Comparative Study of the Effect of Botanical Extract Mouthwashes of Tea Tree Oil/Aloe Vera and Chlorhexidine on Prevention of Ventilator-associated Pneumonia in Admitted Patients in Intensive Care Units of Arak Hospitals, 2022

Preventing ventilator-associated pneumonia (VAP) as one of the most common and also the most fatal complications caused by intubation and mechanical ventilation in intensive care units (ICU) has always been emphasized in countless studies. Chlorhexidine mouthwash is commonly used as a gold standard in the control of dental plaques and prevention of VAP. Given the increasing prevalence of gram-negative infections due to resistance to commonly used antibiotics and the associated complications, this study aimed to investigate and compare the impact of tea tree oil/aloe vera herbal mouthwash, known for its antibacterial and anti-inflammatory properties, on the occurrence of ventilator-associated pneumonia.

This study is a double-blind randomized clinical trial. 62 intubated patients, aged from 16 to 65 and hospitalized in the intensive care units of Hazrat Waliasr Hospital in Arak City in 2023, were assigned using a simple randomization method in two interventions (tea tree oil/aloe vera mouthwash) and control groups (chlorhexidine mouthwash). Mouthwash bottles were covered before distribution. None of the patients, colleagues (nurses), and the specialist determining the final result of the study were aware of the allocation of patients in the intervention or control group. Oral care in both groups was performed by washing hands, wearing gloves, evaluating the mouth condition, adjusting the pressure of the endotracheal tube cuff (20-30 Cm.H2O), brushing with a soft toothbrush, mouthwash twice daily and open suctioning of oral and subglottic secretions. Lastly, at intervals of 3 days (to assess the incidence of early VAP) and 7 days (to assess the incidence of late VAP) after the intervention, the modified clinical pulmonary infection score (MCPIS) was calculated and a score greater than or equal to 6 was considered as a diagnosis of pneumonia. This tool has been utilized in similar studies and its validity and reliability have been confirmed. Eventually, the data was statistically analyzed using the chi-square test, independent t-test, and repeated measures test to investigate the effect of the intervention over time with SPSS version 20 software.

According to the results, 64.5% of the participants were male and 35.5% of them were female. There was no statistically significant difference between the two groups in terms of average age, gender, reason for admission, history of underlying diseases, invasive interventions, average number of drugs and antibiotics, type and amount of nutrition, and duration of mechanical ventilation. The incidence of early-onset pneumonia was 9.7% in the intervention group and 12.9% in the control group. Although the incidence was lower in the intervention group, there was no statistically significant difference between the two groups (P-value=0.99). The incidence of late-onset pneumonia in the intervention group was 12.9% and 16.1% in the control group. Despite of lower incidence of late-onset pneumonia in the intervention group, there was no statistically significant difference (P-value=1.00). Moreover, according to the results of Bonferroni's paired comparisons test, the difference in the average MCPIS score between 3 days and 7 days later in the intervention group was not significant and did not increase significantly (P-value=0.06), which means that in this group, the effect of the intervention can be seen at this time.

Oral care using tea tree oil/aloe vera mouthwash or 0.2% chlorhexidine has no preference or significant advantage over each other, and both can be effective in reducing ventilator-associated pneumonia. Considering the lower incidence of early and late pneumonia in the intervention group, it is recommended to conduct studies with a larger sample size and also use accurate oral assessment tools to confirm the removal of dental plaque (plaque score) in this population of patients.