Oral hygiene care for critically ill patients

to prevent ventilator‐associated pneumonia

CITRA AULIA, S.Kep,Ners

 OUTLINE

O
 Background

 Introduction

 Conclusion

 Oral hygiene procedures

for patients on
mechanical ventilator

Presentation title 2
 Ventilator associated pneumonia (VAP)
is the most common nosocomial
infection in Intensive Care Unit. One
major factor causing VAP is the
aspiration of oral colonization because
Background
of poor oral care practices. We feel the
role of simple measure like oral care is
neglected, despite the ample evidence
of it being instrumental in preventing
VAP.
 Introduction
Ventilator-associated Ventilator-associated
pneumonia (VAP) is a pneumonia occurs in up to
health care associated 25% of ventilated patients
infection (HAI) that and is re sponsible for
often results in high approximately 90% of
morbidity dan mortality. nosocomial infections.

Presentation title 4

Patients require at least
.
.
48 hours of
endotracheal intubation
for their infection to be
considered VAP, and it
is early onset if the
infection presents in the
first 4 days of
mechanical ventilation
(MV).
Presentation title
Introduction
Of all the factors
relating to VAP
occurrence,
colonization in the
oropharynx is the most
critical risk factor and
can be combated with
proper oral care and
chlorhexidine (CHX)
use
5

Similar to pneumonia,
.
.
VAP also involves
pathogens, but in an
intubated and
mechanically ventilated
patient of at least 48
hours. Any patient who
is mechanically
ventilated is at risk of
developing VAP
because of the loss of
airway defense
mechanisms.
Presentation title
Introduction
Ventilator-associated
pneumonia involves
bacterial aspiration
from the oropharynx
down into the lungs,
with subsequent failure
of patient defenses to
clear said bacteria,
resulting in an infection
of the lungs
6
 Introduction

The risk of VAP increases The most common

.

.
the longer a patient is
intubated. Once this occurs, potential respiratory
it progresses quickly and bacterial pathogens
easily. The microorganisms (PRPs) for a
found to cause VAP are most
commonly located in the ventilated patient are
oropharynx and the stomach Staphy lococcus
and find their way to the aureus, Pseudomonas
lungs past the endotracheal
cuff via aspiration. aeruginosa,
Acinetobacter
species, and enteric
Presentation title species 7
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Presentation title
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Introduction

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P r in
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8
 Introduction

• One of the common problems of patients

undergoing mechanical ventilation is poor
oral health. Patients in intensive care units
(ICUs) quickly develop oral problems for
various reasons such as malnutrition,
presence of the tracheal tube and nasogastric
tube that is placed in the mouth of patients for
treatment purposes, reduced fluid intake, and
reduced salivation caused by fever, diarrhea,
burns, and drug usage such as opiates
Presentation title 9
 Introduction

• In patients in ICUs, dental plaques are formed more and

faster than other patients. Oral flora changes in the
course of 48 h after hospitalization in favor of gram-
negative organisms, which grow in the oral cavity
resulting in the formation of dental plaque. Plaque mass
is increased with an accumulation of aerobic and
anaerobic microorganisms and its colonization by Gram-
negative bacteria is an important factor in the
accumulation of oral and pharyngeal bacteria. The
results of several studies have revealed that bacteria
present in dental plaque are causes of ventilator-
associated pneumonia (VAP)
Presentation title 10
 Introduction

• VAP develops within 48 h of intubation and

mechanical ventilation. VAP is the second
most prevalent nosocomial infection among
patients in ICUs.The prevalence rate of VAP
in patients undergoing mechanical
ventilation is 9%–68%, and its resulting
mortality is reported to be 30%–70%. It
extends hospital and ICU stay by 6–7 days,
raises healthcare costs, increases the length
of mechanical ventilation, and increases
morbidity,
Presentation title
mortality, and patient suffering. 11
 Introduction

• Various studies have shown that

optimum oral care was accompanied
by a reduction in the occurrence of
VAP in ICUs. For instance, a study
showed that the implementation of an
oral care program in ICUs could
significantly decrease the relative risk
of VAP and reduce its prevalence from
10.4 to 3.9 cases per 1000 ventilator
days.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6178571/# 12
 Introduction

• Therefore, providing oral care and

hygiene should be considered as a
fundamental aspect of nursing care in
ICUs. However, despite the
importance of oral care in patients in
ICUs, some studies mainly focus on
the pathophysiology of VAP and
discuss the importance of oral care
when examining the physiology of
oral cavity.
Presentation title 13
 Introduction

• Some studies have investigated oral-

care-related tools such as toothbrush
and mouthwashes. According to a
meta-analysis, the use of
chlorhexidine mouthwash in patients
in ICUs significantly reduced the
incidence of VAP. Some studies show
that brushing is an effective way of
reducing dental plaque and VAP
Presentation title 14
 Introduction

Aspiration of oral colonization

Whenever endotracheal (ET)
has been identified as one of the
tube is in place, most defenses
common causes of VAP in ICU
against pneumonia are impaired.
as a result of poor oral care.

Saliva plays an important role in

oral clearance with mastication
and swallowing.
Presentation title 15
 Introduction

Centre for disease control and

Oral assessment can be done casing
prevention has developed evidence-
Modified Beck Oral Assessment
based patient care treatment
Scale and Mucosal Plaque Score
practices for reducing VAP

It has been found that incorporation

of routine oral hygiene may reduce
VAP by as much as 60%

Presentation title 16
 Modified Beck Oral Assessment Scale

Presentation title 17
 Mucosal Plaque Score

Presentation title 18
 Introduction

• Centre for disease control and

prevention has developed
evidence-based patient care
treatment practices for reducing
VAP.
• It has been found that
incorporation of routine oral
hygiene may reduce VAP by as
much as 60%.
Presentation title 19
 Introduction

• Such practices should include

brushing teeth, gums, and tongue
at least twice a day with a soft
pediatric toothbrush and
moistening oral mucosa and lips
every 2-4 h.

Presentation title 20
 Introduction

• They also recommend the use of

0.12% oral chlorhexidine to rinse
the oral cavity twice daily and to
suction oral cavity/pharynx in
addition to brushing use oral
swabs with 1.5% hydrogen
peroxide to clean plaque from
mouth.

Presentation title 21
 Introduction

• It is necessary that every heath

care institution must have written
an oral care protocol and training
plan so that the patient receives
comprehensive oral care in a
consistent manner.

Presentation title 22
 Introduction

• Teeth should be regularly cleaned with a

toothbrush. Soft bristled pediatric toothbrush is
recommended for brushing, flossing is also
recommended but there is a risk of gingival trauma.
Mechanical plaque removal is shown to be very
effective in ICU.

• The preferred treatment for dry mouth is regular

moistening of oral mucosa with water or normal
saline, the use of saliva substitute or application of
moistening gel.
Presentation title 23
 Recommended Oral Care Interventions
for Ventilated Patients
Assessment of oral cavity Maintain saliva
• Intervention Conduct • Intervention Unit specific
protocols should be
an initial admission implemented that assist
as well as daily patients at risk of VAP in
assessment of the maintaining saliva
production, oral tissue health,
lips, oral tissue, and minimizing the
tongue teeth, and development of mucositis.
saliva of each patient • Rationale Saliva provides
on a mechanical both mechanical and
ventilator. immunological effects which
act to remove pathogens
colonizing the oropharynx.
Presentation title
Elevate head
• Intervention Keep the head of the
bed elevated at at least 30°
(unless medically
contraindicated) especially
important during such activities
as feeding and brushing teeth.
• Rationale Elevation aids in
preventing reflux and aspiration
of gastric contents; oral secretions
may drain into a subglottic area
where they become rapidly
colonized with pathogenic
bacteria.
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 Recommended Oral Care Interventions
for Ventilated Patients

Subglottic suctioning
• Intervention Patients oral and
subglottic secretions should be
suctioned continuously or
intermittently/routinely with the
frequency dependent upon
secretion production.

Presentation title 25
 Pneumonia is a prevalent disease that
is responsible for approximately 75%
of all hospital acquired infections.
Because of the severity of this
Conclusion disease, it is necessary that medical
personnel to have knowledge about
risk factors for the development of
hospital-acquired Pneumonia and the
prevention strategies.
 Ventilated patients are more at risk as
their normal host defense mechanism
are impaired. One basic prevention
strategy is comprehensive oral care
Conclusion protocol. The rapid potentially
pathologic charges that occur in the
ventilated patients’ oral environment
make oral care a critical component
of Hospital Acquired Pneumonia.
 Prosedur Oral Hygiene
Pada Pasien Terpasang Ventilator

PERSIAPAN ALAT ORAL HYGIENE

Sarung Tangan Bersih Sikat Gigi dan Pasta Gigi 28

 Persiapan Alat Oral Hygiene

Spuit 20 ml Air Putih 29

 Persiapan Alat Oral Hygiene

Catheter suction Regulator Suction 30

 Persiapan Alat Oral Hygiene

Connecting Suction Kontainer Suction 31

 Persiapan Alat Oral Hygiene

Set Oral Hygiene Oral Minosep Gurgle (Chlorhexidin 0.,2% 32

 Persiapan Alat Oral Hygiene

Minyak Zaitun Lidi Kapas 33

 Persiapan Alat Oral Hygiene

Masker Apron 34
 Persiapan Alat Oral Hygiene

Plester ETT Gunting 35

 Prosedur Oral Hygiene
Pada Pasien Terpasang Ventilator

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 Prosedur Oral Hygiene
Pada Pasien Terpasang Ventilator

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