Infiltration of microbial agents in the parenchyma of the lungs causes pneumonia

Pneumonia is caused by the infiltration of microbial pathogens into the lung parenchyma. In turn, the infiltration produces lung irritation. Ventilator-associated pneumonia occurs 48 hours after the intubation phase has ended (Gohel & Kirby, 2016). Gram-negative bacteria may colonize dental plaque, contributing to the oropharyngeal bacterial pool. This happens in people who are sedated and have mechanical ventilation. Dental plaque colonization is caused by a decrease in saliva flow, a lack of natural tongue and mouth movements, and infrequent saliva swallowing (Jang & Shin, 2016). Additionally, biofilm, increased colonization, dental plaque formation and growth of pathogens is caused by the failure to clean the oropharynx, the teeth, and the oral cavity.

Synthesis of Evidence

Timely treatment of patients suffering from ventilator-associated pneumonia may be worthwhile as it is lifesaving. The natural defense system of the body is impaired when the endotracheal tube bypasses the epiglottis (Gohel, & Kirby, 2016). This occurs when the endotracheal tube bypasses pathogens that enter the respiratory tract from the oropharynx. The latter makes patients under ventilator treatment more susceptible to nosocomial infections that are airway. The best weapon against Ventilator-Associated Pneumonia (VAP) is oral care and hygiene (Jang & Shin, 2016).

Clinicians base their research on the review of nursing practices that are closely related to oral care, compliance with oral care protocols and method of application (Gohel, & Kirby, 2016). The reduction of VAP rates techniques have resulted to low patients taken to the Intensive Care Unit (ICU). The latter has been widely attributed to compliance with the preventive techniques that have been researched on in the recent past (Ikeda, Yoshizawa, Takahashi, Ishida, Komai, Kobayashi, & Sugiura, 2016). However, studies have also proved that some of the clinicians view the oral care as a measure to comfort the patients diagnosed with VAP and not necessarily as a preventive measure for VAP. The misunderstanding by the nurses has led to their improper compliance to the protocols related to oral hygiene protocols.

Also, nurses under critical care units attest the perception of mouth care treatment and oral care practices have remained inconsistent to them claiming that they are just means of comforting the patients ailing from VAP. They also argue that the treatment of VAP should be based on critical components of the disease and not any other factor that doesn’t align with the bacterial infection caused to the lung parenchyma. Nurses, being taking the frontline as care provision, recognize that prevention of VAP is through the maintenance of oral hygiene which they consider a priority control measure.

VAP Pathophysiology

The translocation of endogenous or the exogenous bacteria into the lower respiratory tract that is commonly considered sterile is the means through which intubated patients develop VAP. The occurrence of the translocation process may be through the inhalation of the bacteria from a causative equipment that is contaminated, hematogenous seeding, contagious spread and gastric colonization.

Oral Hygiene and VAP

In patients who have established health, the oral cavity is considered to be the home to common flora species well as microbes that are highly infectious to them. To secure these people from infection, the oral cavity is kept in check from time to time by ensuring the immune defenses are intact. However, in patients that are critically ill, their immunologic defenses systems may be incapable of combating the infectious microbes. Invasive ventilatory support and inadequate oral hygiene create fairgrounds and a high risk for the development of VAP. This is because the mouth is the reservoir for plaque and pathogens.

Oral care has a broad range of help attributed towards aiding the treatment of VAP; minimizes the proliferation of secondary bacteria to the xerostomia, stimulates the flow of saliva that further helps in getting rid of microbial plaque, contains protective immunoglobins and also relieves the mouth of bacterial burden. Opportunistic organisms flourish leading to the colonization of the oropharyngeal site when oral care is not provided to patients that are mechanically ventilated. Considering such infection, the Pseudomonas aeruginosa, which forms resistance to most antibiotics and a distinct slightly putrid sweet odor, contributes to the colonization of the oropharyngeal site.

The micro-organisms in oral cavities can be removed by through routine oral care that reduces the likelihood of inhaling them into the lungs. Oral diseases and associated infections can be prevented through decontamination and adequate oral care. Through research carried out in the recent past, the incidences of VAP have reduced by 44% from the previous 90% through the implementation of oral care protocol (Ikeda, Yoshizawa, Takahashi, Ishida, Komai, Kobayashi, & Sugiura, 2016).

Effectiveness of Oral Care

Oral care for intubated patients should be a high priority nursing activity. This is attributed to the high cost of treatment, the suggestive evidence that oral care can be the most effective means to reduce VAP risk and the mortality and morbidity associated with VAP (Niederman, 2016). However, oral care has been continually perceived as a comfort measure that is non-essential rather than a fundamental aspect of infection that can safely be omitted. Additionally, this point is argued from the perspective that nurses often deliver the oral care treatment in an ineffective means making it useless to the patients. This argument is not based on evidence but rather on persistent habits and traditional ideas (Niederman, 2016). In order to make the oral care system an effective treatment method for patients diagnosed with VAP, the nurses administering the treatment must think beyond patient, knowledge and system barriers that may stand to oppose the approach.

Barriers; Knowledge, Patient, and System

Knowledge Barriers

The prevention of hospital-acquired infection such as VAP is faced with one major significant barrier; the gap between practice and evidence. In the most topics underlying nursing education, the topic on the link between systematic infections and oral health is usually inadequately covered (Niederman, 2016). Studies and research conducted also shows that oral pedagogy in the 68 nursing textbooks that had been published between 1870-1997 remained formulaic and had not yet been practically influenced (Ikeda, Yoshizawa, Takahashi, Ishida, Komai, Kobayashi & Sugiura, 2016). Some of the recently published text books on nursing were found to contain erroneous information on oral treatment and hygiene procedures. This is one mean of misguiding students taking the nursing course and would later on in their lives render them incompetent in their lines of work.

Patient Barrier

The studies done in the recent past on Intensive Care (ICU) give the suggestion that oral care routine is not delivered during daytime hours and most likely within the first two days of admission to the unit. This is very dangerous as this is the period within which most patients are most susceptible to changes by the by oral flora (Do, Seah & Phee, 2016). The delay in the admission of the system care is often attributed to the false thought that oral care isn’t as effective to patients compared tom other forms of interventions. This is quite absurd considering the fact that during the admission time, most of the nurses mostly focus on the stability if the patient’s health condition. Other factors may also be the endotracheal tube restricts access to the oral cavity making it risky to administer the treatment as it may dislodge the tube, cause discomfort to the patient or provoke aspiration (Do, Seah & Phee, 2016). From then argument point of the nurses in the neuroscience ICUs; the administration of oral care will lead to an increase in the pressure within the intracranial. Contrary to the latter, research suggests that oral poses no effect on the intercranial pressure and research should be carried in patients with intubated head injuries (Do, Seah & Phee, 2016). In addition, some patients also make it difficult for the nurses to administer oral care as some may have sensory deficits, communication difficulties or at times quite confused.

System Barriers

Other than factors discussed above, some of the reasons for the omission of oral care may be due to high patient acuity, time constraints, insufficient staffing, demanding workload and even the direction of attention towards other ICU patients. Evidently, the high Patient-nurse ratios increased the risk of VAP (Chipps, Carr, Kearney, MacDermott, Visger, Calvitti, Vermillion & Landers, 2016). Other factors that further impede oral care in intubated patients is the lack of supplies and absence of medical procedures.

Conclusion

Owing to the possible confusion that arises relating to the admission of oral care to intubated patients, oral care education program should be carried out by the American Association of Critical-Care Nurses (AACN) to clarify doubts and guiding on how oral care treatment should be conducted. The Association for Professionals in Infection control and Epidemiology recommend and approve the education of nursing students on preventing health care acquired pneumonia in their particular institutions((Niederman, 2016). Additionally, they also support the use of oral care products and practices (Danckert, Ryan, Plummer & Williams, 2016). The experts also insist that the education program should include institutional policies, rates on VAP and development of oral care protocols. It is also vital that nurses compare clinical guidelines and health care recommended by various medical institutions so that they come up with better health care policies and treatment methodologies (Niederman, 2016).

References

Chipps, E. M., Carr, M., Kearney, R., MacDermott, J., Visger, T., Calvitti, K., Vermillion, B., ... Landers, T. (April 01, 2016). Outcomes of an Oral Care Protocol in Postmechanically Ventilated Patients. Worldviews on Evidence-Based Nursing, 13, 2, 102-111.

Danckert, R., Ryan, A., Plummer, V., & Williams, C. (March 01, 2016). Hospitalisation impacts on oral hygiene: an audit of oral hygiene in a metropolitan health service. Scandinavian Journal of Caring Sciences, 30, 1, 129-134.

Do, T. N., Seah, T. E. T., & Phee, S. J. (June 01, 2016). Design and Control of a Mechatronic Tracheostomy Tube for Automated Tracheal Suctioning. Ieee Transactions on Biomedical Engineering, 63, 6, 1229-1238.

Gohel, T. D., & Kirby, D. F. (January 01, 2016). Access and Complications of Enteral Nutrition Support for Critically Ill Patients.

Ikeda, T., Yoshizawa, K., Takahashi, K., Ishida, C., Komai, K., Kobayashi, K., & Sugiura, S. (January 01, 2016). Effectiveness of electric toothbrushing in patients with neuromuscular disability: A randomized observer-blind crossover trial. Special Care in Dentistry, 36, 1, 13-17.

Jang, C. S., & Shin, Y. S. (October 01, 2016). Effects of combination oral care on oral health, dry mouth and salivary pH of intubated patients: A randomized controlled trial. International Journal of Nursing Practice, 22, 5, 503-511.

Niederman, M. S. (March 01, 2016). New Strategies to Prevent Ventilator-Associated Pneumonia: What to Do for Your Patients. Current Treatment Options in Infectious Diseases, 8, 1, 1-15.