| Background:With the development of critical care medicine, application of mechanical ventilation is in growing popularity in ICU. Ventilator-associated pneumonia (VAP) become one of the most common infectious diseases to the patients receiving mechanical ventilation.Ventilator-associated pneumonia (VAP) refers to pneumonia that develops in48hours or longer after mechanical ventilation is applied by means of endotracheal tube or tracheostomy. It is a particularly common hospital-acquired pneumonia in ICU. VAP is a serious complication for people treated with mechanical ventilation. Ventilator-associated pneumonia causes prolonged mechanical ventilation, prolonged hospitalization, elevated morbidity and mortality, increased cost of hospitalization. According to foreign reports, incidence of VAP ranged from6%to52%with the mortality rate between14%to50%, the death rate could reach76%in case of multiple resistant bacteria and pan resistant bacteria. In China, VAP incidence ranged from4.7%to55.8%and the mortality rate was19.4%～51.6%, VAP leaded to prolonged mechanical ventilation for5.4～14.5d, ICU stay governance increased6.1～17.6d. Numerous studies suggested that pathogens of ventilator-associated pneumonia mainly come from the oral cavity. The consistency of positive samples collected in the lower respiratory tract and oropharyngeal flora culture reach53.8%. The literature reported that high-quality oral care interventions can reduce33.3%of VAP incidence.Researches are looking for effective methods, frequency and oral care solution for oral care of intubated patients. As they recognize the importance of oral care to patients with mechanical ventilation. These researches mainly focused on the area of nursing intervention and medical solutions selected. While relatively less studies on how to assess the oral cavity and determine the frequency of oral care were conducted.1) Oral cavity assessment:there is no uniform standard on assessment of the oral cavity at home and abroad. Domestic nursing textbooks mention quite little about oral care assessment prior to practical oral care. The assessment mainly involves ideology, level of cooperation of the patient and observation of part of the oral cavity. There is no scoring criteria to measure oral health.In foreign countries, a variety of oral assessment tools have been developed to evaluate the oral health status of different populations and the effect of oral care, but has not been widely used clinically.2) Oral care methodology:There are various ways of oral care:cotton ball wipe is taken widely in traditional oral care; rinsing is also used widely. However, brushing is currently recognized as the most effective measures to remove plaque. The domestic and foreign literatures showed that a single use of the mouth wash or scrub is neither able to remove the dental plaque effectively, nor thorough clean the oropharyngeal area and other special parts of the oral cavity. Every method has its limitations. Therefore, many scholars have proposed a comprehensive oral care methods:i.e. integrated use of wiping, rinsing, brushing and other oral care measures.3) For the study of oral care solution chosen, the most commonly used oral care solution remains normal saline. Reports on the use of chlorhexidine solution, metronidazole, sodium bicarbonate, hydrogen peroxide, diluted povidone iodine solution, and herbal preparations, and so on were also found. Chlorhexidine mouthwash is a broad-spectrum antimicrobial solution, with a strong inhibition of Gram-positive bacteria and weak inhibitory effect of Gram-negative bacilli. In2010, the United States IHI used0.12%chlorhexidine as a preventive care measures of VAP, which is extensively used in recent years.4) In regard to the frequency of oral care, the frequency of oral care lack of clinical evidence.Hospitals do not use a unified quantitative evaluation tool to determine the specific implementation and frequency of oral care.Objective:This research bases on evidence-based medicine theory. Using the Beck oral assessment scale to evaluate the oral condition of endotracheal intubated patients, and to implement a comprehensive oral care programme according to the result. By providing a comprehensive, professional, high-quality dental care to improve oral health. And further evaluate the effect of the measures for preventing ventilator-associated pneumonia.Research Methods:Object of the study:70orotracheal intubated patients on mechanical ventilation were recruited according to case exclusion and inclusion criteria from intensive care unit in a3A hospital from March2013to February2014. Subjects were randomly divided into two groups:test group and control group. Inclusion criteria:a) target patients intubated with mechanical ventilation; b) absence of oral diseases before intubation; c) at least18years old; d) begin the oral care intervention in the first24h of intubation; e) have correct understanding of the study, cognitive and signed informed consent.Exclusion criteria:hospitalize more than48hours prior to intubation; have tracheal intubation history recently; have a clinical diagnosis of pneumonia at the time of intubation; have advanced malignant disease and in dying state; expected time of mechanical ventilation less than96hours; no teeth or with oral, facial trauma; depressed immune function; with use of immunosuppressive agents.2. Randomization Randomizing method:Using randomizing software RandA1.0. Subjects were randomly divided into two groups:Observation group and control group,35cases in each group.33cases in the observation group (2cases removed)and32patients (3cases removed)in the control group. Before treatment, there was no significant difference(p>0.05) between the2groups on gender, age, APACHE II score, use of antibiotics, antacids and sedatives.The baseline showed no significant difference.Control group:Used the requirement of oral care operation in the men guard version of" basic nursing " to assess the oral situation. After oral assessment,0.12%chlorhexidine mouthwash solution and comprehensive oral care procedure were applied (Clean mouth airway and nasal secretions. Then used suctionable toothbrush to brush the teeth and suck out excess mouthwash and secretions, used a syringe to extract oral care solution after brushing oral rinse, rinse the mouth of dirt, side edges flush draw)twice a day and mouth wiping twice per day.Observation group:Used the Beck Oral Assessment Scale(BOAS) to assess the oral condition. Rating from the lips, gums and oral mucosa, tongue, teeth and saliva to assess the five aspects of oral conditions1-4points for each item, total score5-20points. Depending on the score to determine the intervention of oral care, performed oral care4-6times per day, which included comprehensive oral care procedure2-3times per day and oral mouth wiping2-3times per day.Observation group and control group both used the same0.12%chlorhexidine mouthwash solution as the standard solution of care and comprehensive oral care law. Cotton swab dipped with warm water was used to moist the lips and mouth.The two groups of patients took the same daily care, and other measures for the prevention of ventilator-associated pneumonia.3. Monitoring indicatorsObservation period lasts5days. Compare and contrast the incidence of oral odor, oropharyngeal colonies, BOAS of the two groups on Day1, Day3and Day5before the intervention, as well as the incidence of VAP on the fifth day.4. Statistical AnalysisThe data obtained will be analyzed using SPSS13.0statistical software. Measurement data of normal distribution using the "mean±standard" deviation to indicate, which used two independent samples t test; count data used χ2test; oropharyngeal culture results used in two-sample rank sum test;3time points Beck oral assessment scale were compared using repeated measures analysis of variance. Take P<0.05was considered statistically significant.Results1. Comparison the incidence of oral odor after intervention:The incidence of oral odor of the observation group with nursing intervention significantly decreased: from63.6%on Day1,24.3%on Day3to15.2%on Day5. The incidence of oral odor on Day5differ statistically significant (P<0.05) between the observation group and control group.The incidence of oral odor is lower on observation group.2. Comparison the oropharyngeal bacteria count after intervention:After two-sample rank sum test, difference was statistically significant(P<0.05) on oropharyngeal bacteria count between the observation group and control on Day5. Observation group had lower oropharyngeal bacteria count than the control group on Day5.3. Beck oral assessment scale (BOAS) comparison after oral care intervention: using repeated measures analysis of variance showed that:on the first day of oral care of patients in the two groups had no significant difference in BOAS scores, suggesting that before intervention the indicator baseline level of two groups was comparable. On the whole, BOAS scores of the observation group and the control group on the three time points decreased gradually with significant differences (P<0.05). BOAS score of both the observation group and control group decreased, suggesting oral health status were improved. On the3rd and fifth day BOAS score between the two groups were significantly different in statistical view (P<0.05), suggesting that BOAS score improved more significantly in the observation group than the control group after intervention.4. Comparing the VAP incidence of two groups:The VAP incidence of the observation group is6.1%to25%of control group. Different was statistically significant (P<0.05). The result of observation group is lower than the control group.5. Comparison of the BOAS before nursing intervention of patients with high and low APACHE II score:low APACHE II score group (APACHE Ⅱ<20points) had lower BOAS than high APACHE II score group (APACHE II≧20points), before oral care interventions.Beck score(BOAS) differ statistically significant(P<0.05). Suggested that the more severe the patient’s condition, the worse oral health status.ConclusionThis study showed that the use of comprehensive oral care intervention programme on Beck Oral Assessment Scale can standardize oral care procedure, reduce the incidence of oral odor as well as the bacterial colonization in the oropharynx, and improve the oral environment and reduce the incidence of VAP. |
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