VAP is a common complication that occurs in intensive care unit (ICU) patients and is a high-risk factor for patient mortality. Physicians diagnose VAP using a combination of clinical and imaging findings. Gradual or sudden onset of pulmonary infiltrates may be observed during chest imaging. Clinical VAP symptoms include fever, increased respiratory rate, decreased oxygenation, and purulent sputum. Microbiological assessment of respiratory samples to identify associated pathogens is key in VAP diagnosis, treatment, and management. In patients who received endotracheal intubation, VAP preventive measures include maintaining oral hygiene as well as daily monitoring of the endotracheal tube's cuff pressure, patient head alignment, and subglottic secretion drainage (the focus of a 2022 ECRI webinar).
Oral Hygiene
Daily oral hygiene is a critical care component in patients receiving mechanical ventilation because pathogens that colonize the mouth and throat can serve as a reservoir for potential nosocomial infections. Aspiration of organisms from the oropharynx into the lower respiratory tract in ventilated patients can result in life-threatening VAP.
Daily oral hygiene is needed to minimize biofilm formation and microbial burden in the oropharyngeal tract in order to prevent aspiration of microorganisms into the lower respiratory tract and subsequent VAP. Oral care strategies include mechanical plaque removal and the use of antimicrobial products. Biofilm can be removed through manual or electric toothbrushes. CHG has commonly been used to decontaminate the oral cavity in mechanically ventilated patients. Other antimicrobial agents include PI, hydrogen peroxide, and consumer-grade mouthwashes.
Clinical Research
In a recent evidence assessment on “Oral Hygiene’s Effectiveness for Reducing Ventilator-Associated Pneumonia,” ECRI’s Clinical Evidence researchers identified four systematic reviews (SRs) and three randomized controlled trials (RCTs) suggesting that daily tooth brushing and/or using chlorhexidine gluconate (CHG) may reduce VAP rates in mechanically-ventilated patients.
Evidence-based Guidelines
ECRI’s Clinical Evidence researchers also identified two clinical practice guidelines recommending oral health assessments and tooth brushing without CHG for preventing VAP.
Impact
A 2020 review of VAP in adults (Papazian et al.) estimates that between 5 and 40% of patients receiving mechanical ventilation for more than two days develop VAP and that the traceable cost of VAP typically exceeds $40,000 per case.
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