Co-relation between Prior Airway Management and Incidence of Ventilator Associated Pneumonia in Traumatic Brain Injury Patients: A Prospective Observational Study

INTRODUCTION: Incidence of Ventilator Associated Pneumonia (VAP) in traumatic brain injury (TBI) ranges from 24–60%. Airway characteristics of such patients are compromised due to multiple referrals and inadequate medical care. This study was conducted to observe prior airway characteristics and co-relate with incidence of VAP in severe TBI admitted to Intensive Care Unit (ICU). METHODOLOGY: Adults with severe TBI (GCS </= 8), intubated with endotracheal tube (ET) admitted to ICU, were included. Patients who died/extubated within 48 hrs or had concomitant blunt trauma chest (>3 rib fractures) were excluded. Demographic, prehospital airway devices, injury severity details were collected. Airway characteristics like soiled ET, endotracheal secretions, triage stay, use of bag-valve-mask-ventilation/antibiotics, chest X ray, were recorded. Duration of mechanical ventilation, ICU/hospital stay, mortality were observed. Tracheobronchial aspirates was used to confirm Early onset VAP (EOVAP). The data was entered into a spreadsheet and analysed. RESULTS: Fifty five patients were included. Incidence of EOVAP was 45.4%. EOVAP was lower in patients without rib fractures (n=20/50; 40%, p=0.015), intubated earlier in triage (2.5 vs 4.5 hrs, p=0.02), had minimal/mucoid secretions at first suctioning (p=0.006), didn't have infiltrates on chest X ray and were hemodynamically stable (p=0.03) at admission. Patients with VAP had greater days of mechanical ventilation, ICU and hospital stay. Acinetobacter baumanii was most common organism isolated. DISCUSSION: The study found 45.5% incidence of EOVAP among severe TBI patients. Reported occurrence of EOVAP among trauma victims varies from 24–60%(1). Higher risk of VAP in such patients is attributed to low GCS, loss of airway reflexes causing aspiration of gastric contents, pharyngeal secretions/blood. Facio-maxillary injury, blunt trauma chest, lung contusion further enhance the risk.(2) In present study, patients with EOVAP had shorter interval between injury and airway securement, fever, purulent ET secretions, opacities at chest X ray and were hemodynamically unstable at ICU admission. CONCLUSION: Presence of mucopurulent secretions, fever, chest X ray opacities, and shock are predictors of EOVAP among trauma victims.