Running head: CHLORHEXIDINE GLUCONATE IN THE PREVENTION OF VAP
Chlorhexidine Solution in the Prevention of Ventilator Associated Penumonia
Ashley Borowiak
Ferris State University
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Running head: CHLORHEXIDINE GLUCONATE IN THE PEVENTION OF VAP
Abstract
With ventilator-associated pneumonia being the leading cause of death in intensive care units
and the most common hospital-acquired infection, we need to ask what we can do to improve
these outcomes. Chlorhexidine gluconate has been used to prevent colonizing bacteria from
traveling into the lungs leading to pneumonia. This paper will discuss the results of nursing
research to determine the effectiveness of chlorhexidine gluconate in the reduction of
ventilator-associated pneumonia and how this evidence based practice can be implemented
into nursing policies.
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Running head: CHLORHEXIDINE GLUCONATE IN THE PEVENTION OF VAP
Chlorhexidine Gluconate in the Prevention of Ventilator Associated Penumonia
Ventilator-associated pneumonia is a hospital acquired infection which occurs when bacteria is
aspirated into the lungs 48 hours after intubation (Roberts & Moule, 2011). It has been found
that chlorhexidine gluconate (CHX) is recommended in the routine oral care of a mechanically
ventilated patient. CHX is a broad spectrum anti-bacterial which kills the plaque and bacteria
which migrate from the mouth to colonize in the lungs when aspirated, something that a
ventilated person is at high risk for (Roberts & Moule, 2011). In addition to oral care, other
measures taken to prevent VAP include ensuring the head of the bed is elevated at all times,
daily breaks from sedation, assessment for readiness for extubation and prophylaxis for peptic
ulcers and deep vein thrombosis (Hutchins, K., Karras, G., Erwin, J. & Sullivan, K. L., 2009).
With this being said, oral care plays a large role along with these other interventions to reduce
VAP, and the question is whether CHX should be incorporated into this bundle of
interventions.
PICO Question
Not only does ventilator-associated pneumonia (VAP) increase hospital expenses and
care provided to the patient, it can mean a poor prognosis for a patient who is on a ventilator
for any length of time, whether it be a temporary or permanent ventilation. VAP is one of the
most common hospital-acquired infections, and is the leading cause of death in intensive care
units (Booker, Murff, Kitki & Jablonski, 2013). Oral care should be performed frequently and
routinely on patients who are mechanically ventilated to prevent the aspiration of infected
contents into the lungs. This can be done using a number of techniques and solutions, but does
using chlorhexidine gluconate solution specifically reduce the number of cases of VAP
compared to using other oral techniques in mechanically ventilated patients?
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Running head: CHLORHEXIDINE GLUCONATE IN THE PEVENTION OF VAP
The quality of care delivered to patients is pertinent in the outcomes of their current
health status. Patients who are intubated through the endotracheal route may be ventilated
permanently or temporarily, though both of these individuals are at a great risk for developing
VAP and other infectious diseases if proper preventative measures are not taken. Much
research has been done to find the best evidence based practice to successfully prevent VAP,
though many studies are focusing on the effects of CHX and its role in reducing the number of
cases of pneumonia contracted in the ventilated patient.
A nursing leader in this profession will use many ways to communicate this information
to other colleagues and staff to reduce the numbers of VAP. Infection prevention is a key
component in the research findings of CHX solution and VAP, and an infection control nurse
and physician would conduct research or discover what the best method of oral hygiene is best,
and implement this into the practice standards of their institution. CHX solution is a
prescribed solution, only to be administered by those who are licensed to give medications.
Many times unlicensed personnel are performing oral care with routine hygiene practices, and
these individuals cannot administer CHX solution. With this being said, nursing leaders must
ensure that the correct personnel are available to administer oral care using the prescribed
medications and that it is being performed correctly to maximize the results.
Research Findings
A study was performed at Mercy Medical Center and a quality improvement program
was developed to decrease VAP by implementing a ventilator bundle using some of the
interventions listed above along with deep oral suctioning and oral care at least twice a day and
as needed using CHX. From 2004 to 2007 after the implementation of the ventilator bundle,
the VAP rate was decreased by 89.7%, and after the bundle was initiated, the decrease in VAP
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Running head: CHLORHEXIDINE GLUCONATE IN THE PEVENTION OF VAP
rate was almost immediately present (Hutchins, K., Karras, G., Erwin, J. & Sullivan, K. L.,
2009). This quality improvement project directly related a decrease in cases of VAP to the
addition of the ventilator bundle and CHX.
Roberts & Moule (2009) completed a literature review of a large amount of studies
conducted to determine the effectiveness of CHX. Their review found that the use of CHX has
been proven to reduce VAP, though may be more effective when it is used with a solution that
targets gram-negative bacteria. The research also found that CHX was effective in reducing
dental plaque in patients, therefore reducing hospital acquired infections, such as VAP
(Roberts & Moule, 2009).
In a study conducted on the effects of chlorhexidine in the newly intubated trauma
patients, it was found that when a single application of CHX was applied to the oral cavity, the
patients’ chance of developing VAP vastly decreased (Grap, Munro, Hamilton, Elswick,
Sessler & Ward, 2011). The standard recommended dose is 15 mililiters for an oral rinse in an
alert patient, though in this particular study, an amount as small as two milliliters was adequate
enough to cover the entire oral cavity and decrease the colonizing bacteria from spreading
down the respiratory tract into the lungs. (Grap, Munro, Hamilton, Elswick, Sessler & Ward,
2011).
The nursing research discussed above shows that CHX oral rinse in even small amounts
can be effective in preventing VAP. The bacterial organisms that can cause pneumonia in
ventilated patients can be killed using CHX, and should be implemented in patients who are at
high risk for developing pneumonia secondary to mechanical ventilation. The research
discussed above shows how effective CHX can be with the implementation of other
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Running head: CHLORHEXIDINE GLUCONATE IN THE PEVENTION OF VAP
interventions and evidenced based practice should show that these interventions should be
implemented.
Recommendations to Improve Quality and Safety
While research shows the effectiveness of CHX rinse to decrease pneumonia secondary
to ventilation, it is still not a common practice. Some health care professionals may not be
aware of the benefits that research has proven, or they might not have the resources to
implement these practices. Often times, unlicensed personnel are providing oral care to
ventilated patients during their hygiene rounds. These individuals are not licensed and
therefore are not able to administer CHX solution. If units do not have the proper licensed
personnel to administer these medications proven to be effective, then the desired results may
not be achieved. Having the available resources at hand, such as proper staffing, will assist in
aiding to decrease VAP cases.
These research findings are showing that evidence based practice shows that CHX
solution can be safely used in practice to provide a better outcome for the patient. With quality
and safety in mind, facilities can provide exceptional care to their patients by offering them the
best methods of care which are supported by research. By offering this information to patients
and their families, they will be assured that quality care is being delivered with up to date
research in mind.
While research has answered the question regarding the effectiveness of CHX rinse in
mechanically ventilated patients to reduce the risk of developing VAP, the problem still stands
as to what is standing in the way of these policies being implemented in facilities as a practice
standard. Though barriers have been recognized, many of these barriers in which stand in the
way of these desired outcomes are able to be changed and new policies implemented.
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Running head: CHLORHEXIDINE GLUCONATE IN THE PEVENTION OF VAP
Research on this subject needs to continue to ensure that evidence based practice is being
implemented.
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Running head: CHLORHEXIDINE GLUCONATE IN THE PEVENTION OF VAP
References
Booker, S., Murff, S., Kitki, L. & Jablonski, R. (2013). Mouth care to reduce ventilatorassociated pneumonia. American Journal of Nursing, 113(10), 24-30.
doi:10.1097/01.NAJ.0000435343.38287.3a
Grap, M.J., Munro, C.L., Hamilton, V.A., Elswick, R.K., Sessler, C.N. & Ward, K.R. (2011).
Early, single chlorhexidine application reduces ventilator-associated pneumonia in
trauma patients. Heart and Lung, 40, 115-122.
Hutchins, K., Karras, G., Erwin, J., & Sullivan, K.L. (2009). Ventilator-associated pneumonia
and oral-care: A successful quality improvement project. American Journal of
Infection Control, 37(7), 590-597. doi: 10.1016/j.ajic.2008.12.007.
Roberts, N. & Moule, P. (2011). Chlorhexidine and tooth-brushing as prevention strategies
in reducing ventilator-associated pneumonia rates. Nursing in Critical Care, 16(6),
295-302. doi: 10.1111/j.1478-5153.2011.00465.x
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