Safety and efficacy of oral care for intubated neuroscience intensive care unit patients

University dissertation from Department of Health Sciences, Lund University

Abstract: The overall aim of this research was to investigate the safety of oral care in terms of intracranial dynamics and changes in oral health during intubation and 48 hours after extubation among neuroscience intensive care unit (NICU) patients. Additional aims included comparison of a comprehensive oral care protocol (i.e., tongue scraping, electric toothbrush, non-foaming toothpaste, and application of oral moisturizers) to a standard protocol (pediatric manual toothbrush, standard toothpaste, lubricant) with respect to safety and efficacy to promote oral health and to reduce the incidence of oral nosocomial bacteria and ventilator-associated pneumonia (VAP) in NICU patients.

First, a 12-month prospective cohort study with data from 45 intubated patients in an NICU was conducted to identify changes in oral health during intubation until 48 hours after extubation. Specifically, changes in oral health, intracranial pressure (ICP) recorded during non-specified oral care, the prevalence of oral nosocomial bacteria, and the incidence of VAP were analyzed. The results from the cohort study (Paper I) reflected significant deterioration in oral health during intubation and improved oral health 48 hours after extubation, as measured by the Oral Assessment Guide (OAG). During unspecified oral care methods, normal ICP recordings remained stable while ICP values greater than 20 mm Hg before oral care decreased after care (p<0.001). Progressive colonization of oral nosocomial bacteria was documented during intubation, and the overall rate of VAP was 24%. Based on literature and the results of the cohort study (Paper I), it was then hypothesized that a comprehensive oral care protocol would be safely tolerated by NICU patients, oral health would improve, and a decrease in oral nosocomial bacteria and the frequency of VAP compared to NICU patients receiving standard oral care would be observed.

A two-year randomized controlled trial (RCT) was therefore conducted to compare the outcomes of intubated NICU patients undergoing a standard oral care protocol or a comprehensive oral care protocol. Outcome variables included changes in ICP and cerebral perfusion pressure (CPP) among 47 patients (Paper II); changes in oral health among 56 patients (Paper III); and changes in oral and sputum nosocomial bacteria and the frequency of VAP among 78 patients (Paper IV).

During standard and comprehensive oral care (Paper II) ICP increased significantly (mean increase 1.7 mm Hg, p<0.001), while ICP decreased significantly (mean decrease 2.1 mm Hg) after oral care (p<0.001). Neither change was clinically significant. There were no changes in CPP before, during, or after oral care. Based on the total OAG score and all item measurements (p<0.001), oral health deteriorated significantly in patients receiving the standard protocol and large effect sizes were present (Paper III). The total OAG score of subjects receiving the comprehensive oral care protocol also deteriorated (p<0.004), but no deterioration was noted in the individual item scores for teeth, tongue, gingiva, or mucous membranes. During the first week of intubation, there were no significant differences in the oral and respiratory nosocomial colonization between groups (Paper IV). However, patients in the comprehensive group tended to have fewer nosocomial colonized oral and sputum samples. VAP rates were equivalent between the two treatment groups (p=0.61).

A comprehensive oral care protocol appeared to be safely tolerated in NICU patients with normal ICP values. Four key components of oral health (i.e., teeth, tongue, gingiva, and mucous membranes) were supported by the comprehensive oral care protocol. Further research is necessary to refine the psychometric properties of the OAG for intubated patients and to define optimum oral care practices for this at-risk population.