Ventilator-associated pneumonia (VAP) is a pneumonia that occurs in a hospitalized patients who have received more than 48 hours of mechanical ventilation (MV), presenting with Xray evidence of new or progressive infiltrate or consolidation, along with associated symptoms, signs and laboratory investigations. The incidence of VAP in traumatic brain injury (TBI) patients was reported to be significantly high , ranging between 24% to 60% and  was shown to be associated with early death and higher mortality, especially in patients with a GCS less than or equal to  8. Apart from contributing to a greater proportion of death and disability, the treatment and increased hospital length of stay leads to a significant economic burden worldwide. 

Following head injury, a cascade of primary and secondary insults is initiated inducing significant morbidity in these patients. The primary insults include brain parenchyma injury, deranged cerebral metabolism, changes in cerebral blood flow with consequent cerebral edema which cannot be averted. Among the devastating secondary insults, depressed level of consciousness, airway obstruction, inability to clear mucus secretions and loss of protective airway reflexes are potential factors known to increase the risk of aspiration and other pulmonary related complication in critical head injury patients. Of note, a recent data has related trauma induced factors like full stomach, pain, agitation, facio-maxillary injuries, cervical spine immobilization and prehospital airway management as adjunctive causes accounting for early onset pneumonia in patients receiving critical care.

In lower middle income countries like ours, prehospital airway management is negligible and hence on arrival to Emergency Room, the airway characteristics of these TBI patients are mostly compromised. The implications of trauma, prehospital / triage airway management and its association with VAP have not been investigated so far in our settings. Also most of the data in literature on prehospital airway management has been done retrospectively. This study design intends to observe prior airway characteristics and co-relate the incidence of VAP in patients admitted to our trauma intensive care following severe head injury.  The diagnosis of VAP follows the American Thoracic Society (ATS) definition and will be confirmed by microbiological culture.