What are the evidence-based oral care practices for preventing Ventilator-Associated Pneumonia (VAP) in intubated neonates?

From the Guidelines

Oral care for intubated neonates to prevent ventilator-associated pneumonia should include a comprehensive protocol with sterile water or normal saline, and not chlorhexidine gluconate, due to potential neurotoxicity and limited evidence of benefit in this population. When considering the prevention of ventilator-associated pneumonia (VAP) in intubated neonates, it is crucial to prioritize evidence-based oral care practices that minimize the risk of infection while ensuring the safety and well-being of these vulnerable patients. Key components of an effective oral care protocol for intubated neonates include:

• Performing oral care every 3-4 hours using sterile water or normal saline with a soft, small swab to gently clean the oral cavity, including the gums, palate, and tongue 1.
• Regular repositioning of the endotracheal tube to prevent pressure injuries to the oral mucosa.
• Suctioning as needed using aseptic technique with appropriately sized catheters to remove secretions that could harbor pathogens.
• Practicing strict hand hygiene before and after oral care procedures and wearing clean gloves.
• Maintaining documentation of oral care as part of routine care. The use of chlorhexidine gluconate (CHG) in adults has been shown to reduce VAP incidence, as evidenced by a meta-analysis that found oral application of CHG significantly reduced VAP incidence (RR = 0.73,95% CI = 0.55-0.97) 1. However, its application in neonates is not recommended due to concerns about potential neurotoxicity and the lack of substantial evidence supporting its benefit in this age group. Therefore, sterile water or saline remains the preferred choice for oral care in intubated neonates, aiming to reduce bacterial colonization in the oral cavity and prevent the migration of pathogens down the endotracheal tube, which can cause VAP.

From the Research

Oral Care Practices for Intubated Neonates

To prevent ventilator-associated pneumonia (VAP) in intubated neonates, oral care is a crucial aspect of their management. The following evidence-based practices can be considered:

• Oral care using a sponge brush moistened with sterile water has been shown to reduce the bacterial load in the oral cavity and the incidence of early-onset VAP in preterm infants 2
• The use of chlorhexidine in oral care has been found to reduce the occurrence of VAP in mechanically ventilated adults, although its use in neonates requires further exploration 3
• Probiotics have been associated with a reduction in the incidence of VAP, although the quality of the evidence is low and more research is needed to confirm their efficacy and safety in neonates 4, 5

Key Considerations

When implementing oral care practices for intubated neonates, the following points should be considered:

• The choice of oral care agent, such as sterile water or chlorhexidine, should be based on the individual patient's needs and medical history
• The frequency and method of oral care administration should be tailored to the patient's specific requirements
• The use of probiotics as a preventative measure for VAP requires further research to determine their safety and efficacy in neonates

Evidence-Based Recommendations

Based on the available evidence, the following recommendations can be made:

• Oral care should be performed regularly to reduce the bacterial load in the oral cavity and prevent VAP 6, 2
• The use of chlorhexidine or probiotics may be considered as part of an oral care regimen, although more research is needed to confirm their efficacy and safety in neonates 3, 4, 5