Oral Health and Mechanically Ventilated Critically Ill Adults

1. Oral Health and Mechanically Ventilated Critically Ill Adults Deborah J. Jones PhD, MSN, RN June M. Sadowsky, DDS, MPH Donna Warren-Morris, RDH, Med Bela Patel, MD, DABSM, FCCP

2. Outcomes • Define components of oral health in mechanically ventilated adults • Recognizecomplications from poor oral health • Promotegood oral health through the delivery of appropriate oral hygiene • Describe the state of the science regarding oral care practices in mechanically ventilated adults • Assess and deliver evidence-basedoral care • Recognize triggers to consult other healthcare providers

3. Oral and Systemic Health Link • Diabetes • Cardiovascular disease • Respiratory disease • Stroke • Premature birth

4. MechanicallyVentilatedPatients • Characteristics: • Vulnerable to systemic infections due to disruption in host defenses like mucociliary clearance, cytokine production and salivary volume • Dependent on healthcare providers to provide oral care • Havethe potential for bacterial load to be increased due to lack of consistent oral care regimen • Develop oropharyngeal colonization with pathogenic organisms within the first 24 hours of intubation

5. ReasonsforLack of Oral Care Regimen • Nurses receive little to no formal training • Lack of priority, perceived need or time • Patient’s inability to participate or request • Medical conditions and equipment interfere • Fear of endotracheal tube dislodgement • Lack of published randomized controlled trials examining the best practices for oral care in critically ill patients

6. Complications of Poor Oral Hygiene • Oropharyngeal colonization linked to the development of ventilator-associated pneumonia (VAP) • Remains the most deadly hospital acquired infection in intensive care units (8-15% estimated mortality rate) • Increased dental plaque accumulation and oral inflammation • Disruption of tissue integrity • Further complicationof pre-existing oral conditions

7. Rationale for Good Oral Hygiene • Oral care protocols (usually included in VAP bundles) show decrease in incidence of VAP • Oral care reflects preventive measures aimed at reducing pathogenic organisms, and promoting holistic patient care • Patient comfort • Prevention of halitosis

8. Although…to date • No gold standard oral care protocol with optimal frequency or products have been well established; several organizations have published recommendations to guide oral care of the mechanically ventilated patient • Institute for Healthcare Improvement (IHI) • American Association of Critical-Care Nurses (AACN) • Centers for Disease Control and Prevention (CDC)

9. Institute for Healthcare Improvement (IHI) Recommendation • Daily oral care with 0.12% chlorhexidine • Develop a comprehensive oral care process that includes the use of 0.12% chlorhexidine oral rinse • Schedule chlorhexidine as a medication, which then provides a reminder for the RN and triggers oral care process delivery • Educate the RN staff about the rationale supporting good oral hygiene and its potential benefit in reducing ventilator-associated pneumonia

10. American Association of Critical-Care Nurses (AACN) Recommendation • Develop and implement a comprehensive oral hygiene program for patients in critical care and acute care settings who are at high risk for ventilator-associated pneumonia (VAP) • Brush teeth, gums and tongue at least twice a day using a soft pediatric or adult toothbrush • Provide oral moisturizing to oral mucosa and lips every 2 to 4 hours • Use an oral chlorhexidine gluconate (0.12%) rinse twice a day during the perioperative period for adult patients who undergo cardiac surgery • Routine use of oral chlorhexidine gluconate (0.12%) in other populations is not recommended at this time

11. Centers for Disease Control and Prevention(CDC) Recommendation • Perform regular oral care with an antiseptic solution • The optimal frequency for oral care is unresolved

12. Oral Care Protocol for Intubated Patients • Follow standard precautions and infection prevention procedures including asepsis, gloves, a mask, and eye protection (as needed) • Obtain all necessary equipment prior to beginning oral care • Explain to the patient what you are planning to do so they are not startled • Note the position and placement of the endotracheal tube prior to oral care

13. Assessment and Oral Cancer Screening • Assess all areas of the mouth for any signs of trauma, inflammation, bleeding, ulcerations or suppuration • Redness, swelling, exudate, tenderness and ulcerations are signs of infections that should be further assessed to rule out oral cancer.

14. Assessment • Slight bleeding of the gums is common if homecare has been deficient. With good oral hygiene, bleeding will cease in a few days of adequate care • Xerostomia (dry mouth) • Common in intubated patients

15. Assessment • Assessment of the oral cavity should include all surfaces of the mouth, carefully inspecting for abnormalities. • When inspecting the intubated patient be careful to observe the position and placement of the endotracheal tube.

16. Suctioning • Prior to beginning the oral care protocol and immediately following oral care it is important to suction the patients mouth and the subglottic space in order to prevent aspiration of pooled secretions • Suctioning should be repeated as needed during oral care

17. Tooth Brushing • The teeth and mouth should be cleaned at least twice a day • Use a soft bristle toothbrush with a small head (pediatric size) for better access • A smear of a sodium fluoride toothpaste • Do not use a sodium monofluorophosphate fluoride if chlorhexidine gluconate is to be used since the two are not compatible

18. Tooth Brushing Technique • Use a systematic sequence • Angle the bristles toward the gumline and brush with gentle pressure in small circular strokes on each tooth. The bristles of the toothbrush will extend underneath the gumline if adapted correctly • Facial surfaces of all maxillary teeth, then linguals, then repeat on the mandibular teeth. Brush the occlusal or biting/chewing surfaces last with a scrub stroke • Brush the tongue with long outward sweeping strokes Gently move the tube from side to side as necessary for access

19. Tooth Brushing • Teeth should be brushed in a circular motion. • Teeth of mechanically ventilated adults should be brushed using the same technique with the exception of the following modifications: • observe the placement of the endotracheal tube by the markings on the tube before and during oral care, suction the oral cavity frequently and suction the subglottic space following oral care to prevent aspiration . A mouth prop, tongue blade or bite block may be used to hold the mouth open for unresponsive patients

20. Antiseptic/microbial application • Antimicrobial • Chlorhexidinegluconate (0.12%) • Recommended with little side effects (tooth staining) • Swab the endotracheal tube as well to prevent bacterial biofilm formation • Swab twice a day with no rinsing afterward for a minimum of 30 minutes

21. Moisturizing the Mouth • Every two hours, moisturize the lips, mucosa, tongue and corners of the mouth with a water-based moisturizer • Petroleum based products should be avoided as they can dry tissues and are harmful if aspirated

22. Detrimental Practices. • Foam Swabs do not remove plaque bacteria as well as a toothbrush and should not be substituted • Hydrogen peroxide is acidic and can burn soft tissues if not diluted enough and may also cause black hairy tongue • Lemon glycerin swabs are very acidic and can cause soft tissue burns and decalcify the teeth • Petroleum jelly dries out oral tissues and can also degrade latex gloves

23. Special Considerations • Neuroscience patients • Intracranial pressure • Edentulous patients • Brush the gums gently • Facial trauma patients • Modify tooth brushing

24. Role of Healthcare Providers • Nurses • Patient and other healthcare provider education • Daily assessment of oral cavity • Delivery and documentation of oral care • Consultation as needed • Respiratory Therapists • Further assessment around endotracheal tube holders • Maintenance of closed ventilation circuit

25. Role of Healthcare Providers • Physicians/Nurse Practitioners/Physician Assistants • Oral assessments • Routine/standard order of antimicrobial rinse • Collaboration with dental professionals • Patient education • Dental Hygienists/Dentists • Referral follow-up • Collaboration with critical care clinicians

26. References • Berra L, Sampson J, Wiener-Kronish J. Pseudomonas aeruginosa: Acute lung injury or ventilator-associated pneumonia? Minerva Anestesiol. 2010;76(10):824-832. • NseirS, Di Pompeo C, Pronnier P, et al. Nosocomial tracheobronchitis in mechanically ventilated patients: Incidence, aetiology and outcome. EurRespir J. 2002;20(6):1483-1489. • Craven DE, Driks MR. Nosocomial pneumonia in the intubated patient. SeminRespir Infect. 1987;2(1):20-33. • Torres A, El-Ebiary M, Gonzalez J, et al. Gastric and pharyngeal flora in nosocomial pneumonia acquired during mechanical ventilation. Am Rev Respir Dis. 1993;148(2):352-357. • Greene R, Thompson S, Jantsch HS, et al. Detection of pooled secretions above endotracheal-tube cuffs: Value of plain radiographs in sheep cadavers and patients. Am J Roentgenol. 1994;163(6):1333-1337.

27. References • Jones DJ, Munro CL, Grap MJ. Natural history of dental plaque accumulation in mechanically ventilated adults: A descriptive correlational study. Intensive Crit Care Nurs. 2011;27(6):299-304. doi: 10.1016/j.iccn.2011.08.005. • Munro CL, Grap MJ, Jones DJ, McClish DK, Sessler CN. Chlorhexidine, toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults. American Journal of Critical Care. 2009;18(5):428-437. Accessed 25 February 2011. • FourrierF, Duvivier B, Boutigny H, Roussel-Delvallez M, Chopin C. Colonization of dental plaque: A source of nosocomial infections in intensive care unit patients. Crit Care Med. 1998;26(2):301-308. • Barkvoll P,Rölla G,Bellagamba S. Interaction between chlorhexidinedigluconate and sodium monofluorophosphate in vitro. Scand J Dent Res. 1988 Feb;96(1):30-3. • Abidia RF. Oral Care in the Intensive Care Unit: A Review. J Contemp Dent Pract2007 January;(8)1:076-082. http://vilarmoreiranunes.files.wordpress.com/2009/11/abidia.pdf

28. References • MDCT Evaluation of Foreign Bodies and Liquid Aspiration Pneumonia in Adults. http://www.ajronline.org/content/190/4/907.full.pdf+html • Garrouste-Orgeas M, Chevret S, Arlet G, et al. Oropharyngeal or gastric colonization and nosocomial pneumonia in adult intensive care unit patients. A prospective study based on genomic DNA analysis. Am J RespirCrit Care Med. 1997;156(5):1647-1655. • Chastre J. Ventilator-associated pneumonia: What is new? Surg Infect (Larchmt). 2006;7 Suppl 2:S81-5. doi: 10.1089/sur.2006.7.s2-81. • AlbertosR, Caralt B, Rello J. Ventilator-associated pneumonia management in critical illness. CurrOpinGastroenterol. 2011;27(2):160-166. doi: 10.1097/MOG.0b013e32834373b1. • Ashraf M, Ostrosky-Zeichner L. Ventilator-associated pneumonia: A review. HospPract (Minneap). 2012;40(1):93-105. doi: 10.3810/hp.2012.02.950

29. References • Martin B. AACN practice alert: Oral care for patients at risk for ventilator-associated pneumonia. http://www.aacn.org/WD/Practice/Docs/PracticeAlerts/oral%20care%2004-2010%20final.pdf. Updated 2010. • Chan EY, Ruest A, Meade MO, Cook DJ. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: Systematic review and meta-analysis. Br Med J. 2007;334(7599):889-893. Accessed 9 March 2011. • Institute for Healthcare Improvement. http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/IndividualChanges/DailyOralCarewithChlorhexidine.htm. Updated Implement the ventilator bundle: Daily oral care with Chlorhexidine.