口腔護理加入刷牙措施是否更能有效預防呼吸器相關肺炎?Effect oral care toothbrushing to prevent Ventilator -associated pneumonia

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2020-01-20 已刊登
新刊登 綜 整 預防/治療/介入類型

作  者

温玉松* 林翠森

實證知識類別

A 類:實證健康照護綜整

PICO

治療/預防性問題

治療/介入措施

胸腔暨重症加護醫學 Pulmonary and Critical Care Medicine

科別

  • 病人安全 Patient Safety
  • 感染/傳染性疾病護理 Infectious / Communicable Disease Nursing
  • 重症護理 Critical Care Nursing

中文關鍵詞

刷牙 口腔護理 呼吸器相關肺炎 氣管內插管呼吸器使用病人

英文關鍵詞

Toothbrushing ventilators mechanical oral care、oral hygiene pneumonia ventilator- associated

機構名稱

彰化基督教醫療財團法人彰化基督教醫院

申請單位

呼吸照護中心

中文摘要

形成臨床提問:
呼吸器相關肺炎 (Ventilator -associated pneumonia, VAP) 是呼吸器使用病人常發生的院內感染合併症,其會延長住院時間、增加死亡率風險及醫療成本。目前疾病管制署(2017)提出「呼吸器相關肺炎組合式照護措施指引」中,針對口腔護理建議每日至少2次執行口腔抗菌照護。臨床實際照護上,每日至少2次使用含0.12%- 0.2%氯己定(chlorhexidine, CHX)之漱口水執行口腔漱口或以潔牙棒擦拭抗菌照護,並未強調須使用牙刷刷牙。然而,美國重症監護護士協會(American Association of Critical-Care Nurses, AACN)指出刷牙是最有效移除微生物膜和預防病菌的口腔護理措施。本篇系統性回顧文獻之目的為:探討呼吸器病人口腔護理合併刷牙,是否較單純使用潔牙棒更能有效預防VAP之成效。本篇文獻總整之結果,將可做為護理人員執行口腔護理、及回答病人家屬疑問之重要依據。
文獻搜尋的方法與分析:
本研究設定"ventilators, mechanical"[MeSH Terms]、"intensive care units"[MeSH]、"toothbrushing"[MeSH Terms]、"oral health"[MeSH Terms]、"oral hygiene" [MeSH Terms]、"pneumonia, ventilator- associated"[MeSH Terms]、氣管內插管、呼吸器使用、口腔護理、刷牙、呼吸器相關肺炎等中英文關鍵字,搜尋PubMed、CINAHL、Cochrane Library、華藝線上圖書館等資料庫,搜尋時間至2019年7月,限制研究設計為隨機控制研究(Randomized Controlled Trail)與系統性回顧(Systematic Review)。最初文獻搜尋共找到385篇研究,排除重複後剩下312篇。首先檢視文獻標題及摘要,刪除與主題不合之文獻279篇。其次針對剩餘33篇逐一閱讀全文,最終納入系統性文獻回顧3 篇及隨機對照試驗 13篇。其中以Camargo(2019)發表之系統性文獻回顧暨統合分析研究,符合本次所設定之PICO、且已納入本研究搜尋所找到的隨機控制試驗研究,經團隊討論,最後選擇此篇系統性回顧文獻進行評讀。
文獻的品質評讀:
本文採用Critical Appraisal Skills Programme (2014)「CASP- Systematic Reiview Checklist」進行嚴格文獻評讀。本篇統合分析針對「使用抗菌劑(CHX)、併用刷牙進行口腔照護」及「使用抗菌劑(CHX)、併用潔牙棒或紗布棒進行口腔照護」進行比較(872位個案)在VAP發生率沒有統計上顯著的差異。另外「使用抗菌劑(CHX)刷牙進行口腔照護」及「未使用抗菌劑(CHX)刷牙進行口腔照護」進行比較(376位個案)在VAP發生率亦無統計上顯著的差異,異質性I2為65.2%,可能因納入研究所使用的抗菌劑(CHX)濃度不一、口腔護理頻率不同所致。根據CASP評讀結果,僅因納入個案數較少導致信賴區間較寬、其餘品質均為「是」顯示研究品質良好,其研究證據結果可採信並做為臨床實務照護參考。
結論與建議:
雖然美國牙科協會(ADA)建議氣管內管留置病人每天兩次用牙刷和牙膏刷牙維持口腔清潔健康,且家屬也提出質疑,是否僅以潔牙棒及抗菌劑進行口腔護理不足以預防VAP。但根據本篇系統性文獻回顧結果顯示,「使用抗菌劑(CHX)、併用刷牙進行口腔照護」或「使用抗菌劑(CHX)、併用潔牙棒或紗布棒進行口腔照護」效果相當,重症插管病人採刷牙方式進行口腔護理不會使得VAP發生率更低。口腔清潔用具成本粗估花費不到50元,且僅有少數病人產生口腔粘膜刺激之反應。相較於治療呼吸器相關肺炎之費用,利大於弊,值得推行。因此,建議臨床上遵從呼吸器相關肺炎組合式照護指引,使用CHX漱口水、合併潔牙棒落實執行口腔護理即可。當家屬對臨床照護措施提出質疑時,可適當地提供科學證據加以說明,以減少醫病溝通之衝突、提升護理專業度。

英文摘要

Ask an answerable question (PICO):
Ventilator-Associated Pneumonia (VAP) is the most common nosocomial infection in patients who use mechenical ventilator. It can prolong patients’ hospital stays, increase the risk of mortality and medical costs. The clinical guideline for VAP bundle care is to use chlorhexidine (CHX) to mouthwash or gel and toothbrush for oral hygiene care at least twice daily. The actual clinical care, at least 2 times a day containing 0.12% - 0.2% mouthwash CHX of performing an oral rinse or dentifrice antimicrobial wipe care stick, does not emphasize the need to use toothbrush. However, the American Association of Critical-Care Nurses (AACN) points out that tooth-brushing is the most effective approach of oral care to remove microbial membranes and prevent germs. Therefore, the purpose of this systematic review was to clarify the effect of a combination of CHX with a use toothbrush on the prevention of VAP than simply using a swab. The results of this article will be an important basis for nursing staff to perform oral care and answer questions from patients' families.
The Method and Analysis of Literature Review:
Article search about oral hygiene care to prevent Ventilator-Associated Pneumonia, keywords were endotracheal intubation in patient with mechanical ventilator, oral hygiene care, tooth brushing, and Ventilator-Associated Pneumonia. Database included PubMed, CINAHL, Cochrane Library, Huayi Online Library databases. First, 385 articles were searched during July 2019 and 312 articles were remained due to repeated articles. Secondly, 279 articles were deleted because the title and abstract were not in line with the subject. Thirty three articles remained and only three systematic revifew and 13 randomized controlled trials were selected. Among these articles, one article titled “ The efficacy of tooth- brushing procedures performed in intensive care units in reducing the risk of ventilator-associated pneumonia: A systematic review article " was chosen for a critical appraisal.
Critical Appraisal:
The validity, importance/impact and practice of this article was review by the Critical Appraisal Skills Programme (2014) "CASP-Systematic Review Checklist". This meta-analysis compared the incidence of VAP in “Using chlorhexidine (CHX) with toothbrushing cleaning” versus “Using CHX and swab/gauze cleaning” for oral care (872 cases). There are no statistically significant differences.In addition, there was no statistically significant difference in the incidence of VAP when comparing the use of CHX toothbrushing cleaning” versus the use of CHX for oral care (376 cases). I2=65.2%. According to the CASP evaluation results, the trust interval is wide due to the small number of cases included, and the remaining qualities are "yes", indicating that the research quality is good. The results of the research evidence can be trusted and used as a reference for clinical practice care.
Conclusions and Recommendations:
Although the American Dental Association (ADA) recommends that endotracheal indwelling patients use toothbrushes and toothpaste to brush their teeth twice a day to maintain a clean and healthy oral cavity, and family members have also questioned whether or not oral care with swab/gauze cleaning and CHX is sufficient to prevent VAP. According to the results of this systematic literature review, "use of CHX and brushing teeth cleaning " or "use of CHX and swab/gauze cleaning " have comparable effects. Brushing teeth for oral care does not reduce the incidence of VAP. The cost of oral cleaning appliances is estimated to cost less than NT50, and only a few patients have a response to oral mucosal irritation. Compared with the cost of ventilator-associated pneumonia, the advantages outweigh the disadvantages and are worth implementing. Therefore, it is recommended to follow the guidelines for a combined care for ventilator-associated pneumonia clinically, and use CHX mouthwash, combined with a swab to implement oral care. When family members question clinical care measures, it can provide scientific evidence to explain it appropriately, so as to reduce the conflict of medical communication and improve nursing professionalism.