Impact of Bronchoscopic Lavage and Aggressive Chest Physiotherapy on Clinical Pulmonary Infection Score of Patients of Severe Traumatic Brain Injury


  • Usman Ahmed Kamboh Department of Neurosurgery, Allama Iqbal Medical College /Jinnah Hospital, Lahore
  • Nabeel Choudhary
  • Mehwish Manzoor Department of Neurosurgery, Allama Iqbal Medical College /Jinnah Hospital, Lahore
  • Asif Raza
  • Ghulam Naseer-ud-Din
  • Muhammad Adeel Rauf



Severe traumatic brain injury, Critical Pulmonary Infection Score, Brain contusion, Subdural Hematoma, Diffuse axonal injury


Introduction:  Traumatic brain injury patients present in the emergency room with a variable conscious status depending upon the severity of the injury. The process of aspiration starts from the scene of trauma as the patients with Traumatic brain injury and chest trauma have higher rates of aspiration pneumonia. Materials and Methods:  We conducted a prospective study to assess the impact of bronchoscopy lavage and aggressive chest physiotherapy on the Critical Pulmonary Infection Score of Patients with Severe Traumatic Brain Injury in the Neurocritical Care Unit. Patients with severe traumatic brain injury who met the inclusion criteria were enrolled in the study. Patients of both genders, ages ranging from 05 – 70 years were included in the study. Results:  48 patients who met the inclusion criteria were enrolled in the study. 8 patients expired before 7 days and were excluded from the study. 88% were male and 12 % were females. Out of 40 patients, 30 were ventilated and 10 were managed without ventilation. Brain contusion was the most common CT scan finding. Out of 40 patients, 18 underwent surgical intervention, with decompressive hemicraniectomy being the most commonly performed procedure. Out of 40 patients, 32 patients underwent bronchoscopy. 8 patients out of 32 had more than two sessions of bronchoscopy. Conclusion:  As Critical Pulmonary Infection Score is an important indicator for pneumonia in the neurocritical care unit, the importance of standardized chest care with the help of bronchoscopic lavage and chest physiotherapy in keeping the Critical Pulmonary Infection Score on the lower side can prevent patients from developing life-threatening pneumonia.


Miller PR, Croce MA, Bee TK, Qaisi WG, Smith CP, Collins GL, Fabian TC. ARDS after pulmonary contusion: accurate measurement of contusion volume identifies high-risk patients. J Trauma. 2001; 51 (2): 223-8. Discussion 229-30.

Winstein CJ. Neurogenic dysphagia. Frequency, progression, and outcome in adults following head injury. Phys Ther. 1983; 63 (12): 1992-7.

Torres A, El-Ebiary M. Bronchoscopic BAL in the diagnosis of ventilator-associated pneumonia. Chest, 2000; 117 (4 Suppl. 2): 198S–202S.

Terre R, Mearin F. Prospective evaluation of oro-pharyngeal dysphagia after severe traumatic brain injury. Brain Inj. 2007; 21 (13-14): 1411-7.

Flanders SA, Collard HR, Saint S. Nosocomial pneumonia: state of the science. Am J Infect Control. 2006; 34 (2): 84-93.

K Vejdan A, Khosravi M. BAL for pneumonia prevention in tracheostomy patients: A clinical trial study. Pak J Med Sci. 2013 Jan; 29 (1): 148-51.

Doi: 10.12669/pjms.291.1971. PMID: 24353528; PMCID: PMC3809188

Pugin J, Auckenthaler R, Mili N, Janssens JP, Lew PD, Suter PM. Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic and nonbronchoscopic “blind” bronchoalveolar lavage fluid. Am Rev Respir Dis. 1991; 143 (5 Pt 1): 1121-9.

Castro AA1, Calil SR, Freitas SA, Oliveira AB, Porto EF. Chest physiotherapy effectiveness to reduce hospitalization and mechanical ventilation length of stay, pulmonary infection rate and mortality in ICU patients. Respir Med. 2013; 107 (1): 68-74.

Fabregas N, Ewig S, Torres A, El-Ebiary M, Ramirez J, de La Bellacasa JP, Bauer T, Cabello H. Clinical diagnosis of ventilator associated pneumonia revisited: comparative validation using immediate post-mortem lung biopsies. Thorax. 1999; 54 (10): 867-73.

Papazian L, Thomas P, Garbe L, Guignon I, Thirion X, Charrel J, Bollet C, Fuentes P, Gouin F. Bronchoscopic or blind sampling techniques for the diagnosis of ventilator-associated pneumonia. Am J Respir Crit Care Med. 1995; 152 (6 Pt 1): 1982-91.

Iregui M, Ward S, Sherman G, Fraser VJ, Kollef MH. Clinical importance of delays in the initiation of appropriate antibiotic treatment for ventilator-associated pneumonia. Chest. 2002; 122 (1): 262-8.

Yang GH, Wang GF. Value of the clinical pulmonary infection score for the prognosis of ventilator-associated pneumonia. Chinese Journal of Tuberculosis and Respiratory Diseases. 2006; 29 (11): 751-4.

Mcgowan JE. Antimicrobial Resistance in Hospital Organisms and Its Relation to Antibiotic Use. Rev Infect Dis. 1983; 5 (6): 1033-48.

Papazian, L., Klompas, M. & Luyt, CE. Ventilator-associated pneumonia in adults: a narrative review. Intensive Care Med. 2020; 46: 888–906.

Choo R, Anantham D. Role of bronchoalveolar lavage in the management of immunocompromised patients with pulmonary infiltrates. Ann Transl Med. 2019; 7 (3): 49.

P Goussard, P Pohunek, E Eber, F Midulla, G Di Mattia, M Merven & JT Janson. Pediatric bronchoscopy: recent advances and clinical challenges, Expert Review of Respiratory Medicine, 2021; 15: 4, 453-475.

Arnold HM, Micek ST, Skrupky LP, Kollef MH. Antibiotic stewardship in the intensive care unit. Semin Respir Crit Care Med. 2011; 32 (2): 215-27.

de Man P, Verhoeven BA, Verbrugh HA, Vos MC, van den Anker JN. An antibiotic policy to prevent emergence of resistant bacilli. Lancet. 2000; 355 (9208): 973-8.

Dik JW, Vemer P, Friedrich AW, Hendrix R, Lo-Ten-Foe JR, Sinha B, Postma MJ. Financial evaluations of antibiotic stewardship programs-a systematic review. Front Microbiol. 2015; 6: 317.

Geissler A, Gerbeaux P, Granier I, Blanc P, Facon K, Durand-Gasselin J. Rational use of antibiotics in the intensive care unit: impact on microbial resistance and costs. Intensive Care Med. 2003; 29 (1): 49-54.

Megahed MM, El-Menshawy AM, Ibrahim AM. Use of Early Bronchoscopy in Mechanically Ventilated Patients with Aspiration Pneumonitis. Indian J Crit Care Med. 2021; 25 (2): 146-152.

Loftus TJ, Lemon SJ, Nguyen LL, Voils SA, Brakenridge SC, Jordan JR, Croft CA, Smith RS, Moore FA, Efron PA, Mohr AM. Early bronchoalveolar lavage for intubated trauma patients with TBI or chest trauma. J Crit Care, 2017 Jun; 39: 78-82. Epub 2017 Feb 12. PMID: 28231518; PMCID: PMC5401803.

Minshall CT, Eriksson EA, Hawkins KS, Wolf S, Minei JP. Early nonbronchoscopic bronchoalveolar lavage: predictor of ventilator-associated pneumonia? J Trauma Acute Care Surg. 2013; 74 (2): 448-52.