1. INTRODUCTION
The aim of this report is to support the evidence of prevention of Ventillator Associated
Pneumonia(VAP), by providing appropriate oral care in mechanical ventilated patient of
Intensive Care Unit(ICU)
Ventilator Associated Pneumonia is the infection caused by nosocomial bacterial pneumonia
which develops in patient receiving mechanical ventilation says Kollef(1999). According to
author Zack et al.(2002), Ventilator Associated Pneumonia is the main reason for mortality
and extended hospital stay for the ICU patients who are mechanically ventilated. According
to Doyle, A.(2011), the incidence and mortality rate of VAP is estimated 10-20% and
15-50% respectively. In order to prevent the incidence and prevalence of VAP bundled
practices associated with preventive strategies are need for improving the health of the
patients, says Pruitt & Jacobs(2006). Thus VAP being an essential aspect for nurses in ICU
for adaption of current research on evidence based practises for the prevention of Ventillator
Associated Pneumonia.
LITERATURE SEARCH METHODOLOGY
The data base used for the research are Cinahl Plus; the British Nursing Index; the Cochrane
Library; Medline and Psych Info. Results on search option included Full text, Reference
Available, Abstract Available, Publication date 2006-2011. The search word is nosocomial
infection, critical care unit, Intensive Care Unit Nurses, Ventilator Associated Pneumonia,
prevention, Evidence Based Practice for nurses.
RESULTS FROM LITERATURE SEARCH
Search on nosocomial infection produced 1567 results. In this wide aspect of infection
acquired in hospital, I short listed the research on ventilator associated pneumonia in
intensive care unit. This brought the results to 487 and on the issue of its prevention I got 47
results. In various ways of prevention strategies I took oral care in prevention of VAP which
sorted 10 reliable research articles for critiquing.
KEY WORDS: nosocomial infection, ventilator associated pneumonia, intensive care unit,
prevention, critically ill, ICU nurses.
THE EVIDENCE: TOOTH BRUSH Vs CHLORHEXIDINE.
In Munro et al(2009), the research article is done critically ill adults. The subjects are the
patients of three different ICU’s (medical , surgical/trauhe effect ma, neuro). The study is
about the effect of tooth brushing and chlorhexidine in the prevention of Ventilator
Associated Pneumonia(VAP). Out of (n = 10913) the total patients in all the ICU’s only (n =

2. 547) were selected for the study. The inclusion criteria for the study is no previously
intubated patients, patients with dental problem, patients in ventilation were included within
24 hours, no present history of pneumonia during intubation. This is a randomised controlled
trial done on 2 by 2 factorial experimental design. Ethical rights reserved from Office of
Research Subjects of Virginia Common Wealth University, Richmond, Virginia. The four
treatments include for the study are 0.12% chlorhexidine solution given by oral swab, tooth
brushing thrice a day, chlorhexidine twice a day and usual care. In tooth brushing technique,
all the four quadrants of the mouth is thoroughly brushed by five strokes in each quadrant.
Whereas the palate and tongue were rinsed with Biotine 2.5ml per area. In applying
chlorhexidine solution method, tooth swab was used to coat all the tooth, tongue and palate.
Using descriptive statistics, the data analysis is done for the percentages for discrete variables
and mean. Used standard deviation, the data analysis for continuous variables is done to the
study population. The sample number (n = 547) is reduced to (n = 192) on day 3 and again
reduced to (n =158) on day 5 out of 158 patients 116 remained in analysis sample and 51
patients without pneumonia at baseline. Clinical Pulmonary Infection Score (CPIS)
evaluating on the effect of prevention of pneumonia, (CPIS>_6) is presence of pneumonia
and (CPIS_<6) absence of pneumonia. On day 5 the samples count has been brought to (n =
76) in analysis sample and (n = 37) of patients without pneumonia at baseline. The results of
the study is delivered as tooth brushing did not have any effect on prevention of pneumonia
with the mean (SD) value showing (Pa = 0.21%). Chlorhexidine has mean (SD) value of (Pb
= 0.46%) in the prevention of pneumonia. Chlorhexidine technique only had the bactericidal
activity which helped in preventing pneumonia to occur in intubated patients. But tooth
brushing technique had just helped in reduction of micro organism thus not able to prevent
pneumonia iv intubated patients. According to Zack et al(2002), he in his observational study
found within a year the prevalence of VAP in ICU’s i brought down by (P< 0.001). this is
made by providing oral care atleast once in a day, extubation of patients on ventilator as soon
as possible, elevating the head end, reduction in more use of antibiotics and maintaining
ventilatory circuit management. The results also show that individual effect of tooth brushing
alone would not have given this result of prevention of VAP. In an another study by Koeman
et al(2006), he conducted a randomised control study which detected the effect of 2%
chlorhedine or 2% chlorhexidine with colistin combination on prevention of VAP. The
results show good effect on prevention of VAP ( chlorhexidine Vs control, P = 0.01) and
( chlorhexidine + colistin , P = 0.03). this shows that chlorhexidine has greater effect in the
prevention of Ventilator Associated Pneumonia.
THE EVIDENCE: EFFECT OF ORAL CARE
In Cutler et al(2005), conducted an observational study conducted on patients in 8 different
ICU’s ( medical, surgical, neurological, cardiac and trauma diagnosis). The sample size is (n
= 253) out of that 139(55%) of patients were observed during the baseline phase and
114(45%) during the intervention phase . Descriptive statistics, mean and SD were data
analysis method used for valuating continuous data. Percentages and numbers used for all the
variables described in the study. In base line phase, observation of oral care is done in which
the swabs impregnated with sodium bicarbonate combined with 1.5% hydrogen peroxide

3. solution. But no assessment has been done on oral cavity, whether tooth brushed, whether
lips and mouth moisturized, whether oropharyngeal suctioning done or tubing’s changed
often. In interview phase of observation all procedures pre and post care and assessment was
done on oral care. These observations done by nurses were happened only for four hours
which should have lasted from 11pm till 5am. Nursing staff thinking of not to disturb patients
and guessing on the effect of oral care made the study weak. This paved way for Hawthrone
effect. Thus this observational study had no effect in finding the effect of oral care in
ventilator patients for prevention of Ventilator Associated Pneumonia. In Cutler, C. J.(2005),
in his observational study on 253 patients implementation of oral care on patients in
mechanical ventilation has positive effect on health of patient. This adds to the evidence
based support on oral care in prevention of VAP. Feider, L.L.(2010), a descriptive, cross
sectional study says that oral care practices prevail in nurses but not effective in prevention of
VAP.
THE EVIDENCE: INTUBATED PATIENTS AND PNEUMONIA
In Prendergast, V. Et al, the research study was conducted in patients of Neuroscience
Intensive Care Unit to find the development of VAP due to the changes in oral health and its
effect on intracranial pressure. This is an experimental study done on 45 consecutive patients
in the Neuroscience ICU for 1 year. Patients bio-chemistry values are checked often to find
the growth of gram-negative bacteria before and after intubation. The occurrence of VAP was
checked particularly after 72 hours after intubation. Abnormalities in WBC cells either
leuckocytosis or leukopenia, changes in body temperature, any purulent pulmonary secretion
and chest radiography results. Results show that on day 4 out of 31 patients on experiment
8(26%) developed VAP and on day 7 out of 21 patients 7(33%) developed VAP. Finally on
day 10 out of 13 patients 6(46%) had VAP. The gram-negative bacteria detected on these 6
patients is the reason for VAP in intubated patients of Neuroscience ICU. From this study it
is evident on the need of oral care on intubated patients.
BEST PRACTISE
Accountability and reliability are the prime source for nurses on decision making says
Nursing and Midwifery Council(2008). Decision making in life is done either by following
philosophical contents of ones belief or by trial and error method of life. In nursing field
decision making solely depends on the evidences, trends and issue, research. Evidenced
Based Practice is the best way for practice and for the improvement in health status of the
patient. In preventing Ventillator associated Pneumonia among intubated patients there are
many practices that are followed in different hospitals in relevance to their policies. Looking
on to the evidences of research on the large number of samples for the effect of best care oral
care plays a major role in preventing VAP. Though there are many techniques involved in
prevention like head end elevation of 30-40 degree, suctioning the endo-tracheal secretion
periodically, changing intubators periodically and by not extending hospital stay. It is a
complete care and preventive strategy for VAP to have a combined effect on oral care.
Chlorhexidine plays the dominant role in prevention through oral care. The clinical research

4. evidences of Munro et al(2009), Koeman et al(2006) shows that it has greater effect than
tooth brushing or suctioning.
DISCUSSION
Prevention of Ventilator Associated Pneumonia has always been a challenge for nurse in
ICU. Because patients admitted without this infection after days of hospitalization develops
VAP. Nurses have their accountability on this. Though any nurse follows possible step in
promoting the health, there are certain areas which cannot be guessed or predicted in
accordance to their experiences. Thus research on the problem faced by nurses on this
problem is essential. Ventilator has both sides like a coin . it saves the life of patient by
giving oxygen and it helps in easy formation bacterial colonization. Researches have
described the effect of each step of the nurse on the prevention. They are less use of
antibiotics, head end elevation, suctioning oral secretion, changing intubators periodically,
accepting aseptic technique, mechanical tooth brushing, using chlorhexidine solution. Among
these nurse is ready to follow the appropriate care for the prevention. Thus there will be no
place for experienced staff ideas or hospital policies. Thus evidence based practice helps in
solving the problem.
LIMITATIONS
Though Evidence Based practice have some wide range in its uses for nurses in providing
care for the patients. It also has some drawbacks on its effect and issue. In this research on
preventing VAP by providing appropriate oral care, the research has widely concentrated on
only the possible technique used for killing gram-negative bacteria. These bacterias are the
major causating agent for pneumonia. But the research have not explained how this particular
gram-negative bacteria has got into patients circulatory. It have not explained the source of
developing for these bacteria. Intensive Care Unit is supposed to have clean and sterile
environment. Only nurses, physiotherapist and physician were supposed to be inside any
ICU. Nurses handle the patients physically according to universal aseptic and sterile
technique. Also researchers have not explained about why there is increase in bacterial count
after three days for this particular infection VAP, even after administering specific
antibiotics. Likewise the different techniques in prevention of VAP, using chlorhexidine is
just a simple technique in reducing the bacterial count. Research has to be made strong on
avoiding completely the act of micro-organism.
CONCLUSION
The patients who took part in the study in very large number in the hospital sector has made
the research effective..Though there are many practices that have been widely used by
clinicians and nurses which have less effect in the prevention of VAP. Using chlorhexidine
has a greater effect than all other techniques. Effective nursing care is based on following the
latest trends and issues in nursing that are really helpful in bringing betterment of the patient
condition. Nurse has the part in accountability of patient condition and acts as an advocator
for the patient. Thus Evidence Based Practice helps the nurse to overcome clinical trial and
place the research on the right time for recovery of the problem

5. REFERENCES
Cutler, C.J. & Davis, N.(2005). ‘Improving oral care in patients receiving mechanical
ventilation’. American Journal Of Critical Care. 14(5).pp.389-394.
Doyle, A., Fletcher, A., Carter, J., Blunt, M. & Young, P.(2011). ‘The incidence of ventilator-
associated pneumonia using the PneuX System with or without elective endotracheal tube
exchange: A pilot study’. BMC Research Notes.4(92).pp.1-5.
Koeman M, van der Ven AJ, Hak E, et al(2006). ‘Oral decontamination with chlorhexidine
reduces the incidence of ventilator associated pneumonia’. Am J Respir Crit Care Med.
;173(12):1348-1355.
Kollef, M.H.(1999). ‘The prevention of ventilator-associated pneumonia’.
New England Journal of Medicine.340.pp.627–634.
Feider, L.L., Mitchell, P., Bridges,E.(2010). ‘Oral care practices for orally intubated critically
ill adults’. American Journal Of Critical Care. 19(2)
Munro, C.L. , Grap M.J. , Jones, D.J. , Mclish, D.K. (2009). Chlorhexine, Toothbrushing and
Preventing Ventilator Associated Pneumonia In Critically Ill adults’. American Journal Of
critical Care.18(5).pp.428-437.
Prendergast, V., Halberg, I. R., Jahnke, H., Kleiman, C.(2009). ‘Oral health, Ventilator-
Associated Pneumonia and Intracranial Pressure in intubated patients in a Neuroscience
Intensive Care Unit’. American Journal Of Critical Care.18(4).pp.368-375.
Pruitt B. & Jacobs M. (2006). ‘Best practice interventions: How can you prevent ventilator-
associated pneumonia?’.Nursing. 2006, 36(2), 36–42
Zack, J.E. & Garrison, T. & Trovillion, E. Et al(2002). Effect of an education programme
aimed at reducing the occurrence of ventilator associated pneumonia’.. Critical care
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