Effect of Chlorhexidine Oral Spray versus Mechanical Toothbrushing

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Effect of Chlorhexidine Oral Spray versus
Mechanical Toothbrushing Chlorhexidine Gel in
Decreasing VAP in Critically Ill Adults

• Peggy McCartt, PhD (c),CCRN, ARNP

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Background Significance

• Oral bacterial colonization increases in
  critically ill adult patients with poor oral
  health. (Kite Pearson, 1995, Rumbak, 2000).
• Patients with poor oral health are at high risk
  of developing nosocomial pneumonia if
  mechanically ventilated. (Rumbak, 2000 Kollef,
  1999 Johanson, Pierce, Sanford Thomas, 1972)
• The CDC reports that aspiration of oral
  pharyngeal pathogens places patients at high risk
  for developing ventilator associated pneumonia
  (VAP). (Munro, Grap, Sessler Carter, 2003).

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Background Significance

• The effectiveness of oral hygiene and the use of
  antimicrobial agents appears to be
  promising.(Fourrier, Cau-Pottier, Boutigny,
  Roussel-Delvallez, Jourdain Chopin, 2000).
• Interventions aimed at preventing bacterial
  colonization have not been well studied. (Moore,
  1995 Walsh, 1990).
• Research results would facilitate development of
  evidence-based standards related to oral care of
  critically ill adults at risk to develop VAP.
  (Zack, Garrison, et.al, 2002 Wardth, Hallberg,
  Berggren, Anderson Sorensen, 2000)

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Purpose

• The purpose of this study is to identify if
  oropharyngeal cleaning in conjunction with
  decontamination with an antiseptic agent
  decreases ventilator associated pneumonia in
  critically ill adults.

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Specific Aims

• Is there a difference in three study groups
  related to
  Oral Culture Scores
  Oral
  pH
  
  
  
  
  Clinical Pulmonary Infection Score (CPIS)
  1-white blood cell count, 2-temperature,
  3-tracheal secretions, 4-oxygenation
  (calculated by PaO2/FiO2, 5-chest radiograph
  and 6-tracheal aspirates.(Pugin, J.,
  Auckenthaler, R., Mili, N., Janssens, J. Lew,
  P. Sutter, P. (1991 Development of
  VAP

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Setting Recruitment

• Patients admitted to a not for profit acute care
  facility in Northeast Florida who are orally
  intubated. Recruitment methods include nursing
  referrals and identification by this researcher.

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SAMPLE

• Inclusion criteria
• Orally intubated patients 18 years of age or
  older.
• Subjects of any ethnic group or sex.
• N30 per group.
• Exclusion criteria
• Admitting diagnosis of pneumonia
• Nasally intubated patients
• Patients expected to be extubated in less than 24
  hours

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Design

• Experimental, RCT

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Variables

• Dependent Variables (CPIS) developed by Pugin et
  al, based on 6 clinical and laboratory variables,
  oral pH, tracheal aspirate score.
• Independent Variables chlorhexidine spray 0.12
  or chlorhexidine gel 0.12 with mechanical
  toothbrushing.

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Procedures

• Screen Orally Intubated
• Subjects
• Obtain Consent
• Randomize to One of
• Three Study Groups

• 1-Chlorhexidine Spray 0.12 every twelve hours
• 2-Chlorhexidine gel 0.12 with toothbrushing
  every twelve hours
• 3-Routine oral hygiene care per hospital policy
  and procedure

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Sample Data Collection Tool

• 
  Comments/Results
• Patient is Orally Intubated
• Number of DMF Teeth Noted
• CPIS Documented
• Head of Bed Elevated
• Cumulative Score on
• Mini Nutritional Assessment
• Oral pH
• Oral Culture Score

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Conclusions

• Study in progress

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Limitations

• Oral assessment tools for orally intubated
  patients are limited.
• Recruitment of subjects may be difficult since
  elective intubation is not the norm.
• Little research exists on optimal products for
  oral hygiene care.

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Future Directions

• Improving and integrating knowledge of best
  practices may contribute to
• Establishment of evidence-based oral care hygiene
  protocols
• Education programs
• Oral assessment tools for critically ill adult
  patients at risk to develop ventilator associated
  pneumonia.

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Implications

• Adult patients retain their teeth longer,
  therefore, are more susceptible to poor oral
  health.
• Chemical prophylaxis may play a prominent role in
  decreasing nosocomial VAP in critically ill adult
  patients.