Effectiveness of Mouthwash

Question: Describe about effectiveness of mouthwash using a chlorhexidine solution in theadults patient in reducing prevalence of ventilator associated pneumonia in the adult Intensive Care Unit? Answer: Background The patients who are critically ill, have been ventilated mechanically for a time longer than 48 hours, have the risk of developing Ventilator-Associated Pneumonia (VAP). It is a hospital acquired infection that develops in patients during the process of treatment within the hospital setting and is not present at the time of admission. The pathogenesis of VAP is actuallywhen bacteria enters into the lower respiratory tracts and overwhelms the patients defenses. The chances of mechanically ventilated patients developing VAP are between 9% and 27% with a high mortality rate where 33-50% of patients acquiring VAP dying. Approximately one-third patients in ICUs receive mechanical ventilation as support therapy. When a chest radiograph of a patient shows a progressive or new infiltrate, cavitations, consolidations, or pleural effusions along with one or all of the following symptoms: change in color or new onset of purulent sputum, increase or reduction in white blood cells, organisms cultured from blood, bronchial brushing, etiological agent isolation by transtracheal aspirate or increase in temperature, VAP can be identified in the patient (Synders, Khondowe and Bell, 2011). The risk factors identified with VAP are: staffs inadequate hand washing, ventilator circuit management practices, antibiotic therapy previously, patients supine positioning without backrest elevation, nasogastric alkalinization or the presence of a nasogastric tube. According to the Institute of Healthcare improvements ventilator bundle, a 30 or more elevation of patients bed head, prophylaxis for deep vein thrombosis and peptic ulcer, sedation vacation, and assessing readiness to extubate may reduce risk of complications with mechanical ventilation (Munro et al., 2009). Oropharyngeal colonization, aspiration, gastric colonization and compromised lung defences are the factors associated with VAP development. The pooling of micro-aspiration of the secretion with bacteria which is above the endotracheal cuff of patients intubated results in the respiratory tract. Chlor-hexidine, a cationic chlorophenyl bis-biguanide which is an antiseptic agent, binds the oral tissues along with subsequently releasing the antiseptic properties slowly enabling long period of anti-bacterial action and hence has been used in mechanically ventilated patients as an oral disinfectant (Synders, Khondowe and Bell, 2011). Inclusion Criteria Studies Randomized controlled studies that uses the comparative groups, published in English in order to investigate the oral chlorhexidine like a decontaminant in VAP prevention in critically ill, mechanically ventilated adult patients were included. Interventions Studies that analyzed the usage of oral chlorhexidine against the tooth brushing, placebo and/or oral care interventions comparators to decrease in VAP in critically ill, and in patients who are mechanically ventilated, were focused. Participants Study participants had to be mechanically ventilated, aged 18 years or older, critically ill and admitted to the ICU. Outcome Measures To the measure the reduction in prevalence of VAP in those who are mechanically ventilated as well as critically ill ICU patients was the primary outcome interest. Exclusion Criteria Studies that were excluded included the research not investigating the VAP even if chlorhexidine was used, study of patients below 18 years, patients with known allergy or hypersensitivity to chlorhexidine, edentulous patients, extubated patients and patients already clinically diagnosed with pneumonia at the start of study. Incomplete study or data within studies included, unavailability of full-text articles and high attrition rates are the exclusion criteria for this review. Methodology Search Strategy An extensive search was undertaken for literature of published clinical trials that report prevention of Ventilator-Associated Pneumonia with the use of chlorhexidine in case of oral care. Electronic databases searched to identify sources for relevant studies included MEDLINE, NCBI, and the University of Adelaide libraries. The reference list of articles and summaries were examined. Search terms such as Ventilator-Associated Pneumonia,chlorhexidine, mechanically ventilated patients, oral care,hospital acquired pneumonia, oral hygiene and mouthwash were used for the search. Data Collection The titles of the articles obtained by employing the search terms mentioned were considered and those that were relevant to the study on hand were identified. The articles were retrieved and reviewed considering the criteria mentioned for inclusion. The relevant articles were reviewed and analyzed independently to determine the quality of methodology. The methodological quality was assessed using quality assessment form freely available in Cochrane website. The external and internal validities of the RCTs were addressed by the assessment. Data Extraction To collect information from relevant studies, a data extraction tool was employed. An initial study determined the practicality of the study, range of search, testing as well as extraction tools. The tool included baseline characteristics such as citation, study id, setting, methodology, population, and sample size. Treatment effect measures The treatment effect measurement choice was the usage of the random effects model which is Mantel Haenszel method, risk ratio with 95% confidence intervals for weighted mean difference and intervals for dichotomous data. The value set for p was 0.05. Missing Data All studies included randomized the patients to a treatment or a group that can control it. Wherever pertinent data were missing from the trials included, it was called the absence of the results that add value to the study. Data Synthesis A statistical analysis software package, Review Manager was used for analysis where all the data was entered. The Cochrane Collaboration website offers the software for free. The included studies differed from each other with regard to age, trial settings, methods of treatment etc. The use of the random effects model allows the distribution of effects, and provides a combined estimate and average of value distribution. The effects of interventions were demonstrated using Forest plots. Subgroup analysis After identifying clinical diversity, subgroup analysis was conducted with respect to the varying concentrations of chlorhexidine used. Data was entered into review manager to obtain sensitivity analysis. Validity, Reliability and Quality These assessments of the study data was confirmed by initializing and employing a standardized form of data extraction from the Cochrane Collaboration. Results Using the random effects model, a pooled risk ratio of 0.64 was obtained. The possibility of critically ill, mechanically ventilated patients who acquire VAP while using chlorhexidine was found to be 36% less likely than in the controls. The result was consistent with a previous meta-analysis done by Chelbicki and Safdar in 2007 yielding a ratio of 0.70. Chan et al, in 2007 conducted a trial on effect of antiseptic oral decontamination on VAP and the results showed a significant reduction in with a ratio of 0.56. 2% chlorhexidine demonstrated a significant effect on VAP incidence. Patients with more underlying co-morbidities and multiple medical problems have a period of ventilation and intubation exceeding 24 to 48 hours and are found to be more prone to developing VAP and a host of other infections (Chan et al., 2007). Critical analysis Ironically, the use of chlorhexidine 0.12% or 2% was not found to reduce VAP occurrence. Therefore results obtained supported only the use of 2% chlorhexidine for reducing VAP in critically ill patients. Also, all studies except one reported blinding of assessors. This shows that bias could have been involved in studies that never reported blinding if blinding of assessors did not happen. The studies showed no effect of chlorhexidine in decreasing the mortality though. Owing to the limited number of trials that were carried out, it can be recommended that more studies need to be carried out on the administration procedure, optimal concentration and dosage of chlorhexidine even though 2% concentration had showed positive results. References 1. Berry, A., Davidson, P., Masters, J. and Rolls, K. (2007). Systematic Literature Review of Oral Hygiene Practices for Intensive Care Patients Receiving Mechanical Ventilation. American Journal of Critical Care, 16(6), pp.552 - 562.2. Chan, E., Ruest, A., Meade, M. and Cook, D. (2007). Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ, 334(7599), pp.889-889.3. Chlebicki, M. and Safdar, N. (2007). Topical chlorhexidine for prevention of ventilator-associated pneumonia: A meta-analysis*. Critical Care Medicine, 35(2), pp.595-602.4. Hillier, B., Wilson, C., Chamberlain, D. and King, L. (2013). Preventing Ventilator-Associated Pneumonia through Oral Care, Product Selection, and Application Method. AACN Advanced Critical Care, 24(1), pp.38-58.5. Khezri, H., Zeydi, A., Firouzian, A., Baradari, A., Mahmoodi, G., Kiabi, F. and Mogaddasifar, I. (2014). The Importance of Oral Hygiene in Prevention of Ventilator-Associ ated Pneumonia (VAP): A Literature Review. International Journal of Caring Sciences, 7(1), pp.12-23.6. Klompas, M., Speck, K., Howell, M., Greene, L. and Berenholtz, S. (2014). Reappraisal of Routine Oral Care with Chlorhexidine Gluconate for Patients Receiving Mechanical Ventilation. JAMA Internal Medicine, 174(5), p.751.7. Munro, C., Grap, M., Jones, D., McClish, D. and Sessler, C. (2009). Chlorhexidine, Toothbrushing, and Preventing Ventilator-Associated Pneumonia in Critically Ill Adults. American Journal of Critical Care, 18(5), pp.428-437.8. Parsons, S., Lee, C., Strickert, D. and Trumpp, M. (2013). Oral Care and Ventilator-Associated Pneumonia. Dimensions of Critical Care Nursing, 32(3), pp.138-145.9. Synders, O., Khondowe, O. and Bell, J. (2011). Oral chlorhexidine in the prevention of ventilatorassociated pneumonia in critically ill adults in the ICU: A systematic review. South African Journal of Critical Care, 27(2), pp.48-56.