Effectiveness of Chinese herbal medicine mouthwash in preventing ventilator-associated pneumonia in patients with endotracheal intubation: A systematic review and meta-analysis
Clinical Snapshot
PICO Framework
| P — Population | Patients with endotracheal intubation requiring mechanical ventilation |
| I — Intervention | Chinese herbal medicine mouthwash (CHMM) alone or with routine oral care |
| C — Comparator | Non-CHMM interventions (saline, chlorhexidine, routine oral care) |
| O — Outcomes | Incidence of ventilator-associated pneumonia (VAP) |
Bottom Line
This meta-analysis of 27 RCTs suggests Chinese herbal medicine mouthwash may reduce ventilator-associated pneumonia incidence by approximately 59% compared to standard care. However, the evidence quality is low, with most primary studies having poor methodological quality. The authors appropriately conclude they cannot recommend routine clinical use. For Australian intensivists, this evidence has limited applicability due to regulatory barriers (TGA approval required), lack of product availability, and uncertainty about safety profiles. Current evidence-based VAP prevention bundles using chlorhexidine remain the standard of care. While the large effect size is noteworthy, the low certainty evidence, methodological concerns, and practical implementation barriers preclude any change to current Australian ICU practice. Future high-quality RCTs with rigorous methodology and safety evaluation would be needed before considering any clinical application in Australian healthcare settings.
Key Findings
P Value: P < 0.00001
Effect Size: Risk Ratio 0.41 for CHMM vs non-CHMM
Primary Outcome: Incidence of ventilator-associated pneumonia
Nnt Or Sensitivity: Approximately 59% relative risk reduction in VAP incidence
Confidence Interval: 95% CI: 0.34-0.50
Clinical Application
Poor feasibility in Australian practice - CHMM products not TGA-approved or readily available No alignment with current ANZICS or CICM guidelines for VAP prevention. Standard care involves chlorhexidine-based oral care protocols. TGA approval would be required for any herbal medicine products. Limited applicability to Australian ICU patients due to cultural and healthcare system differences
Abstract
BACKGROUND: To systematically evaluate the effectiveness and safety of Chinese herbal medicine mouthwash (CHMM) in preventing ventilator-associated pneumonia (VAP) in patients with endotracheal intubation (ETT). METHODS: Computer searches were conducted for relevant randomized controlled trials (RCTs) in the China National Knowledge Infrastructure (CNKI), WANFANG DATA, Chinese Scientific and Technical Journal Database (VIP), Chinese Biomedical Literature Database (SinoMed), PubMed, Embase, Cochrane Library, and CINAHL Database from the establishment to April 5, 2023. The data were analyzed by RevMan 5.3 software. The methodological quality of papers was evaluated by the Cochrane version 5.1.0 and the certainty of evidence was evaluated by the GRADE system. RESULTS: We included 27 RCTs with 2426 patients. Most of the included studies were of poor methodological quality. Meta-analysis showed that CHMM (RR = 0.41, 95% CI: 0.34-0.50, P < .00001, low-certainty evidence) or CHMM + routine oral care (RR = 0.31, 95% CI: 0.18-0.56, P < .0001) could reduce the incidence of VAP compared to non-CHMM. CHMM may be superior to saline (low-certainty evidence) and chlorhexidine (moderate-certainty evidence) in preventing VAP (P < .05). CONCLUSION: Low-certainty evidence shows that CHMM may be more advantageous in reducing the incidence of VAP compared to non-CHMM. However, due to some limitations and the low certainty of evidence, we cannot recommend CHMM for routine clinical use at this time. Large-scale and high-quality RCTs are also needed to definitively evaluate the safety and clinical benefits of CHMM in the future.
References
- 1.Liu, Y., Liu, H., Ren, L., Yue, S., Li, Z., Li, X., & Su, C. (2024). Effectiveness of Chinese herbal medicine mouthwash in preventing ventilator-associated pneumonia in patients with endotracheal intubation: A systematic review and meta-analysis. Medicine, 103(15), e48179. https://doi.org/10.1097/MD.0000000000048179
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