Kez et al. 2021). Studies also

additionally showed that chlorohexidine reduces the risk of infection of more than one VAD and

can stop several different growth patterns of bacteria when used. (Kez et al. 2021).

Chlorohexidine could improve the incidence rate of patients experiencing these issues when they

are ventilated. Several studies should be conducted to find the best method of reducing these

diseases due to so much skewed and biased data related to this topic. Clinical practices while

using chlorohexidine should be clearer, and the number of times it is used per day if increased

could improve patients’ overall health when ventilated.

10
WHAT IS THE BEST FORM OF ORAL CARE FOR VENTILATED PATIENTS

References

Dai, W., Lin, Y., Yang, X., Huang, P., Xia, L., & Ma, J. (2022). Meta-Analysis of the Efficacy

and Safety of Chlorhexidine for Ventilator-Associated Pneumonia Prevention in

Mechanically Ventilated Patients. Evidence-Based Complementary & Alternative

Medicine (ECAM), 1–8. https://doi.org/10.1155/2022/5311034

de Lacerda Vidal, C. F., Vidal, A. K., Monteiro, J. G., Cavalcanti, A., Henriques, A. P., Oliveira,

M., Godoy, M., Coutinho, M., Sobral, P. D., Vilela, C. Â., Gomes, B., Leandro, M. A.,

Montarroyos, U., Ximenes, R. de, & Lacerda, H. R. (2017). Impact of oral hygiene

involving toothbrushing versus chlorhexidine in the prevention of ventilator-associated

pneumonia: A randomized study. BMC Infectious Diseases, 17(1), 2–8.

https://doi.org/10.1186/s12879-017-2188-0

Kes, D., Aydin Yildirim, T., Kuru, C., Pazarlıoglu, F., Ciftci, T., & Ozdemir, M. (2021). Effect

of 0.12% Chlorhexidine Use for Oral Care on Ventilator-Associated Respiratory

Infections: A Randomized Controlled Trial. Journal of trauma nursing : the official

journal of the Society of Trauma Nurses, 28(4), 228–234.

https://doi.org/10.1097/JTN.0000000000000590

Munro, C. L., Grap, M. J., Sessler, C. N., Elswick, R. K., Mangar, D., Karlnoski-Everall, R., &

Cairns, P. (2015). Preintubation application of oral chlorhexidine does not provide

additional benefit in prevention of early-onset ventilator-associated pneumonia. Chest,

147(2), 328–334. https://doi.org/10.1378/chest.14-0692

Tantipong, H., Morkchareonpong, C., Jaiyindee, S., & Thamlikitkul, V. (2008). Randomized

controlled trial and meta-analysis of oral decontamination with 2% chlorhexidine solution

11
WHAT IS THE BEST FORM OF ORAL CARE FOR VENTILATED PATIENTS

for the prevention of ventilator-associated pneumonia. Infection Control & Hospital

Epidemiology, 29(2), 131–136. https://doi.org/10.1086/526438