Early Bronchoscopy for the Prevention of Pneumonia in Trauma Patients Undergoing Emergent Intubation: An Interim Analysis

Authors:
Michelle Lippincott, Louis Perkins, Laura Haines, Jessica Weaver

Body of Abstract:
Background: Patients who are intubated emergently are at increased risk for developing ventilator associated pneumonia. This risk is theoretically further increased in trauma patients who often undergo prolonged noninvasive ventilation with altered mental status in the prehospital setting. We hypothesized that early bronchoscopy in these patients reduces the risk of pneumonia by decreasing airway bacterial burden and removing inflammatory gastric acid and digestive enzymes. Methods: After implementation of an early bronchoscopy protocol at a Level 1 Trauma center, a retrospective cohort study was performed on all patients intubated in the prehospital setting or within 1 hour of arrival to the hospital. Patients were excluded if they died or were extubated within 24 hours of arrival or they were transferred to another ICU service. Patients who underwent bronchoscopy within 24 hours of admission (early bronchoscopy) were compared to those who did not receive a bronchoscopy within 24 hours (control group). The primary outcome was diagnosis of pneumonia during the same hospitalization. Secondary outcomes included ICU length of stay (LOS), ventilator days, hospital LOS, and mortality. Results: Among the 59 patients included in our interim analysis, 7 (11.9%) underwent bronchoscopy within 24 hours of admission. No patients in the early bronchoscopy group developed pneumonia, compared to 28.8% in the control group. There was no difference in median ventilator days (3 vs 4 days, p=0.41), median ICU LOS (4 vs 6.5 days, p=0.49), hospital LOS (median 10 vs 11 days, p=0.93), or mortality (28.6% vs 21.2%, p=0.64). In the early bronchoscopy group, a bronchial alveolar lavage culture was sent in three patients and 100% were positive for organisms, though none of these patients developed a clinical pneumonia. One patient that received early bronchoscopy received antibiotics for prophylaxis against aspiration pneumonia, while 71% of patients received antibiotics for any indication. Conclusions: In this preliminary analysis, for trauma patients intubated in the pre-hospital setting or within 1 hour of arrival, early bronchoscopy was not associated with a statistically-significant difference in pneumonia rates, hospital LOS, ICU LOS, ventilator days or mortality. However, no patients developed pneumonia in the early bronchoscopy group. Continued data collection for a larger sample size is necessary to demonstrate if there is any benefit in these patients.