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Treatment

of Multiple

Rib Fractures*

Randomized Controlled Trial Comparing Ventilatory with Nonventilatory Management


Chris and T Bolliger, Stephan F M.D. Van Eeden,

, ,
B. Sc. of multiple mask

Hon.;

M.Med.

We
patients

studied

the treatment

rib fractures

in NIC,

(24/33),

respectively.

Infections

caused

the

difference

in

comparing two

ventilatory with who were randomly (1) a CPAP (n 36); ventilation with

nonventilatory methods in 69 allocated to one ofthe following combined with regional and meoutcome days intubation 33). Clinical

treatments:

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 shorten through intubation a CPA? and and mask simplify mechanical combined treatment infection with rate, regional when and (Chest NIC
score
=

analgesia chanical was


group

or (2) endotracheal with PEEP (n duration

analgesia patients, compared we recommend 1990;


injury 97:943-48) severity

can mainly with

in these

as follows:
(p
=

mean

of treatment,

4.5 2.3

a decreased

for the group

0M003);

CPAP and 7.3 3.7 days for the intubated mean number of days spent in intensive respectively 8.4 7. 1 days and patients and 73 percent

ventilation,

this treatment

in patients

similar

to our sample.

care, 5.32.9 days and 9.54.4 days, (p = <0.0001); mean period ofhospitalization, and 14.6 8.6 days, respectively (p 0.0019); developing complications: 28 percent (10/36)

nonpenetrating

injury

to the

chest;

ISS

T
four the

he treatment
undergone decades 1930s by
0

of multiple
radical and changes is still stabilization sandbags, external utilization hooks,

rib evolving. of of

fractures ouver the different the Whereas chest compression,

in NIC last three up wall mechanical or pins became

has to until

the

risks

invoived
05,06

with

intubatioon

and

mechanical not

ventilation.

Pain
sent

relief
prooblems,

the the

was
and

in mechanical ventilation dooes as the respiratoory depression


administered analgesics on must is often relief. or epidural studies
treatment

due

pretoo
in a

achieved devices

systemically desired patient respiratory temic analgesia of pain blocks means nerve in breathing

is ooften however, depression Therefore, by local are feasibility they oor lacked were the the analgesia of multiple mechanical
was

initially oof the sysregioonal

patients drive

a be

ventilator; any avoided. options


L7

such radically

as wires,

screws,

spo)ntaneously, replaced main analgesia. shoown


of

fashionable
the stabilization

over

the

next

20 years.

During

the

1950s dein-

different

concept

of internal

pneumatic

veloped.23
tubation

with positive-pressure This technique required


and mechanical
O)f

breathing was endotracheal


of the patient. froonl resulting

The have

intercostal ouf nomeither matching different

ventilation

Previous
ventilatory

the bitt behveen

The
chest
ill

evoolution
effects wall
gas

the
injury

understanding
directed ofthe the underlying and has since

of the
attentio)n king

pathophysthe such an acuse such and

NIC,

ioolo)glc

of NIC

retrospective,05 or randoomization

o)nly

descriptive,aS (or both)

too the

exchange

disturbances

co)mplicatio)ns becoome

treatment
randomized CPAP fractures, lation with
CPAP

04,

05.22

We
trial with

therefore
too compare regioonal and

coonducted
use too the rib ventiin I)atietlts with less ventilatioun. the coompli-

a
of a

as

the

ARDS.4#{176}#{176} ventilatioun

controolled nlask cumbined mode which PEEP. wo)illd intubatioon


MATERIALS

Mechanical

cepted
and of this
as

foorm
flail chests; invasive

oof treatment
however, form

for
with

multiple
the

rib
widespread
I)arootrauma,

fractures

coonventiounal with moderate mask than

oof management is intubatioon Our he hypothesis NIC, and mechanical


METuons

of treatment,
t2

complications

that

respiratory

sepsis,

too severe shorter and

treatment cause

tracheal
Recently, modes CPAP

stenoosis
there treatment, a tightly
O)f

became
has such fitting

evident.
been a return as ooptimal face mask too mooninvasive pain relief and the too increase

catio)ns

via

ANI)

FRC.13.t4
principle
*From
Manuscript

The
Respiratory

use

of CPAP
pneumatic
Intensive Hospital,
Juoly 20;

via a mask
stabilizatioon
Care Cape
Unit,

maintains
but
(of internal 2.

the
avoids

Pb;ulation Between
sequentially

ofinternal
the Tygenheng
received

Janutarv ICU
randomized

1988 with

amid March multiple


painwise

1989, nil)
to) either

70 patiemots fractures in mask

admitted NIC were treatment

to)

Department

oouon respiratourv coombined with

Medicine,

Town,
accepted

Soouith Africa.
Octuher

CPAP

revision

regional

analgesia

our to) endotracheal

inttohatioon

and

CHEST

I 97

I 4 I

APRIL

1990

943

Downloaded From: http://journal.publications.chestnet.org/ on 01/08/2014

ventilatioumi. approved Ethics according by

Infourmed the

coonsent Patients

was with

oulotained. NIC were foollouwing

The Faculty

study

had in the

been stiody

cm

H2O;

(2) PaCO2 rate


were injiory deterioration

greaten greater
of level

than than

6.5 35/mm;

kPa

(48.8 (4) FVC

mm
less

hg)

and

rising;

University criteria listed

ouf Stellenhoosch in the

ouf Medicine

(3) respiratory

than

10 mI/kg; dyspnea
preexisting

Coommittee. too the

ennoulled tahuolation:

and (5)
prior to

oof coonsciousness.

Variables

defined according

as follows: too the NYHA

(1) dyspnea
classification;

baseline
(2)

pulmoonary

disease

any

clinical

symnptomns signs

our previoouosly cigarettes both

docupen gnoouops
(4)

Incluosion (all oof the folloowimig): Moore than three rib fractures Admissioon too houspital within 24 hoours after injury Insufficient coough mechanism dume to) pain or preexisting pnlmnonany disease (our both) Excluision (any (of the fullousuing): Depressed level oof counscioousness Important facial injuries (excluding tolenance ouf CPAP mask) Fracttores too l)ase ouf skull Severe luong contusion (alveolar infiltrate umidenlying rib fractuores on admissioun chest x-ray film and PaO2-(8 kPa oun 40 percent (oxygen mask)
Need for initial tipper laparotomy our other majoun surgery

mented
disease;

signs
(3)

as well
smooker
-

as nadiougraphic cumnnent
less

ouf preexisting of 5 our more from

puolmounany

smoking
six

day hong

or daily conttosion

pipe

smouking,
=

including than ribs

ex-smo)kens
mounths prior

wh(O ceased subjacent


abdominal

smouking

too admission;

radiognaphic contusion sputum positive

evidence within our niptione

ouf alveolar (our booth)


our by

infiltrates (5) blunt (of internal


(6)

to the
trauma (diagnoosed bronchitis

fractuored
-

six hooumns (of injury;

organs
acute

clinically,
=

s(unoognaplucally,

laparootomy);

punolent with

(or bronchial culture oor 25

washing) netotrophils Gram on the

without pen stain; by any sputum, blood cell five oof


(c) count

pulmoonary high-poower

infiltrate, field
=

(on both)

with

microorganisms

Spinal injury Contraindications dency)

for

regional

aoialgesia

(bleeding

ten-

(7) pneumoonia outher neason)


raised

with

new puilmiinany infiltrate (not explained at least two oof the folIoowing: purtmlent (>38.3#{176}C [100.9#{176}F]), raised mm and 80 percent (or booth); white neuotr(Ophils), (8) septicemia (b) fever
[96.1#{176}F],

temperature (> 12 x lOYcto Gram


=

oxount
PTVCCdUWS

and (all

positive (>38.3#{176}C

and Measunments
to the ICU physical
chemistry,

sputum , all patients previoous examination; full levels blouod on cell rooom received coondition count, air and the following kings; analx-ray percent best underrelief was with by
(of following)

stain

on cultsore evidence per


our hypothermia

On woorktop:

admissioon detailed

(a) clinical (>90 beats foollowing

ouf infection,
(<35.6#{176}C

history
of injury; blood

regarding

of the chest 40 (the

[100.9#{176}F],

rectal)

rectal),

circumstances

and laboratory

tachycardia greaten least altered level at least (>2 one one than

minute), or less criteria than

(d) four an

white altered baseline),

bboood

cell and

yses, film, ouxygen, three The went

includimig ECG, efforts patients the insertion with rug


the

20 x 10#{176}/cu mm (in relation and

4 x 10#{176}/cu mm, perfusion elevated

(e) at state: lactate

arterial
was

blood oubtained reponted).

gas with allocated

of the mm(ol/L), houn).

amid FVC

a portable too CPAP epidtoral

spirometen mask treatment Pain

o)f

mentation

to patients (ooutptot

ouliguria

<30

ml or <0.5

mi/kg

fon

nandomly louprenoorphine per injectioon The


number and

of a luombar

catheten.#{176}- Reckitt in 10 to 20 injectiorm


between the

oubtaimmed 0. 1 too 0.3 saline


muoltiplying

(Temgesic; diluted of the level

amid Colman), ml was calcuolated


level

Statistical

Analysis the necessary


level. The

of physioloogic We estimated
in oorder 95 percent

soltmtioun.
epidural catheter

vooltome the

sample
dtoration

size

at 30 patients
ouf the of mechanical ICU

per
stay

gnotmp
at the

of segments

imisertion

too demomstrate coonfidemsce

a oomme-dav

neductioumu

the ml.
fnom needs,

of the by the pain) being used The

highest patient before

hnoken amid after oon the

rib by

1.5
line

ventilati(on
(OWn previous

The pain
0 (no with paimi) The the nerve

level ntomloer

was

assessed oof injections interval

oun a straight

was

likely

to be

seven

to) eight

days

according between

too our the

too 10 (maximum muinimuom blocks per nb CPAP with douse) fractures mask

negioomial patients (Mancaine)

recoords.

analgesia. imitercoostal

depended

The criteria
(of treatment

used
were

too coompare length ouf stay uosed

oumtcoomes in the The the ICU data


variables.

twoo methods
or

six houons. hydnochloonide in patients patients intuthatiomi

Altennativel; with moudenate then placed

of treatment

(CPAP
, duiratioon were

mask

mechanical distributed.
differences

htipivacaine were only. system.

ventilatioon),
and

duration tests
X test

of hoospitalizatkon,

(maximum,
NIC, The
9(X) C,

150 ing

presence statistical
and

oofcomplicatiouns. were
Ion categorical

mion-mally f-test
Significant

le, unilateral patients were

were and

The
variables

Studento

four countintoous

out) a freestanding ventilatioon

assigned intubated

too emidotmacheal amid connected

mechanical (Siemens morphine Roche) IMV mode. too


>90

were In histor
dyspnea

cxompared additioon, evidence


prioon

at the 95 percent booth


too injuir) grouips were

level.
stratified according to) smoking

too a respiratory reliefwith (Dormicum; in the in


oxygemi

( (
The

Bird) amid received systemic pain 1 mmig/kg/day) and sedatioon with midazolam
1.5 mg/kg/day)
F1o2 amid adequoate level

CPAP

ouf preexisting
Analysis

pulmonary within was


and

disease
between

and the by

grade analysis

of of

(woo grooups

as mieeded.
ouf CPAP oxvgenatioun

They
were

were
adjusted (arterial

kept

for

these

pootential

confotonders

performed

both

grouuips

variance.

maiimtaimm

sattonatioun

percent All groutips


the

amid arterial patiemits was received at least


cooumld

carbon as possible. 48 hoouns


maimitaimi

dioxide aggressive The after

pnessuone dionation admnissioon greater

kPa

[45 mmii hgj). daily and were for both until (60 mm 30/mm, stability discharged of gas levels
blooood

RESU Of group chest the with x-ray by 70 patients CPAP films had showed entered too be

LTS

physiootherapy and than ofless rate (4) Patients arterial blood films)
ventilating

mouboilized
patient

as early

oof treatment contintted 8 kPa than

into than and

the

trial, four rib

one

in the serial

excluded

because

(1) a PaO2
(2) a nespiratory 15 mI/kg, and after and

fewer

fractures.

iig) (3) fnom

oon 40 Ircermt FVC the oof more pulse ICU The daily
bacteriodogic

ouxygen, than and level,


samples,

Finally,

36 patients
endotracheal

were

treated

by CPAP
mechanical

mask,

and
venti-

hemoudynamic were

(noormal
treatment. analyzed
co)tttit,

rate pain

bloood 24 FVC,

pressttre).

33

intubation

within

hotons

discoontinuoation
(white

specific were cell

in all patients. or whemo


intubating

Other examinations and chest x-ray


by the
mechanically

lation. The age, grade pulmonary


onset of by oxygen The

groups were comparable in respect to sex, of dyspnea prior to the injury, preexisting disease, smoking habits, the FVC before
treatment, mask on of and admission rib fractures, the PaO2 (Table the with 1). proportions of 40 percent

were

obtained (our booth).


patients oms

every

third

day
for

indicated
and

clinical oofthe
oxygen

cootorse

Criteria

the CPAP less than

mask 8 kPa

regimen (60 mm

were big)

oone

or moe

foolloowing:

(1) PaO2

number

on 40 percent

and CPAP

of 10

patients

with

hemothorax
Treatment

(pneumothorax),
of Multiple
Rib Fractures

pulmonary
(Bo!Iigeo

944

Van Eeden)

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Table

1 -Clinical

Characteristics

on Admission

of 69

Table

2-Comparison
Data

ofOutcome
(PAP
36

in 69 Patients
lmmtuoboautiomm
3.3

with
io
.

NIC

Patients
1)ata No. Meami I)vspnea
disease Smnookers

with
CPAP
36

NIC
!Ilausk
Mask

Iiotuoboatomi 3.3 22

p \tlute* No.
ufpatieimts
. . .

ofpatiemmts ofmnen) 46.3 ( grade 2) age

I)uvs
Days

ouftreatumetmt
iim intemmsive immimospital caro-

4.5
5.3

2.3 7. 1

7.3 9.5

:3.7 4.4 8.6

O.(XX)3* <0.0001* 0.0()19* 0.(X)2

Sex (No.

26

NSf
14.9 NS NSt NSt

2.9

15.7

47.8

I)avs No.

13.4 with

14.6

8
12

6
8

ofpatiemots (.lonmplicati0001st

10

24

Pno.existitog I)tillmio)rmarY

*t_test 28 22 NSt

(moicaim

SD).
iii Table

FVC/L
PaO with

1.530.63 40
loerco-mit boy mumask

1.480.66

NS

tl)etaileol :1:X2 anal\

amialvsis
sis.

3.

ooxvgeim

kPa
mon

15.74.2
Jig
fractures (pioeuomnoothoorax)

14.23.4
106.525.5
6.92.3 i7

NS
. .

117.831.5
6.92.2 16

The (Table grouup

results 2): days with CPAP

ouf clinical
0)11

ooutc(ome

were intubated

as

hollouovs fur tile grouup

No.

oufnib

NS NSt

specific
and 7.3

treatment,
3.7 ito

4.5 2.3

I Ienooutlmoorax
Ptolnioomiarv No. oofputietits additiounal ISS *NS Score not
analysis.

coontutsiom with fractures traomnoa

6 15 2 11.53.6

5 14 7 14.35.9

NSf NSt

four the

(r = 0.0003); days spent 9.54.4 days, respectively


pitalizatioon, (i 8.4
7. 1 and

the ICU, (p<O.(X)Ol); 8.6 days,

5.3 2.9 and days of boosrespectively

Blumit abodoumminal

NSf
0.021t

14.6

significamit.

0 . O() 19); amid 28 Percent (10/36) Details of the are H2O One lung and lug. listed too the and Patient collapse; vetitilated Tivoo deaths mnati (p>O.05).
iii

1)atieiits and 73

develiuping coOtill)l ications, 1)ercelit (24133) (p = O.()02). during the CPAP grouup
witil

tx2
t-test

complications
in

perioud

in the

(mneamm SD).

ICU
delivered
dl

Table
group

3. The
receiving

average

level

ouf CPAP
5.4 2.3 1.3 cm a

lnjuony

severity

store.

was
6.6

to) the
tile

intul)ated
group

was

contusion,

additional

fractures

o)utside

the
trauma

rib did

cage not

H2O

( Fig
show groups of different

1), and,
any either. 11.53.6

finally,
significant When amid

blunt
using

al)doominal
the (p ISS,t which 0.02

CPAP

developed itituti)ated weangroup; 1)tlltinie at the


(tile

differences
14.35.9, level

between
we

the
found significantly

two)
values

ni ttltifactorial

respirato)rv l)tieitmflooliia) for

failure amid in the

(aicoohool had tou i)e successful intui)ated o)i)strtictive and failure a 70-vear-ould autopsy suti)dtlral and befoore

were 12).

twou weeks ooccurred with severe

at a 5 percent

74-year-old

chroonic failure,

niounary

disease
died died a

who
suddenly

had

acute

i)roonchitis

CPAP
n:36

MASK
2110

INTUBATION
n::33

oof injury

ouf respirators severe cardiac

wouniato revealed

in cardiac

contusiom

Table

3-Complications

in 69

Patients

with
intitloatiomi

N1C
J) \altio
. .

3.
No.

(unplicatioti ofpatiemmts Pmiemmmmmotliorax Suoloc-utatmeomos Broumicimopleural emmmpiovso-mmia


fistula

(PAP
36

Niaslo

33 1 0 2 1 1 2 i6 3 1
0

1_

104
o

I
Ii

Barotmaumna 2 i
0

NS NS NS NS NS NS <0.(X)5 NS NS

ol

I mifectiomm
Acute

hromicliitist

2 0
0

Simmumsitis I.anytmgitis Pneui,moonmiat

5 0 1
hiemimatonia I

Septicetmmiat

01
Fictisu:

nomimiloer amool l(ucaliy.atunm offractuoro-s iii each treatt-o.l gnoumj). Meamm mimitmmloer of rib fractuorosin lootlm grouop with (PAP muask aomd intmohated group was 6.9 (247/36 amid 228/33, respectively).

1 . liotal

Other Luomog coillapse


Extraplo.ural

Respirator l)eath *X.: amialvsis.


tAs (lefimiO(l

failmore

1
0 significoimt.

1
2

NS NS NS

NS,
un(ier

not

nmethoools.

CHEST

I 97

I 4 I APRIL,

1990

945

Downloaded From: http://journal.publications.chestnet.org/ on 01/08/2014

hematoma stem, neither on admission). A stratified groups at the showed

without

signs had

o)f herniation been and no clinically between

oof the

brain

of which analysis that there level

apparent
the difference when co)mMORTALOTY

within was regarding

two

significant ooutcome

5 percent

paring
with (p>O.O5),

smookers
and without

and

nonsmokers
preexisting greater than 23

(p>O.O5),
pulmonary or equal were

patients
disease to grade given 2 an after (Voltamethods of pain of the
FlcuRE
-

or dyspnea

and

dyspnea
In the group

less

than
with did

(p>O.OS).
CPAP, no)t need injection ward. Both the patients

epidural
and an ren) one initial

catheter,
patient intramuscular emergency good by pain

12 received

intercostal
further pain analgesic the

nerve
relief

blocks,
10 20 30 40 50 70 years 60

of diclofenac amount

INJURY 49
years

SEVERITY

SCORE

in the

OO50-69years

provided experienced

relief,

reducing after

cooughing

application

drug by an average oof 50 percent as assessed by the patient on the linear scale; however, the twoo methoods were no)t used eoually. Intercostal blocks were given preferentially too patients with fewer fractures on oone side oof the chest only. On the average, the epiditral catheters to) seven was 4.4,
was 0.78 Both

2. Injury severity scon& Mean scores for grooump with CPAP (14.3) intersect at almoust identical of age.

four

three

different

age

groups.

groouop (11.5) amid intuhated group mortality (percentage) regardless

severe
grcoups Two

than
and patients

the
did

chest

trauma
the intutbated

in all
duration group

patients
underwent one bladder

of both
early rup-

noot influence in the (one splenic

of treatment.

were left in place for three days (range, two days), the average to)tal nulilber oof injectioons and the average t(otal doose o)f buprenoorphine
mg treated per groups the the absence group with patient. received Noo complications the same intensity were of

laparotoomies

rupture;

ture),
Figure

with
2, 11.5

an uneveniful
it is apparent for the group

postooperative
that with although CPAP and

course.
the 14.3 ISS

Froum
score for the

observed. chest
sedatioon patients

was
physiotherapy,
and in

but

due
ofan CPAP

to

the
could

lack
be

of

initial
the

intitbated regardless
(Of

grooup, of age.
as of than The age that deaths of

both The
both or

groups have similar mortality ISS pro)ved too be a goood index


the older, deaths whose patients probably occurred risk for not of in patients dying was score to the in our a given related

endotracheal

tithe, mobilized

mortality, years 2).

70 (Fig

earlier and participated moore actively with otherapist than the patients in the intutbated
DiscUSSION

the

physi-

greater

of younger were

group.

mode
poor a randomized by CPAP mask coontrolled combined and intubation
groups,

oof treatment;
indicatoor

however,
the and condition a detailed grade 0 and

the

ISS was

was
morbidity

a relatively chest.
particular prior evidence to the of of degree

considerable

In this trial with multiple demonstrate be much Previous fractures patient, less severe intubatiom

study,

we coonducted treatment analgesia

whose
from to and between the gas criteria

major
age the

site

of injury
sex, we of the history

the

tcm compare regio)nal ru)

Apart importance injury dyspnea to

attached lung of the

too endotracheal

mechanical

ventilatioun
fractures that
shorter

with
in NIC.

PEEP
In our by CPAP fewer that NIC

in patients
sample, mask we prooved

with
could than rib of the had study,

obtained

4 (NYHA),

treatment and had

preexisting
We ratoory used

pulmonary
FVC impairment for were length and exchange.

disease,
as a measurement the Pa02

and
as an outcomes of the

smoking
of initial indicator between different FRC; and stay the

status.
respiof the the treatin the rate of

complicatioons with multiple patients

and studies could but chest

mechanical
shoowed be managed the trauma.

ventilatioon.
without no)nventilated With a randomized intubatkon

pulmo)nary Our twoo ments ICU; highly that groups (specific to)tal

comparing the duration

in general

treatment

too increase

we oobtained
matched The trauma although reached nature important, 946 higher (seven on of this as for all

two

treated
for the

groups
bitt for intubated

which
the ISS

were
(Table can group CPAP), not

well
1). be

oof hoospitalizatioon)

parameters

connplications
significant treatment

in each
difference by CPAP

group.
mask

The
combined

results
with

showed
indicating regional

ISS score
for by greater
direct score. the

fcor all criteria,

accoounted

incidence
group 155 compariso)n in the

cfblunt
with was due this

abdomiinal
which different, quadratic was was not less

vs twoo in the

analgesia shortened all periods caused far fewer complicati.ons.


Comparisons none et al ofthem had
two

co)nsiderably
were however, difficult, Dittmann

and
as

significance

too the difference trauma

with used

other

studies score;

Clinically, blunt

a severity

abdominal

groups
Treatment

whose
of Multiple

severity
Rib Fractures

of chest
(Bo!!igeo

trauma
Van Eeden)

Downloaded From: http://journal.publications.chestnet.org/ on 01/08/2014

was
the days (Table by days) but study). studies

comparable
ICU, for Trinkle compared not for Despite mentitoned, the with the 4.5

to) our
days length with ventilated tootal well

population.
foor the group, were

Their
nonventilated similar

periods

in

analgesia hand, and


active

and 1)rouxide

interco)stal pain chest reliefand

nerve allow in tutrn, with the er physiotherapy

blocks, early vith can CPAP luonohar approuach, are space.

oon the the po)tentiate approach since trained prooveci Most

outher

amid 9.8 too omrs in a stu(iy group with days in is (9.3


CPAP

moobilizatioon patients the for

aggressive
Particil)atioulo.

2). The

o)f hospitalizatioll noollVelltilated that difficulties oofoour in can grouttp (31 .3 grooup commoon of NIC

This,
obtaitoed usimig useol

et al#{176} four their


ventilated soume the treatment

increase Epidural tiloffacic trial. the safe \Ve luniixtr and

in FRC analgesia
1)aili

their the that hospi-

relief-52#{176} 1)ro)e(1 this

satisfactoorv

comnparing message shoorten

primarily

imi (our in our


oumily in too i)e o)f (uttr per 24

institution

the
effective needed

nlajority
in the oonly

ouf douctoors
Buprenourphiole epidural oune too twou 1)ain

nonventilatory tahzati(on A detailed occurred low incidence

techni(Iue.

dramatically.
view during ofour the period co)mplications in the

cifpneumoothorax

sema,
however,

lung
the frequent in

collapse,
number in the 48 (5/36

and
intitbated

bronchitis

(Table ICU showed

3) which a very emphy-

patients hoours important coumplicatioons \Ve site the of

itijectiouns relief. our catheter-related

too maintaito respiratory were that coonclude

adeoiuate depression noot oi)served. in patients chest shooitld regional This and

Clinically

subcutaneous

for both
infectioons was with grooup fistula, oonly occurred group.

groups;
much

oof severe (16/33

with who criteria

NIC

xshoose

main amy mask amid oof the

more occurring with cemia intubated with Sinusitis,

group, in the

pneumonia compared with and CPAP septiin the Tougether were the

injury

is

the

doo n(ut meet four exchtsioumo, use is (ofa CPAP physioutherapy,

percent
patients)

patients),

previoously
ofchuice

mentiooned

14 percent laryngitis, with the positive and

treatment

I)e the analgesia, treatment

broonchopleural bkRod culture ventilated these

combined early has less

with mobilization. associated

coost-effective, and shortens

mechanically

additioomial

mnoorbidity,

pneumoonias,

complications

hoospitalizatioon draniatically
ACKN()WIEDG!1ENTS: Barnes four reviewimmg
amoalvsis, amiol E.

main therefore in this


rate

factoors group.
the

contributing duration These


type

to increased of each agree


studies. of

mo)rbidity of treatment with the Trinkle


group. percent

and
the

longer

period well
due

findings
of complications in an many incidence

high et
of 84

Bademmhoorst

sVo thank Prof. H. Stewart amm(i Mrs. J. article. Prof. D. Kotzo four statistical atid B. Karg four comimpilimig time niammu-

and

to mechanical
02.04,15

script.

ventilation
al#{176} even percent Our

reported
reported (16/19 overall patients) rate

RE FE RE N( ES
1 Fimidlav 38:489 2 Jensen
injuonies

pneumoonia

RT NK.
ofthe

Fractures Recoovery
chest.

of the

scapula

amid ribs.
fumictioon 22:319

Aooi

in their

ventilated of 28

Suing

1937;

of complications

(10/

ouf pulmonary Dis Chest 1952;

after

crnshimmg

36) in the group in the intubated


in the intubated Trinkle the tality tions ventilated was due group with group,

with CPAP and of 73 percent group, as well as the mortality


CPAP were grooup was 21 CPAP 100 and overall was percent mask per of 6 percent to percent (19/19). rate 21 (2133) the and Their comparable

(24/33) of zero
in the trial in of in the moor-

3 Avery

EE,

Moench Candiovasc DC, Petty

ET, Suing TL, breathing

Benson 1956; Bigeloow (CPPB) JH.

D\V. DB,

Critically harris

cruoshed TM. respiratorv

chests.

Thoorac

32:291-309 Continmiouis distress diagnoosis of crushed


of-oontusioo,i

4 Ashhauogh poositive syndrome. 5 Blair 6 Garzon chest 7 Craven amid flail bluommt chest AA,

pressuore E, Topuoziut trautma. Seltzer Ann oii

in aduolt

et a1.#{176} Their group 0 and to the

of complications

J Thoorac
C,

Candiovasc Davis

Suong 1969; Delayed 1971; KE. 11:129-45

57:31-40 our missed in

nonventilatory

Trauma 1968;

percent, and did


within

respectively.

Complicanegligible

B, Kanlson Sting

Phvsioopatholoogv LDII. Effects amid oxygen


Pulnmoonarv

itmjuories. KD, chest Phvsiod R, Suing


\\E, 109:819-23

168:128-36 iuerfusion exo-lmatmge.


(-ootitnsio)n.

se were result

Oppenheimer puolmnomiarv 47:729-37 R, 1979; Bittner 1974;


Smith

L, \so.d

(nasal
tinuation The treated nary possible

pressure
of the stratified groups disease,

sores)
treatment. analysis exchtded and

not

in any discoontour too twoo

J AppI and I)etWeen preexistitig prior that mo)derate peouple


8 Ros.-iier Arch
9 I)eN1,ttii 1965;

Stoo-kmmmamimm U
JNI. Pioltoiommmarv

smoking, ofdyspnea This function suggests with

pulmo-

109:508-10
commototsiommi. Am

degree

injury
with too severe

as

Surg

confounders.

10 (iloismis I 1 Jette 12 Phillips


imi ioatiermts

J,
NT,

Jamimos 0,

Quail

A.

Niammagenmo-tot

of

1-li) 1973: 45:

of oimost 1 13(0-35 chest.

impaired NIC can ventilation.


We ofCPAP see

pulmonary be treated
the by mask

injmmnv scith Anaesthesia

ro.spinatoonv Barasim 1977;


receiving

failure. Troutmiiemit

Br

Aimaostim

without

intiml)atio)n
outcome as a result in ofthe

and

mechanical
with

PC.

of a fluil

immjmtry of the tract

32:475-79
(ilmlAgilOOSa

I . P.uudin,unmas

ro-spirotonv

imofec-tiomms
1967;

successful treatment and increasing which

our grooup coombination booth

mrm-ciianical

5etitilatu)mm. ouf pain

J I I vg
imm t-hest

(( oiimio)
irmjmtrv.

nonventilatory

65:229-35 13 (ibohr.onms Amiaesth

regio)nal the

analgesia,

of which

J,
JK,

Janmes

0, Quail
JA,

A. Relief
Trami

Br KV

have
The problem

been
CPAP,

shown
by in NIC,

to be beneficial
FRC, is contusion

in NIC
aims ofthe

on their
at the

town.
majoor

1973;

45:1136-38
Richandsomom

14 Tnmokle
mechaimical

JL,
Suorg

Grover
of

Fl.,
chiost

Ammo

il#{246}lstnom 15 Shackfiond

FNI(;, SR.

et Smnith

al.
Anti

Niamoagenient
Tlmorac

flail CL,

svithoouit 11W.

underlying

ventilatiourm.

1975;

19:3.55-63 Virgilio

lung,

with

abnormalities

in gas

exchange.#{176} Epidural

I)E,

Zarimms

CK,

Rice

CHEST

I 97

I 4 I APRIL,

1990

947

Downloaded From: http://journal.publications.chestnet.org/ on 01/08/2014

The
16 Covelli

muanagement

ouf flail

chest:

a coomparisoumi

of ventilatory
132:759-63

and

25

Froomme and paimi.

GA,

Steidl epiduoral Analg

U, 1985;
liv

Danielson mmorphine 64:454-55

DR.

Comparisom

oof lumbar

nom-ventilatoony

treatment.

Am

Sung

1976;

thonacic Anesth
DB.

four relief
analgesia

of postthoracotomy
using epiditral meth-

liD,
airway

\Veled
pnessumre

BJ, Beckman
administered
analgesia.

JF.

Efficacy
mask.

ouf coontinuoms Chest 1987;


26

po)sitive 17 18 19
20

by face
Philadelphia:

Welch adoune:

Founimm:

postoperative

81: 147-50 Broniage 1978 Bnomage PR, Camnporesi analgesia. F. ML, ofpain.
foollowing

administratioon

the

lumbar C,

route MacEvilly

for

thonacic M.

pain

PR.

Epidural

WB

Satonders,

relief. 27
Mtmrphv

Anaesthesia

1981;

36:1051-54 Fitzpatrick Epidunal


1985;

DF,

Cahill
for

J,

EM, Olshwang

Chestmitot Analg D,
Lamicet

D.

Epiduiral 59:473-80

narcotics

huopremiorphimie 64:456-57 28 Broomnage aimd their 34:161-77 29 Pav,mo


CME

I)5to0Perative
ofanalgesic

l)aim0 relief.
soolutioomis

Atiesth

Analg

foor poostoqwrutive

Anesth

1980; Davidsoon
1979;

Behan
Cotoaclmer D\V

M,

Magora
imm treatnio-mmt ID,

JT PD,

Epidural hleaviside

PR. Spread
site

in the

epidttral

space 1962;
S Afr

m110)rphimlo-

1:527-28

of actiomi:
amid

a statistical
spimmal

stutd

Br
an

Amiaesth

Paes
amialgesi.u

Jao-ouhsemm L,
thooracic

Phillips sumrger
JI).

Eioiobuiral

Ammaesthesia
extrastutd Br

K.

Epidutral

amiaesthesia:

onervies:

1983;
21 (;nmfliths olural

38:546-51
DPC, amialgesia Diamnoommd foHouwing A\ Camneroon surgery: Postouperative a feasibility thooracic

1985; :3(0 Vami Eedemi l)erfutsio)mi


penetrating 31 Boone IIC,

3:21-30 SF, Kloopper imaging


injury Fisher too the

JF,
chest.

Albeit

B,

Bardiom

PC.

Vemitilationin noon-

in evaluiatitig CJ, Clemmner trial sepsis

Aimaesth

1975: NI, imi the 1978;


,

47:48-55 Keller R, \%olff C. A ratioomiale rib fractuires. ouf 50 oases and to


ioe

negioummal luong fmonctioomi Chest 1989; 95:6.32-38

2.2 1)ittmuamimm amialgesia Care 23 Rankin


immjutry Amoaesth

four epidoiral Intensive (of chest mnoorphimie.

TP,

Slootmnan Sepsis shock.


\VB.

GJ,

Mets

CA, Balk
Gnouop: in the a

treatmnent

of mnultiplo
Management

RA.

The

Methvlprednisoohone climmical (ofsevere

Severe uf high-douse amid septic

Stuody N Emigl The

Med APN with B.

4: 193-97 Coumloer RELI


Care 1984;

coomitroolled
.

methylprednisoolone

treatment 317:653-58 32 Baker


scoune: and

Med

1987; severity injuonies

i regimen

(of epiduorul

huopivacaine

lmitensive

12:311-14

SP, ONeill
a methood

B, Iladdoun
for describing care. emergency

W Long
patients Trauma

injury mntoltiple 14:187-96

24

Efron Biometrika

Forcimig 1971;

a seouiential 58:403-17

experiment

balanced.

with 1974;

evaluoating

East Coast
The
Resort

Workshop
will
Hollvwoood,

in Electrocardiography
this
Floorida. 33733

Roogers
and

heart
Country

Fooundation
Club,

sponsor

workshop
For (813:894-079(0).

May

30-Jume
contact:

3 at the
Rogers

Diploniat
Heart

infornoatioon,

Foouondatiom,

P0

Box

12588,

St.

Petersburg,

Introduction
This two-day coourse

to Occupational
Resource Center Health Program,
01655

Medicine
Worcester, Medical MA, spons(ored School, amid coo-

b
For

the

sponsored

Occupational by the 55 Lake

will be held Ma Health Program,

15-16 at the Marriott Hotel, University of Massachusetts University (508:856-2322).

Harvard
coontact

Educational
Occupatiomoal

for Occupational

Safety

and

Health.
Medical

infoormation:

of Massachusetts

Center,

Avenue

North,

Worcester

948

Treatment

of Multiple

Rib Fractures

(BoI!igeo

Van Eeden)

Downloaded From: http://journal.publications.chestnet.org/ on 01/08/2014