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.
Results, 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.
