Resumen
Introducción: Los pacientes con ventilación mecánica corren riesgo de adquirir neumonía cuando la higiene bucodental es deficiente, a causa de la colonización bacteriana del tracto respiratorio. Se sugiere verificar esta asociación para implementar acciones de prevención.
Objetivo: Identificar la asociación entre el estado de salud bucal, la neumonía asociada a ventilador y la mortalidad en pacientes con ventilación mecánica en un hospital de tercer nivel de Pereira, Colombia.
Material y métodos: Estudio transversal realizado entre mayo y septiembre de 2018. Pacientes mayores de 18 años con ventilación mecánica > 48 horas. Se excluyeron casos con diagnóstico de neumonía previo a la intubación endotraqueal, traqueostomía y broncoaspiración. Se midieron variables sociodemográficas, referentes al cuidado bucal, clínicas y propias de la estancia hospitalaria, además del examen odontológico. Se emplearon análisis univariado, bivariado y multivariado de ajuste.
Resultados: Se incluyeron 99 pacientes con mediana de edad de 56 años; el 41.4% eran de sexo femenino. El diagnóstico de ingreso más frecuente fue trauma craneoencefálico. El 75% de la población evaluada presentó al menos 26 dientes perdidos por caries; los hallazgos más prevalentes fueron queilitis, úlceras y periodontitis. Se diagnosticaron nueve casos de neumonía (9.1%). La úlcera bucal (odds ratio ajustada [ORa] = 14.3; intervalo de confianza del 95% [IC95%]: 1.5-137), la periodontitis (ORa = 5,4; IC95%: 1.0-28.1) y la enfermedad renal crónica (ORa = 10; IC95%: 1.4-71-7) derivaron de neumonía asociada a ventilador, mientras que la apertura bucal ≤ 35 mm (OR cruda = 5.3; IC95% = 2.1-13.5) presentó asociación no ajustada con la mortalidad intrahospitalaria.
Conclusiones: Son convenientes los cuidados de higiene bucal en los pacientes con ventilación mecánica. Convendría mantener bajo vigilancia a los pacientes con úlcera bucal, periodontitis e insuficiencia renal, por el riesgo de neumonía.
Abstract
Background: Patients mechanically ventilated, are under potential risk of acquiring pneumonia, when there is poor oral hygiene, and due to bacterial colonization of respiratory tract. It is required to verify the association among oral health, mechanical ventilation and pneumonia to implement effective prevention.
Objective: Identify the association between oral health conditions with ventilator-associated pneumonia, and mortality in patients with mechanical ventilation in a third-level hospital in Pereira, Colombia.
Material and methods: Cross-sectional study performed between May and September 2018. Patients older than 18 years with mechanical ventilation over 48 hours were evaluated. Cases of diagnosed pneumonia prior to endotracheal intubation, tracheostomy, bronchial aspiration were excluded. Measured variables: sociodemographic, clinical and characteristics of hospital stay, dental examination and conditions related to oral care. Univariate, bivariate and adjusted multivariate analysis were performed.
Results: 99 patients with median age of 56 years were included; 41.4% female. Most frequent admission diagnosis was traumatic brain injury. 75% of evaluated population had at least, 26 teeth lost due to caries; most prevalent findings were cheilitis, ulcers, periodontitis. Nine cases of pneumonia were diagnosed (9.1%). Oral ulcer (adjusted odds ratio [Ora] = 14.3; 95% confidence interval [95%CI]: 1.5-137), periodontitis (ORa = 5.4; 95%CI: 1.0-28.1) and chronic kidney disease (ORa = 10; 95%CI: 1.4-71.7), derived from ventilator-associated pneumonia; while mouth opening ≤ 35 mm (OR: 5.3; 95%CI = 2.1-13.5) had an unadjusted association with in-hospital mortality.
Conclusions: It is required to implement oral hygiene care in patients treated with mechanical ventilation. Patients with mouth ulcer, periodontitis, kidney failure should be especially monitored for the risk of pneumonia.
Bibliografía
1. Mendiburu C. Enfermedades pulpares y periapicales en pacientes sistémicamente comprometidos en el Centro de Salud de Uayma, Yucatán, México TT - Pulp and periapical diseases in systemically compromised patients: Health Center of Uayma, Yucatan, Mexico. Rev Cuba estomatol [Internet]. 2016;53(4):198–209. Disponible en: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0034-75072016000400003%0Ahttp://www.revestomatologia.sld.cu/index.php/est/article/view/683
2. Navarrete M, Caro JC, Prato A, Secchi I. Implantología y Rehabilitación Oral Asociación entre osteoporosis y periodontitis crónica. Rev Clínica Periodoncia, Implantol y Rehabil Oral [Internet]. 2016;9(1):25–9. Disponible en: http://dx.doi.org/10.1016/j.piro.2015.02.014
3. Torres FM, Mazzini WU, Campuzano TM. Predisposing factors affecting oral health in diabetes mellitus patients. Rev Odontológica Mex. 2017;21(2):e101–6.
4. Badiee P, Alborzi A, Joukar M. Molecular assay to detect nosocomial fungal infections in intensive care units. Eur J Intern Med [Internet]. 2011;22(6):611–5. Disponible en: http://dx.doi.org/10.1016/j.ejim.2011.08.025
5. Da Cruz MK, Nascimento De Morais TM, Trevisani DM. Clinical assessment of the oral cavity of patients hospitalized in an intensive care unit of an emergency hospital. Rev Bras Ter Intensiva. 2014;26(4):379–83.
6. Schunemann FH, Canani SH, Marín C. Oral evaluation of children and adolescents in intensive care unit. Rev Sul-Brasileira Odontol. 2018;1(3):135.
7. Gaetti-Jardim Júnior E, Okamoto A, Meca L, Silva P, Bombarda F, Schweitzer C. Família Enterobacteriaceae, Acinetobacter baumannii e Pseudomonados na microbiota bucal de pacientes mantidos em unidades de terapia intensiva. Currículo Lattes. 2014;3:40–8.
8. Herculano AB de S, Castro DS de, Gaetti-Jardim EC, Silva JCL da. Qualidade de saúde bucal e pneumonia associada à ventilação mecânica. Arch Heal Investig. 2017;6(7):298–303.
9. Ministerio de la protección social. Aspectos metodológicos para la construcción de la linea de base para el seguimiento a las metas del objetivo número de 3 del Plan Nacional de Salud Pública [Internet]. Bogotá: Ministerio de protección social; 2010. p. 55. Disponible en: https://www.minsalud.gov.co/Documentos y Publicaciones/DOCUMENTO TÉCNICO LÍNEA DE BASE CON ATLAS VERSIÓN 3 - ABRIL 2010.pdf
10. Instituto Nacional de Salud. Protocolos de vigilancia y control [Internet]. 2018. Disponible en: http://www.ins.gov.co/buscador-eventos/Paginas/Fichas-y-Protocolos.aspx
11. Xu Y, Lai C, Xu G, Meng W, Zhang J, Hou H, et al. Risk factors of ventilator-associated pneumonia in elderly patients receiving mechanical ventilation. Clin Interv Aging. 2019;14:1027–38.
12. Souza K De, Tulio C, Stramandinoli-zanicotti RT, Dirschnabel AJ, Schussel JL, Krelling A, et al. Alterações no perfil da microbiota bucal durante permanência na UTI : colonização por patógenos respiratórios potenciais Pacientes sob cuidados intensivos constituem um grupo de indivíduos em condições graves , A Unidade de Terapia Intensiva ( UTI ) repre. 2018;7:351–7.
13. Kim CH, Kim MS, Kang MJ, Kim HH, Park NJ, Jung HK. Oral mucosa pressure ulcers in intensive care unit patients: A preliminary observational study of incidence and risk factors. J Tissue Viability [Internet]. 2019;28(1):27–34. Disponible en: https://doi.org/10.1016/j.jtv.2018.11.002
14. Organización Mundial de la Salud. Salud bucodental [Internet]. Notas descriptivas. 2018 [cited 2019 Dec 6]. Disponible en: https://www.who.int/es/news-room/fact-sheets/detail/oral-health
15. Ministerio de Salud y Protección Social. IV Estudio Nacional De Salud Bucal. IV. Bogotá: MinSalud; 2014. 381 p.
16. Guimarães GR, Queiroz APG, Ferreira ACR. Instituição de um protocolo de higiene bucal em pacientes internados no CTI do HUSF TT - Establishment of a oral hygiene protocol in hospitalized patients at the ICU HUSF. Periodontia [Internet]. 2017;27(1):7–10. Disponible en: http://www.revistasobrape.com.br/arquivos/2017/marco/REVPERIO_MARÇO_2017_PUBL_SITE_PAG-07_A_10 - 27-03-2017.pdf
17. Jones DJ, Munro CL, Grap MJ. Natural history of dental plaque accumulation in mechanically ventilated adults: A descriptive correlational study. Intensive Crit Care Nurs. 2011;27(6):299–304.
18. Oliveira LCBS de, Carneiro PPM, Fischer RG, Tinoco EMB. A presença de patógenos respiratórios no biofilme bucal de pacientes com pneumonia nosocomial. Rev Bras Ter Intensiva. 2007;19(4):428–33.
19. Bellissimo-Rodrigues WT, Menegueti MG, Gaspar GG, Nicolini EA, Auxiliadora-Martins M, Basile-Filho A, et al. Effectiveness of a Dental Care Intervention in the Prevention of Lower Respiratory Tract Nosocomial Infections among Intensive Care Patients: A Randomized Clinical Trial. Infect Control Hosp Epidemiol. 2014 Nov;35(11):1342–8.
20. Jaimes F, De La Rosa G, Gómez E, Múnera P, Ramírez J, Castrillón S. Incidence and risk factors for ventilator-associated pneumonia in a developing country: Where is the difference? Respir Med. 2007;101(4):762–7.
21. But A, Yetkin MA, Kanyilmaz D, Aslaner H, Baştuğ A, Aypak A, et al. Analysis of epidemiology and risk factors for mortality in ventilator-associated pneumonia attacks in intensive care unit patients. Turkish J Med Sci. 2017;47(3):812–6.
22. Gursel G, Demir N. Incidence and risk factors for the development of acute renal failure in patients with ventilator-associated pneumonia. Nephrology. 2006;11(3):159–64.
23. Wu D, Wu C, Zhang S, Zhong Y. Risk factors of ventilator-associated pneumonia in critically III patients. Front Pharmacol. 2019;10(MAY):1–7.
24. Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016;63(5):e61–111.
25. Shiraishi A, Yoshimura Y, Wakabayashi H, Tsuji Y, Shimazu S, Jeong S. Impaired oral health status on admission is associated with poor clinical outcomes in post-acute inpatients: A prospective cohort study. Clin Nutr [Internet]. 2019;38(6):2677–83. Disponible en: https://doi.org/10.1016/j.clnu.2018.11.020
26. Lee HJ, Choi EK, Park JB, Han KD, Oh S. Tooth Loss Predicts Myocardial Infarction, Heart Failure, Stroke, and Death. J Dent Res. 2019;98(2):164–70.
27. Fields LB. Oral care intervention to reduce incidence of ventilator-associated pneumonia in the neurologic intensive care unit. J Neurosci Nurs. 2008;40(5):291–8.
28. Scannapieco FA, Stewart EM, Mylotte JM. Colonization of dental plaque byrespiratory pathogens in medical intensive care patients. Crit Care Med. 1992;20(6):740–5.
29. Hua F, Xie H, Hv W, Furness S, Zhang Q, Li C. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia ( Review). Cochrane Libr. 2016;(10).
30. Berry AM, Davidson PM. Beyond comfort: Oral hygiene as a critical nursing activity in the intensive care unit. Intensive Crit Care Nurs. 2006;22(6):318–28.
31. Pires JR, Matareli S, Ferreira RG, Toledo BEC de. Espécies de Candida e a condição bucal de pacientes internados em Unidade de Terapia Intensiva. Rev Assoc Paul Cir Dent. 2011;65(5):332–7.
32. Baeder FM, Cabral GMP, Prokopowitsch I, Araki ÂT, Duarte DA, Santos MTBR. Condição odontológica em pacientes internados em unidade de terapia intensiva. Pesqui Bras Odontopediatria Clin Integr. 2012;12(4):517–20.
33. Cliff PR, Sandoe JAT, Heritage J, Barton RC. Use of multilocus sequence typing for the investigation of colonisation by Candida albicans in intensive care unit patients. J Hosp Infect. 2008;69(1):24–32.
34. Feider LL, Mitchell P, Bridges E. Oral care practices for orally intubated critically ill adults. Am J Crit Care. 2010;19(2):175–83.
35. Grap MJ, Munro CL, Ashtiani B, Bryant S. Oral care interventions in critical care: frequency and documentation. Am J Crit Care [Internet]. 2003 Mar [cited 2019 Dec 5];12(2):113–8; discussion 119. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/12625169
36. Celik GG, Eser I. Examination of intensive care unit patients’ oral health. Int J Nurs Pract. 2017;23(6):1–9.
37. Deschepper M, Waegeman W, Eeckloo K, Vogelaers D, Blot S. Effects of chlorhexidine gluconate oral care on hospital mortality: a hospital-wide, observational cohort study. Intensive Care Med [Internet]. 2018;44(7):1017–26. Disponible en: https://doi.org/10.1007/s00134-018-5171-3
38. James P, Worthington H V., Parnell C, Harding M, Lamont T, Cheung A, et al. Chlorhexidine mouthrinse as an adjunctive treatment for gingival health. Vol. 2017, Cochrane Database of Systematic Reviews. John Wiley and Sons Ltd; 2017.
39. Gordis L. Epidemiology 5th Ed [Internet]. 2015 [cited 2019 Dec 5]. Disponible en: https://www.us.elsevierhealth.com/epidemiology-9781455737338.html
40. Hugonnet S, Uçkay I, Pittet D. Staffing level: A determinant of late-onset ventilator-associated pneumonia. Crit Care. 2007;11(4):1–7.