Oral Care to Address Aspiration-risk Patients

ASPIRATION PNEUMONITIS AND ASPIRATION PNEUMONIA

Paul E. Marik, M.B., B.CHN Engl J Med, Vol. 344, No. 9 ·March 1, 2001

“Aspiration pneumonia develops after the inhalation of colonized oropharyngeal material. Aspiration of colonized secretions from the oropharynx is the primary mechanism by which bacteria gain entrance to the lungs.”

Marik PE, N Engl J Med, Vol. 344, No. 9 ·March 1, 2001

Defining HAP and HCAPHospital-Acquired Pneumonia (HAP)

Not on Vent and Positive Respiratory culture after

2 days from admission.

Health Care-Associated Pneumonia (HCAP)

1. Transferred from another facility.

2. Long-term dialysis.3. Prior Hospitalization within

30 days who do not meet VAP definition.

Kollef MH, et al., Chest. Dec 2005;128(6):3854-62.

Positive respiratory culture within 2 days of admission and any of the following:

Patients At Risk

• Those suffering from neurologic dysphagia, stroke, COPD, malignancy, renal disease, dementia, liver disease, enteral feeding, suppressed immune systems, emergency room admission and more.1,2

1. Marik PE, N Engl J Med. 2001;344(9):665-71. 2. Kozlow JH, et al., Crit Care Med. 2003;31(7):1930-7

Predictors of Aspiration Pneumonia: How Important Is Dysphagia?*

Susan E. Langmore, PhD

Dysphagia 13:69–81 (1998) “Aspiration pneumonia is a major problem for the elderly, leading to hospitalization, costly care, and at times death. It accounts for anywhere from 13% to 48% of all infections in nursing home residents and is the second most common type of nosocomial infection in hospitalized patients, after urinary tract infections.”

Susan E. Langmore, PhD Dysphagia 13:69–81 (1998)

High Mortality, Longer Stays, Increased Costs

Kollef MH, et al., Chest. Dec 2005;128(6):3854-62.

Mortality

Length of Stay

Mean Hospital Charges

HCAP

19.8%

8.8 days

$27,647

HAP

18.8%

15.2 days

$65,292

VAP

29.3%

23 days

$150,841

Biofilm as a Risk Factor for Pneumonia

Staphylococcus aureus biofilm on an indwelling catheter.

Biofilm Defined

• A thin, usually resistant layer of microorganisms (as bacteria) that form on and coat various surfaces.

Biofilm. (n.d.). Merriam-Webster's Medical Dictionary. Retrieved July 03, 2007, from Dictionary.com website: http://dictionary.reference.com/browse/Biofilm

Biofilms and Infectious Diseases

• Biofilms have been found to be involved

in a wide variety of microbial infections

in the body– by one estimate, 80% of

all infections.

Immunology of Biofilms. Immunology and Immunotherapy Program, Center for Integrative Biology and Infectious Diseases, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, 2004.

Biofilms and Infectious Diseases

• Infectious processes in which biofilms have been implicated include common problems such as urinary tract infections, catheter infections, middle-ear infections, formation of dental plaque and gingivitis.

Immunology of Biofilms. Immunology and Immunotherapy Program, Center for Integrative Biology and Infectious Diseases, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, 2004.

http://www.erc.montana.edu/Res-Lib99-SW/Image_Library/Medical%20&%20Health/default.htm

How They Form

http://www.erc.montana.edu/Res-Lib99-SW/Image_Library/Structure-Function/default.htm

Formation of Biofilm Biofilm forming over 12 hours

http://www.tumoutou.net/702_05123/it_jamilah.htm

Plaque as a Biofilm

http://www.erc.montana.edu/Res-Lib99-SW/Image_Library/Medical%20&%20Health/default.htm

Biofilm Dispersing

http://www.erc.montana.edu/Res-Lib99-SW/Image_Library/Structure-Function/default.htm

Biofilm Entering into Alveoli

http://www.erc.montana.edu/Res-Lib99-SW/Image_Library/Medical%20&%20Health/default.htm

Biofilm Growing and Strengthening

http://www.erc.montana.edu/Res-Lib99-SW/Image_Library/Medical%20&%20Health/default.htm

Biofilm Calcifies

http://www.erc.montana.edu/Res-Lib99-SW/Image_Library/Medical%20&%20Health/default.htm

How Do WeHow Do We

Combat Biofilms?Combat Biofilms?

Mechanical Cleansingwith Antiseptic Agent

Oral Health Care Drug Products for Over-the-Counter Human Use;Antigingivitis / Antiplaque Drug Products;Establishment of a Monograph;Federal Register,68(103):32232-87 (available atwww.fda.gov/cder/otcmonographs/Oral_Health_Care/gingivitis_&_plaque_PR_20030529.pdf).2

Oral Debridement

Oral Health Care Drug Products for Over-the-Counter HumanUse;Tentative Final Monograph;Federal Register,53(17):2436-61 (available at www.fda.gov/cder/otcmonographs/Oral_Health_Care/oral_health_care_TF_PR_19880127.pdf).

With q12º brushing and q2º-q4º swabbing, we should stop the development of biofilms.

http://www.tumoutou.net/702_05123/it_jamilah.htm

Recap

Mechanical Cleansing with an oral antiseptic helps to kill and remove biofilms.

Oral Debridement helps lift and remove inactive biofilms that are left behind.

Listen to the ExpertsCDC Guidelines for Preventing Health Care-Associated Pneumonia

*In addition to other interventions.

1.Tablan OC, et al., “Guidelines for preventing health-care--associated pneumonia, 2003,” Recommendations of CDC and HICPAC, 2003.

“...Develop and implement a comprehensive oral-hygiene program (that might include use of an antiseptic agent) for patients in acute-care settings or residents in long-term--care facilities who are at risk for health-care--associated pneumonia (II).”*,1

ACCN Practice Alert

• Expected Practice:• Develop and implement a comprehensive oral

hygiene program for patients in critical care and acute care settings who are at high risk for healthcare-associated pneumonia.Brush teeth, gums and tongue at least

twice a day using a soft pediatric or adult toothbrush.

In addition to brushing, provide oral moisturizing to oral mucosa and lips every

2 to 4 hours.AACN Practice Alert - Oral Care in the Critically Ill - Aug 2006.

Oral Care Reduces Pneumonia in Older Patients in Nursing Homes

Yoneyama et al. J Am Ger Soc 50:2002

• 11 nursing homes in Japan.

• 417 patients randomly assigned to “oral care” or “no oral care.”

• Oral care provided by nurses or caregivers.

• Pneumonia, febrile days, death from pneumonia decreased significantly in patients with oral care.

Yoneyama et al. J Am Ger Soc 50:2002.

• Marik says “Any condition that increases the volume of bacterial burden of oropharyngeal secretions in a person with impaired defense mechanisms may lead to aspiration pneumonia.

• Neurologic dysphagia, stroke,

COPD, malignancy, renal disease,

dementia, liver disease, enteral

feeding, suppressed immune

systems, emergency room

admission and more.1,2

Who’s at Risk?

1. Marik PE, N Engl J Med. 2001;344(9):665-71. 2. Kozlow JH, et al., Crit Care Med. 2003;31(7):1930-7

Oral Care for Everyone

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Evidence Based Protocols

• Assessment

• Cleaning

• Debriding

• Suctioning

• Moisturizing

Support

• Educational Website

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• Implementation plan

• Protocol support tool

• Cost Justification tool• Performance Improvement plan

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