Ventilator Bundle Adjusted: Daily Oral Care with Chlorhexidine

The following was posted on the IHI website regarding adjustments to the ventilator bundle made in May 2010. You can read the update (as well as implementation tips) in its entirity here.

You can read the updated description of the IHI Ventilator Bundle here: here



Daily Oral Care with Chlorhexidine
IHI added this element to the Ventilator Bundle in May 2010 following continued review of the literature and use of the element in the IHI Ventilator Bundle in Scotland for over a year. The recommended chlorhexidine solution strength is 0.12%.

Dental plaque biofilms are colonized by respiratory pathogens in mechanically ventilated patients. Dental plaque develops in patients that are mechanically ventilated because of the lack of mechanical chewing and the absence of saliva, which minimizes the development of biofilm on the teeth. Dental plaque can be a significant reservoir for potential respiratory pathogens that cause ventilator-associated pneumonia (VAP). Chlorhexidine antiseptic has long been approved as an inhibitor of dental plaque formation and gingivitis. As early as 1996, DeRiso and colleagues published a study that provided evidence to support the use of 0.12% chlorhexidine oral rinse as a prophylactic measure to reduce nosocomial respiratory tract infections in cardiac surgery patients. [1]

Since that time there has been much discussion about the utilization of chlorhexidine as an important adjunct to oral hygiene, but there have been few studies published that provide firm evidence that the use of chlorhexidine as a decontamination antiseptic reduces the incidence of ventilator-associated pneumonia. Chlorhexidine has been studied in two strengths: 0.12% and 0.2%. The US Food and Drug Administration recommends 0.12% oral chlorhexidine for use as mouth rinse. In a meta-analysis published in 2007 by Chan and colleagues in the British Medical Journal, eleven studies were evaluated for effect of oral decontamination on the incidence of ventilator-associated pneumonia and mortality in mechanically ventilated adults. Results of that analysis concluded that oral decontamination of mechanically ventilated adults using chlorhexidine is associated with a lower risk of ventilator-associated pneumonia. [2]

There is little if any evidence of other oral care processes having an effect on the development of VAP, but it makes sense that good oral hygiene and the use of antiseptic oral decontamination reduces the bacteria on the oral mucosa and the potential for bacterial colonization in the upper respiratory tract. This reduction in bacteria has been shown to reduce the potential for the development in ventilator-associated pneumonia for patients on mechanical ventilation.

References:

1. DeRiso AJ, Ladowski JS, DillonTA, Justice JW, Peterson AC. Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest. 1996;109:1556-1561.
2. Chan EY, Ruest A, O’Meade M, Cook DJ. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: Systematic review and meta-analysis. British Medical Journal. 2007;10:1136.

Additional Reference:
Munro CL, Grap MJ, Jones DI, McClish DK, Sessler CN. Chlorhexidine, tooth brushing and preventing ventilator-associated pneumonia in critically ill adults. American Journal of Critical Care. 2009 Sep;18(5):428-437.