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PubMed1990

[Clinical results of selective treatment for flail chest].

A better understanding in pathophysiology of flail chest has brought an evolution to the principles of it's management. The methods of stabilization changed from surgical to pneumatic measures and now, a concept of conservative treatment is recognized. Adhering to our protocol for flail chest, which essentially limits mechanical ventilation, we have prospectively treated 36 patients since 1981. The patient were divided into two groups according to their need for mechanical ventilation. There were 16 patients (44.4%) in a group treated in conservative manner and with no mechanical ventilation (Group A). There were 20 patients (55.6%) in a group treated by mechanical ventilation (Group B). Group A had 6.2% incidence of pneumonia, 3.6 days average stay in ICU and mortality rate of 0%. Group B had 75% pneumonia, 22.5 days average in ICU and 15% mortality. Group B patients required respiratory support for 14 days average, which was not reduced by surgical stabilization. Restrictive pulmonary disturbance in group A was milder than that of group B, and this again was not affected by surgical stabilization. We conclude that 40% of flail chest are controllable without mechanical ventilation and that the result of this conservative therapy is superior to any other treatments.

Adult↗
PubMed1982

Selective management of flail chest and pulmonary contusion.

Four hundred and twenty-seven patients with severe blunt chest trauma were treated resulting in (1) flail chest, (2) pulmonary contusions, (3) pneumothorax, (4) hemothorax, or (5) multiple rib fracture. The need for endotracheal intubation and mechanical ventilation was determined selectively by standard clinical criteria. Avoidance of fluid overload and vigorous pulmonary toilet was attempted in all patients. Three hundred and twenty-eight patients were treated by nonintubation; 318 patients (96.6%) had a successful outcome, while ten required intubation. Only one patient died. The 99 patients who required intubation and mechanical ventilation had a high mortality because of associated shock and head injury; however, the total mortality for the entire group of patients was 6.5%, with only 1.4% mortality caused by pulmonary injury. The incidence of pneumonia was high (51%), but there was only a 4% incidence of tracheostomy complications. Flail chest and pulmonary contusion without flail chest occurred in 95 and 135 patients, respectively. Half of the flail chest patients were intubated, but 69.5% were intubated less than three days. Twenty per cent of the patients with pulmonary contusion required mechanical ventilation, usually for less than three days. This study demonstrates that patients with severe blunt chest trauma can be managed safely by selective intubation and mechanical, ventilation and that the incidence of complications associated with controlled mechanical ventilation can be greatly reduced.

Adolescent↗
PubMed2006

[Surgical fixation of the ribs for flail chest injuries].

The record of 20 patients presenting with flail chest injury from 1998 to 2005 was reviewed to determine surgical indication and timing. There were 4 groups with each indication as followed: 1) 8 patients with surgical indication for injury regions other than fractured ribs, 2) 5 without improvement of flail chest after internal pneumatic stabilization for more than 10 days, 3) 4 performed surgical fixation positively for flail chest with respiratory failure, 4) 3 with strong deformation of the thorax without respiratory failure. Eight patients (40%) required artificial respiration for more than 6 days after surgical stabilization. The reasons of prolonged artificial respiration included unconsciousness in 4 patients, pneumonia in 2, and others in 2. In the group consisting of 8 patients taking more than 6 days to be extubated after surgical fixation, the injury severity score (ISS) was significantly higher (p = 0.006) than that of the other group. In patients with no improvement of flail chest after internal pneumatic stabilization for more than 10 days, surgical fixation reduces the period of internal pneumatic stabilization and the risk of pneumonia. For the elderly who can develop complications easily, early indication of surgical fixation should be considered. In patients with unconsciousness or ISS > or = 25, the extubation delays frequently after surgical fixations.

Adult↗
PubMed1996

Respiratory muscle response to flail chest.

We have previously shown that flail chest in the dog causes an inspiratory inward displacement of the ribs and an increased inspiratory activity in the external intercostal muscles, and we have speculated that this increased activity is due to an increased spindle afferent activity. The present studies were designed to test this hypothesis. Twenty-nine supine anesthetized dogs were studied, and flail was produced surgically by fracturing ventrally and dorsally two to four contiguous ribs on the right side of the chest. Although flail elicited an increased inspiratory activity in the external intercostal and levator costae muscles in the disconnected segment of the rib cage, it did not alter the inspiratory activity in the diaphragm and parasternal intercostals. Expiratory activity in the triangularis sterni, internal intercostals, and transversus abdominis remained unchanged also, as did the inspiratory activity in the external intercostals on the left side of the chest. After flail, the normal inspiratory shortening of the external intercostal muscles in the disconnected segment was also reversed into an inspiratory muscle lengthening. However, when the fractured ribs were connected to the adjacent ribs so that the external intercostals were prevented from lengthening during inspiration, external intercostal and levator costae inspiratory activity was unaltered. These observations support the hypothesis that the increased external intercostal muscle activity seen in flail chest results primarily from an increased activation of the muscle spindles.

Animals↗
PubMed1983

Management of flail chest.

This paper compares the management of two groups of patients with flail chest. The 25 patients in group 1 had a flail chest without other significant injuries or shock, whereas the 57 in group 2 had a flail chest with multiple injuries, shock or both. The group 1 patients were treated with repeated multiple intercostal nerve blocks or high segmental epidural analgesia, oxygen, intensive chest physiotherapy, fluid restriction, furosemide diuretics, methylprednisolone sodium succinate and colloid infusion in an intensive care unit. In addition to these measures, the group 2 patients underwent endotracheal intubation and assisted mechanical ventilation with a volume respirator that provided continuous positive airway pressure and positive end-expiratory pressure. Of the 57 group 2 patients 36 required prolonged ventilation, eventually through a tracheostomy, because of severe head injury, pneumonia, severe facial injury, quadriplegia, pre-existing lung disease or severe sepsis. However, tracheostomy was avoided in the other 21 patients in group 2. There were no deaths in group 1, but 8 (14%) of the patients in group 2 died. These results show that avoidance of tracheostomy and ventilation in selected patients with flail chest is consistent with a low morbidity and mortality.

Adult↗
PubMed1994

Flail chest as a marker for significant injuries.

The records of 92 patients with flail chest injury treated at a Level I trauma center were analyzed retrospectively. Associated intrathoracic injuries included pulmonary contusion (46 percent) and pneumothorax or hemothorax, or both (70 percent). The incidence of great vessel, tracheobronchial and diaphragmatic injuries was no different from that of a control population with simple rib fractures. Adult respiratory distress syndrome developed in 27 percent of patients with flail chest; 69 percent of all patients required ventilation (mean duration, 22 days). Mean length of hospital stay was 24 days. The mortality rate was 33 percent. We conclude that flail chest serves as a marker of significant intrathoracic injury, highly associated with pulmonary contusion, but even more so with pneumothorax or hemothorax. Flail chest does not seem to be a marker for great vessel, tracheobronchial, or diaphragmatic injuries. The majority of patients (more than two-thirds) will require mechanical ventilation for prolonged periods. Of paramount importance is the recognition of flail chest as a marker of high kinetic energy absorption, resulting in life-threatening thoracic as well as nonthoracic injuries.

Adult↗
PubMed2006

Conservative management of flail chest after cardiopulmonary resuscitation by continuous negative extrathoracic pressure.

Flail chest after blunt trauma usually requires good pain control and positive pressure support. Continuous negative extrathoracic pressure (CNEP) causes a splinting effect around the anterior chest wall and upper abdomen which increases functional residual capacity and improves lung mechanics. We report an 82-year-old woman with flail chest after cardiopulmonary resuscitation. She underwent mechanical ventilation, with two failed attempts at extubation. She was subsequently ventilated non-invasively using CNEP, allowing early successful extubation. This case illustrates the use of CNEP for weaning and ventilating patients with flail chest after blunt trauma.

Aged, 80 and over↗
PubMed2002

Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients.

BACKGROUND: We compared the clinical efficacy of surgical stabilization and internal pneumatic stabilization in severe flail chest patients who required prolonged ventilatory support. METHODS: Thirty-seven consecutive severe flail chest patients who required mechanical ventilation were enrolled in this study. All the patients received identical respiratory management, including end-tracheal intubation, mechanical ventilation, continuous epidural anesthesia, analgesia, bronchoscopic aspiration, postural drainage, and pulmonary hygiene. At 5 days after injury, surgical stabilization with Judet struts (S group, n = 18) or internal pneumatic stabilization (I group, n = 19) was randomly assigned. Most respiratory management was identical between the two groups except the surgical procedure. Statistical analysis using two-way analysis of variance and Tukey's test was used to compare the groups. RESULTS: Age, sex, Injury Severity Score, chest Abbreviated Injury Score, number of rib fractures, severity of lung contusion, and Pao2/Fio2 ratio at admission were all equivalent in the two groups. The S group showed a shorter ventilatory period (10.8 +/- 3.4 days) than the I group (18.3 +/- 7.4 days) (p < 0.05), shorter intensive care unit stay (S group, 16.5 +/- 7.4 days; I group, 26.8 +/- 13.2 days; p < 0.05), and lower incidence of pneumonia (S group, 24%; I group, 77%; p < 0.05). Percent forced vital capacity was higher in the S group at 1 month and thereafter (p < 0.05). The percentage of patients who had returned to full-time employment at 6 months was significantly higher in the S group (11 of 18) than in the I group (1 of 19). CONCLUSION: This study proved that in severe flail chest patients, surgical stabilization using Judet struts has beneficial effects with respect to less ventilatory support, lower incidence of pneumonia, shorter trauma intensive care unit stay, and reduced medical cost than internal fixation. Moreover, surgical stabilization with Judet struts improved percent forced vital capacity from the early phase after surgical fixation. Also, patients with surgical stabilization could return to their previous employment quicker than those with internal pneumatic stabilization, even in those with the same severity of flail chest. We therefore concluded that surgical stabilization with Judet struts may be preferably applied to patients with severe flail chest who need ventilator support.

Flail Chest↗
PubMed1995

Rib cage distortion in a canine model of flail chest.

Although blunt chest injuries frequently lead to respiratory failure, the effects of flail chest on the mechanics of breathing have not been evaluated. In the present studies, we have measured the respiratory displacements of the ribs and sternum and the electromyograms (EMG) of the parasternal and external intercostal muscles in eight supine, anesthetized, spontaneously breathing dogs before and after the third to sixth ribs on the right side of the chest were fractured both dorsally and ventrally. After flail, the fractured ribs moved inward, rather than outward, during inspiration, but their inspiratory cranial displacement remained unchanged. The inspiratory outward and caudal displacement of the sternum, the inspiratory EMG activity of the parasternal intercostals, the pattern of breathing, and the arterial blood gases were also unaltered. However, the inspiratory EMG activity recorded from the external intercostals increased consistently to 327 +/- 101% of control (p < 0.05). These observations indicate that with flail chest, the disconnected segment of the rib cage shows paradoxical motion exclusively along the lateral axis; the increased external intercostal activation may account, at least in part, for the persistent inspiratory cranial motion of the ribs. These observations also suggest that the harmful effects of blunt chest injuries are related to pulmonary contusion and pain, rather than to flail chest per se.

Animals↗
PubMed1997

Long-term follow-up of patients with operative stabilisation of a flail chest.

The outcome is reported of patients after external chest wall stabilisation for respiratory insufficiency due to a traumatic flail chest. Since 1990, all patients with a flail chest causing respiratory insufficiency despite peridural analgesia and without further reason for prolonged mechanical ventilation underwent osteosynthesis of the chest wall using the AO-technique with 3.5 mm thick reconstruction plates, and were prospectively followed-up by use of clinical and radiological evaluation. 23 patients underwent external chest wall fixation between 1990 and 1996 and were followed for a mean time of 28 months. 2 patients died after the operation, giving a 30-day-survival rate of 91.3% 21 patients survived and were extubated and transferred to the ward after a mean time interval of 3.9 and 7.8 days, respectively. 95% of the survivors revealed a 100% working capacity at assessment and 86% returned to preoperative sports activities without complaining of chest wall or shoulder girdle pain or dysfunction. External chest wall fixation appears to be an attractive alternative to prolonged intubation and mechanical ventilation for selected patients with flail-chest respiratory insufficiency despite peridural analgesia, providing they do not require prolonged intubation for other reasons.

Adult↗
PubMed1981

Stabilization of flail chest by compression osteosynthesis--experimental and clinical results.

It has been demonstrated that the impaired ventilatory parameters can be normalized after early stabilization of flail chest. Most methods for operative fixation, however, have given disappointing results and only plate fixation procedures have been effective. The experimental results of osteosynthesis with dynamic compression plates are presented and demonstrate the superiority of compression osteosynthesis in rib fractures. Compression osteosynthesis resulted in a primary fracture healing with stable fragments after 14 days, whereas conventional plate fixation techniques required a much longer time and showed secondary fracture healing. The benefits of compression osteosynthesis could also be demonstrated in 10 patients with traumatic flail chest. Osteosynthesis resulted in marked pain relief, immediate stabilization of the chest wall, and a shorter time of intubation. Not all fractured ribs need stabilization, dorsal fractures are well fixed by the strong erector muscles, and in the lateral position only ribs III to VII need to be considered. Reasonable stabilization may be achieved with fixation of every second rib. In patients with bilateral rib serial fractures subcutaneous implantation of one or 2 rib struts is recommended--good results were obtained in 12 patients. The indication for operative stabilization of flail chest should be restricted to: 1. Patients with severe ventilatory restriction due to chest wall paradox alone. 2. Flail chest combined with intra-thoracic lesions which require thoracotomy. 3. Flail chest combined with lesions which require a prone position for surgical exploration. 4. Respiratory distress patients when the unstable chest wall interferes with mechanical ventilation or with underlying organs.

Adolescent↗
PubMed2001

Pneumatic stabilization for flail chest injury: an 11-year study.

The use of prolonged mechanical ventilation in the treatment of flail chest injury may increase the incidence of pulmonary morbidity. The aim of this study was to examine the results of performing internal pneumatic stabilization in our hospital. A retrospective review of the medical records of 59 patients with flail chest injury who presented within an 11-year period was conducted. During the second half of the period examined, we routinely adopted three characteristic procedures in the treatment of flail chest injury, namely, pressure support on spontaneous breathing, continuous positive airway pressure via a mask, and respiratory physical therapy by physical therapists. We compared the background, prognosis, and methods of treatment for flail chest injury before and after the introduction of these three procedures. A marked decline in the duration of endotracheal intubation and controlled mechanical ventilation, and in the frequency of pulmonary morbidity, was evident following the introduction of the above procedures.

Adult↗
PubMed1975

Management of flail chest without mechanical ventilation.

The pathophysiology of flail chest is usually described only on the basis of paradoxical respiration, ignoring underlying pulmonary contusion. Two groups of comparable patients were treated either with early tracheal intubation and mechanical ventilation (Group 1), or with fluid restriction, diuretics, methylpredinisolone, albumin, vigorous pulmonary toilet, and intercostal nerve blocks, ignoring the paradox and treating only the underlying lung (Group 2). When tracheostomy and mechanical ventilation were not used the mortality rate went from 21% to O(p = 0.01), the complication rate from 100% to 20% (p = 0.005), and the average hospitalization from 31.3 to 9.3 days (p = 0.005). We conclude that most patients with flail chest do not need internal pneumatic stabilization if the underlying lung is treated appropriately and that tracheostomy and prolonged mechanical ventilation with a volume respirator, as practiced in most respiratory care centers, is usually a triumph of technique over judgment.

Adolescent↗
PubMed2004

[Flail chest due to blunt trauma: clinical features and factors affecting prognosis].

BACKGROUND: We evaluated the clinical features of patients with flail chest, together with treatment results, and the factors affecting prognosis. METHODS: The study included 34 patients (27 males, 7 females; mean age 41 years; range 15-61 years) who underwent treatment for flail chest. A retrospective analysis was made regarding the etiology, injury to the chest wall, pulmonary contusion, hemothorax and pneumothorax requiring chest tube, associated injuries, injury severity score (ISS), the presence of shock on admission, the amount of blood transfusions within the first 24 hours, treatment, and the results. RESULTS: The most common cause of flail chest was traffic accidents (79.4%). Shock was detected in 41.2% and pulmonary contusions in 55.9%. Ventilatory support was required in 70.6%. The mean ISS was 36; mortality occurred in 32.4%. In seven patients without associated injuries and who did not receive ventilatory support, the mean ISS was 22.8 and all survived. However, in 18 patients with associated organ injuries, the mean ISS was 43.6, with mortality being 50% (p<0.05). Factors responsible for prolonged ventilatory support, pneumonia, and septic deaths included ISS above 31, associated fractures and injuries, blood transfusions, the need for chest tube, age equal to or above 50 years, and the presence of bilateral flail chest. The incidences of pneumonia and mortality were significantly less in patients treated with internal fixation (p<0.05). CONCLUSION: Our data show that careful fluid management and effective pain control, stabilization of the chest wall, immediate ventilatory support and early weaning from ventilation are the mainstays of treatment.

Accidents, Traffic↗
PubMed2001

Flail chest stabilization with palacos prosthesis.

The approach and management of patients with post-traumatic flail chest continue to be a controversial issue. A method of surgical stabilization of flail chest using palacos, a cement-like material is described. A ready-made prosthesis is placed on the external side of the ribs vertically bridging the flailed chest segment, and fixed to the first upper and first lower intact rib as well as to the mobile segments of the affected ribs. Surgical fixation was carried out in 56 patients. The results proved the method to be a simple and effective procedure.

Adolescent↗
PubMed1981

Selective use of ventilator therapy in flail chest injury.

We have prospectively treated 36 patients with flail chest using a treatment protocol for limited use of mechanical ventilation. Age of the patients ranged from 6 months to 83 years. Patients were divided into three groups dependent upon their clinical presentation and need for respiratory support: Group I patients had severe pulmonary dysfunction-tachypnea, dyspnea, arterial PO2 less than or equal to 60 torr, arterial PCO2 greater than or equal to 50 torr or shunt fraction greater than or equal to 25%. Group II patients had no pulmonary dysfunction but did require temporary respirator support for an associated injury. Group III patients had no pulmonary dysfunction. Thirteen patients were assigned to Group I. They required respiratory support for an average of 10.5 days; 11 of the 13 had complications, and there were two deaths in this group resulting from a combination of respiratory failure and myocardial infarction. Seven patients were assigned to Group II. six patients were extubated immediately postoperatively; one patient with a head injury was hyperventilated for 48 hours to reduce intracranial pressure and then extubated. Sixteen patients were assigned to Group III. Fifteen required no ventilatory support. One 83-year-old man developed pneumonia and was mechanically ventilated for 31 days. Early effective pain control and chest physiotherapy were critical to success and were used in all patients. Increase in respiratory rate, fall in tidal volume or vital capacity, and increased pain were used as criteria for administration of analgesia. Nonventilatory therapy of flail chest reduces morbidity, mortality, and hospital cost.

Adolescent↗
PubMed1990

Delayed diagnosis of flail chest.

A retrospective review of 99 consecutive patients with flail chest after trauma was conducted to determine the incidence and significance of delayed presentation. Patients ranged in age from 7 to 88 yr (mean 50.3). Hospitalization ranged from 1 to 129 days (mean 23). Mean Injury Severity Score was 30. Sixty (61%) patients were managed with mechanical ventilation. Pulmonary complications developed in 48 (48%) patients and 14 (14%) patients died. The flail chest injury was documented on initial examination of 77 (78%) patients. Delayed presentation occurred in 22 (22%) patients from 1 to 10 days after injury. Reasons for delayed diagnosis included intubation and mechanical ventilation before complete physical examination, development of pulmonary complications with the attendant increased work of breathing, and physician error. The time of presentation was not associated with patient age, sex, severity of injury, need for mechanical ventilation, duration of ventilation, incidence of pulmonary morbidity, or mortality.

Adolescent↗
PubMed2006

Operative stabilization of flail chest using a prosthetic mesh and methylmethacrylate.

Surgical stabilization of flail chest is a controversial operation, but recent data has shown that selected patients benefit from it. We describe a simple and practical method of operative stabilization of flail chest using a prosthetic mesh and methylmethacrylate anchored to the ribs and sternum. The methylmethacrylate-mesh complex is inexpensive, can be extracted electively as soon as full thoracic stability is achieved, and can be used to stabilize extended chest wall injuries.

Adult↗