Evidence-Based Nursing Research
Ventilator-Associated Pneumonia (VAP) is a subcategory of hospital-gotten pneumonia that affects patients under mechanical ventilation through a tracheostomy or endotracheal tube for at least forty-eight to seventy-two hours. This form of pneumonia affects nine to twenty-seven percent of patients in the ICUs. In the USA, the expenditure is two billion dollars yearly and nearly thirty thousand to forty thousand dollars per case (Berry et al. 2017). The rate of mortality for VAP varies from twenty to seventy percent. VAP intensifies the duration of hospital stay and mechanical ventilation. It is also liable or for fifty percent of the antibiotics recommended in the ICUs.
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The most significant method in VAP development is the unceasing micro-aspiration of oropharyngeal colonization into the lower respiratory tract. A day after a patient’s entry to the ICU, common oropharyngeal flora adjusts into gram-negative pathogens that elevate dental plaque. Plaques are conducive environments for the accumulation and growth of pathogens. Moreover, the tracheal tube may function as a channel for the oral cavity pathogens of the oral cavity to the lungs (Woodrow. 2011). Numerous research has demonstrated an association between respiratory pathogens and dental plaque colonization. Luckily, the incidence of VAP IS minimized through improving prevention methods and by identifying the risk factors. Currently, the rate of mortality of VAP has been projected at about nine to thirteen percent.
Population: Adult population in the Intensive Care Unit with a mechanical ventilator.
Intervention: Oral topical decontamination
Comparison: No standard oral care or no solution.
Outcome: Minimize ventilated associated pneumonia among adult ICU patients with a mechanical ventilator.
Answerable question: What is the efficacy of oral rinse with 0.2 percent and 2 percent chlorhexidine on oropharyngeal in minimizing the prevalence of ventilator related pneumonia?
The answerable question was developed by first identifying the population who are adult patients in ICU with a mechanical ventilator. Secondly, I came up with the intervention that is to minimize the likelihood of contracting pneumonia among adult patients with a mechanical ventilator. Then thirdly, a comparison is made, which is then followed by the outcome of the intervention. Finally, an answerable question is formulated that comprises of the above-stated parts.
Ventilator-associated pneumonia progresses to cause difficulties to the cause of eight to twenty-eight percent of patients getting mechanical ventilation. In divergence to infections of more regularly engaged organs (for instance skin and urinary tract), for which mortality is little, varying from one to four percent, the rate of mortality for VAP varies from twenty-four to fifty percent and can get to seventy-six percent when lung infection is caused by some high-risk pathogens or in some specific settings. The leading organisms liable for infection are Pseudomonas aeruginosa, Staphylococcus aureus, and Enterobacteriaceae, though etiologic agents extensively vary according to the patient's population in an intensive care unit, prior antimicrobial therapy, and duration of hospital stay. Since suitable antimicrobial therapy of a patient with VAP substantially enhances results, more accurate selection of microbial agents and rapid identification of infected patients represent crucial clinical targets. Notwithstanding the major developments in strategies for the management of patients who are dependent on a ventilator and the regular utilization of useful methods to clean respiratory tools, VAP progresses to set hurdles to the course of eight to twenty-eight percent of the patients getting mechanical ventilation. Pneumonia rates are noticeably greater among hospitalized patients in the ICU contrasted with those in hospital wards, and the threat of pneumonia is intensified by three to tenfold for the patient who is intubated and is getting mechanical ventilation.
The current review is based on an assessment of the literature, chosen through a computerized MEDLINE search from the year 1980 to the year 2001. Consensus statements, review articles, and the references cited were also contemplated in this attempt to revise our present knowledge on the diagnosis, epidemiology, and treatment of VAP. Since the Hospital Infection Practice Advisory Committee of the Centers for Disease Prevention and Control published up-to-date and extensive suggestions for the deterrence of nosocomial pneumonia in 1997 and other comprehensive reviews are also available.
Correct data on VAP epidemiology are constrained by the lack of harmonized criteria for its diagnosis. Theoretically, VAP is described as the inflammation of the lung parenchyma instigated by agents that are infectious that are incubating or absent at the time the MV began. Notwithstanding the clearness of this conception, the last 3 decades have seen the advent of several definitions of operation, which none is accepted universally. In focal areas of the lobe, pneumonia may fail to be seen, microbiologic research may be negative notwithstanding the existence of inflammation in the lung and practitioners may differ concerning the discoveries. The nonexistence of a ‘gold standard’ remains to bring disagreements concerning the relevance and adequacy of many studies in this field.
Persistent (greater than forty-eight hours) MV is the most significant element linked with nosocomial pneumonia. Nevertheless, VAP may take place with the first forty-eight hours after intubation. Since the princeps study by coworkers and Langer, it is normal to differentiate early on-onset VAP that takes place during the first four days of MV, from late-onset VAP, that advances 5 or more days after the start of MV. Not only are the pathogens that cause the disease usually different but the prognosis is better in early-onset than late-onset VAP and the disease is normally less severe.
Wide-Scale 1-point prevalence research of pneumonia beginning in the intensive care unit was undertaken on April 29, 1992, in one thousand four thousand and seventeen intensive care units. Accumulation of ten thousand and thirty-eight patients was examined: two thousand and sixty-four (twenty-one percent) had intensive care unit gotten infections, including pneumonia in nine hundred and sixty-seven (forty-seven percent) patients, for a general nosocomial pneumonia prevalence of ten percent. In that research, regression analysis for the logistic recognized MV as one of the seven factors of risk for the intensive care unit –acquired infections. Another wide-scale research, undertaken in one hundred and seven intensive care units showed a crude rate of pneumonia of nine percent, in that research, Mechanical ventilator was linked with a three-fold greater threat of advancing VIP than that examined by for non-ventilated patients. On the grounds of their assessments of general rates of nosocomial pneumonia, Roup and Cross-reported ten-fold greater occurrences
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The current randomized clinical trial was intended to implement and design a protocol for oral care and compare the results of two diverse concentrations of chlorhexidine on minimizing VAP and oropharyngeal colonization among hospitalized patients in the intensive care units of Shahid Rajaee and Nemazee hospitals. This research was registered in the Iranian Registry of Clinical Trials and commended by the Ethics Committee of Shiraz University of Medical Sciences. The criteria of inclusion of the research comprised patients aged eighteen years or above, being under mechanical ventilation for at least forty-eight hours and not suffering from inflammation of the oral mucosa or trauma to the mouth. Others include not having a history of allergy to chlorhexidine, not suffering from burn damages, not having immune disorders caused by illness or medication not being pregnant, not suffering from burn damages and being admitted to the ICU for the first time. Admission of patients was because of surgery, trauma, medical, neurological, or neurosurgical challenges. The projected occurrence of VAP in the ICUs was about fifteen to twenty-two per one thousand days of mechanical ventilation. Primarily, written enlightened consent was gotten from every patient’s legal or relative guardian (due to the patient’s consciousness that is low level). The patients were then erratically assigned to two groups of 0.2 percent and 0.2 percent chlorhexidine based on a computer-generated table of randomization. Patients, who had noticeable aspiration, were identified with thrombocytopenia and likelihood of bleeding because of oral care, or had globally normalized ratios above two were exempted from the research.
The occurrence of VAP occurrence of VAP was examined by Clinical Pneumonia Infection Score (CPIS). We also contemplate the adjustment in antibiotic therapy by intensivists at ICUs. The Beck of mucosal-plaque and oral assessment scale was utilized to assess the oral cavity status. Moreover, tracheal and oropharyngeal colonization were examined by semi-quantitative culture APACHE IV was utilized to examine the gravity of the disease during the first twenty-four-hour of admission in Intensive Care Units. This trial addressed a focused issue of oral care ventilated patients in intensive care units. The assignment of patients to treatments was randomized. The practitioners conducted random patient treatment and the allocation sequence was not hidden from patients and researchers. Health workers, patients, and study personnel were not blind to treatment. All the groups were involved in the treatment of the disease. In the beginning, the researcher looked at all guidelines and protocols associated with oral care from 2003 onward. Then, numerous meetings of the team were held with an intensivist, a specialist in microbiology, two faculty members from the School of Nursing, a periodontal disease specialist, an infectious disease specialist, two ICU nurses, a clinical pharmacist, and ICU and infection control supervisors.
In the subsequent stage, a dental assistant trained the researcher in the utilization of the oral assessment tool. The researcher for five patients and in the presence of the assistant upon arrival undertook oral care and oral assessment. The patient’s information on demography was gathered through interviews with the patient’s medical and families’ records. The researcher finalized the checklist based on CPIS by examining the flowsheets of the patient with the collaboration. In instances where the accumulated CPIS monia, the patient’s outcomes of the tracheal culture were assessed, in case of positive culture outcomes, the patient was exempted from the research. non-intubated patients allowed in the intensive care unit who required mechanical and intubation ventilation for more than forty-eight were also researched. As soon as admission to the intensive care unit, a culture of the oropharyngeal secretions was taken after, suction o the throat utilizing a sterile applicator that was taken from the laboratory. A tracheal tube culture was also obtained through the aspiration of the tracheal tube and the BAL tube. The two samples were conserved in normal saline and sent to the laboratory. The samples of the tracheal were cultured on the EMB, Chocolate, Blood, and Thioglycollate Agar in the laboratory and were incubated for twenty-four hours under thirty-seven degrees centigrade. In instances of growth of microorganism spotted with particular biochemical tests after twenty-four-hour of incubation at thirty-seven degrees centigrade, the type of bacteria was ascertained. In case of growth of microorganisms, the samples were reincubated and the type of the microorganism was established utilizing a table.
The investigator gathered the information of the patient utilizing the checklist of CPIS daily and for instance, their scores were above or equal to 0.6 a chest X-ray was taken (with regards to the opinion of the appropriate physician). Furthermore, a tracheal tube secretions culture was forwarded to the laboratory a definite diagnosis. Oral care examination and protocol of the patients for the incidence of VAP were conducted until forty-eight hours after the exclusion of the tracheal tube, detection of obvious aspiration, the occurrence of pneumonia, discharge from the hospital, allergic reactions to chlorhexidine solution, death or twenty-eight days. In the current research, the result measures comprised of duration of mechanical ventilation (days), length of ICU stay, mortality rate in the ICU, ventilator free-days at day twenty eight, the consequence of oral rinse with 0.2 percent and two percent chlorhexidine on the rates VAP and oropharyngeal colonization, and undesirable effects of chlorhexidine (Nieszkowska et al. 2015). The information was inputted into SPSS statistical software, version nineteen and examined utilizing the chi-square test, Mann –Whitney U test and the t-test. A figure of p less than 0.05 was contemplated to be significant statistically. The information was presented as mean plus or minus Standard deviation or interquartile range and median. At the time of the 5-month research period, four hundred and fourteen patients were admitted to the wards under research; however, two hundred and ninety-seven were exempted
Minimizing VAP through oral care is key to prevent the increase of microorganisms that are resistant to an antibiotic. In the current research, two percent chlorhexidine was selected since prior research demonstrated that this concentration was more useful compared to other concentrations in a patient that have a high threat patients and demonstrated good activity in opposition to multi-drug defiant bacteria in the environment of the laboratory. The current research demonstrated that the greater concentration of chlorhexidine (two percent) was useful in minimizing the occurrence of VAP. These results are constant with those of Koeman, Azab, and Tantipong. Tantipong conveyed that the occurrence of VAP was 4.9 percent in the chlorhexidine group and 11.4 percent in the saline group. Additionally, Koeman stated that the occurrence of VAP in chlorhexidine, placebo, and chlorhexidine classes was ten percent (n=13), eighteen percent (n = 23), and thirteen percent (n=16), correspondingly. The outcomes demonstrated that two percent chlorhexidine was more efficient than 0.2 chlorhexidine against both gram-negative and gram-positive bacteria (Scannapieco. 2016). Nevertheless, two percent of chlorhexidine was less efficient in opposition to Acinetobacter. This was ascribed to the organism’s drug resistance and prevalence. The outcomes are similar to those of Tantipong and Koeman. The mixture of two percent chlorhexidine and two percent chlorhexidine-colistin were similarly efficient in minimizing oropharyngeal gram-positive colonies. Nevertheless, the mixture of chlorhexidine-colistin was more efficient in gram-negative microorganism in contrast with chlorhexidine on its own (p < 0.001). In the research by Tantipong, colonization of oropharyngeal with gram-negative bacilli was either delayed or reduced in patients who had gotten chlorhexidine two percent. In that research, more than sixty percent of patients who had gotten oropharyngeal colonization that is gram-negative that was associated with underneath patients and diseases preceding hospitalizations. Correspondingly, Kusahara and Scannapieco demonstrated that chlorhexidine did not minimize the accumulated number of gram-negative microorganisms. The results of the current research demonstrated that oropharyngeal pathogens were comparable to pulmonary pathogens in VAP patients (Grap et al. 2013). Moreover, pathogens of VAP by this time was present in the tract of oropharyngeal. Treloar stated that 37.5 percent of oropharyngeal samples from tracheal tube patients had comparable microorganisms to samples of tracheal. However, disparities in the forms of microorganisms segregated from samples in the research might consequence from disparities in the forms of the prescribed antibiotic, periods, and concentration of antibiotics, research methodologies and prevalence rates of bacteria.
The present research disclosed that reversible and mild oral mucosa irritation took place in the two groups, and discoloration of the teeth took place in the 2 percent group of chlorhexidine (Munro & Grap. 2014). Nevertheless, oral mucosa inflammation was minimized following the gentle cleaning of the mucosa of the oropharyngeal. Therefore, appropriate cleaning of the teeth before utilizing chlorhexidine could reduce its adverse effects and increase its effectiveness. In the research by Tantipong reversible and mild inflammation of oral mucosa was detected in ten patients which represent 9.8 percent of the chlorhexidine group and in one patient 0.9 percent of the regular group that is saline. Nonetheless, this inflammation was minimized after the nurses were directed to moderately clean the mucosa of the oropharyngeal. In the research by Koeman, tongue edema was witnessed in the chlorhexidine –colistin group on the 2nd day. In divergence, it was reported by Bellissimo-Rodriguez no stern effects that are adverse, even though three patients in the group of the experiment and five in the group of placebo protested concerning the solution’s unfriendly taste.
Comparable to the research by Tantipong, the present research demonstrated that two percent of chlorhexidine did not result in more hostile consequences in comparison to 0.2 chlorhexidine. Thus, in prospective research, the unfavorable outcomes of two percent chlorhexidine have to be examined under the supervision of the dentist. Even though both the groups in the current research were not substantially diverse in terms of duration of mechanical ventilation, length of the stay in ICU, and the rate of mortality, all this results reduced in the two percent group of chlorhexidine (Mori et al. 2016). This result conforms with those of most research undertaken on the matter. The disparity between the outcome of the current research and those of others might be credited to disparities in methods and protocols of VAP prevention, place and time of intervention, treatment methods, populations under scrutiny and protocols for the discharge of patient’s. In the present research, intensivists and laboratory endorsing the analysis of VAP did not know concerning the intrusions. Furthermore, the researchers undertook continuous oral care based on the protocol (Feider et al. 2010). This intensified the research’ preciseness. Contrarily, even though uninformed of the assignments of the group the researcher was liable for finalizing the checklist for CPI, examining the mouths of the patients, doing oral care and bias might have taken place.
Based on the research by Wallace, the description of the CDC should be utilized for surveillance, since it may miscalculate the occurrence of the VAP. CPIs can also over-approximate the occurrence of the VAP. In the present research, tracheal and oropharyngeal cultures were semi-quantitative. Due to the low costs and the convenience, semi-quantitative reports of culture are usual in the VAP analysis, nevertheless, its specificity and sensitivity are not as important as those of a culture report that is quantitative are.
In the current research, there was also challenges disturbing appropriate oral care because of the existence of oropharyngeal airways and tracheal tubes and some restlessness. As well, numerous elements, for instance, diverse interventions and sample size that were out of control of the investigator disturbed the VAP development. These could have led to the drawbacks in assessing the benefits of oral care.
In conclusion, the results of the present research demonstrate that oral discontagion is greatly efficient with two percent chlorhexidine than with 0.2 percent chlorhexidine in minimizing the incidence of VAP and the oropharyngeal colonization (Grap et al. 2014). These results may form the ground for continued clinical use and trials of the two percent in such instances.
- Berry, A. M., Davidson, P. M., Masters, J., & Rolls, K. (2017). Systematic literature review of oral hygiene practices for intensive care patients receiving mechanical ventilation. American Journal of Critical Care, 16(6), 552-562.
- Feider, L. L., Mitchell, P., & Bridges, E. (2010). Oral care practices for orally intubated critically ill adults. American Journal of Critical Care, 19(2), 175-183.
- Grap, M. J., Munro, C. L., Ashtiani, B., & Bryant, S. (2013). Oral care interventions in critical care: frequency and documentation. American Journal of Critical Care, 12(2), 113-118.
- Grap, M. J., Munro, C. L., Elswick Jr, R. K., Sessler, C. N., & Ward, K. R. (2014). Duration of action of a single, early oral application of chlorhexidine on oral microbial flora in mechanically ventilated patients: a pilot study. Heart & Lung: The Journal of Acute and Critical Care, 33(2), 83-91.
- Mori, H., Hirasawa, H., Oda, S., Shiga, H., Matsuda, K., & Nakamura, M. (2016). Oral care reduces the incidence of ventilator-associated pneumonia in ICU populations. Intensive care medicine, 32(2), 230-236.
- Scannapieco, F. A. (2016). Pneumonia in nonambulatory patients: the role of oral bacteria and oral hygiene. The Journal of the American Dental Association, 137, S21-S25.
- Munro, C. L., & Grap, M. J. (2014). Oral health and care in the intensive care unit: state of the science. American Journal of critical care, 13(1), 25-34.
- Nieszkowska, A., Combes, A., Luyt, C. E., Ksibi, H., Trouillet, J. L., Gibert, C., & Chastre, J. (2015). Impact of tracheotomy on sedative administration, sedation level, and comfort of mechanically ventilated intensive care unit patients. Critical care medicine, 33(11), 2527-2533.
- Woodrow, P. (2011). Intensive care nursing: a framework for practice. Routledge.
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