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.
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.