REDUCING THE INCIDENCE OF VAP WITH EBP

Reducing the Incidence of Ventilator-Associated Pneumonia With Evidence-Based Interventions

Victoria Clayton
University of South Florida

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Abstract
Ventilator associated pneumonia is one of the most common hospital acquired conditions.
Despite this, current health care interventions have not helped to significantly reduce this. One of
the most common standards of care is to cleanse the oral mucosa. The objective of this paper was
to compare current health care standards to new interventions to combat the incidence of
ventilator associated pneumonia. The search engines used to conduct this evidenced-based
practice study include PubMed and CINAHL. These were used to find randomized clinical trials
on current interventions that are being used to reduce the incidence of ventilator-associated
pneumonia. Key words used include ventilator-associated pneumonia, current interventions,
antiseptics and oral care. By comparing three separate randomized clinical trials, it was
concluded that the use of chlorhexidine solution swabs in the oral mucosa significantly reduced
the incidence of ventilator-associated pneumonia in ventilated patients. Results were gathered
from a large sample of patients in multiple settings (dentate patients, intensive care patients, etc).

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Reducing the Incidence of VAP with EBP

Ventilator-associated pneumonia poses a tremendous threat in ventilated patients. It is
diagnosed when a ventilated patient acquires pneumonia within 48 hours of endotracheal
intubation. Intensive care unit patients are most affected by this. In fact, 10-30% of ICU patients
that are intubated will acquire ventilator-associated pneumonia (Li, Ai, Li, Zheng, & Jie, 2015).
Ventilator-associated pneumonia results in longer hospital stays, larger costs, and higher
mortality rates in intensive care unit patients. Due to this, it is a clinically significant issue that
needs to be resolved. Many evidence based practice studies are being conducted to discover
which intervention is most effective in reducing the incidence and mortality rate of ventilatorassociated pneumonia.
The most effective way new interventions can be put into practice is through comparing
randomized clinical trials that test current standards of care to new interventions. Since the cause
of ventilator-associated pneumonia generates from bacterial organisms colonizing in the oral
mucosa and traveling down into the bronchioles, the answer lies in oral care practices. Reducing
the incidence of ventilator-associated pneumonia must originate from preventing bacterial
growth in the oropharynx and upper GI tract. A type of antiseptic would be most efficacious in
preventing the colonization of bacteria. However, the question also lies in which type, what
strength and how much of the solution would be most effective. Also, how and when the solution
is inserted into the oral mucosa. A meta-analysis of 17 randomized clinical trials concluded that,
while more studies are needed to conclude the effectiveness of these interventions, they
concluded that using chlorhexidine solution has proven more effective than other standards of
care (Li et al., 2015).

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The aim for this clinical review is to answer the following question: In ventilated patients
(P) how does using 0.12% chlorhexidine swabs (I) compared with basic oral hygiene (i.e. use of
sterile water and tooth brushing) (C) reduce the prevalence of VAP (O) until the ventilator is
removed from the patient?
Literature Search
In order to compare randomized clinical trials related to interventions to reduce the
incidence of ventilator-associated pneumonia, PubMed and CINAHL were searched. Keywords
used to search include ventilator-associated pneumonia, prevention, current interventions,
oral care, and randomized clinical trial. By narrowing the search to randomized clinical trials
and evidence-based practices from less than five years ago, helped to produce the most recent
studies.
Literature Review
The first randomized clinical trial titled Early, single chlorhexidine application reduces
ventilator-associated pneumonia in trauma patients by Grap, et al., was conducted to test the
effectiveness of a single swab of chlorhexidine wipes within the first 12 hours of intubation
(2012). This was a randomized two group clinical trial. One group was assigned to the
intervention group and one group was assigned to the control group. Data were collected on 145
trauma patients; 71 were assigned to the intervention group and 74 were assigned to the control
group. The mean age of these participants was 42.4 years old. In the intervention group, a single
5 mL dose of 0.12% chlorhexidine was swabbed in the buccal cavity within 12 hours of
intubation. The control group solely received standard mechanical oral care, namely, tooth
brushing. The intervention group also received the standard oral care. The duration of data

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collection was 72 hours. Data were collected prior to intubation, at 48 hours and at 72 hours to
evaluate the Clinical Pulmonary Infection Score (CPIS). The results of this study concluded that
the early use of chlorhexidine does reduce the incidence of ventilator-associated pneumonia from
admission to 48 hours (p=0.020) and 72 hours (p=0.027). In the control group, 55.6% of the
participants had developed VAP between 48 to 72 hours. Amongst the intervention group, 33.3%
had developed VAP during the 48 to 72 hours.
Strengths of this study include the large sample size, randomized nature of the study, and
the simplicity and cost-effectiveness of replicating the intervention at any hospital. Weaknesses
of this study include the fact that the study was not double blind, the patients were already at an
increased risk for infection. Comparing the strengths and weaknesses of this study, the outcomes
of the study are deemed valid.
The second RCT is titled Chlorhexidine, tooth brushing, and preventing ventilatorassociated pneumonia in critical adults by Munro, Grap, McClish and Sessler (2009). This RCT
used a sample size of 547 from three different Intensive Care Units. Patients were placed in one
of the three groups: the first group patients received tooth brushing and chlorhexidine oral care,
the second group received only tooth brushing and the last group received only chlorhexidine. It
was found that tooth brushing alone did not significantly impact the incidence of VAP. The
outcomes were based on the clinical pulmonary infection score (CPIS) which took into account
the white blood cell counts, temperature and tracheal secretions. Data were collected upon
admission, on day 3, on day 5 and on day 7. It was found that on day 3 the use of chlorhexidine
did significantly reduce the incidence of VAP among patients who had a baseline of CPIS <6
(p=0.006).

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The strengths of this study include the randomization of the clinical trial, the large sample
size and the simplicity of the intervention. Based on these strengths, the study is deemed valid.
A third randomized, double-blind clinical trial titled Chlorhexidine decreases the risk of
ventilator-associated pneumonia in intensive care unit patients: A randomized clinical trial by
Ozcaka et al., was conducted to test the efficacy of 0.2% chlorhexidine gluconate in reducing the
risk of ventilator associated pneumonia (2012). The identifiers were blinded from the patients
and investigators, which included the periodontist, respiratory ICU physician and the outcome
statistician. Sixty-one patients that were scheduled to be intubated for at least 48 hours were
randomly selected and placed in one of two groups. Twenty-nine patients received oral care four
times daily with chlorhexidine swabs. Thirty-two patients received routine oral care with normal
saline four times a day. Sponge pellets were used to cleanse the oral mucosa. Measurements and
lower respiratory tract specimens were collected upon admission and when VAP was suspected
or on the 7th day of intubation. The results of the study, with an odds ratio of 3.12 and a 95%
confidence interval 1.09-8.91, produced the following results: 68.8% of the saline group
developed VAP versus 41.4% (p=0.03) of the chlorhexidine group developed VAP.
Strengths of this study include the randomization of the group, the double-blinded
method, the easily understood and evaluated outcomes and the patient population with few
comorbidities. Weaknesses of this trial include a small sample size (61) and the setting of the
study (Respiratory ICU) where patients are more at risk for developing VAP. Based on
comparing the strengths and weaknesses of the study, this RCTs validity has been confirmed.
The Agency for Healthcare Research and Quality in 2011 published national guideline for
the prevention of ventilator-associated pneumonia. The guidelines objective is two-fold, To
eliminate ventilator-associated pneumonia in adult patients in an intensive care unit and To

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increase the use of ventilator-associate pneumonia bundle in all ventilated patients in an intensive
care unit (National Guidelines Clearinghouse, 2011). Through literature search of randomized
clinical trials, meta-analyses and systematic reviews, the guideline concluded on a set of
interventions to reduce VAP which included keeping the head of bed between 30-45 degrees,
maintaining the endotracheal cuff between 20-25 cm, in-line suctioning, and kinetic bed therapy.
Additionally, the guideline stated that the use of 2% chlorhexidine solution in oral care reduced
the rate of VAP. This is consistent with the above RCTs evidence. The National Guidelines
suggests a stronger solution than Grap et al. (2012). However, the National Guidelines do not
that the use of 2% chlorhexidine oral solution four times a day until the patient is extubated does
irritate the oral mucosa, which is not mentioned in the randomized clinical trials (National
Guidelines Clearinghouse, 2011).
Synthesis
The three randomized clinical trials have many similarities and differences. Grap et al.
(2012) and Ozcaka et al. (2012), were both published in Periodontal Research journals. Grap et
al. (2012) focuses on the early use of chlorhexidine. Munro, Grap, Jones, McClish, and Sessler
(2009); and Ozcaka et al. (2012) focus on comparing the use of chlorhexidine versus other
interventions. Grap et al., (2012), tested the effectiveness of 0.12% chlorhexidine within the first
12 hours of intubation specifically. The clinical pulmonary infection score was checked after 48
hours and 72 hours. In the randomized clinical trial studied by Munro et al. (2009), patients were
either assigned to a tooth brushing intervention group (3 times daily), chlorhexidine intervention
group (5 ml of 0.12% solution twice daily), group that combined the two interventions (tooth
brushing three times daily and 0.12% chlorhexidine every 12 hours), and a control group. Data
were gathered on these patients on day 3, 5 and 7. Ozcaka et al. (2012), collected data at the 48

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hour mark on an intervention group and a control group. This randomized clinical trial utilized
the strongest concentration of chlorhexidine solution at 30 ml of 2% which was swabbed in the
oral mucosa via a sponge for one minute four times daily. All of the selected RCTs differ on
their data collection time frames. However, all three RCTs came to the same conclusion that the
use of chlorhexidine does indeed reduce the incidence of VAP. All the RCTs used chlorhexidine
as an oral swab, but only the first RCT stressed the importance of its early use. The other two
studies used chlorhexidine swabs several times daily. Lastly, the National Guidelines
Clearinghouse suggests a stronger concentration (2% chlorhexidine) four times daily which can
cause oral irritation (National Guidelines Clearinghouse, 2011).
Clinical Recommendations
Based on the evidence gathered from these randomized clinical trials and through
comparing the clinical guidelines, I would implement the use of 0.12% chlorhexidine gluconate
solution in the oral care of intubated patients. Oral swabbing the patient within the first 12 hours
of intubation and at least twice daily swabbing with the 0.12% chlorhexidine solution would be
beneficial in reducing the incidence of VAP, as evidenced by these clinical trials.

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References
Grap, M., Munro, C., Hamilton, V., Elswick, R.,Sessler, C., & Ward, K. (2012). Early, single
chlorhexidine application reduces ventilator-associated pneumonia in trauma patients.
Journal of Evidence based Dental Practice, 12(3), 15-17.
doi:10.1016/j.hrtlng.2011.01.006
Li, L., Ai, Z., Li, L., Zheng, X., & Jie, L. (2015). Can routine oral care with antiseptics prevent
ventilator-associated pneumonia in patients receiving mechanical ventilation? An update
meta-analysis from 17 randomized controlled trials. International Journal of Clinical and
Experimental Medicine, 8(2), 16451657.
Munro, C., Grap, M., Jones, D., McClish, D., & Sessler, C. (2009). Chlorhexidine, tooth
brushing, and preventing ventilator-asssociated pneumonia in critical adults. American
Journal of Critical Care, 18(5), 428-37. doi:10.4037/ajcc2009792.
National Guideline Clearinghouse: Agency for Healthcare Research and Quality. (2011).
Prevention of ventilator-associated pneumonia: Health care protocol. Retrieved from
http://www.guideline.gov/content.aspx?id=36063
zaka, ., Basoglu, ., K.,Buduneli, N., Tasbakan, M., S., Bacakoglu, F., & Kinane, D., F.
(2012). Chlorhexidine decreases the risk of ventilator-associated pneumonia in intensive
care unit patients: A randomized clinical trial. Journal of Periodontal Research, 47(5),
584-592. doi:10.1111/j.1600-0765.2012.01470.x