The study “ Impact of oral hygiene involving tooth brushing versus chlorhexidine in the prevention of ventilator-associated pneumonia: A randomized study” addresses the problem of ventilator acquired pneumonia in the hospitals’ intensive care units. Approximately nine to forty percent of all the illnesses contracted in the ICU by patients are related to Ventilator use. These in turn lead to extended hospital stay, increased rates of morbidity and mortality, and high medical care expenses. Nosocomial pneumonia is associated with dental plaque. In addition, the infection is linked to oropharynx colonization in individuals who are under mechanical ventilation. According to the article, endotracheal tube functions as a path for microorganisms to enter the lower respiratory tract hence causing nosocomial pneumonia. The process can be interrupted by inhibiting colonization of bacteria that cause the infection hence prevents VAP.
The purpose of the research is to determine if dental care implemented by brushing teeth using chlorhexidine at a concentration of 0.12% minimizes the risk of VAP, period spent on mechanical ventilation, hospitalization period, and mortality in intensive care units. A comparison was made between brushing teeth using chlorhexidine and using chlorhexidine only at the same concentration but without brushing teeth. The study was conducted in patients above the age of 18 years under mechanical ventilation in ICUs. The study was based on the idea that removing dental plaque could reduce the amount of oral bacteria hence minimize the possibility of developing VAP. The researchers have placed the study problem within the existing literature on the problem addressed. Ventilator Acquired Pneumonia (VAP) is a problem that is relevant to nursing practice and the research will address an issue that is prevalent in nursing field.
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Review of Literature
Although the authors state that existing literature on the problem is limited, different studies have been conducted to address the problem. The concepts explored in the literature review include oral care pneumonia prevalence at community context and hospital settings. The role played by dental plaque in acquiring ventilator associated pneumonia in patients hospitalized in intensive care units is also explored. Studies that assess the impact of topical use of chlorhexidine prior doing intubation is done with the aim of reducing nosocomial pneumonia in patients. The effect of mechanical cleaning of teeth using a toothbrush in removing bacteria from plaque is addressed in the literature review and efficacy of the procedure explored. Out of the twenty five, majority of them are current considering the study’s date of publication. However, there are few old studies that date as back as 1992. The possible reasons as to why they were included are because they are consistent with current research findings and provide important insights into the problem addressed in the study.
Theoretical Framework
The authors of the article do not provide a theoretical framework for the study. The study does not draw from any formal theory either in nursing or from other fields. Pender’s health promotion framework could be suitable for the study. The theory directs health promotion at increasing the well-being of a patient. The study’s research question although not stated in question form in the article is, “Does dental care by brushing teeth using chlorhexidine in form of gel at a concentration of 0.12 percent minimize the likelihood of acquiring VAP, reduce mechanical ventilation period, hospitalization duration, and the mortality levels in the ICU when compared to application of chlorhexidine alone without brushing teeth in adult patients receiving mechanical ventilation in clinical and the cardiology ICUs?” Independent variables are the impact of chlorhexidine and teeth brushing among ICU patients. Dependent variables for the study are length of hospitalization, rate of mortality related to VAP, possibility of developing VAP, and time spent on mechanical ventilator. Definition of the variables is not provided in the article. The dependent variable of the study is measurable and concrete.
Methodology
The study is a quantitative research that applies inductive reasoning. It moves from particular observation to making generalizations. 213 patients hospitalized in the intensive care unit were enrolled for research by the authors. All the patients who fulfilled the established inclusion criteria were included in the research. Purposive sampling was applied. The sample was them randomly allocated to either a control or an intervention group. One hundred and eight participants were allocated the control sample while one hundred and five patients were assigned the intervention sample. In testing the independent variables, 0.12 percent chlorhexidine was used as part of oral hygiene on the control group for every twelve hours while the experimental group used tooth brushes with 0.12 percent chlorhexidine for every twelve hours. Number of days spent on mechanical ventilation and hospitalized days were calculated for patients in each of the groups, rates of mortality calculated based on deaths resulting from VAP, and clinical criteria used to test for possible VAP. The tools used for measurement measured what they claimed to measure and in a consistent manner hence reliable and valid. Ethical considerations relating to authorization to implement the intervention by the patients were necessary for the study. Approval and permission from the ethical committee were provided. In addition, informed consent was given by patients or their relatives before beginning the study.
Data Analysis
Ventilator Associated Pneumonia was calculated as the percentage of prevalence for every 1.000 of ventilation per day. Chi square test was used to analyze both clinical and demographic aspects while t-test was used to analyze continuous variables. Discrete variables were calculated in form of counts for some and percentages for others while for continuous variables, mean and SD were used for analysis. In addition, logistic regression was applied in adjusting any confounding factors. Findings of the study indicate that VAP happened in 28 patients in the control sample and seventeen from the experimental sample. The prevalence was 14.2% by one mechanical ventilation per day. Furthermore, the results indicate that tooth brushing with 0.12 percent chlorhexidine led to a decrease in the risk of developing VAP when compared to using chlorhexidine in the absence of brushing teeth among the studied patients.
Summary/Conclusions, Implications, and Recommendations
Other than the ones stated by the authors, there are no other identifiable strengths of the study. However, there is one more limitation of the study apart from the ones identified by the authors of the article. The authors do not provide adequate literature that supports the study’s hypothesis. In addition, interruptions in the course of the study that affected the sample size may have affected the findings/outcomes. The results of the study cannot be generalized on larger populations because of the small sample size used. The findings indicate the need to implement the intervention in my nursing practice in order to minimize the prevalence of VAP in my patients to promote their health, reduce mortality rates related to VAP, and ensure their well-being. For the nursing profession, the study’s findings imply the need to establish oral hygiene protocols to be implemented by nursing professionals. Training nurses on such protocols would also be important to ensure their efficacy and effectiveness. The results further stress findings from other studies that recommend oral hygiene as one of the effective interventions that can lower the occurrence of ventilator associated pneumonia. The researchers recommend more research to define the most appropriate design for dental care in intensive care units and precise tests to validate dental plaque removal using tooth brushes.
Reference
De Lacerda Vidal, C. F., Vidal, A. K., Monteiro, J. G., Cavalcanti, A., Henriques, A. P., Oliveira, M., Godoy, M., Coutinho, M., Sobral, P. D., Vilela, C. Â., Gomes, B., Leandro, M. A., Montarroyos, U., Ximenes, R. D., & Lacerda, H. R. (2017). Impact of oral hygiene involving toothbrushing versus chlorhexidine in the prevention of ventilator-associated pneumonia: A randomized study. BMC Infectious Diseases , 17 (1). https://doi.org/10.1186/s12879-017-2188-0
