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Research and Projects

Comprehensive Mouth Care and Post-operative Pneumonia (CUPPA)

Theme: CLAHRC - Evidence for Policy and Practice
Status: Live

Project Lead: Dr Charly Gibson, Royal Devon & Exeter Hospital


Trainee anaesthetists working in South West hospitals observed that patients having major abdominal surgery were at risk of developing post-operative pneumonia.

Inhaling secretions from the mouth and throat is one of many factors that can contribute to the development of post-operative pneumonia. Previous research has shown that reducing concentrations of oral pathogenic microorganisms with an antiseptic such as chlorhexidine may reduce ventilator associated pneumonia in critical care patients, as well as reducing pneumonia in nursing home residents. Regular oral disinfection is standard care for intubated patients in Intensive Care Units who are unable to attend to their own dental hygiene.

The trainees wondered whether rigorous attention to oral hygiene might reduce post-operative pneumonia in patients undergoing major abdominal surgery. Through the South West Anaesthesia Research Matrix (SWARM) they carried out a feasibility study (CUPPA) across six NHS hospitals in the South West, with a view to planning and implementing a randomised controlled trial (RCT) to test this hypothesis.

The ‘CUPPA’ (Comprehensive moUth-care to reduce Post-operative PneumoniA) trial was funded by a grant from the National Institute of Academic Anaesthesia (NIAA) with support from PenCLAHRC.

What is SWARM?

SWARM (South West Anaesthesia Research Matrix) is a trainee-led research collaborative with over 200 members across the South West, set up to break through the glass ceiling that can prevent trainees from being credible Principal or Chief Investigators. Individual trusts and funders are hesitant to invest in doctors on rotations because they have insufficient time to gain traction at a particular hospital before moving on.

The network model overcomes these issues, as the SWARM network, supported by consultant mentors, can grow research ideas from inception to delivery. By running projects in parallel at six hospital sites, an economy of scale achieves meaningful volume quickly.  

Project aims

The project aimed to assess the feasibility of using a comprehensive oral hygiene regime for patients before and after undergoing major elective abdominal surgery, to decrease their risk of post-operative pneumonia.

Project activity 

Chief Investigator Dr Charly Gibson, since appointed as a Consultant Intensivist at Royal Devon & Exeter Hospital, initiated and led the trial, which was delivered by over 45 SWARM trainees in conjunction with NIHR CRN nurses and administrators at hospitals in Torquay, Plymouth, Exeter, Truro, Taunton and Barnstaple. 

120 people undergoing major elective abdominal surgery took part in the trial, half of which received a comprehensive oral hygiene intervention, and half received standard care (i.e. their usual oral hygiene regime). Patients in the intervention group were given 0.2% chlorhexidine mouthwash to use daily, along with 'disclosing' (food dye) tablets to stain up their dental plaque so they could brush it all off with 1% chlorhexidine toothpaste.

Data was collected between June 2015 and July 2016 on whether patients developed pneumonia within 30 days after their operation. PenCLAHRC SWARM Fellow Victoria Field coordinated data collection and analysis.

Next steps

Data and practical lessons learned from the CUPPA trial have been incorporated into the design of a large multi-centre RCT endorsed by the NIAA Clinical Trials Network, exploring the effect of administering a chlorhexidine mouthwash prior to anaesthesia, on the recovery of patients following major abdominal surgery. The 'COMMAS' study (ChlOrhexidine Mouthwash prior to anaesthesia in patients undergoing Major open Abdominal Surgery) is funded to run in 2017 and aims to recruit more than 6,000 participants.

Related publications

The SWARM CUPPA project has been featured in the July 2017 edition of the Royal College of Anaesthetists Bulletin


Local trust project leads:

Derriford Hospital, Plymouth
Dr Natalie Smith
Dr Victoria Field
Royal Cornwall Hospital, Truro
Dr Barney Scrace
Dr Kathleen Mulcahy
Torbay Hospital, Torquay
Dr Aidan Melia
Dr Louise Cossey
Dr Victoria Lewis
Musgrove Park Hospital, Taunton
Dr Alexandra Jones
Dr Carmen Marginean
North Devon District Hospital, Barnstaple
Dr Marc Brown
Royal Devon & Exeter Hospital, Exeter
Dr Katharine Smurthwaite
Dr Wren Holdom
Please see the SWARM project page for a full list of partners.