Operative chest wall stabilization in flail chest—outcomes of patients with or without pulmonary contusion

doi:10.1016/S1072-7515(98)00142-2

Journal of the American College of Surgeons

Volume 187, Issue 2, August 1998, Pages 130-138

https://doi.org/10.1016/S1072-7515(98)00142-2 Get rights and content

Abstract

Background: The aim of operative chest wall stabilization in patients with flail chest and respiratory insufficiency is to reduce ventilator time and avoid ventilator associated complications. The purpose of this retrospective study was to analyze the indications and outcomes of operative chest wall stabilization in defined groups of patients sustaining flail chest with and without pulmonary contusion.

Methods: The hospital records of 405 patients with multiple trauma (Injury Severity Score > 17) between 1988 and 1994 were reviewed. Forty-two patients sustained flail chest. Twenty of these underwent operative chest wall stabilization for the following indications: 1) flail chest with indication for thoracotomy due to intrathoracic injury (n = 6); 2) flail chest without pulmonary contusion (n = 9); 3) paradoxical movement of a chest wall segment in the weaning period from the respirator (n = 3); and 4) severe deformity of the chest wall (n = 2). For the purpose of analysis the patients were separated into groups: group 1: operative chest wall stabilization in flail chest without pulmonary contusion (n = 10); group 2: operative chest wall stabilization in flail chest with pulmonary contusion (n = 10); group 3: flail chest without pulmonary contusion and without chest wall stabilization (n = 18); group 4: flail chest with pulmonary contusion and without chest wall stabilization (n = 4). Data were coded for time of operation, duration of ventilatory support, and complications.

Results: There were no significant differences in age, severity of injury, and extent of injury between groups 1, 2, and 3 (p < 0.42). Group 4 was excluded for statistical analysis because of the small number of patients. Patients in group 1 required a shorter ventilatory support time compared to patients in group 3 (6.5 ± 7.0 versus 26.7 ± 29.0 days) and group 2 (p < 0.02). In group 2 (ventilator time 30.8 ± 33.7 days) early extubation was only possible in patients being operated on for chest wall instability during weaning from the ventilator. One patient in group 1, three patients in group 2 and five patients in group 3 developed pneumonia with further disturbance of gas exchange. All patients in group 1 survived; deaths in group 2 were attributed to massive hemorrhage in two and septic multiorgan failure in one patient. Four patients in group 3 died of head injury, one of acute respiratory distress syndrome, one of severe hemorrhage, and one of multiple organ failure.

Conclusions: In patients with flail chest and respiratory insufficiency without pulmonary contusion, operative chest wall stabilization permits early extubation. Patients with pulmonary contusion do not benefit from chest wall stabilization. Secondary operative chest wall stabilization in these patients is indicated when progressive collapse of the chest wall is evident during weaning from the ventilator.

Section snippets

Methods

The hospital records of 405 consecutive patients with multiple trauma (Injury Severity Score [ISS] > 17) including patients with isolated severe blunt chest trauma (Abbreviated Injury Scale [AIS]-thorax ≥ 3) primarily admitted to the Department of Trauma Surgery, University Hospital Essen, Germany between 1988 and 1994 were reviewed (ISS 25.5 ± 10.0). Two hundred and ninety-five (out of 405) of these patients (ISS 26.7 ± 10.0) sustained severe blunt chest trauma AIS thorax 3.4 ± 0.6). Forty-two

Extent of injury

Group 1: The mean ISS was 31.0 ± 7.0 (range, 24–41). Only one patient sustained isolated blunt chest trauma; all other patients had multiple injuries. The major diagnosis was blunt chest trauma demonstrated by a mean AIS-thorax of 4.1 ± 0.3 (range, 4–5). Associated injuries were injuries of the head (AIS 1.7 ± 1.3 [range, 0–3]), of the abdomen (AIS 1.7 ± 1.6 [range, 0–4]), of the extremities (AIS 1.6 ± 2.6 [range, 0–4]), and of the face (AIS 0.9 ± 1.6 [range, 0–4]). The most common associated

Discussion

Despite improved methods in intensive trauma care and advanced techniques in mechanical ventilation, mortality of patients with flail chest remains quite high.4, 13 To avoid the well known complications of longterm ventilation, internal pneumatic stabilization should be avoided. Local pain relief (epidural analgesia), chest physiotherapy (mask continuous positive airway pressure [CPAP]) and removal of pulmonary secretions are essential in management of flail chest without ventilatory support.

Conclusions

1.
Flail chest without pulmonary contusion necessitating ventilatory assistance despite sufficient analgesia and mask-CPAP from persisting hypoxemia seems to be a rational indication for operative chest wall stabilization in patients without severe head injury. Early operative chest wall stabilization within 48 hours permits extubation after a mean ventilator time of 6.5 days.
2.
There is a role for selective operative chest wall stabilization in patients with pulmonary contusion, and it should only

References (25)

J.H Calhoon et al.
Chest traumaapproach and management
Clin Chest Med
(1992)
Z Ahmed et al.
Management of flail chest injuryinternal fixation versus endotracheal intubation and ventilation
J Thorac Cardiovasc Surg
(1995)
R.J Landreneau et al.
Strut fixation of an extensive flail chest
Ann Thorac Surg
(1991)
J.D Richardson et al.
Selective management of flail chest and pulmonary contusion
Ann Surg
(1982)
K.D Craven et al.
Effects of contusion and flail chest on pulmonary perfusion and oxygen exchange
J Appl Physiol
(1976)
M Freedland et al.
The management of flail chest injuryfactors affecting outcome
J Trauma
(1990)
G.B Hassler
Open fixation of flail chest after blunt trauma
Ann Thorac Surg
(1990)
K.P Schmit-Neuerburg et al.
Stabilisierende Operationen am Thorax
Chirurg
(1986)
S.P Baker et al.
The injury severity scorea method for describing patients with multiple injuries and evaluating emergency care
J Trauma
(1974)
I.D Civil et al.
The abbreviated injury scale, 1985 revision
J Trauma
(1988)

R.C Bone

The pathogenesis of sepsis

Ann Intern Med

(1991)

J.F Murray et al.

An expanded definition of the respiratory distress syndrome

Am Rev Respir Dis

(1988)

Cited by (161)

Timing matters: Early versus late rib fixation in patients with multiple rib fractures and pulmonary contusion
2024, Surgery (United States)
Recent literature has shown that surgical stabilization of rib fractures benefits patients with rib fractures accompanied by pulmonary contusion; however, the impact of timing on surgical stabilization of rib fractures in this patient population remains unexplored. We aimed to compare early versus late surgical stabilization of rib fractures in patients with traumatic rib fractures and concurrent pulmonary contusion.
We selected all adult patients with isolated blunt chest trauma, multiple rib fractures, and pulmonary contusion undergoing early (<72 hours) versus late surgical stabilization of rib fractures (≥72 hours) using the American College of Surgeons Trauma Quality Improvement Program 2016 to 2020. Propensity score matching was performed to adjust for patient, injury, and hospital characteristics. Our outcomes were hospital length of stay, acute respiratory distress syndrome, unplanned intubation, ventilator days, unplanned intensive care unit admission, intensive care unit length of stay, tracheostomy rates, and mortality. We then performed sub-group analyses for patients with major or minor pulmonary contusion.
We included 2,839 patients, of whom 1,520 (53.5%) underwent early surgical stabilization of rib fractures. After propensity score matching, 1,096 well-balanced pairs were formed. Early surgical stabilization of rib fractures was associated with a decrease in hospital length of stay (9 vs 13 days; P < .001), decreased intensive care unit length of stay (5 vs 7 days; P < .001), and lower rates of unplanned intubation (7.4% vs 11.4%; P = .001), unplanned intensive care unit admission (4.2% vs 105%, P < .001), and tracheostomy (8.4% vs 12.4%; P = .002). Similar results were also found in the subgroup analyses for patients with major or minor pulmonary contusion.
These findings suggest that in patients with multiple rib fractures and pulmonary contusion, the early implementation of surgical stabilization of rib fractures could be beneficial regardless of the severity of pulmonary contusion.
Comparison of surgical stabilization of rib fractures vs epidural analgesia on in-hospital outcomes
2023, Injury
Surgical stabilization of rib fractures (SSRF) improves functional outcomes compared to controls, partly due to reduction in pain. We investigated the impact of early SSRF on pulmonary complications, mortality, and length of stay compared to non-operative analgesia with epidural analgesia (EA).
Retrospective cohort study of the Trauma Quality Improvement Program (TQIP) 2017 dataset for adults with rib fractures, excluding those with traumatic brain injury or death within twenty-four hours. Early SSRF and EA occurred within 72 h, and we excluded those who received both or neither intervention. Our primary outcome was a composite of pulmonary complications including acute respiratory distress syndrome (ARDS) or ventilator-associated pneumonia (VAP). Additional outcomes included unplanned endotracheal intubation, in-hospital mortality, and hospital and intensive care unit (ICU) length of stay (LOS) for those surviving to discharge. Multiple logistic and linear regressions were controlled for variables including age, sex, flail chest (FC), injury severity, additional procedures, and medical comorbidities.
We included 1,024 and 1,109 patients undergoing early SSRF and EA, respectively. SSRF patients were more severely injured with higher rates of FC (42.8 vs 13.3%, p<0.001), Injury Severity Score (ISS) > 16 (56.9 vs 36.1%, p<0.001), and Abbreviated Injury Scale (AIS) Thorax > 3 (33.3 vs 12.2%, p<0.001). Overall, 49 (2.3%) of patients developed ARDS or VAP, 111 (5.2%) required unplanned intubation, and 58 (2.7%) expired prior to discharge. On multivariable analysis, SSRF was not associated with the primary composite outcome (OR: 1.65, 95%CI: 0.85–3.21). Early SSRF significantly predicted decreased risk of unplanned intubation (OR:0.59, 95%CI: 0.38–0.92) compared with early EA alone, however, was not a significant predictor of in-hospital mortality (OR: 1.27, 95%CI: 0.68–2.39). SSRF was associated with significantly longer hospital (Exp( $β$ ): 1.06, 95%CI: 1.00–1.12, p = 0.047) and ICU LOS (Exp( $β$ ): 1.17, 95%CI: 1.08–1.27, p<0.001).
Aside from unplanned intubation, we observed no statistically significant difference in the adjusted odds of in-hospital pulmonary morbidity or mortality for patients undergoing early SSRF compared with early EA. Chest wall injury patients may benefit from referral to trauma centers where both interventions are available and appropriate surgical candidates may receive timely intervention.
Surgical Rib Fixation in Isolated Flail Chest Improves Survival
2022, Annals of Thoracic Surgery
The presence of severe associated injuries in flail chest complicates the interpretation of outcomes and the role of rib fixation. This study examined the impact of fixation in patients with isolated flail chest.
All patients diagnosed with flail chest injuries were queried from the National Trauma Data Bank (2016-2017). Patients who died within 72 hours, transferred from an another hospital, or had associated thoracic aortic injuries or significant extrathoracic injuries were excluded. Patients with rib fixation were propensity score matched 1:3 with similar patients treated nonoperatively, and outcomes were evaluated. Multivariate analysis was used to identify independent predictors for mortality and prolonged mechanical ventilation.
Of 287,947 patients with rib fractures, there were 12,110 patients (4.2%) with flail chest. After exclusion, 5293 patients with isolated blunt flail chest injuries were included in the analysis. Rib fixation was performed in 575 (10.9%), and 4718 (89.1%) were managed nonoperatively. After matching, the mortality rate was significantly lower in the fixation group (2.0% vs 5.5%, P = .001). On multivariate analysis, rib fixation was associated with improved mortality (odds ratio, 0.355; P = .002). The timing of the operation was not a significant independent risk factor for mortality. However, early fixation (≤72 hours) was associated with a significantly lower need for prolonged ventilation (>7 days).
Operative fixation in patients with isolated flail chest is associated with improved survival and should be considered liberally. The timing of fixation did not affect mortality, but early fixation was associated with a reduced need for prolonged mechanical ventilation.
Controversies in Surgery: Trauma
2021, Surgical Clinics of North America
Early Outcomes of Surgical Stabilisation of Traumatic Rib Fractures: Single-Center Review With a Real-World Evidence Perspective
2021, Journal of Surgical Research
Randomized controlled trials have demonstrated that surgical stabilization of rib fractures (SSRF) in selected trauma patients is associated with potential benefits. This study evaluates the real-world outcomes of SSRF since its implementation at Westmead Hospital, Australia. We hypothesize these outcomes to be similar to that reported by best-evidence in the literature.
A retrospective analysis of data on all consecutive SSRF performed between January 2013 to December 2018 was completed.
Sixty-three patients (54 male; average age 55.9 ± 14.1 y) with median ISS 24 (IQR 17;30) underwent SSRF. Thirty-seven patients were admitted to Intensive Care Unit (ICU), with median ICU length of stay (LOS) 10.0 (5.0-17.0) d. Median hospital LOS was 15.5 (10.0-24.8) d. Fifty-five (87.3%) patients did not have any surgery-specific complications. The highest observed surgical morbidity was wound infection (n = 4, 4.7%). There was one mortality after rib fixation that was not related to surgery. SSRF within 3 d of hospital presentation in ventilated patients with flail chest was associated with significantly reduced median ICU LOS (3.0 [2.0;4.0] versus 10.0 [9.3;13.0] d; P = 0.03). Early (2013-2015) versus late (2015-2018) phase SSRF implementation demonstrated no significant difference in outcome variables.
Experience with SSRF demonstrates early outcomes similar to best-evidence in the existing literature. As a quality assurance tool, ongoing evaluation of real-world data is needed to ensure that outcomes remain consistent with benchmarks available from best-evidence.
The Chest Wall Injury Society Recommendations for Reporting Studies of Surgical Stabilization of Rib Fractures
2021, Injury
: Publications investigating the efficacy of surgical stabilization of rib fractures (SSRF) have increased exponentially. However, there is currently no standardized reporting structure for these studies, rendering both comparisons and extrapolation problematic.
: A subject matter expert group was formed by the Chest Wall Injury Society. This group conducted a review of the SSRF investigational literature and identified variable reporting within several general categories of relevant parameters. A compliment of guidelines was then generated.
: The reporting guidelines consist of 26 recommendations in the categories of: (1) study type, (2) patient and injury characteristics, (3) patient treatments, (4) outcomes, and (5) statistical considerations.
: Our review identified inconsistencies in reporting within the investigational SSRF literature. In response to these inconsistencies, we propose a set of recommendations to standardize reporting of original investigations into the efficacy of SSRF.

View all citing articles on Scopus

View full text

Original Scientific ArticlesOperative chest wall stabilization in flail chest—outcomes of patients with or without pulmonary contusion

Abstract

Section snippets

Methods

Extent of injury

Discussion

Conclusions

Clin Chest Med

J Thorac Cardiovasc Surg

Ann Thorac Surg

Selective management of flail chest and pulmonary contusion

Ann Surg

Effects of contusion and flail chest on pulmonary perfusion and oxygen exchange

J Appl Physiol

The management of flail chest injuryfactors affecting outcome

J Trauma

Open fixation of flail chest after blunt trauma

Ann Thorac Surg

Stabilisierende Operationen am Thorax

Chirurg

The injury severity scorea method for describing patients with multiple injuries and evaluating emergency care

J Trauma

The abbreviated injury scale, 1985 revision

J Trauma

The pathogenesis of sepsis

Ann Intern Med

An expanded definition of the respiratory distress syndrome

Am Rev Respir Dis

Original Scientific Articles
Operative chest wall stabilization in flail chest—outcomes of patients with or without pulmonary contusion