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The Managementof Flail Chest

A Comparison of Ventilatoty and Nonventilatory Treatment

Steven Ft. Shackford, LT MC USN, San Diego, California


David E. Smith, LCDR MC USN, San Diego, California
Christopher K. Zarins, LCDR MC USNR, San Diego, California
Charles L. Rice, CDR MC USN, San Diego, California
Richard W. Virgilio, CDR MC USN, San Diego, California

The treatment of flail chest injuries continues to be search Unit from the operating room. Serial blood gas
a difficult clinical problem. Tracheal intubation and analyses were performed on all patients.
internal pneumatic stabilization with volume-cycled Prior to October 1973, all patients with flail chests
ventilators have supplanted external stabilization of diagnosed on admission were ventilated with a volume-
cycled respirator until the flail segment had stabilized.
the flail segment as the treatment of choice. The
After October 1973, patients were not routinely ventilated.
mortality rate, however, remains high despite this
Mechanical ventilation was reserved for those patients
change in therapy [I-81. In addition, the morbidity who, after initial evaluation and treatment in the emer-
has increased because of complications caused by gency department, manifested clinical respiratory distress.
tracheal intubation and mechanical ventilation. Criteria of clinical respiratory distress were tachypnea,
These results have led at least one investigator to dyspnea, air hunger, and agitation, with an arterial PO2 on
question the routine use of ventilatory support in the room air of less than 60 mm Hg, or a PC02 of greater than
treatment of flail chest [9]. We have treated selected 60 mm Hg. All other patients were treated with chest
patients without mechanical ventilation during the physiotherapy and either intercostal nerve blocks or epi-
past year and retrospectively compared them to a dural anesthesia. Mechanical ventilation was provided by
similar group of patients who were treated with me- the Bennett MA-l volume-cycled respirator. All patients
were treated by the same nursing staff and staff sur-
chanical ventilation.
geons.
Using the criteria of clinical respiratory distress with an
Material and Methods arterial PO2 of less than 60 mm Hg or a PC02 of greater
The records of all patients admitted to the Trauma than 60 mm Hg, all patients were retrospectively assigned
Service, Naval Hospital, San DKgo, with the diagnosis of to one of three groups: group I, “appropriately” ventilated;
flail chest from March 1972 to July 1975 were reviewed and group II, “inappropriately” ventilated; group III, non-
comprise the series. The diagnosis of flail chest was based ventilated. Patients who were ventilated only during op-
upon the presence of paradoxical movement in a segment eration and extubated before stabilization of the flail seg-
of chest wall. Initial evaluation in the emergency depart- ment were included in group III.
ment included complete physical examination, chest x-ray, These groups iere compared with respect to the fol-
and arterial blood gas analysis. All patients found to have lowing variables: age, number of ribs fractured, number of
hemothorax or pneumothorax underwent tube thoracos- associated injuries, number of days of respiratory support,
tomy in the emergency department. Patients whose asso- complications, and mortality rate. Means and standard
ciated injuries did not require an operation were admitted errors of the mean were calculated and differences between
directly to the Trauma Research Unit. Those patients re- groups were assessed using Student’s t test, analysis of
quiring an operation were transferred to the Trauma Re- variance, and the chi square distribution. Significance was
attributed to p < 0.01.

Results
From the Trauma Reeearch Mt. Naval RegIonal Medical Center, San Dii,
California. This work was supported in part by ONR Contract N-6-
484972-25925. The opinions or assertions expressed herein are those of
The forty-two patients (40 males, 2 females)
the author and are not to be construed es official or as reflecting the views ranged in age from eighteen to eighty years (mean
of the Navy Department or the naval service at large.
age, 43 years). Thirty patients were injured in auto-
Reprint requests should be &kessed to Steven R. Shackfod, LT MC USN,
Tram Research Unit, Naval Regional Medical Center, San Diego, California mobile accidents, four were injured in falls, three
92134.
Presented at the Twenty-Eighth Annual Meeting of the Southwestern
were struck by automobiles, two were assaulted, one
Surgical Congress, Houston, Texas, May 3-6, 1976. was injured in an airplane crash, and one sustained

Volume 132. Demmber 1976 759


Shackford et al

TABLE I Associated Injuries

No. of
Twe Patients

Orthopedic
Axial fractures 12
Other (acromioclavicular separations, pelvic 17
fractures, etc)
Abdominal (requiring operative intervention)
Liver Injuries 2
Splenic Injuries 4
Neurologic
Concussion 15
Subdural hematoma 1
Peripheral nerve injury 2
Vascular
Aortic arch injury 2
Peripheral arterial injury 2
Figure 1. Retrospective assignment of patients with flail
chest /njuf/es to treatment groups.
TABLE II Comparison of Treatment Groups

Group I Group II Group III


with chest physiotherapy and analgesia alone. The
“Appro- “Inappro-
priately” priately” Nonven- twenty-four patients treated with mechanical ven-
Ventilated Ventilated tilated tilation included nine who were “appropriately”
ventilated and fifteen who were “inappropriately”
Number of patients 16 15 11
49 35 45 ventilated. The three nonventilated patients were
Age W
Admission PO, 43* 68 65 included in group III. Of fifteen patients admitted
Admission PCO, 35 34 32 after October 1973, seven were “appropriately”
Associated injuries 1.44 1.27 0.64 ventilated (group I) and five were treated with chest
Number of frac- 4.6 5.3 4.2 physiotherapy and analgesia (group III). Three pa-
tured ribs
tients were ventilated during operations for associ-
Hemopneumothorax 8/16 6/15 2/11
Ventilator time 18.6 12.9 0.3* ated injuries but extubated before stabilization of
(days) their flail segments. (Figure 1.)
Complications 2.8 1.9 0.3* Six patients (14 per cent) died. The cause of death
Treatment-associated 12116 9115 4/l 1
was attributed to sepsis in two, renal failure in two,
complications
Deaths 5* 1 0 and adult respiratory distress syndrome in two.
Thirty patients (71 per cent) had complications:
* p < 0.01.
pneumonia (18 patients), atelectasis (lo), tracheo-
laryngeal injury (lo), bacteremia (lo), renal failure
a flail chest during external cardiac,massage. Twelve (6), arrhythmia (4), adult respiratory distress syn-
patients had a chest injury only, sixteen had one drome (2), disseminated intravascular coagulopathy
additional organ system injured, eleven had two ad- (a), gastrointestinal hemorrhage (2), pancreatic ab-
ditional organ systems injured, and three had three scess (a), urinary tract infection (2), acalculous
or more organ systems injured. (Table I). Sixteen cholecystitis (1) , and hepatic failure (1). All eighteen
patients had a hemothorax or a pneumothorax. patients with pneumonia were ventilated. Of the ten
Arterial blood gas analysis was performed in mechanically ventilated patients who had a signifi-
thirty-five patients prior to the administration of cant tracheal complication confirmed by either lar-
supplemental oxygen. Seven patients were received yngoscopy or bronchoscopy, four had tracheal ste-
from other hospitals where this test was either not nosis; three, vocal cord ulcers; two, vocal cord paral-
performed or performed while the patient was ysis; and one, tracheoesophageal fistula.
breathing supplemental oxygen. The patients who required ventilation (group I)
Twenty-four of twenty-seven patients admitted were the most severely injured and had the highest
prior to October 1973 were intubated and mechani- mortality rate. (Table II.) Admission PO2 in group
cally ventilated. Three patients, admitted with blunt I was significantly less than in groups II and III (re-
chest trauma and rib fractures, demonstrated a flail flecting the method of separating the groups). The
segment after admission. These patients were treated PC02 was the same in all groups, indicating that

760 The American Journal 01 Surgery


Flail Chest Management

hypoxia rather than hypercarbia determined the TABLE III Review of 10 Year Experience with

need for ventilation. Flail Chest


-- -
Groups II and III were similar with respect to age, Mortal-
POz, PCO2, number of ribs fractured, and associated Author Year Patients Deaths ity (%]
injuries. The complication rate in group II was sig- Reid and 1965 33 12 36
nificantly greater than in group III. Nine patients (60 Baird [I]
per cent) in group II had complications directly re- Perry and 1965 74 26 35
lated to respirator therapy. Four had pneumonia, Galway [2]
Ransdell [3] 1965 86 43 50
three sustained tracheal injury, and two had pneu- Garzon et al 1966 19 9 47
mothorax while on mechanical ventilation, Atelec- [41
tasis developed in four patients (36 per cent) in group Duff et al [5] 1968 71 16 22
III and was the only treatment-associated compli- Sankaran and 1970 100 24 24
Wilson [6]
cation.
Diethelm and 1971 75 9 12
Battle [ 71
Comments Relihan and 1973 85 30 35
Litwin [8]
The primary aim in the treatment of flail chest has Total 543 169 31

been stabilization of the flail segment. Initially, this


was accomplished by external means such as sand-
bags and towel clips [I&12]. Surgically applied or- a decrease in alveolar ventilation leading to respira-
thopedic devices were also used to splint rib and tory distress. However, pendulluft has never been
sternal fractures in order to maintain chest wall shown to have physiologic significance [5,16], and
stability [13,14]. Later, positive pressure ventilation some investigators have refuted its existence [16,17].
was introduced in the treatment of flail chest injuries None of our patients had impaired ventilation (PC02
[15]. This provided internal pneumatic stabilization ranged from 23 to 42 mm Hg with a mean of 34 mm
for the flail segment and promoted optimal gas ex- Hg). According to the pendulluft theory, the larger
change. the flail segment, the greater the magnitude of res-
However, mechanical ventilation has failed to piratory distress and the greater the need for venti-
improve survival. A review of eight series (Table III) latory support. Using the number of fractured ribs
of patients with flail chest treated with mechanical as an estimate of the size of the flail segment, we
ventilation during the past ten years revealed mor- found no difference in the number of fractured ribs
tality rates of 12 to 50 per cent. The overall mortality between patients with respiratory distress and pa-
rate was 31 per cent. In addition, significant com- tients without respiratory distress. This indicates
plications developed directly related to mechanical that the magnitude of chest wall instability has little
ventilation, including pneumonia, barotrauma, and importance in the development of respiratory dis-
tracheal injury. In our series, pneumonia occurred in tress.
60 per cent (18 of 31) of ventilated patients, each case Mechanical ventilation, when indicated, should be
being hospital-acquired with causative organisms used to correct abnormalities in gas exchange rather
frequently resistant to all but potentially hazardous than to overcome chest wall instability. The decision
antibiotics. Significant tracheal complications oc- to place a patient on a ventilator should be based
curred in 33 per cent (10 of 31). One of the patients upon the patient’s clinical appearance, arterial PO2
in group II died as a direct result of a tracheo- and PCOs, and, if available, alveolar-arterial oxygen
esophageal fistula; another in group II, ventilated for gradient and intrapulmonary shunt. Using the cri-
only twelve days, required resection for tracheal teria of clinical respiratory distress (tachypnea,
stenosis. Barotrauma occurred in two ventilated dyspnea, air hunger, PO2 < 60 mm Hg, and PCOs >
patients. 60 mm Hg), we have had to ventilate only seven of
The fact that mechanical ventilation has failed to fifteen patients (46 per cent) with flail chest com-
improve survival is not surprising. The therapeutic pared with twenty-four of twenty-seven (66 per cent)
intent of stabilization of the flail segment is based ventilated prior to the institution of these criteria.
upon the concept of pendulluft. This is “the pen- The hypoxemia which occurs in patients with flail
dulum-like movement of air from one lung to the chest is a result of the ventilation-perfusion (V/Q)
other” [16] brought about by the paradoxical abnormalities brought about by the splinting of the
movement of the flail segment. This was thought to chest wall and the underlying pulmonary contusion.
cause an increase in dead space and, subsequently, Splinting of the affected side inhibits cough, allowing

Voiumo132,lbwmbef 1976 761


Shackford et al

the accumulation of tracheobronchial secretions and function. This allowed division of patients into three
the development of atelectasis. groups: “appropriately” ventilated; “inappro-
Initial hypoxemia is a good indicator of the need priately” ventilated; and nonventilated. Admission
for mechanical ventilation, but additional factors PO2 in the “appropriately” ventilated patients was
must be considered. If hypoxemia can be corrected significantly lower than in the other two groups be-
by administration of supplemental oxygen, the V/Q cause the former were admitted with respiratory
abnormality is minor and mechanical ventilation can distress and hypoxemia. Significantly more compli-
be avoided. Likewise, correction of mechanical cations occurred in the ventilated groups than in the
problems such as tension pneumothorax or hem- nonventilated. Treatment-associated complications
othorax may resolve the hypoxemia. Hypoxemia were more frequent in the ventilated groups. Because
persisting after correction of mechanical factors and of these findings, we believe that mechanical venti-
administration of supplemental oxygen indicates lation should be used in the treatment of flail chest
severe abnormalities in gas exchange and mechanical injuries only for significant pulmonary dysfunction
ventilation should be instituted. and not for the purpose of stabilizing the chest wall.
Our patients in group III demonstrate that selected If respiratory support is required, it should be dis-
patients do well without mechanical ventilation or continued when normal gas exchange has been re-
any other means of chest wall stabilization. We stored.
treated eleven patients with analgesia and aggressive
pulmonary toilet without mortality or significant References
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762 The Amedcan Journal 01 Surgery