Presentation is loading. Please wait.

Presentation is loading. Please wait.

Oral Health and Mechanically Ventilated Critically Ill Adults

Similar presentations


Presentation on theme: "Oral Health and Mechanically Ventilated Critically Ill Adults"— Presentation transcript:

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 This presentation is on the oral health of mechanically ventilated critically ill adults.

2 Outcomes Define components of oral health in mechanically ventilated adults Recognize complications from poor oral health Promote good 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-based oral care Recognize triggers to consult other healthcare providers At the conclusion of this presentation, participants should be able to: Define components of oral health in mechanically ventilated adults Recognize complications from poor oral health Promote good 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-based oral care Recognize triggers to consult other healthcare providers

3 Oral and Systemic Health Link
Diabetes Cardiovascular disease Respiratory disease Stroke Premature birth In the past two decades, studies have demonstrated the link of poor oral health with cardiovascular disease, respiratory disease, diabetes, stroke and premature birth.

4 Mechanically Ventilated Patients
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 Have the 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 Mechanically Ventilated Patients are vulnerable to systemic infections due to disruption in host defenses like mucociliary clearance, cytokine production and salivary volume. They are completely dependent on healthcare providers to provide oral care during the duration of intubation and have the potential for bacterial load to be increased due to the lack of a consistent oral care regimen. Respiratory infections can be caused by anaerobic bacteria such as those that colonize the teeth of patients and individuals who cannot care for their own oral hygiene. When these bacteria mix with saliva, they can be aspirated into the lungs causing infection or pneumonia. Endotracheal tubes act as a reservoir and can carry this bacteria directly to the lungs as well. This oropharyngeal colonization with pathogenic organisms develops within the first 24 hours of intubation.

5 Reasons for Lack 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 Despite the link between oral health and systemic health and the dependence of intubated patients on healthcare providers to provide oral care; comprehensive oral care is often neglected. Possible Reasons for the Lack of an Oral Care Regimen include: The fact that nurses receive little to no formal training, There is a lack of priority for oral care over other seemingly more demanding tasks There is a lack of a perceived need or time by the healthcare provider, The patient’s inability to participate or request oral care is another factor associated with a lack of a consistent regimen, the concept that medical conditions and equipment may interfere with oral care, the fear of endotracheal tube dislodgement, as well as a lack of published randomized controlled trials examining the best practices for oral care in critically ill patients all contribute to inadequate delivery of oral care.

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 complication of pre-existing oral conditions Although there has been progress made in the prevention of ventilator-associated pneumonia or VAP, it still remains a costly and frequent complication of mechanical ventilation. Oropharyngeal colonization plays a major role in the pathogenesis of VAP. The endotracheal tube allows a direct passageway for bacteria to enter the lungs and lower respiratory tract causing infection. Ventilator associated pneumonia is the most deadly hospital acquired infection in patients in the intensive care unit (ICU). Mortality rate attributable of VAP is estimated 8-15%. Other complications of poor oral hygiene in mechanically ventilated adults include: Increased dental plaque accumulation and oral inflammation Disruption of tissue integrity Further complication of 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 Oral health is an important aspect of general health and Oral care protocols have shown a decrease in the incidence of VAP. Oral care in the intubated patient is aimed at preventing and reducing the colonization of pathogenic organisms, promoting holistic patient care, establishing and maintaining patient comfort and 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) 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. The Institute for Healthcare Improvement (IHI) The American Association of Critical-Care Nurses (AACN) The 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 The Institute for Healthcare Improvement recommends comprehensive oral care as a part of VAP prevention protocols. This oral care includes daily oral care with 0.12 chlorhexidine. Antimicrobial products such as Chlorhexidine mouth rinse offer supplemental benefits to brushing. These products alone without mechanical cleansing are insufficient to remove bacterial biofilm and prevent oral disease. A comprehensive oral care process that includes the use of 0.12% chlorhexidine oral rinse can be implemented and chlorhexidine can be scheduled as a medication, which will then provide a reminder for the RN and triggers oral care process delivery. The RN staff should be educated about the rationale supporting good oral hygiene and its potential benefit in reducing ventilator-associated pneumonia to ensure adoption of oral care regimens.

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

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 The CDC recommends the performance of regular oral care with an antiseptic solution although the optimal frequency for oral care is unresolved although oral studies have shown that bacterial biofilm should be removed daily.

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 In delivering oral care to the intubated patient, healthcare providers should 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 and 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. Assessment of the intubated patient should mimic assessment of a healthy person and include 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 and referred as appropriate to dental professionals 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 Oral health status on admission to the hospital can be an indicator of pre-hospitalized oral health status. There may be slight bleeding of the gums if home care has been deficient. This bleeding will cease in a few days of adequate oral care. Xerostomia or dry mouth is common in intubated patients and the lack of saliva can exacerbate the adherence of bacteria to the tooth surfaces leading to inflammation and greater colonization. A water-based moisturizer should be used often to lubricate the patient’s mouth.

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. 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 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 Although there are few studies on the effects of tooth brushing in mechanically ventilated patients, current recommendations support brushing twice a day. A soft bristle toothbrush with a pediatric or small head should be used to allow access around the endotracheal tube. Powered toothbrushes have shown superior removal of dental plaque and may be used in the ICU on ventilated patients. (needleman, 2011; prendergrast 2012) A Smear of sodium fluoride toothpaste should be used. Studies have shown sodium monofluorphosphate fluoride inhibits the action of chlorhexidine and should not be used with chlorhexidine.

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 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 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 Chlorhexidine gluconate (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 Using a sponge toothette soaked in an alcohol-free chlorhexidine gluconate, swab the buccal and labial mucosa, the gingiva (gums), the tongue and palate. Swab the endotracheal tube as well since bacterial biofilm will form on it as well. Swabbing with this antimicrobial should be performed twice a day with no rinsing afterward for a minimum of 30 minutes. Chlorhexidine gluconate can cause a temporary staining of the teeth similar to that seen from tobacco or coffee use. This staining can easily be removed through a regular dental hygiene cleaning.

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 The mouth of an intubated patient should be kept as moist as possible. 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 Commonly substituted for a toothbrush, foam swabs or toothettes do not remove plaque bacteria or clean the teeth like a toothbrush and should not be substituted for toothbrushes. They are useful for the application of mouth rinses or lubricating agents. 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 demineralize the teeth. Petroleum based products are not recommended for moistening the lips and oral tissues as they are drying and harmful if aspirated.

23 Special Considerations
Neuroscience patients Intracranial pressure Edentulous patients Brush the gums gently Facial trauma patients Modify tooth brushing There are special considerations when delivering oral care in critically ill patients. Patients with Traumatic Brain Injury, Intracranial Hemmorhage, hydrocephalus and other conditions that may affect intracranial pressure may require intracranial pressure monitoring during the procedure. Edentulous patients can harbor bacteria and their gums should be brushed gently at least twice a day Teeth brushing may be difficult for patients with severe facial trauma and modifications should be made to brush the teeth based on the individual patient condition.

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 Because mechanically ventilated patients are dependent on healthcare providers to provide all aspects of oral care for the duration of intubation; healthcare providers play a major role in good oral hygiene. Nurses should provide patient education about the procedure before, during and after the procedure. Dental Hygienists should also educate nurses and healthcare providers regarding the importance of good oral hygiene in mechanically ventilated patients. Nurses should assess the oral cavity at least daily and consult the clinician provider as appropriate based on the findings. Oral care in mechanically ventilated adults is typically delivered by nurses and documentation of this care should be included in the medical record. Respiratory therapist generally replace or assist in replacement of endotracheal tube holders and can be major contributors in assessment of the skin and mucous membranes under the securement device. Report and documentation of this assessment is important in optimizing communication between providers and improving patient care. Maintenance of a closed ventilation circuit is an important aspect in decreasing bacteria from entering the lower respiratory tract and causing infection

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 Assessment of the oral cavity and patient education regarding oral care treatment should be performed by the treating provider. A standard order for an antimicrobial rinse would assist in triggering oral care and the seamless delivery of oral care. The treating critical care clinician should collaborate and consult dental professionals as appropriate for oral health findings that may warrant additional assessment or treatment. Dentists and Dental hygienists may be consulted on critically ill patients and follow-up or treatment my be warranted. The potential for proliferation of pathogenic bacteria and deterioration of oral health during intubation and the vulnerable nature of the critically ill patient mandates delivery of best practices to promote good oral health. This can only be achieved through interdisciplinary collaboration.

26 References Berra L, Sampson J, Wiener-Kronish J. Pseudomonas aeruginosa: Acute lung injury or ventilator-associated pneumonia? Minerva Anestesiol. 2010;76(10): Nseir S, Di Pompeo C, Pronnier P, et al. Nosocomial tracheobronchitis in mechanically ventilated patients: Incidence, aetiology and outcome. Eur Respir J. 2002;20(6): Craven DE, Driks MR. Nosocomial pneumonia in the intubated patient. Semin Respir 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): 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):

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): doi: /j.iccn 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): Accessed 25 February 2011. Fourrier F, 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): Barkvoll P, Rölla G, Bellagamba S. Interaction between chlorhexidine digluconate and sodium monofluorophosphate in vitro. Scand J Dent Res Feb;96(1):30-3. Abidia RF. Oral Care in the Intensive Care Unit: A Review. J Contemp Dent Pract 2007 January;(8)1:

28 References MDCT Evaluation of Foreign Bodies and Liquid Aspiration Pneumonia in Adults. 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 Respir Crit Care Med. 1997;156(5): Chastre J. Ventilator-associated pneumonia: What is new? Surg Infect (Larchmt). 2006;7 Suppl 2:S81-5. doi: /sur s2-81. Albertos R, Caralt B, Rello J. Ventilator-associated pneumonia management in critical illness. Curr Opin Gastroenterol. 2011;27(2): doi: /MOG.0b013e b1. Ashraf M, Ostrosky-Zeichner L. Ventilator-associated pneumonia: A review. Hosp Pract (Minneap). 2012;40(1): doi: /hp

29 References Martin B. AACN practice alert: Oral care for patients at risk for ventilator-associated pneumonia. 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): Accessed 9 March 2011. Institute for Healthcare Improvement. Updated Implement the ventilator bundle: Daily oral care with Chlorhexidine.


Download ppt "Oral Health and Mechanically Ventilated Critically Ill Adults"

Similar presentations


Ads by Google