A Peri-intubation Oral Intervention to Reduce Oral Flora and VAP

Pneumonia is the leading cause of death from nosocomial infections. Intubation and
mechanical ventilation greatly increase the risk of ventilator associated pneumonia (VAP)
which is highest in trauma, burn, neurosurgical and surgical patients. Oral bacteria have
been shown to be responsible for the development of VAP since the endotracheal tube provides
a pathway for direct entry of bacteria from the oropharynx to the respiratory tract.
Therefore, reducing the number of microorganisms in the mouth reduces the pool of organisms
available for translocation to and colonization of the lung. The Tri-Service Oral Health
Survey showed that military recruits had inferior oral health when compared to their
civilian cohorts. Further, oral hygiene is likely to deteriorate in combat situations,
increasing oral microbial flora. Intubation of combat casualties in the future will likely
be performed in the field by the EMT-B trained combat medic (91W) under adverse conditions.
Therefore, interventions to reduce oral microbial flora with intubation are attractive to
reduce the incidence of VAP in combat casualties. This study will test the effect of a
single peri-intubation oral intervention on oral microbial flora and the development of VAP
in traumatic injury. Two hundred trauma patients requiring endotracheal intubation will be
randomly assigned to either the intervention or control group over an 18-month data
collection period. Data related to oral microbial flora (measured by semi-quantitative oral
culture) and VAP (measured by the clinical pulmonary infection score-CPIS) will be obtained
on study admission, at 24 (oral culture data only), 48 and 72 hours after intubation. The
exact Wilcoxon two-sample one-sided test will be used to test for difference between groups.
CPIS data will be compared using an analysis of covariance model. Covariates such as
baseline oral culture category, trauma-injury and severity score (TRISS), illness severity
(APACHE III) and frequency and timing of usual oral care will also be included. The findings
from this study will be the first report of an empirically based peri-intubation oral
intervention to reduce VAP and can be easily applied to the care of traumatic injury in both
combat and civilian casualties.

Inclusion Criteria:

- trauma victim

- endotracheal intubation within the past 12 hours

- mechanical ventilation

Exclusion Criteria:

- diagnosis of pneumonia at the time of intubation

- previous endotracheal tube placement in the last 48 hours

- burn injuries