Cochrane · intervention · CD008367
Oral hygiene care for critically ill patients to prevent ventilator‐associated pneumonia
Zhao, T, Wu, X, Zhang, Q, et al. · Cochrane Database of Systematic Reviews · 2020 · Cochrane Library
Full textEvery question was extracted from the full review (methods and results), not only its Summary of Findings table.
Questions
56
current version
GRADE rated
10
No studies
5
Included studies
40
as reported
No studies 5 · 8.9%Ungraded 41 · 73.2%Very low 4 · 7.1%Low 4 · 7.1%Moderate 2 · 3.6%High 0 · 0%
Ungraded means an effect was reported without a GRADE rating; it is not a gap. No studies means the review found nothing to answer the question. The six categories are a display order, not a score.
Review question
| Element | Planned (methods) | Found (results) |
|---|---|---|
| Population | Critically ill patients in hospital settings receiving mechanical ventilation (for a minimum of 48 hours), without VAP or respiratory infection at baseline | Critically ill patients on mechanical ventilation in ICU; mostly adults, one study children, one newborns; conducted in China, USA, Brazil, Iran and others (n=5675) |
| Intervention | Oral hygiene care such as healthcare-professional-assisted toothbrushing, oral and pharyngeal cavity rinse, decontamination of oropharyngeal cavities with antiseptics | Chlorhexidine (n=13); Chlorhexidine vs other agents (n=7); Toothbrushing (n=8); Powered toothbrushing (n=1); Other oral care agents (n=15) |
| Comparison | No treatment; placebo; usual care; or a different specific oral hygiene care procedure | Placebo/usual care; No toothbrushing; Manual toothbrushing; Other oral care agents (potassium permanganate, ozonated water, Nanosil, hydrogen peroxide, miswak, saline, water, bicarbonate) |
| Outcomes | Incidence of VAP; Mortality; Duration of mechanical ventilation and/or ICU stay; Systemic antibiotic use; Colonisation of dental plaque/saliva/oropharyngeal mucosa/endotracheal aspirates; Oral health indices (gingival, plaque, bleeding, periodontal); Adverse effects; Caregivers' preferences; Economic data | Incidence of VAP; Mortality; Duration of ventilation; Duration of ICU stay; Systemic antibiotic use; Oral health indices; Adverse effects |
| Study designs | Randomised controlled trials (RCTs) of oral hygiene care interventions (quasi-randomised excluded) | RCT (n=40) |
| Timing | Not specified | Follow-up mean 1 month |
Search date: 2020-02. Databases: Cochrane Oral Health's Trials Register; CENTRAL; MEDLINE Ovid; Embase Ovid; LILACS BIREME; CINAHL EBSCO; VIP Database; ClinicalTrials.gov; WHO ICTRP
Questions and results
Show all 4 versionsChlorhexidine (mouthrinse or gel), as part of oral hygiene care vs Placebo or usual care
Population: Critically ill patients (adults and children) receiving mechanical ventilation in ICU
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Caregivers' preferences for oral hygiene care | The outcome of caregivers' preferences was not reported by any study in this comparison. | 0 studies | No studies |
Oral health indices (plaque index) | Plaque index: Fu 2019 found a significant reduction in the chlorhexidine group; Ozcaka 2012 and Scannapieco 2009 found no difference; 3 studies; no usable pooled estimate. | 3 studies | Ungraded |
Duration of ICU stay Follow-up: mean 1 month | MD -0.89 [-3.59, 1.82] | 5 studies · 627 participants | Low Downgraded: imprecision, inconsistency |
Incidence of VAP Follow-up: mean 1 month | RR 0.67 [0.47, 0.97] 261 per 1000 vs 175 per 1000 | 13 studies · 1206 participants | Moderate Downgraded: inconsistency |
Mortality Follow-up: mean 1 month | RR 1.03 [0.80, 1.33] 190 per 1000 vs 247 per 1000 | 9 studies · 944 participants | Moderate Downgraded: imprecision |
Adverse effects | Adverse effects: information from 2 studies; one stated there were none, the other reported mild reversible irritation of the oral mucosa; very low certainty. There was a lack of evidence about adverse effects. | 2 studies | Very low Downgraded: imprecision, inconsistency |
Duration of mechanical ventilation Follow-up: mean 1 month | MD -1.10 [-3.20, 1.00] | 4 studies · 594 participants | Very low Downgraded: risk of bias, imprecision, inconsistency |
Cost / economic data | The outcome of cost was not reported by any study in this comparison. | 0 studies | No studies |
Duration of systemic antibiotic use | MD 0.65 [-0.58, 1.88] | 1 study · 146 participants | Ungraded |
Toothbrushing (with or without antiseptics), as part of oral hygiene care vs No toothbrushing (with or without antiseptics)
Population: Critically ill adults receiving mechanical ventilation in ICU
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Incidence of VAP Follow-up: mean 1 month | RR 0.61 [0.41, 0.91] 259 per 1000 vs 179 per 1000 | 5 studies · 910 participants | Low Downgraded: risk of bias |
Mortality Follow-up: mean 1 month | RR 0.84 [0.67, 1.05] 250 per 1000 vs 210 per 1000 | 5 studies · 910 participants | Low Downgraded: risk of bias |
Systemic antibiotic use | This outcome was not reported by any of the studies in this comparison. | 0 studies | No studies |
Caregivers' preferences for oral hygiene care | The outcome of caregivers' preferences was not reported by any study in this comparison. | 0 studies | No studies |
Oral health indices (plaque score) | Plaque score: one study (Yao 2011) showed evidence of reduced plaque in the toothbrushing group; no usable pooled estimate. | 1 study | Ungraded |
Duration of mechanical ventilation Follow-up: mean 1 month | MD -0.43 [-1.17, 0.30] | 4 studies · 810 participants | Low Downgraded: risk of bias |
Cost / economic data | The outcome of cost was not reported by any study in this comparison. | 0 studies | No studies |
Adverse effects | Adverse effects: information from two studies, which stated that there were none; very low certainty. There is a lack of evidence about adverse effects. | 2 studies | Very low Downgraded: imprecision, inconsistency |
Duration of ICU stay Follow-up: mean 1 month | MD -1.89 [-3.52, -0.27] | 3 studies · 749 participants | Very low Downgraded: risk of bias, imprecision |
Powered toothbrushing (as part of comprehensive oral care) vs Manual toothbrushing (standard oral care)
Population: Critically ill patients receiving mechanical ventilation in ICU
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Incidence of VAP | RR 0.84 [0.37, 1.91] | 1 study · 78 participants | Ungraded |
Duration of ICU stay | MD -2.00 [-5.93, 1.93] | 1 study · 78 participants | Ungraded |
Mortality | RR 1.05 [0.16, 7.10] | 1 study · 78 participants | Ungraded |
Duration of mechanical ventilation | MD 0.00 [-1.78, 1.78] | 1 study · 78 participants | Ungraded |
Povidone iodine rinse vs Saline rinse or placebo
Population: Critically ill patients receiving mechanical ventilation in ICU
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Mortality | RR 1.00 [0.66, 1.50] | 2 studies · 217 participants | Ungraded |
Incidence of VAP | RR 0.69 [0.50, 0.95] | 3 studies · 356 participants | Ungraded |
Duration of ICU stay | MD -0.35 [-3.90, 3.21] | 2 studies · 217 participants | Ungraded |
Adverse effects | Adverse effects (Seguin 2014): no evidence of a difference in acute respiratory distress syndrome (RR 11.00, 95% CI 0.62 to 195.61), agitation and/or hypertension (RR 0.48, 95% CI 0.12 to 1.86), epistaxis (RR 0.14, 95%… | 1 study | Ungraded |
Povidone iodine rinse vs Usual care (suction alone, no rinse)
Population: Critically ill patients receiving mechanical ventilation in ICU
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Incidence of VAP | Povidone iodine versus usual care (Seguin 2006, 67 participants): a reduction in VAP was found; single study, not replicated, interpret with caution. | 1 study · 67 participants | Ungraded |
Mortality | Povidone iodine versus usual care: single study (67 participants), no evidence of a difference in mortality. | 1 study · 67 participants | Ungraded |
Saline rinse vs Saline-soaked swab
Population: Critically ill patients receiving mechanical ventilation in ICU
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Duration of mechanical ventilation | MD -6.83 [-8.94, -4.72] | 2 studies · 176 participants | Ungraded |
Mortality | RR 0.29 [0.12, 0.69] | 2 studies · 270 participants | Ungraded |
Incidence of VAP | RR 0.47 [0.37, 0.62] | 4 studies · 488 participants | Ungraded |
Saline rinse plus swab vs Saline-soaked swab alone (usual care)
Population: Critically ill patients receiving mechanical ventilation in ICU
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Incidence of VAP | RR 0.41 [0.23, 0.72] | 2 studies · 153 participants | Ungraded |
Duration of mechanical ventilation | MD -3.91 [-5.85, -1.97] | 1 study · 47 participants | Ungraded |
Saline rinse vs Usual care (no rinse)
Population: Critically ill patients receiving mechanical ventilation in ICU
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Duration of mechanical ventilation | MD -0.40 [-2.55, 1.75] | 2 studies · 324 participants | Ungraded |
Duration of ICU stay | MD -1.17 [-3.95, 1.60] | 2 studies · 324 participants | Ungraded |
Incidence of VAP | RR 0.60 [0.39, 0.91] | 2 studies · 324 participants | Ungraded |
Mortality | RR 1.10 [0.87, 1.39] | 2 studies · 324 participants | Ungraded |
Sodium bicarbonate rinse (plus toothbrushing) vs Water rinse (plus toothbrushing)
Population: Critically ill patients receiving mechanical ventilation in ICU
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Incidence of VAP | RR 1.57 [0.62, 3.99] | 2 studies · 347 participants | Ungraded |
Adverse effects | Adverse effects (Berry 2011, CHX versus sodium bicarbonate versus water): no adverse events were reported associated with the interventions. | 1 study | Ungraded |
Triclosan rinse vs Saline rinse
Population: Critically ill patients receiving mechanical ventilation in ICU
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Duration of mechanical ventilation | MD -5.24 [-5.64, -4.84] | 1 study · 324 participants | Ungraded |
Incidence of VAP | RR 0.89 [0.71, 1.12] | 1 study · 324 participants | Ungraded |
Duration of ICU stay | MD -4.97 [-5.55, -4.39] | 1 study · 324 participants | Ungraded |
Listerine (essential oils) rinse vs Sterile water rinse
Population: Critically ill patients receiving mechanical ventilation in ICU
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Incidence of VAP | Listerine versus sterile water (Berry 2013): no evidence of a difference in VAP incidence; single study, high risk of bias. | 1 study | Ungraded |
Listerine (essential oils) rinse vs Sodium bicarbonate rinse
Population: Critically ill patients receiving mechanical ventilation in ICU
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Incidence of VAP | Listerine versus sodium bicarbonate (Berry 2013): no evidence of a difference in VAP incidence; single study, high risk of bias. | 1 study | Ungraded |
Biotene OralBalance vs Control
Population: Critically ill patients receiving mechanical ventilation in ICU
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Incidence of VAP | Biotene OralBalance versus control (Stefanescu 2013, 41 participants): no difference in incidence of VAP; single study, high risk of bias. | 1 study · 41 participants | Ungraded |
Adverse effects | Adverse effects (Stefanescu 2013): no significant difference between groups with respect to adverse events in buccal mucosa. | 1 study | Ungraded |
Chlorhexidine vs Potassium permanganate
Population: Critically ill patients receiving mechanical ventilation in ICU
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Incidence of VAP | RR 0.87 [0.50, 1.52] | 2 studies | Ungraded |
Mortality | RR 1.11 [0.89, 1.38] | 2 studies | Ungraded |
Chlorhexidine vs Ozonated water
Population: Critically ill patients receiving mechanical ventilation in ICU
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Incidence of VAP | Chlorhexidine versus ozonated water (Hanifi 2017): some evidence of a benefit for ozonated water; single study, not replicated, interpret with caution. | 1 study | Ungraded |
Chlorhexidine vs Nanosil (nanosilver)
Population: Critically ill patients receiving mechanical ventilation in ICU
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Incidence of VAP | Chlorhexidine versus Nanosil (Khaky 2018): some evidence of a benefit for Nanosil; single study, not replicated, interpret with caution. | 1 study | Ungraded |
Mortality | Chlorhexidine versus Nanosil (Khaky 2018): no evidence of a difference in mortality; single study. | 1 study | Ungraded |
Chlorhexidine vs Hydrogen peroxide
Population: Critically ill patients receiving mechanical ventilation in ICU
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Incidence of VAP | Chlorhexidine versus hydrogen peroxide (Dahiya 2012): no evidence of a difference in incidence of VAP; single study. | 1 study | Ungraded |
Chlorhexidine vs Miswak
Population: Critically ill patients receiving mechanical ventilation in ICU
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Incidence of VAP | Chlorhexidine versus miswak (Irani 2019): no evidence of a difference in incidence of VAP; single study. Also no difference in number treated with systemic antibiotics. | 1 study | Ungraded |
Hydrogen peroxide vs Normal saline
Population: Critically ill patients receiving mechanical ventilation in ICU
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Incidence of VAP | Hydrogen peroxide versus normal saline (Nobahar 2016): a reduction in VAP was found; single study, not replicated, interpret with caution. | 1 study | Ungraded |
Potassium permanganate vs Placebo
Population: Critically ill patients receiving mechanical ventilation in ICU
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Mortality | Potassium permanganate versus placebo (Meidani 2018, 100 participants): no evidence of a difference in mortality; single study. | 1 study · 100 participants | Ungraded |
Incidence of VAP | Potassium permanganate versus placebo (Meidani 2018): no evidence of a difference in VAP incidence; single study. | 1 study | Ungraded |