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PubMedDate not supplied

Clinical management of flail chest in dogs and cats: a retrospective study of 24 cases (1989-1999).

Cases of flail chest injury for 24 client-owned companion animals following various traumas were evaluated. Concurrently sustained injuries, initial emergency treatments, and definitive treatment and outcome for regimens that utilize stabilization of the flail segment were compared with cases treated with no stabilization. Flail chest was confirmed in 24 animals: 21 dogs and three cats. There was an even division (12 each) of right and left flail segments. The median number of ribs involved was three (range, two to seven). Flail segment stabilization was performed in nine, and 15 were treated with no stabilization. Statistical analysis using multiple data permutations evaluating all combinations failed to reveal a significant difference in outcome between stabilized and unstabilized cases.

Animals↗
PubMed1999

Differential lung physiotherapy using a double lumen tube in flail chest and refractory lung atelectasis.

The management of refractory lung atelectasis in a patient with flail chest can be difficult. Treatment of lung atelectasis is complicated by practical problems with the application of chest physiotherapy, postural drainage and incentive spirometry. Although double lumen endotracheal tubes have been used in such cases for the purpose of differential lung ventilation, the use of differential lung physiotherapy has not been reported before. This report describes the successful application of this technique in a patient with flail chest and refractory lung atelectasis.

Adult↗
PubMed1995

[Surgical stabilization of post-traumatic flail chest. Our experience with 116 cases treated].

The therapeutic approach in a patient with traumatic flail chest is varied and controversial, both as regards the type of treatment and as regards the surgical techniques to be employed. The authors have examined 116 cases of flail chest treated surgically; these represented 17.7% of the 655 chest traumas operated in the period from July 1975 to March 1993. Increasing experience has reduced indications for surgery: at present it is not performed in cases of serious craniocerebral lesions, of severe pulmonary contusions, or, however, when mechanical ventilation is required. As for surgical techniques, external traction was applied in the first 15 cases treated but then discontinued because of the poor outcome. Osteosynthesis (77 cases), associated with thoracotomy, was carried out with Kirschner wires, Vecsei metal plates, Judet agraffe, alone or variously combined. Recently, a less aggressive personal technique has been employed prevalently: Kirschner wires placed vertically within the chest, bridging between one rib (generally the V or VI, well fixed with metal plates), and the clavicle and/or sternum. The overall mortality rate, prevalently due to associated lesions, was 20.6%. Excluding emergencies, these patients should be operated in deferred emergency within 24-48 hours of trauma. Osteosynthesis, when indicated is the procedure offering the greatest assurance of success. The authors believe that, in selected cases, surgical stabilization is necessary.

Adolescent↗
PubMed1983

Experimental pendulum air in the flail chest.

Conditions for occurrence of pendulum airflow under spontaneous ventilation were studied in adult dogs with flail chest experimentally constructed by removing three ribs and the chest wall. Pendulum air flow was recorded pneumotachometrically from outside the body by intubation to the bronchi. Despite objections to the occurrence of pendulum air by many investigators, we found that pendulum airflow occurs under various conditions. The main factors facilitating the occurrence included 1) Significant differences in airway pressure and ventilatory volume between the lungs on the injured and the opposite side. 2) A high frequency of respiration. 3) Increased resistance in the upper airway. The pendulum airflow occurred not only at the area of tracheal bifurcation but also in the peripheral bronchial airway in the ipsi-lateral thorax of the flail chest. However, pendulum airflow was observed only transiently coinciding with the time of change from one phase of respiration to the other, and volume of pendulum airflow was considered to be so minimal that it had no significant deleterious influence on the alveolar ventilation. In cases of marked dysfunction of the chest wall or with increasing upper airway resistance, pendulum airflow may disturb alveolar ventilation to a considerable extent.

Airway Resistance↗
PubMed1999

Determinants of rib motion in flail chest.

We have previously developed a canine model of isolated flail chest to assess the effects of this condition on the mechanics of breathing, and these studies have led to the conclusion that the respiratory displacement of the fractured ribs is primarily determined by the fall in pleural pressure (Delta Ppl) and the action of the parasternal intercostal muscles. The present studies were designed to test the validity of this conclusion. A flail was induced in six supine anesthetized animals by fracturing both dorsally and ventrally the second to fifth ribs on the right side of the chest, after which the phrenic nerve roots were bilaterally sectioned in the neck. Sectioning the phrenic nerves caused a 34% decrease in Delta Ppl, associated with a 39% increase in parasternal intercostal inspiratory EMG activity (p < 0.05), and resulted in a marked reduction in the inspiratory inward displacement of the ribs. In three animals, the inward rib displacement was even reversed into a small outward displacement. When the airway was then occluded at end-expiration to increase Delta Ppl during the subsequent inspiration, all animals again showed a clear-cut inward rib displacement. These observations therefore confirm that in dogs with flail chest, the inspiratory displacement of the fractured ribs is set by the balance between the force related to pleural pressure and that generated by the parasternal intercostals. These observations also point to the critical importance of the pattern of inspiratory muscle activation in determining the magnitude of rib cage paradox in such patients.

Animals↗
PubMed1997

Actions of the inspiratory intercostal muscles in flail chest.

We have previously shown in dogs that the ribs in flail chest move paradoxically inward during inspiration but continue to move cranially. We have also shown that flail elicits, probably via an increased activation of the muscle spindles, a threefold to fourfold increase in external intercostal inspiratory EMG activity without inducing any changes in parasternal intercostal activity. Therefore, the present studies were undertaken to test the hypothesis that the persistent cranial motion of the fractured ribs resulted primarily from the action of the external intercostals. A flail was induced in seven supine anesthetized animals by fracturing both dorsally and ventrally ribs 3 to 6 on the right side of the chest, after which the external intercostal muscles in interspaces 1 to 7 were severed. Severing the external intercostals caused a small increase in the inspiratory inward displacement of the fractured ribs, from 2.76 +/- 0.31 to 3.25 +/- 0.38 mm (p < 0.05), but it did not affect the parasternal intercostal EMG activity or the cranial rib displacement (before, 3.61 +/- 1.03 mm; after, 3.22 +/- 1.43 mm; NS). However, when the parasternal intercostals in interspaces 1 to 7 were also denervated, the inspiratory inward displacement of the ribs increased markedly to 5.95 +/- 0.48 mm (p < 0.01), and their inspiratory cranial displacement was reversed into a 1.05 +/- 0.58 mm inspiratory caudal displacement (p < 0.01). We conclude, therefore, that in dogs with flail chest the respiratory displacements of the ribs are still primarily determined, besides pleural pressure, by the action of the parasternal intercostals. These observations also suggest that in anesthetized dogs, spindle-induced excitation of the external intercostals has little impact on the mechanical behavior of the ribs.

Animals↗
PubMed1985

[Surgical treatment of flail chest by sliding staples].

The authors have compared the results obtained in two series of patients with flail chests treated by internal fixation. In the first series of 36 patients, Judet rib staples were used. The average time of artificial ventilation was 5.8 days. In the second series of 43 patients, gliding staples were used. The average time of artificial ventilation was only 2.6 days, a significant reduction. Thanks to this new technique, the indications for artificial ventilation in the treatment of flail chests have been reduced from 47 per cent to 33 per cent. The technique of fixation has also been used in seven cases of operative treatment of funnel chests. In five other cases it has been used to reinforce plastic mesh inserted after extensive resection for malignant tumour.

Adolescent↗
PubMed1979

Early and late results of controlled ventilation in flail chest.

From 1967 through 1974, a consecutive series of 35 patients with flail chest were treated with intermittent positive-pressure breathing (IPPB). The controlled ventilation contributed to stabilization of the thoracic cage in a favorable position for healing of the fractures. Surgical stabilization of the chest was not attempted in any of the cases. During treatment with IPPB, one patient died from profuse bleeding due to a generalized coagulation disorder, but the remaining 34 were discharged in a satisfactory respiratory condition. A late follow-up study of the pulmonary function one to eight years after the trauma included x-ray films of the trachea and lungs, kymographic studies of the diaphragm, spirometric and radiospirometric testing, and arterial blood gas levels. Eighteen patients were examined. Spirometric testing revealed astonishingly little impairment of the total pulmonary function. The radiospirometric studies with 133xenon showed a significant reduction of the regional perfusion only in five patients (2 to 4.5 pulmonary segments). Kymographic study of the diaphragm gave no further information and was less selective compared with the other tests of pulmonary function. Owing to the encouraging early and late results in this study, early treatment with IPPB is considered to be the method of choice in flail chest with paradoxic respiratory movements.

Adolescent↗
PubMedDate not supplied

Flail chest in closed chest trauma.

The dramatic events following closed chest injury are often unpredictable and may be fatal. Chest injury is one of the commonest causes of road traffic accident deaths in Papua New Guinea. Flail chest is an important complication of closed chest injury which has not been described previously in the locally published literature. Flail chest, its complications and management are discussed with an illustrative case history.

Flail Chest↗
PubMed1998

Use of bilevel positive airway pressure ventilatory support for pathological flail chest complicating multiple myeloma.

Multiple myeloma is a common disease that universally involves the skeletal system. Although rib involvement may occur, the development of pathological flail chest is rare. We describe the treatment and course of this condition in an elderly female, and the use of the bilevel positive airway pressure (BiPAP) ventilatory system in providing pneumatic stabilization, while definitive chemotherapy was given to heal the pathological fractures. Our experience with this patient suggests that, despite its dramatic clinical manifestation, the association of flail chest with multiple myeloma may not predict a poor prognosis. We have also found that pneumatic stabilization can be achieved by using the bilevel positive airway pressure ventilatory support through a tracheostomy.

Aged↗
PubMed1998

Flail chest: a nursing challenge.

Caring for a patient with a flail chest poses a significant challenge to the ED nurse. Performing serial evaluation, complicated pain management, and diligent pulmonary toilet will put your nursing skills to the test! Finding the time to do it in a busy emergency department ... well, that's a topic for another article.

Emergency Nursing↗
PubMed1984

Long-term disability after flail chest injury.

A review of 62 consecutive patients who sustained flail chest after trauma from 1971 to 1982 was conducted to document the late effects of this injury. The mechanism of injury was motor vehicle accident in 44 (71%), fall in nine (14.5%), and farming accident in nine (14.5%). Patients ranged in age from 7 to 87 years. Twenty-four (39%) patients arrived in shock and 54 (87%) had major extra-thoracic associated injuries. Thirty-seven (60%) patients were managed by intubation and mechanical ventilation and 25 (40%) by chest physiotherapy. Pulmonary complications developed in 60% of the total group. Eight patients (12.9%) died during the initial hospitalization. Five patients died 1 month to 9 years after discharge, and 17 were eventually lost to followup. Six-month to 12-year followup (mean, 5 years) was re-established for 32 patients. Twenty-one of these returned for comprehensive testing including physical examination, chest roentgenograms, spirometry, flow volume curves, diffusion testing, and calculation of dyspnea index. Of 32 patients questioned, only 12 had returned to full-time employment. Eight (25%) still had subjective chest tightness, 15 (49%) complained of thoracic cage pain, and 12 (38%) had experienced moderate or severe change in their overall level of activity. Using the British Medical Research Gradation for Dyspnea, three (9%) patients had moderate and six (19%) severe shortness of breath. Objective dyspnea index calculated from VEBTPS /MVV revealed mild dyspnea in 50% and moderate dyspnea in 20%. Formal carbon monoxide diffusion testing was normal in 90% of patients and revealed mild decrease in 10%.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1996

[Flail chest].

From January 1989 to December 1993 at the Department of Clinical Surgery at the University of Perugia, 7 patients were under observation for multiple costal fractures and flail chest. One of them died almost immediately after his admission and therefore received no more than the initial medical treatment. Another died 17 days after costal osteosynthesis of cerebral complications. Four others successfully underwent a costal osteosynthesis, while the 7th patient received medical therapy with a positive outcome. In the case of a critical flail chest with very serious physio-pathological consequences, if the fractures are in technically favourable places, we think it is better to stabilize immediately, since the operating trauma is minimum and in many cases the patient is already intubated and curarized.

Female↗
PubMed1976

The management of flail chest. A comparison of ventilatory and nonventilatory treatment.

Retrospective analysis of forty-two consecutive patients with flail chest injuries admitted to the Trauma Research Unit of the Naval Regional Medical Center, San Deigo from June 1972 to July 1975 compared ventilatory and nonventilatory management. The actual need for ventilatory support in these patients was determined by analyzing their records for evidence of significant pulmonary dysfunction. This allowed division of patients into three groups: "appropriately" ventilated; "inappropriately" ventilated; and nonventilated. Admission PO2 in the "appropriately" ventilated patients was significantly lower than in the other two groups because the former were admitted with respiratory distress and hypoxemia. Significantly more complications occurred in the ventilated groups than in the nonventilated. Treatment-associated complications were more frequent in the ventilated groups. Because of these findings, we belive that mechanical ventilation should be used in the treatment of flail chest injuries only for significant pulmonary dysfunction and not for the purpose of stabilizing the chest wall. If respiratory support is required, it should be discontinued when normal gas exchange has been restored.

Adolescent↗
PubMed1978

[Surgical treatment of the flail chest (author's transl)].

Six patients with traumatic flail chest underwent surgical stabilization using a procedure introduced by Brunner, Hoffmeister and Koncz (2). Compared with internal stabilization by intermittend positive pressure respiration (IPPR), there are some advantages: Time of artificial respiration is shortened, early mobilization is possible, nursing is easier. The procedure is simple to do and is indicated in those patients, in whom longterm artificial respiration is not necessary for other reasons.

Adult↗
PubMed1979

Technique for the management of anterior flail chest.

A technique for the management of anterior flail chest consisting of osteosynthesis and the positioning of two long Kirschner wires behind the sternum in the form of a St Andrew's cross is described. The procedure is easy to perform, the patient is ambulant early, and the results are good.

Fracture Fixation, Internal↗
PubMed1991

[Treatment of flail chest].

We present our experience in the treatment of 82 patients with flail chest (FC). They were evaluated according to the number of fractured ribs, which apparently correlates with the degree of lung contusion. Treatment methods compared were oxygen mask therapy, epidural analgesia, continuous positive airway pressure (CPAP), intermittent mandatory ventilation (IMV) plus positive end respiratory pressure (PEEP), and high frequency ventilation (HFV) plus PEEP. Oxygen therapy alone was not effective in those with more than 5 fractured ribs, while CPAP was effective in those with up to 10 fractured ribs. No significant difference was found between IMV and HFV. The purpose of respiratory support in FC is to reduce atelectasis and the resulting shunt, and to improve removal of mucus from airways. The patients were discharged without compromise in respiratory function, despite persistence of FC. We conclude that the primary mechanism of respiratory impairment in FC is not the mechanical disturbance, but rather the degree of lung contusion suffered.

Adult↗
PubMed1990

The management of flail chest injury: factors affecting outcome.

The records of 57 patients presenting with flail chest injury from 1981 through 1987 were reviewed to determine factors affecting morbidity and mortality. Fifteen patients (26%) had 8+ rib fractures with a unilateral flail and seven (12%) had multiple rib fractures with a bilateral flail. Thirty-two (56%) had moderate-severe pulmonary contusions and 44 (77%) required chest tubes for hemo-pneumothorax. Ventilatory assistance was used in 36 (63%). The major factors determining the need for ventilatory assistance were: an ISS greater than or equal to 23, blood transfusions in the first 24 hours, moderate-severe associated injuries (fractures, head injuries or truncal organs requiring operation), and shock on admission (p less than 0.001). An adverse outcome occurred in 15 (28%); nine required ventilatory assistance greater than or equal to 14 days and six died of sepsis with pneumonia. The main factors associated with an adverse outcome were: an ISS greater than or equal to 31 (p less than 0.001), moderate-severe associated injuries (p less than 0.001), and blood transfusions (p less than 0.005). Although the primary determinants of an adverse outcome were the associated injuries and blood loss, a bilateral flail (p less than 0.01) and age greater than or equal to 50 years (p less than 0.02) were contributing factors.

Adolescent↗