Comparison of Ventilator-Associated Pneumonia between Oral Care with Normal Saline Solution and Chlorhexidine in a Medical Intensive Care Unit*

Abstract

Ventilator-associated pneumonia (VAP) is pneumonia that occurs in patients who have been on a ventilator for more than two calendar days. The occurrence of VAP affects the patient, causing increased hospitalization time, medical care costs, and increased mortality Also, VAP can aggravate the development of drug-resistant microorganisms and prolong intubation the length of stay in the intensive care unit. Oral care is one part of reducing the pathogens that cause VAP . Patients who are on ventilators will have their oral care with chlorhexidine. However, it was found that the effects of using chlorhexidine have side effects in both local areas and various body systems. It was found that when chlorhexidine is aspirated into the lungs, it can be harmful to lung tissue, causing acute respiratory distress syndrome and an allergic reaction to chlorhexidine, leading to anaphylaxis in some cases. In current practice,ventilator patients receive daily oral chlorhexidine care. However,recent research has called into question the efficacy and safety of oral chlorhexidine in VAP prevention.There is a study on oral care in patients who use ventilators using other liquids or solutions.Studies have been conducted on oral care in mechanically ventilated patients using various solutions or agents.The results of these studies comparing different oral care solutions, such as normal saline solution and povidone-iodine, showed no difference in the occurrence of VAP. As a result, the research team decided to investigate and compare the use of normal saline solution for oral care to determine whether it could prevent VAP as effectively as chlorhexidine, given that saline can prevent and reduce the potential harms associated with chlorhexidine use. This research aimed to 1) compare the incidence of ventilator-associated pneumonia between oral care with normal saline solution and chlorhexidine,2) identify the side effects of oral care with with normal saline solution and chlorhexidine, and 3)compare the oral health status between oral care with with normal saline solution and chlorhexidine This research is a noninferiority randomized controlled trial. The literature review was used to develop the clinical nursing practice guidelines.The sample group in the study was a group of patients who were admitted to the medical intensive care unit. The criteria were 1)using a ventilator for more than 2 calendar days, 2)being aged 18 years and older, 3)having platelet more than 50,000 cells/mm3.The exclusion criteria were 1) having an allergy to chlorhexidine and/or mouth ulcers, 2) being re-intubated within 24 hours, 3) being re-admitted and had participated in the study, 4) requiring surgery, and 5)being were diagnosed with VAP prior to participating in the trial. This research was conducted between February 2022 and April 2023. . The sample size was determined using a computer program, the Power and Sample Size Calculators, with an acceptable level of confidence (α) = .05, a test power (1-β) = .80, and the size of the non-inferiority margin (δ) = .05,resulted in a sample size of 69 people per group. Another 10% of the sample was added to prevent sample loss during the study, thereby having a total sample of 158 participants, which were then randomly divided into two subgroups,each with 79 people. The tools used for data collection included a personal data recording form,a VAP diagnosis data recording form,and an oral health data recording form. Data were analyzed using the chi-square statistic, Mann-Whitney U test, t-test, and Fisher’s exact test.The results showed that the participants of each group (n = 79) had similar baseline characteristics. A comparison was made between the occurrence of VAP during oral care with normal saline solution saline and chlorhexidine. The normal saline solution NSS group had a rate of 6.30% of VAP,while the chlorhexidine group had a rate of 7.60%,with no statistically significant difference.The difference in the proportion of VAP occurrence between the normal saline solution NSS group and the 0.12% chlorhexidine group was -1.30%(95%CI: -9.20 to 6.70%).The incidence of oral mucositis in normal saline solution and chlorhexidine was 0%and 7.6%, respectively. The oral health scores of both groups were mostly categorized as fair . The oral health scores in the saline and chlorhexidine groups were 64.56% and 49.37%, respectively.The oral health status between the two oral care groups was not statistically significantly different. In conclusion, the study’s results could not conclude that oral care with normal saline solution had the same chance of occurring VAP as using chlorhexidine solution. However, there was a side effect of using chlorhexidine solution,which wasoral mucositis. Therefore, research should be conducted in other contexts or organizations to verify the findings from this study or to conduct a long-term study. Additionally, factors that may affect oral health should be more strictly controlled.
Keywords: Chlorhexidine,Normal saline solution,Oral care,Oral mucositis,Ventilator-associated