Prevention of ventilator associated pneumonia - evidence in oral care

Background: Ventilator-associated pneumonia (VAP) is the most important noso- comial infection in intensive care units (ICUs), with an estimated inci- dence rate of 50% and the major cause of mortality and morbidity in ICUs [1,2]. Inadequate oral care develops an important role in this setting allowing various organisms to flourish in oral cavity and cause infections [1]. Many VAP prevention guidelines include oral care, but they don’t specify its demandings. Objective: The aim of this study is to describe evidence-based VAP prevention oral care in ICU, in terms of products, frequency and technique. Methods Integrative review. Research was conducted on B-on, PUBMED, and RCAAP between 24 and 28 December 2015, including guide- lines and original articles from the last 5 years. We found 256 documents and after analysing their abstract and methodological quality, nine documents were selected. Data were compiled in a chart in terms of grade of evidence, acceptance and applicability. Results: We found inconsistent results regarding the use of an antiseptic solution in oral care, though there were meta-analysis which indi- cated the benefit of chlorhexidine mostly in cardio-thoracic surgi- cal patients [2-4]. We also found evidence that tooth brushing reduces oral bacterial colonization and may reduce VAP when used with chlorhexidine [5,6]. There is no consensus regarding the adequate concentration of chlorhexidine. Some studies, thought, find an association with the use of chlorhexidine 2% and the incidence of Acute Respiratory Distress Syndrome [7]. Because of this potential risk, we do not recommend the use of this type of concentration, as more randomized controlled trials are needed. We found evidence in VAP prevention oral care compris- ing suctioning, tooth and gums wash and rising with 15 mL chlorhexidine 0.12%. This procedure should be performed at least 2 times a day. Secretions removal and moisturization should occur between 2 to 4 times a day [1-9]. Conclusions: This review allowed us to describe the adequate oral care in ICUs in order to potentially reduce VAP. As limitation of this study, we can find the lack of high grade of evidence concerning most recommen- dations. More randomized controlled trials are needed to support the impact of each intervention separately.