| BackgroundVentilator-associated pneumonia (VAP) is a sub-type of hospital-acquired pneumonia (HAP) which occurs under the condition when the patients receive mechanical ventilation(MV) for48h, then deactivate mechanical ventilation and remove the artificial airway within48h, which is particularly common in ICU. VAP is one of the most serious complications of common mechanical ventilation. VAP may prolong patients’mechanical ventilation treatment time and increase both morbidity and mortality rate as well as the hospitalization cost. The intubated patients’ inability to eat or swallow and the regular mouth opening status can weaken oral self-purification and local mucosal immunity, meanwhile, oral secretions will be retained in the mouth and the bacteria multiply decomposition will produce indole, sulfur hydrogen radicals and amines, causing bad breath and stomatitis. Numerous studies suggest that pathogens of ventilator-associated pneumonia mainly come from the mouth. Foreign scholars did a lot of researches on how to implement efficient and comprehensive oral care, which involves oral care assessment tools, oral care liquid, nursing methods, nursing frequency, etc. Oral care assessment tools include Eilers oral assessment tool (OAG), Andersson and Barnason improvement tools, and Beck oral assessment tools. The Beck oral assessment tools were developed and designed in2008by Gollins for ICU patients, which are applied to evaluate oral hygiene status involving lips, oral mucosa, tongue, gums, teeth and saliva. Bundle care refers to a group of nursing intervention measures that each part confirmed by clinical trials and verification can improve patient outcomes. The combination of these measures shows more significant therapeutic effect than single measure. To choose oral care solutions, the United States IHI adopts0.12%chlorhexidine as one of the bundle care measures to prevent VAP while the chlorhexidine is being used in Europe. As of choosing providing oral care, Negative Pressure Suction Toothbrush Combining0.12%chlorhexidine has been repetitively recommended as one of the most significant cluster nursing measures to prevent VAP. In addition, foreign scholars presented a normative, professional, comprehensive and continuous oral care process guided by oral care protocol which received good results in reducing the incidence of VAP.At present, domestic scholars have also made relevant researches on the relationship of oral caring to the incidence of VAP. First, the choice of oral care liquor in domestic is different from international standard. The most common domestic choice is carried out in a normal saline solution. In2012, some scholars made a survey on506ICU nurses in18hospitals of seven cities in Guangdong Province,84.8%answered to choose normal saline as oral care solution. In addition, there are also some reports regarding the use of chlorine, flower bayesian liquid, Chinese medicine preparations, nitrofural, metronidazole, sodium bicarbonate, mouth spirit and hydrogen peroxide for oral caring in ICU. Research reports pointed out that the chlorhexidine oral care solution can effectively reduce the oral colony count, inhibit oral bacteria, reduce oral bacterial colonization and the incidence rate of VAP significantly. Secondly, the most adopted choice is traditional oral swabbing in oral care methods, other methods such as choices in oral cavity irrigation, children’s soft toothbrush and negative pressure suction toothbrush have also been reported in certain papers. According to the research in46domestic hospital ICU in2012,89.1%still used medical cotton ball as oral care tool with only a few using toothbrush. Some scholars have also studied the effect of brushing with chlorhexidine to prevent VAP but the results only proved its superiority to the traditional normal saline cotton ball wiping method. Currently, the effect of0.12%chlorhexidine mouthwash combining cleaning method with negative pressure suction toothbrush in the prevention of VAP in orotracheal intubation supported by mechanical ventilation patients is lack of further research and evaluation.ObjectiveVAP has serious impact on the intubated patients with mechanical ventilation at disease rehabilitation and prognosis of the stand or fall. The oral health status has direct correlation with ventilator associated pneumonia. This research aims to test the evidence-based medicine theory as instruction, to explore the optimization method of oral care to improve oral health and prevent the VAP occurrence of intubation on mechanical ventilation patients, and further to shorten the length of hospitalization time and reduce the cost of hospitalization cost.MethodsSelect intubated patients with mechanical ventilation as clinical study object in the general ICU of a top-three A hospital. Conscious patients were voluntary to cooperate in this study and as the object of observation while for the unconscious patients, we obtained consent from their families. According to inclusion criteria and exclusion criteria of medical cases,70intubated patients with mechanically ventilation were selected and randomized into two groups:33patients in observation group(from which2patients were removed) and35in control group. Case inclusion criteria:the patients were treated with tracheal intubation and mechanical ventilation in general ICU. Excluding age<18years old; more than48hours intubation before admission, or a recent history of endotracheal intubation, no teeth, mechanical ventilation is expected time less than48hours and the immunocompromised patients. Cases of exclusion criteria:do not accord with standard of diagnosis and meet the inclusion criteria, lung infected and immune function is low before intubation, short of neutropenia and immunosuppressants adoption.The two groups patients’age, sex, acute physiology and chronic health-Ⅱ (APACHE-Ⅱ) score, consolidated basis of disease, smoking history, indwelling gastric tube history, the application of sedatives, as well as application of antacids should show no significant difference through statistics processing,(P>0.05), which should be comparable.0.12%chlorhexidine mouthwash was applied in control group combining traditional oral cleaning method to complete the oral care. Add mouth wash when it is necessary. The wipping order was in line with oral care standards in the fourth edition of the basic nursing. One nurse did the operation while the contralateral nurse assisted fixing endotracheal intubation to prevent tube shifting.0.12%chlorhexidine mouthwash combined cleaning with negative pressure suction toothbrush was applied in the observation group. When the connecting center vacuum suction, the operating nurse handheld the negative pressure suction toothbrush to scrub the patient mouth in sequence with instantaneous negative suction to prevent mouthwash from being aspiration. The contralateral nurse assisted fixing endotracheal intubation to prevent tube shifting, and used60ml irrigation syringe to inject mouthwash to the mouth slowly.Change clean dental pad for both groups after operation. Fix dental pads properly and endotracheal intubation with fixed belt after confirming intubation depth, both cleaning4times/d and observing seven days. Compare the two groups’ oropharyngeal bacterial culture detection rate (%) before and after oral care, oral odor two hours after oral care in day three, VAP incidence, the time of mechanical ventilation and ICU stay days. The degree of bad breath was judged using visual analogue scale (VAS). While judging the incidence of VAP (%) according to the "ventilator associated pneumonia" diagnostic criteria formulated by the Chinese Society of Respiratory Disease.The collected case observation data and evaluation data were imputed to the database using SPSS13.0statistical software for statistical analysis after being verified. The measuring data of normal distribution is denoted as "mean±standard deviation" using t-test while the count data using chi-square test. Take P<0.05for the difference is statistically significant. The contrast of the bacteria culture before and after oral care was analyzed using repetitive measurement deviation analysis.Results1) The bacteria culture status before and after oral care of two group patientsTwo groups of patients’ oropharyngeal bacterial detection rate before oral care showed no significant difference while the result was significantly different after oral care:the observation group was significantly lower than the control group(P<0.05).2) The oral odor of two group patients after2hours oral careTwo groups of patients’ oral odor results were significantly different (P<0.05)2hours after the first oral care in third day. The observation group showed obvious improvement compared with the control group.3) The incidence of VAP(%) The incidence of VAP(%) of the observation group is lower than that in control group, which showed statistical difference(P<0.05).4) The duration of mechanical ventilation and ICU stay daysThe observation group patients’mean duration of MV and the stay days in ICU were significantly shorter than those of the control group with statistical difference(P <0.05).Conclusions:1) Oral care quality is directly related to the status of oral health and the level of incidence of VAP. So the nurse should pay great attention to the oral care of patients with tracheal intubation.2) Compared with the traditional oral care method, the use of0.12%chlorhexidine mouthwash joint negative pressure suction toothbrush is able to reduce oropharyngeal bacterial propagation, improve bad breath, reduce the incidence of VAP (%), and shorten the patients’MV time and ICU stay days. The results show significant difference(P<0.05).3) Applying negative pressure suction toothbrush cleaning method with0.12%chlorhexidine mouthwash in orotracheal intubation supported by mechanical ventilation patients’ oral care is safe and effective, showing advantages such as simple and easy to operate for the nurses and fitting the patients’ physiological needs, which is worthy of clinical popularization and application. |
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