Oral Care: Vital to VAP Prevention

Ventilator-associated pneumonia (VAP) is the second-most common healthcare infection. As defined by the Institute for Healthcare Improvement (IHI), VAP is an airway infection that must develop more than 48 hours after the patient was intubated. The definition of VAP is simple, but the consequences are not. The financial strife VAP causes to medical systems is huge, and the cost to family’s who lose loved ones is enormous and cannot be measured.

According to Suzanne Pear, RN, PhD, CIC, associate director for infection prevention practices at Kimberly-Clark Health Care:

– 1 out of 4 ICU infections is VAP

– 90 percent of the pneumonias in intensive care units (ICUs) are VAP

– VAP affects 9 percent to 27 percent of ventilated patients

– VAP increases need for ventilator support and ICU stay by four to six days

– VAP costs $20,000 to $40,000 per episode

Proper oral hygiene is very important in the prevention of VAP. Pear discussed this matter with Infection Control Today and offered applicable strategies for healthcare teams.

ICT: What are the most commonly ignored steps in the VAP-prevention oral care process?

Pear: There are a number of components of oral care that may not be provided with the frequency and thoroughness that they should. Comprehensive oral hygiene begins with an admission assessment of the patient’s mouth, and self-care deficits as a baseline to gage the extent of needed interventions, and from which to measure progress.1

If oral health issues are not a routine part of the admission process, it is doubtful that it would consistently be part of the patient care plan. I wonder how many healthcare facilities incorporate oral health assessments upon admission and regularly thereafter as part of basic nursing care for all patients.

One other thing that I am particularly concerned about is the routine use of antiseptic rinses — such as chlorhexidine gluconate (CHG) 0.12 percent — possibly taking the place of, instead of as an adjunct to, mechanical biofilm debridement and cleaning of teeth, tongue, and oral mucus membranes, using a soft toothbrush, and frequent oral moisture replacement.2,3 A couple of meta-analyses have concluded that while CHG rinse does reduce VAP incidence, it does not shorten patient ventilator duration, or decrease mortality.4,5 If used, CHG should be part of a more comprehensive oral care bundle, not be its sole component, as CHG has not been found to be effective on gram negative bacteria,6 a major cause of late-onset VAP.7

ICT: How can oral care oversight be mitigated?

Pear: Education is often the missing component. Because oral care is considered basic care, it is rarely included in in-service training or continuing education programs. Many nurses may have forgotten or never learned about the oral care/pneumonia relationship, and continue to consider oral care as comfort care, rather than critical care. Not all nurses thoroughly understand the clinical connection between the patient’s normal oral flora, subsequent contamination with Gram-negative pathogens, biofilm and plaque formation, xerostomia and mucositis development, and the increased risk for hospital-acquired pneumonia (HAP) including VAP.8,9

Nurses often have to prioritize their care because of patient acuity and workload. If they have not connected the clinical dots between oral care and HAP/VAP prevention, then oral care may not be placed high on the “have-to-do” list, and not be performed as frequently and thoroughly as it needs to be to prevent negative changes in the patient’s mouth.10

As Wayne Halstom, president of the Canadian Dental Association, so aptly stated, we need to “put the mouth back in the body ...because it is the window to many body systems,”11 and, in the case of pneumonia, the portal as well. Educating nurses, respiratory therapists, and other clinicians about the pathway to HAP/VAP and oral care’s role in prevention will go a long way toward improving the quality of oral care provided to all patients.

ICT: VAP seems to be getting more attention than in years past. However, being that it is the most deadly HAI worldwide, do you think the topic deserves more attention, and if so, to what degree?

Pear: [IHI’s] 100,000 Lives, and 5 Million Lives campaigns, have helped us all become more aware of the morbidity and mortality associated with healthcare-associated infections (HAIs), including VAP, and the importance of using evidence-based bundles for prevention.12

However, the need for comprehensive oral care is not always recognized and included in VAP prevention bundles, not to mention of what comprehensive oral care should consist. In some ways, the attention VAP has received may have overshadowed the fact that only 40 percent of HAP occurs to ventilated patients, and that the majority of HAP occurs to patients who have not been mechanically ventilated.13 Certainly, ventilator patients are at highest risk for HAP due to the endotracheal tube and ventilator exposure, but all hospitalized patients are at risk for HAP and need preventive oral care.


1. Garcia R. A review of the possible role of oral and dental colonization on the occurrence of health care-associated pneumonia: underappreciated risk and a call for interventions. Am J Infect Control 2005;33(9):527-541.

2. Bopp M, Darby M, Loftin KC, Broscious S. Effects of daily oral care with 0.12% chlorhexidine gluconate and a standard oral care protocol on the development of nosocomial pneumonia in intubated patients: a pilot study. J Dent Hyg 2006;80(3):9.

3. Laux L, Herbert C. Decreasing ventilator-associated pneumonia: getting on board. Crit Care Nurs Q 2006;29(3):253-258.

4. Chan EY, Ruest A, Meade MO, Cook DJ. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ 2007;334(7599):889.

5. Pineda LA, Saliba RG, El Solh AA. Effect of oral decontamination with chlorhexidine on the incidence of nosocomial pneumonia: a meta-analysis. Crit Care 2006;10(1):R35.

6. Raybould TP, Carpenter AD, Ferretti GA, Brown AT, Lillich TT, Henslee J. Emergence of gram-negative bacilli in the mouths of bone marrow transplant recipients using chlorhexidine mouthrinse. Oncol Nurs Forum 1994;21(4):691-696.

7. Kollef MH. The prevention of ventilator-associated pneumonia. N Engl J Med 1999;340(8):627-634.

8. Bagg J, MacFarlane IR, Poxton R, Smith AJ. The oral microflora and dental plaque. Essentials of Microbiology for Dental Students. 2006;2nd ed.219-232.

9. Dennesen P, van d, V, Vlasveld M, Lokker L, Ramsay G, Kessels A et al. Inadequate salivary flow and poor oral mucosal status in intubated intensive care unit patients. Crit Care Med 2003;31(3):781-786.

10. Grap MJ, Munro CL, Ashtiani B, Bryant S. Oral care interventions in critical care: frequency and documentation. Am J Crit Care 2003;12(2):113-118.

11. Halstrom W. Let’s put the mouth back in the body. CMAJ 2007;176(2):145-.

12. Institute for Healthcare Improvement Protecting 5 Million Lives From Harm Campaign. Getting Started Kit: Preventing Ventilator-Associated Pneumonia How-to Guide. (8-1-2007). Online. Retrieved from www.ihi.org

13. Klevens RM, Edwards JR, Richards CL, Jr., Horan TC, Gaynes RP, Pollock DA et al. Estimating healthcare-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep 2007;122(2):160-166.

Case Study: The Impact of Systematic Assessment and Early Volume Expansion and Secretion Clearance Intervention on Ventilator Associated Pneumonia

By Michael J Hewitt, RRT-NPS, RCP, FAARC, and Michael H Bernstein, RRT, RCP

Background: Ventilator-associated pneumonia (VAP) is a common problem in the intensive care unit (ICU) and accounts for significant morbidity and mortality as well as an increase in the cost of care. Numerous strategies have been implemented to decrease the incidence and the impact of VAP. Though many of these interventions and strategies have resulted in improvement in pneumonia rates, VAP remains a significant problem. In April 2006, the Respiratory Care Services Department at Memorial Hermann Hospital in Texas implemented a revised policy and procedure calling for specific assessments of cough, inspiratory capacity, oxygenation, secretions and patient mobility as well as available chest X-rays in all ICU patients. The purpose of this change in policy was to facilitate early intervention with volume expansion and secretion clearance in patients determined to be at risk for VAP. To our knowledge, a prophylactic approach to providing volume expansion and secretion clearance has not been systematically evaluated and reported.

Methods: A retrospective review of infection control records was conducted to determine the ICU census, the number of number of mechanically ventilated patients, the number of ventilator days and the number of VAPs that occurred in six ICUs between April and December for three consecutive years beginning two years prior to the change in protocol. The standard calculation of VAP rate (VAP per 1,000 ventilator days) was completed for each month in the analysis period. Data were analyzed using a paired t-test comparing monthly VAP rates in consecutive years.

Results: A significant difference in VAP rate (p < 0.01) was observed in the nine-month period following the change in protocol. No difference was observed in the two years prior to the change.

Conclusions: A significant reduction in overall VAP rate was achieved in the period following the change in policy and procedure to facilitate systematic patient assessment and early intervention with volume expansion and secretion clearance therapy. Additional studies are needed to evaluate the role of specific lung expansion and secretion clearance therapies in reducing VAP.