treatment of multiple rib fractures. randomized controlled

$: Treatment of multiple rib fractures. Randomized controlled$
DOI 10.1378/chest.97.4.943 1990;97;943-948 Chest

CT Bolliger and SF Van Eeden

nonventilatory managementcontrolled trial comparing ventilatory with Treatment of multiple rib fractures. Randomized

http://chestjournal.org/cgi/content/abstract/97/4/943services can be found online on the World Wide Web at: The online version of this article, along with updated information and

). ISSN: 0012-3692. http://www.chestjournal.org/misc/reprints.shtml(without the prior written permission of the copyright holder

distributedrights reserved. No part of this article or PDF may be reproduced or College of Chest Physicians, 3300 Dundee Road, Northbrook IL 60062. Allhas been published monthly since 1935. Copyright 2007 by the American CHEST is the official journal of the American College of Chest Physicians. It

Copyright © 1990 by American College of Chest Physicians on February 21, 2008 chestjournal.orgDownloaded from

http://chestjournal.org/cgi/content/abstract/97/4/943

http://www.chestjournal.org

*From the Respiratory Intensive Care Unit, Department (of internal

Medicine, Tygenheng Hospital, Cape Town, Soouith Africa.Manuscript received Juoly 20; revision accepted Octuher 2.

CHEST I 97 I 4 I APRIL 1990 943

Treatment of Multiple Rib Fractures*Randomized Controlled Trial ComparingVentilatory with Nonventilatory ManagementChris T Bolliger, M.D. ,B. Sc. ,Hon.;

and Stephan F Van Eeden, M.Med.

We studied the treatment of multiple rib fractures in NIC,

comparing ventilatory with nonventilatory methods in 69

patients who were randomly allocated to one ofthe following

two treatments: (1) a CPAP mask combined with regional

analgesia (n 36); or (2) endotracheal intubation and me-

chanical ventilation with PEEP (n 33). Clinical outcome

was as follows: mean duration of treatment, 4.5 ± 2.3 days

for the group with CPAP and 7.3 ± 3.7 days for the intubated

group (p = 0M003); mean number of days spent in intensive

care, 5.3±2.9 days and 9.5±4.4 days, respectively

(p = <0.0001); mean period ofhospitalization, 8.4 ± 7. 1 days

and 14.6 ± 8.6 days, respectively (p 0.0019); and patients

developing complications: 28 percent (10/36) and 73 percent

(24/33), respectively. Infections caused the difference in

complications, primarily pneumonias, which occurred in 14

percent (5/36) of the group with CPAP but in 48 percent

(16/33) of the intubated group. We conclude that treatment

with a CPA? mask combined with regional analgesia can

shorten and simplify treatment in these patients, mainly

through a decreased infection rate, when compared with

intubation and mechanical ventilation, and we recommend

this treatment in patients similar to our sample.

(Chest 1990; 97:943-48)

NIC = nonpenetrating injury to the chest; ISS injury severityscore

T he treatment of multiple rib fractures in NIC has

undergone radical changes ouver the last three to

four decades and is still evolving. Whereas up until

the 1930s the stabilization of the chest wall wasachieved by sandbags, external compression, and

0 the utilization of different mechanical

devices such as wires, hooks, screws, or pins became

fashionable over the next 20 years. During the 1950s

the radically different concept of internal pneumatic

stabilization with positive-pressure breathing was de-

veloped.2’3 This technique required endotracheal in-

tubation and mechanical ventilation of the patient.

The evoolution O)f the understanding of the pathophys-

ioolo)glc effects of NIC directed the attentio)n froonl the

chest wall too the injury ofthe underlying king resulting

ill gas exchange disturbances and co)mplicatio)ns such

as the ARDS.4#{176}#{176}

Mechanical ventilatioun has since becoome an ac-

cepted foorm oof treatment for multiple rib fractures

and flail chests;�’� however, with the widespread use

of this invasive form of treatment, complications such

as respiratory t2 sepsis, I)arootrauma, and

tracheal stenoosis became evident.

Recently, there has been a return too mooninvasive

modes O)f treatment, such as ooptimal pain relief and

CPAP via a tightly fitting face mask too increase the

FRC.13.t4 The use of CPAP via a mask maintains the

principle ofinternal pneumatic stabilizatioon but avoids

the risks invoived with intubatioon and mechanical

ventilation. 05,06

Pain relief in mechanical ventilation dooes not pre-

sent prooblems, as the respiratoory depression due too

systemically administered analgesics is ooften initially

desired in patients on a ventilator; however, in a

patient breathing spo)ntaneously, any depression oof the

respiratory drive must be avoided. Therefore, sys-

temic analgesia is often replaced by local o� regioonal

means of pain relief. The main options are intercostal

nerve blocks or epidural analgesia. L7��

Previous studies have shoown the feasibility ouf nom-

ventilatory treatment of NIC, bitt they were either

retrospective,05 o)nly descriptive,aS oor lacked matching

or randoomization (or both) behveen the different

treatment 04, 05.22 We therefore coonducted a

randomized controolled trial too compare the use of a

CPAP nlask cumbined with regioonal analgesia too the

coonventiounal mode oof management of multiple rib

fractures, which is intubatioon and mechanical venti-

lation with PEEP. Our hypothesis was that in I)atietlts

with moderate too severe NIC, treatment with the

CPAP mask wo)illd he shorter and cause less coompli-

catio)ns than intubatioon and mechanical ventilatioun.

Pb;�ulation

MATERIALS ANI) METuons

Between Janutarv 1988 amid March 1989, 70 patiemots admitted to)

oouon respiratourv ICU with multiple nil) fractures in NIC were

sequentially randomized painwise� to) either CPAP mask treatment

coombined with regional analgesia our to) endotracheal inttohatioon and



944 Treatment of Multiple Rib Fractures (Bo!Iigeo Van Eeden)

ventilatioumi. Infourmed coonsent was oulotained. The study had been

approved by the University ouf Stellenhoosch Faculty ouf Medicine

Ethics Coommittee. Patients with NIC were ennoulled in the stiody

according too the criteria listed in the foollouwing tahuolation:

Incluosion (all oof the folloowimig):Moore than three rib fracturesAdmissioon too houspital within 24 hoours after injuryInsufficient coough mechanism dume to) pain or preexistingpnlmnonany disease (our both)

Excluision (any (of the fullousu’ing):Depressed level oof counscioousnessImportant facial injuries (excluding tolenance ouf CPAPmask)Fracttores too l)ase ouf skullSevere luong contusion (alveolar infiltrate umidenlying ribfractuores on admissioun chest x-ray film and PaO2-(8 kPaoun 40 percent (oxygen mask)Need for initial tipper laparotomy our other majoun surgery

Spinal injuryContraindications for regional aoialgesia (bleeding ten-dency)

PTVCCdUWS and Measun’ments

On admissioon to the ICU , all patients received the following

woorktop: detailed history regarding previoous coondition of the kings;

circumstances of injury; physical examination; and laboratory anal-

yses, includimig blood chemistry, full blouod cell count, chest x-ray

film, ECG, arterial blood gas levels on rooom air and 40 percent

ouxygen, amid FVC oubtained with a portable spirometen (the best o)f

three efforts was reponted).

The patients nandomly allocated too CPAP mask treatment under-

went the insertion of a luombar epidtoral catheten.#{176}-’� Pain relief was

oubtaimmed with louprenoorphine (Temgesic; Reckitt amid Colman), with

0. 1 too 0.3 rug per injectioon diluted in 10 to 20 ml of physioloogic

saline soltmtioun.’ The vooltome of the injectiorm was calcuolated by

muoltiplying the number of segments between the imisertion level (of

the epidural catheter and the level of the highest hnoken rib by 1.5

ml.� The pain level was assessed by the patient oun a straight line

fnom 0 (no paimi) too 10 (maximum pain) before amid after negioomial

analgesia. The ntomloer oof injections depended oon the patients’

needs, with the muinimuom interval being six houons. Altennativel�;

imitercoostal nerve blocks with htipivacaine hydnochloonide (Mancaine)

(maximum, 150 ing per douse) were used in patients with moudenate

NIC, le, unilateral nb fractures only. The patients were then placed

out) a freestanding CPAP mask system.

The patients assigned too emidotmacheal intuthatiomi and mechanical

ventilatioon were intubated amid connected too a respiratory (Siemens

9(X) C, CPAP Bird) amid received systemic pain reliefwith morphine

( ± 1 mmig/kg/day) and sedatioon with midazolam (Dormicum; Roche)

( ± 1.5 mg/kg/day) as mieeded. They were kept in the IMV mode.

The F1o2 amid level ouf CPAP were adjusted in both grouuips too

maiimtaimm adequoate oxvgenatioun (arterial oxygemi sattonatioun >90

percent amid arterial carbon dioxide pnessuone �6 kPa [45 mmii hgj).

All patiemits received aggressive physiootherapy daily and were

mouboilized as early as possible. The dionation oof treatment for both

groutips was at least 48 hoouns after admnissioon�’ and contintted until

the patient cooumld maimitaimi (1) a PaO2 greater than 8 kPa (60 mm

iig) oon 40 I�rcermt ouxygen, (2) a nespiratory rate ofless than 30/mm,

(3) FVC oof more than 15 mI/kg, and (4) hemoudynamic stability

(noormal pulse rate and bloood pressttre). Patients were discharged

fnom the ICU within 24 hotons after discoontinuoation of specific

treatment. The pain level, FVC, and arterial blood gas levels were

analyzed daily in all patients. Other examinations (white blooood cell

co)tttit, bacteriodogic samples, and chest x-ray films) were obtained

every third day or whemo indicated by the clinical cootorse (our booth).

Criteria for intubating and mechanically ventilating patients oms

the CPAP mask regimen were oone or mo�e oofthe foolloowing: (1) PaO2

less than 8 kPa (60 mm big) on 40 percent oxygen and CPAP of 10

cm H2O; (2) PaCO2 greaten than 6.5 kPa (48.8 mm hg) and rising;

(3) respiratory rate greater than 35/mm; (4) FVC less than 10 mI/kg;and (5) deterioration of level oof coonsciousness.

Variables were defined as follows: (1) dyspnea baseline dyspneaprior to injiory according too the NYHA classification; (2) preexisting

pulmoonary disease = any clinical symnptomns our previoouosly docu-

mented signs as well as nadiougraphic signs ouf preexisting puolmounany

disease; (3) smooker - cumnnent smoking of 5 our more cigarettes pen

day or daily pipe smouking, including ex-smo)kens from both gnoouops

wh(O ceased smouking less than six mounths prior too admission; (4)

hong conttosion = radiognaphic evidence ouf alveolar infiltrates

subjacent to the fractuored ribs within six hooumns (of injury; (5) blunt

abdominal trauma - contusion our niptione (our booth) (of internal

organs (diagnoosed clinically, s(unoognaplucally, our by laparootomy); (6)

acute bronchitis = punolent sputum (or bronchial washing) without

pulmoonary infiltrate, with positive culture oor 25 netotrophils pen

high-poower field (on both) with microorganisms on the Gram stain;

(7) pneumoonia = new puilmiinany infiltrate (not explained by any

outher neason) with at least two oof the folIoowing: purtmlent sputum,

raised temperature (>38.3#{176}C [100.9#{176}F]), raised white blood cell

oxount (> 12 x lOYcto mm and �80 percent neuotr(Ophils), and positive

sputum Gram stain on cultsore (or booth); (8) septicemia (all five oof

following) = (a) clinical evidence ouf infection, (b) fever (>38.3#{176}C

[100.9#{176}F], rectal) our hypothermia (<35.6#{176}C [96.1#{176}F], rectal), (c)

tachycardia (>90 beats per minute), (d) white bboood cell count

greaten than 20 x 10#{176}/cumm or less than 4 x 10#{176}/cumm, and (e) at

least one of the foollowing criteria four an altered perfusion state:

altered mentation (in relation to patient’s baseline), elevated lactate

level (>2 mm(ol/L), and ouliguria (ooutptot <30 ml or <0.5 mi/kg fon

at least one houn).�’

Statistical Analysis

We estimated the necessary sample size at 30 patients per gnotmp

in oorder too demomstrate a oomme-dav neductioumu ouf the ICU stay at the

95 percent c’oonfidemsce level. The dtoration of mechanical ventilati(on

was likely to be seven to) eight days according too our (OWn previous

recoords.

The criteria used too coompare oumtcoomes between the twoo methods

(of treatment were length of treatment (CPAP mask or mechanical

ventilatioon), duration ouf stay in the ICU , duiratioon of hoospitalizatkon,

and presence oofcomplicatiouns. The data were mion-mally distributed.

The statistical tests uosed were the Student�o f-test four countintoous

variables and X� test Ion categorical variables. Significant differences

were cxompared at the 95 percent level.

In additioon, booth grouips were stratified according to) smoking

histor�� evidence ouf preexisting pulmonary disease and grade of

dyspnea prioon too injuir) Analysis within and between the (woo grooups

for these pootential confotonders was performed by analysis of

variance.

RESU LTS

Of the 70 patients entered into the trial, one in the

group with CPAP had too be excluded because serial

chest x-ray films showed fewer than four rib fractures.

Finally, 36 patients were treated by CPAP mask, and

33 by endotracheal intubation and mechanical venti-

lation. The groups were comparable in respect to sex,

age, grade of dyspnea prior to the injury, preexisting

pulmonary disease, smoking habits, the FVC before

onset of treatment, and the PaO2 with 40 percent

oxygen by mask on admission (Table 1).

The number of rib fractures, the proportions of

patients with hemothorax (pneumothorax), pulmonary



Patients with NICData (PAP !�Ilausk lmmtuoboautiomm io

No. ufpatieimts 36 3.3 . .

I)�uvs ouftreatumetmt 4.5 ± 2.3 7.3 ± :3.7 O.(XX)3*

Days iim intemmsive caro- 5.3 ± 2.9 9.5 ± 4.4 <0.0001*

I)avs immimospital 13.4 ± 7. 1 14.6 ± 8.6 0.0()19*

No. ofpatiemots ‘with 10 24 0.(X)2�

(.lonmplicati0001st

1)ata CPAP Mask Iiotuoboat�omi p \�tlute*

No. ofpatiemmts 36 3.3 . .

Sex (No. ofmnen) 26 22 NSf

Meami age 46.3 ± 15.7 47.8 ± 14.9 NS�

I)vspnea (� grade 2) 8 6 NSt

Pno.’existitog I)tillmio)rmarY 12 8 NSt

disease

Smnookers 28 22 NSt

FVC/L 1.53±0.63 1.48±0.66 NS�

PaO� with 40 loerco-mit

ooxvgeim boy mumask

kPa 15.7±4.2 14.2±3.4 NS�

mon Jig 117.8±31.5 106.5±25.5 . .

No. oufnib fractures 6.9±2.2 6.9±2.3 NS�

I Ienooutlmoorax (pioeuomnoothoorax) 16 i 7 NSt

Ptolnioomiarv coontutsiom 6 5 NSf

No. oofputietits with 15 14 NSt

additiounal fractures

Blumit abodoumminal traomnoa 2 7 NSfISS Score� 11.5±3.6 14.3±5.9 0.021t

The results ouf clinical ooutc(ome were as hollouovs

(Table 2): days 0)11 specific treatment, 4.5 ± 2.3 fur tile

grouup with CPAP and 7.3 ± 3.7 four the intubated grouup

(r = 0.0003); days spent ito the ICU, 5.3 ± 2.9 and9.5±4.4 days, respectively (p<O.(X)Ol); days of’ boos-

pitalizatioon, 8.4 ± 7. 1 and 14.6 ± 8.6 days, respectively

(i 0 . O() 19); amid 1)atieiits develiuping coOtill)l ications,28 Percent (10/36) and 73 1)ercelit (24133) (p = O.()02).

Details of the complications during the perioud in the

ICU are listed in Table 3. The average level ouf CPAP

delivered too the group receiving CPAP was 5.4 ± 1.3

dl H2O and to) the intul)ated grouup was 6.6 ± 2.3 cm

H2O (p>O.05).

One Patient iii tile group witil CPAP developed a

ni ttltifactorial respirato)rv failure (aicoohool �

lung collapse; l)tieitmflooliia) amid had tou i)e itituti)ated

and vetitilated for twou weeks befoore successful wean-

lug. Tivoo deaths ooccurred in the intui)ated group; a

74-year-old mnati with severe chroonic o)i)strtictive 1)tll-

niounary disease who had acute i)roonchitis at the tinie

oof injury died ouf’ respirators’ failure, and a 70-vear-ould

wouniato died suddenly in cardiac failure (tile autopsy

revealed a severe cardiac contusiom and suti)dtlral

Table 3-Complications in 69 Patients with N1C

3.

contusion, additional fractures o)utside the rib cage

(Fig 1), and, finally, blunt al)doominal trauma did not

show any significant differences between the two)

groups either. When using the ISS,t� we found values

of 11.5±3.6 amid 14.3±5.9, which were significantly

different at a 5 percent level (p = 0.02 12).

CPAP MASK INTUBATIONn:36 n::33

2110

� �

1_ � 104 I�ol � � Ii

o�

01 [

(�unplicatioti (PAP Niaslo intitloatiomi J) \altio�

No. ofpatiemmts 36 33 . .

Barotm’aumna

Pmiemmmmmotliorax 2 1 NS

Suoloc-utatmeomos emmmpiovso-mmia i 0 NS

Broumicimopleural fistula 0 2 NS

I mifectiomm

Acute hromicliitist 2 1 NS

Simmumsitis 0 1 NS

I.anytmgitis 0 2 NS

Pneui,moonmiat 5 i6 <0.(X)5

Septicetmmiat 0 3 NS

Other

Luomog coillapse 1 1 NS

Extraplo.ural hiemimatonia I 0 NSRespirator� failmore 1 1 NSl)eath 0 2 NS

Fictisu: 1 . liotal nomimiloer amool l(ucaliy.atunm offractuoro-s iii each treatt-o.l

gnoumj). Meamm mimitmmloerof rib fractuoro’sin lootlmgrouop ‘with (�PAP

muask aomd intmohated group was 6.9 (247/36 amid 228/33, respectively).

Table 1 -Clinical Characteristics on Admission of 69 Table 2-Comparison ofOutcome in 69 Patients with NIC

CHEST I 97 I 4 I APRIL, 1990 945

*NS not significamit.

tx2 analysis.

�t-test (mneamm ± SD).

§lnjuony severity store.

*t_test (moicaim ± SD).

tl)etaileol amialvsis iii Table 3.

:1:X2 anal\ sis.

*X.: amialvsis. NS, not significoimt.

tAs (lefimiO’(l un(ier nmethoools.



MORTALOTY

10 20 30 40 50 60

INJURY SEVERITY SCORE- �49 years O’��O50-69years � 70 years

FlcuRE 2. Injury severity scon&� four three different age groups.

Mean scores for grooump with CPAP groouop (11.5) amid intuhated group

(14.3) intersect at almoust identical mortality (percentage) regardless

of age.

946 Treatment of Multiple Rib Fractures (Bo!!igeo Van Eeden)

hematoma without signs o)f herniation oof the brain

stem, neither of which had been clinically apparent

on admission).

A stratified analysis within and between the two

groups showed that there was no significant difference

at the 5 percent level regarding ooutcome when co)m-

paring smookers and nonsmokers (p>O.O5), patients

with and without preexisting pulmonary disease

(p>O.O5), or dyspnea greater than or equal to grade 2

and dyspnea less than (p>O.OS).

In the group with CPAP, 23 patients were given an

epidural catheter, 12 received intercostal nerve blocks,

and one patient did no)t need further pain relief after

an initial intramuscular injection of diclofenac (Volta-

ren) in the emergency ward. Both analgesic methods

provided good pain relief, reducing the amount of pain

experienced by cooughing after the application of the

drug by an average oof 50 percent as assessed by the

patient on the linear scale; however, the twoo methoods

were no)t used eo�ually. Intercostal blocks were given

preferentially too patients with fewer fractures on oone

side oof the chest only. On the average, the epiditral

catheters were left in place for three days (range, two

to) seven days), the average to)tal nulilber oof injectioons

was 4.4, and the average t(otal doose o)f buprenoorphine

was 0.78 mg per patient. Noo complications were

observed.

Both treated groups received the same intensity of

chest physiotherapy, but due to the lack of initial

sedatioon and the absence ofan endotracheal tithe, the

patients in the group with CPAP could be mobilized

earlier and participated moore actively with the physi-

otherapist than the patients in the intutbated group.

DiscUSSION

In this study, we coonducted a randomized coontrolled

trial tcm compare treatment by CPAP mask combined

with regio)nal analgesia too endotracheal intubation and

mechanical ventilatioun with PEEP in patients with

multiple ru) fractures in NIC. In our sample, we could

demonstrate that treatment by CPAP mask prooved to

be much shorter and had fewer complicatioons than

intubatiom and mechanical ventilatioon.

Previous studies shoowed that NIC with multiple rib

fractures could be managed without intubatkon of the

patient, but in general the no)nventilated patients had

less severe chest trauma. With a randomized study,

we oobtained two treated groups which were well

matched for all parameters bitt for the ISS (Table 1).

The higher ISS score for the intubated group can be

accoounted for by greater incidence cfblunt abdomiinal

trauma (seven vs twoo in the group with CPAP), which

although on direct compariso)n was not different,

reached significance in the 155 due too the quadratic

nature of this score. Clinically, this difference was not

important, as the blunt abdominal trauma was less

severe than the chest trauma in all patients of both

grcoups and did noot influence the duration of treatment.

Two patients in the intutbated group underwent early

laparotoomies (one splenic rupture; one bladder rup-

ture), with an uneveniful postooperative course. Froum

Figure 2, it is apparent that although the ISS score

was 11.5 for the group with CPAP and 14.3 for the

intitbated grooup, both groups have similar mortality

regardless of age. The ISS pro)ved too be a goood index

(Of mortality, as both the deaths occurred in patients

70 years of age or older, whose risk of dying was

greater than that of younger patients for a given score

(Fig 2). The deaths were probably not related to the

mode oof treatment; however, the ISS was a relatively

poor indicatoor of the considerable morbidity in our

groups, whose major site of injury was the chest.

Apart from age and sex, we attached particular

importance to the condition of the lung prior to the

injury and obtained a detailed history of the degree of

dyspnea between grade 0 and 4 (NYHA), evidence of

preexisting pulmonary disease, and smoking status.

We used the FVC as a measurement of initial respi-

ratoory impairment and the Pa02 as an indicator of the

pulmo)nary gas exchange.

Our criteria for comparing outcomes between the

twoo groups were the duration of the different treat-

ments (specific treatment too increase FRC; stay in the

ICU; to)tal length oof hoospitalizatioon) and the rate of

connplications in each group. The results showed a

highly significant difference fcor all criteria, indicating

that treatment by CPAP mask combined with regional

analgesia shortened all periods co)nsiderably and

caused far fewer complicati.ons.

Comparisons with other studies were difficult, as

none ofthem used a severity score; however, Dittmann

et al� had two groups whose severity of chest trauma



CHEST I 97 I 4 I APRIL, 1990 947

was comparable to) our population. Their periods in

the ICU, with 4.5 days foor the nonventilated amid 9.8

days for the ventilated group, were similar too omrs

(Table 2). The tootal length o)f hospitalizatioll in a stu(iy

by Trinkle et al#{176}�four their noollVelltilated group (9.3

days) compared well with that oofoour grouttp with CPAP

but not for the ventilated grooup (31 .3 days in their

study). Despite soume difficulties in comnparing the

studies mentitoned, the commoon message is that

nonventilatory treatment of NIC can shoorten hospi-

tahzati(on dramatically.

A detailed view ofour co)mplications (Table 3) which

occurred during the period in the ICU showed a very

low incidence cifpneumoothorax ,subcutaneous emphy-

sema, lung collapse, and bronchitis for both groups;

however, the number oof severe infectioons was much

more frequent in the intitbated group, with pneumonia

occurring in 48 percent (16/33 patients), compared

with 14 percent (5/36 patients) in the grooup with CPAP

Sinusitis, laryngitis, broonchopleural fistula, and septi-

cemia with positive bkRod culture oonly occurred in the

intubated and mechanically ventilated group. Tougether

with the pneumoonias, these complications were the

main factoors contributing to increased mo)rbidity and

therefore longer duration of each period of treatment

in this group. These findings agree well with the high

rate and the type of complications due to mechanical

ventilation reported in many studies. 02.04,15 Trinkle et

al#{176}�even reported an incidence of pneumoonia of 84

percent (16/19 patients) in their ventilated group.

Our overall rate of complications of 28 percent (10/

36) in the group with CPAP and of 73 percent (24/33)

in the intubated group, as well as the mortality of zero

in the group with CPAP and of 6 percent (2133) in the

intubated group, were comparable to the trial of

Trinkle et a1.#{176}�Their overall rate of complications in

the nonventilatory grooup was 21 percent and in the

ventilated group was 100 percent (19/19). Their moor-

tality was 0 and 21 percent, respectively. Complica-

tions due to the CPAP mask per se were negligible

(nasal pressure sores) and did not result in any discoon-

tinuation of the treatment.

The stratified analysis within and I)etWeen tour twoo

treated groups exchtded smoking, preexistitig pulmo-

nary disease, and degree ofdyspnea prior too injury aspossible confounders. This suggests that peouple with

impaired pulmonary function with mo)derate too severe

NIC can be treated without intiml)atio)n and mechanical

ventilation.

We see the successful outcome in our grooup with

nonventilatory treatment as a result ofthe coombination

ofCPAP by mask and regio)nal analgesia, booth of which

have been shown to be beneficial in NIC on their town.

The CPAP, by increasing the FRC, aims at the majoor

problem in NIC, which is contusion ofthe underlying

lung, with abnormalities in gas exchange.#{176}�’� Epidural

analgesia and interco)stal nerve blocks, oon the outher

hand, 1)rouxide pain reliefand allow early moobilizatioon

and aggressive chest physiotherapy �vith the patient’s

active Particil)atioulo. This, in tutrn, can po)tentiate the

increase in FRC� obtaitoed with CPAP�

Epidural analgesia usimig the luonohar approach for

tiloffacic 1)aili relief-52#{176}’ 1)ro)�’e(1 �‘er�’ satisfactoorv imi (our

trial. \Ve primarily useol this approuach, since in our

institution the nlajority ouf douctoors are trained oumily in

the luniixtr techni(Iue. Buprenourphiole prooveci too i)e

safe and effective in the epidural space. Most o)f (uttr

patients needed oonly oune too twou itijectiouns per 24

hoours too maintaito adeoiuate 1)ain relief. Clinically

important respiratory depression our catheter-related

coumplicatioons were noot oi)served.

\Ve coonclude that in patients with NIC xs’hoose main

site of injury is the chest and who doo n(ut meet am�y oof

the previoously mentiooned criteria four exchtsioumo, the

treatment ofchuice shooitld I)e the use (ofa CPAP mask

combined with regional analgesia, physioutherapy, amid

early mobilization. This treatment is coost-effective,

has less associated additioomial mnoorbidity, and shortens

hoospitalizatioon draniatically

ACKN()WI�EDG!’�1ENTS: ‘sVo thank Prof. H. Stewart amm(i Mrs. J.Barnes four reviewimmg the article. Prof. D. Kotzo’ four statisticalamoalvsis, amiol E. Bademmhoorst atid B. Karg four comimpilimig time niammu-script.

RE FE RE N( ES

1 Fimidlav RT Fractures of the scapula amid ribs. Aooi J Suing 1937;

38:489

2 Jensen NK. Recoovery ouf pulmonary fumictioon after crnshimmg

injuonies ofthe chest. Dis Chest 1952; 22:319

3 Avery EE, Moench ET, Benson D\V. Critically cruoshed chests.

I Thoorac Candiovasc Suing 1956; 32:291-309

4 Ashhauogh DC, Petty TL, Bigeloow DB, harris TM. Continmiouis

poositive pressuore breathing (CPPB) in aduolt respiratorv distress

syndrome. J Thoorac Candiovasc Suong 1969; 57:31-40

5 Blair E, Topuoziut C, Davis JH. Delayed our missed diagnoosis in

bluommt chest trautma. J Trauma 1971; 11:129-45

6 Garzon AA, Seltzer B, Kanlson KE. Phvsioopatholoogv of crushed

chest itmjuories. Ann Sting 1968; 168:128-36

7 Craven KD, Oppenheimer L, \��so.d LDII. Effects of-oontusioo,i

amid flail chest oii puolmnomiarv iuerfusion amid oxygen exo�-lmatmge.

J AppI Phvsiod 1979; 47:729-37

8 Ros.-iier R, Bittner R, Stoo-kmmmamimm U . Pulnmoonarv (-ootitnsio)n.

Arch Suing 1974; 109:508-10

9 I)eN1,ttii \\‘E, Smith JNI. Pioltoiommmarv commototsiommi. Am J Surg

1965; 109:819-23

10 (iloismis J, Jamimo’s 0, Quail A. Niammagenmo-tot of 1-li) � of o’imo’st

injmmnv scith ro.’spinatoonv failure. Br J Aimao’stim 1973: 45: 1 13(0-35

I 1 Jette NT, Barasim PC. Tro�utmiiemit of a fluil immjmtry of the chest.

Anaesthesia 1977; 32:475-79

12 Phillips I . P.u’udin,unmas (il’m”lAgilOOSa ro-spir�otonv tract imofec-tiomms

imi ioatiermts receiving mrm-ciianical 5etitilatu)mm. J I I vg (( �oiimio) 1967;

65:229-35

13 (ibohr.onms J, Janmes 0, Quail A. Relief’ ouf pain imm t-hest irmjmtrv. Br JAmiaesth 1973; 45:1136-38

14 Tnmokle JK, Richandsomom JA, Trami�’ JL, Grover Fl., Ammo KV

il#{246}lstnom FNI(;, et al. Niamoagenient of flail chiost svithoouit

mechaimical ventilatiourm. Anti Tlmorac Suorg 1975; 19:3.55-63

15 Shackfiond SR. Smnith I)E, Zarimms CK, Rice CL, Virgilio 11W.



East Coast Workshop in ElectrocardiographyThe Roogers heart Fooundation will sponsor this workshop May 30-Jume 3 at the Diploniat

Resort and Country Club, Hollvwoood, Floorida. For infornoatioon, contact: Rogers Heart

Foouondatiom, P0 Box 12588, St. Petersburg, 33733 (813:894-079(0).

Introduction to Occupational MedicineThis two-day coourse will be held Ma� 15-16 at the Marriott Hotel, Worcester, MA, spons(ored

b�’ the Occupational Health Program, University of Massachusetts Medical School, amid coo-

sponsored by the Harvard Educational Resource Center for Occupational Safety and Health.For infoormation: coontact Occupatiomoal Health Program, University of Massachusetts Medical

Center, 55 Lake Avenue North, Worcester 01655 (508:856-2322).

948 Treatment of Multiple Rib Fractures (BoI!igeo Van Eeden)

The muanagement ouf flail chest: a coomparisoumi of ventilatory and

nom-ventilatoony treatment. Am J Sung 1976; 132:759-63

16 Covelli liD, \Veled BJ, Beckman JF. Efficacy ouf coontinuoms

po)sitive airway pnessumre administered by face mask. Chest 1987;

81: 147-50

17 Broniage PR. Epidural analgesia. Philadelphia: WB Satonders,

1978

18 Bnomage PR, Camnporesi EM, Chestmitot D. Epiduiral narcotics

foor poostoqwr�utive analgesia. Anesth Analg 1980; 59:473-80

19 Behan M, Magora F. Olshwang D, Davidsoon JT Epiduralm110)rphimlo- imm treatnio-mmt ofpain. Lamicet 1979; 1:527-28

20 Cotoaclmer ID, Paes ML, Jao-ouhsemm L, Phillips PD, hleavisideD\V Eioiobuiral amialgesi.u foollowing thooracic sumrger� Ammaesthesia

1983; 38:546-51

21 (;nmfliths DPC, Diamnoommd A\’� Camneroon JI). Postouperative extra-

olural amialgesia foHouwing thooracic surgery: a feasibility stutd� Br

J Aimaesth 1975: 47:48-55

2.2 1)ittmuamimm NI, Keller R, \%�olff C. A ratioomiale four epidoiral

amialgesia imi the treatmnent of mnultiplo’ rib fractuires. Intensive

Care Med 1978; 4: 193-97

23 Rankin APN , Coumloer RELI . Management ouf 50 oases (of chest

immjutry with i regimen (of epiduor�ul huopivacaine and mnoorphimie.

Amoaesth lmitensive Care 1984; 12:311-14

24 Efron B. Forcimig a seo�uiential experiment to ioe balanced.

Biometrika 1971; 58:403-17

25 Froomme GA, Steidl U, Danielson DR. Comparisom oof lumbar

and thonacic epiduoral mmorphine four relief of postthoracotomy

paimi. Anesth Analg 1985; 64:454-55

26 Welch DB. Founimm: postoperative analgesia using epiditral meth-

adoune: administratioon liv the lumbar route for thonacic pain

relief. Anaesthesia 1981; 36:1051-54

27 Mtmrphv DF, Cahill J, Fitzpatrick C, MacEvilly M. Epidunal

huopremiorphimie for I)�5to0Perative l)aim0 relief. Atiesth Analg 1985;

64:456-57

28 Broomnage PR. Spread ofanalgesic soolutioomis in the epidttral space

aimd their site of actiomi: a statistical stutd� Br J Amiaesth 1962;

34:161-77

29 Pav,mo� K. Epidutral amid spimmal amiaesthesia: an onervies�: S Afr

CME 1985; 3:21-30

:3(0 Vami Eedemi SF, Kloopper JF, Albeit B, Bardiom PC. Vemitilation-

l)erfutsio)mi imaging in evaluiatitig negioummal luong fmonctioomi in noon-

penetrating injury too the chest. Chest 1989; 95:6.32-38

31 Boone IIC, Fisher CJ, Clemmner TP, Slootmnan GJ, Mets CA, BalkRA. The Methvlprednisoohone Severe Sepsis Stuody Gnouop: a

coomitroolled climmical trial uf high-douse methylprednisoolone in the

treatment (ofsevere sepsis amid septic shock. N Emigl J Med 1987;

317:653-58

32 Baker SP, O’Neill B, Iladdoun W Long \VB. The injury severity

scoune: a methood for describing patients with mntoltiple injuonies

and evaluoating emergency care. Trauma 1974; 14:187-96



DOI 10.1378/chest.97.4.943 1990;97;943-948 Chest

CT Bolliger and SF Van Eeden ventilatory with nonventilatory management

Treatment of multiple rib fractures. Randomized controlled trial comparing

This information is current as of February 21, 2008

& ServicesUpdated Information

http://chestjournal.orgfigures, can be found at: Updated information and services, including high-resolution

Citations http://chestjournal.org

This article has been cited by 3 HighWire-hosted articles:

Permissions & Licensing

http://chestjournal.org/misc/reprints.shtmltables) or in its entirety can be found online at: Information about reproducing this article in parts (figures,

Reprints http://chestjournal.org/misc/reprints.shtml

Information about ordering reprints can be found online:

Email alerting serviceup in the box at the top right corner of the online article. Receive free email alerts when new articles cite this article sign

Images in PowerPoint format

article figure for directions. teaching purposes in PowerPoint slide format. See any online Figures that appear in CHEST articles can be downloaded for


http://chestjournal.org

http://chestjournal.org

http://chestjournal.org/misc/reprints.shtml

http://chestjournal.org/misc/reprints.shtml


treatment of multiple rib fractures. randomized controlled

Documents