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Study on oral care in hospitalised pneumonia patients leads to change in international practice

In light of a recent study, toothbrushing has been introduced as an essential part of care for pneumonia patients admitted to hospitals and intensive care units. (Image: Iconic Bestiary/Shutterstock)

TORONTO, Canada: Since the use of an antimicrobial oral rinse in intensive care units (ICUs) and its effectiveness in preventing pneumonia have been questioned in the last eight years, researchers from Canada have recently conducted a study to assess whether discontinuing the use of oral rinse and instead implementing an oral care bundle would reduce ICU mortality in mechanically ventilated patients. They found that the nurse-led oral care intervention performed equally as well as the rinse in preventing pneumonia and helped improve patients’ oral health. As a result, the study led to a major change in a US guideline that governs care in hospitals.

According to the American Thoracic Society, approximately one million adults in the US are admitted to hospital every year owing to pneumonia, and 50,000 people lose their lives from the disease. It is known that pneumonia can be deadly to hospital patients, particularly those admitted to the ICU, since they may be exposed to medications that cause dry mouth, may be subject to restrictions on eating and drinking, and may suffer from poor oral hygiene, all of which can result in changes to the oral microbiome. Additionally, the authors noted that the tracheostomy tube used for ventilation could serve as a point of access for bacteria to enter the lungs, which may lead to pneumonia.

“When there is a large overgrowth of bacteria in the mouth, it can be aspirated from the mouth into the lungs, especially when patients are lying on their backs,” Dr Craig Dale, a Canadian Institutes of Health Research and Institute of Musculoskeletal Health and Arthritis embedded clinician–scientist in oral health at Sunnybrook Health Sciences Centre and an associate professor in the University of Toronto’s Lawrence S. Bloomberg Faculty of Nursing, said in a press release.

According to the researchers, a number of systematic reviews have recently shown that using oral rinse is associated with excess mortality in patients. To further investigate whether oral rinse was indeed contributing to the death of patients and to assess its effectiveness in preventing pneumonia, the researchers of the present study designed a trial in which they discontinued the use of oral rinse in hospitals and ICUs and implemented an oral care bundle that included toothbrushing. Besides examining how this would affect mortality rates, the researchers also evaluated the changes that the intervention would cause in relation to respiratory infection, time spent on the ventilator and patient comfort.

For that purpose, a total of 3,260 patients from ICUs in Toronto were enrolled in the study. The oral health bundle required hospital staff to regularly brush the teeth of patients and moisturise their lips and mouths. “As patients should have their teeth brushed anyway, we saw there was no need for the addition of the mouth rinse, which may have side effects for patients,” Dr Dale noted.

The data showed that, although the discontinuation of the use of oral rinse and the subsequent implementation of an oral care bundle did not yield any benefits in terms of ICU mortality, it did improve the health of the patients. Owing to this observation, the study was among the first in the world to provide evidence that the use of oral rinse should be discontinued in hospitals and ICUs and that an oral care bundle including toothbrushing should be implemented instead.

As a consequence, the study has led to a change in prevention guidelines in the US, although not yet in Canada, and Dr Dale believes that the updated guideline is a step forward in providing improved care for patients and acknowledging the connection between oral and systemic health. He noted that the significance of comprehensive oral care for ICU patients should not be underestimated, since it may help them resume speech, swallowing and a regular diet more quickly after the discontinuation of ventilation. Finally, he stated that nurses are vital in delivering pneumonia prevention at the bedside and that they will be key in helping to implement the practice change in hospitals.

“Providing better oral care will put hospitalised patients in the best position to recover from illness,” Dr Dale concluded.

The study, titled “Effect of oral chlorhexidine de-adoption and implementation of an oral care bundle on mortality for mechanically ventilated patients in the intensive care unit (CHORAL): A multi-center stepped wedge cluster-randomized controlled trial”, was published in the November 2021 issue of Intensive Care Medicine.

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