Oral Care in Mechanically Ventilated Adults

Oral Care in Mechanically Ventilated Adults

Background & Goal

Mechanically ventilated critically ill adults, whether resulting from planned, urgent or emergent intubation, are at high risk for many healthcare acquired infections, particularly ventilator-associated pneumonia (VAP). Prior to Dr. Munro’s research, Oral Care in Mechanically Ventilated Adults, one in four patients who were mechanically ventilated in the ICU developed VAP, with 25% to 75% dying as a result.

Mechanically ventilated patients in the ICU are dependent upon nurses for many self-care activities, including oral care. However, despite the fact that oral care was a standard component of care for mechanically ventilated patients, there was little evidence to judge the benefits or associated risks of oral care. Prior research to reduce VAP included oral or systemic administration of prophylactic antibiotics, but these methods were necessarily limited due to the threat of increased antibiotic resistance in ICU’s. Dr. Munro’s project, Oral Care in Mechanically Ventilated Adults, focused research on the long-term goal of providing definitive guidance for effective evidence-based oral care interventions to reduce VAP and other healthcare acquired infections. 

Program Description

With continuous NIH funding, Dr. Munro conducted three sequential randomized controlled clinical trials (RCTs), with the third currently underway. Dr. Munro’s first RCT examined the effects on dental plaque and risk of VAP with tooth brushing and chlorhexidine application, alone and in combination.  The results of this RCT revealed that ventilated patients who received .12% solution chlorhexidine oral swab twice daily had significantly reduced incidence of pneumonia, but that tooth brushing neither reduced the risk of VAP nor enhanced the effect of chlorhexidine. 

Dr. Munro’s second RCT more closely scrutinized the role of chlorhexidine to determine if adding a pre-intubation application of chlorhexidine further reduced the risk of VAP. The study revealed that pre-intubation application of chlorhexidine did not reduce the VAP risk beyond that afforded by the post-intubation application guidelines, an important finding permitting providers to forego pre-intubation chlorhexidine application for other critical pre-intubation activities that may yield benefits to the patient.

For More Information Contact:


Associate Dean of Research and Innovation, Professor
University of South Florida College of Nursing
12901 Bruce B. Downs Blvd, MDC22
Tampa, FL 33612-4766

Currently, Dr. Munro is conducting a large RCT to determine the optimal frequency of tooth brushing for critically ill, mechanically ventilated patients in order to maximize oral health benefits such as control of mucosal inflammation and dental plaque, while minimizing systemic risks, including healthcare-acquired infections and inflammation. 

Evidence of Success

  • Dr. Munro’s finding that chlorhexidine reduced the risk of VAP was published in September of 2009 and, soon thereafter, in May of 2010, her findings were referenced by the Institute for Healthcare Improvement (IHI) in its updated national recommendations for the care of mechanically ventilated patients (the ventilator bundle), and now the CDC, to include daily oral care with chlorhexidine.By finding that swabbing the mouth with chlorhexidine every 12 hours following intubation suppresses the growth of potential VAP pathogens in the mouth and reduces VAP risk, Dr. Munro’s research provided specific evidence-based guidance for the common nursing intervention of oral care in mechanically ventilated adults.
  • Dr. Munro’s first RCT revealed VAP rates 28% lower in patients who received chlorhexidine as compared to those who did not.
  • Over the past decade, rates of VAP have fallen significantly, to an estimated current 5% of mechanically ventilated patients, as a result of concerted attention to VAP prevention, including a prominent focus on science based oral care practices.
  • With each episode of VAP estimated to cost an additional $5000 in hospital costs, extrapolating Dr. Munro’s first RCT findings of a 28% reduction in the rates of VAP to the 1.7 million mechanically ventilated patients nationally each year, evidenced-based oral care every 12 hours with chlorhexidine could yield a savings of $2 billion annually.