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Three Part Question

In [patients with multiple rib fractures and flail chest] does [early intubation] improve [survival and length of hospital or ICU stay]?

Clinical Scenario

You are working as the middle grade leading a trauma call. Your patient has multiple rib fractures as well as a flail chest and is clearly in pain and has somewhat laboured breathing. The anaesthetist is getting ready to induce and then intubate the patient to take him upto ICU for mechanical ventilation. You wonder if it is a good idea to be this aggressive and if more conservative management would result in a better outcome. You do not however have any evidence to hand to prove things one way or the other.

Search Strategy

Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) 1946 to Present. Intubation AND Rib fracture (8 articles, 4 relevant)
Intubation AND Rib fracture AND mortality (6 articles, 4 relevant)
Embase 1974 to September 4th 2014. ‏Intubation AND thoracic trauma and mortality. 45 results – 5 relevant
Embase 1974 to Sept 5 2014. (intubation AND multiple rib fracture AND mortality).af.1 result – 1 relevant.

After removing duplicate results from the above list, there were 8 relevant papers of sufficient quality. There are summarised in the table of papers

Search Outcome

Comment
Conflicting studies. On the whole though I feel the following conclusions can be drawn:
1) In patients with Major thoracic trauma, an injury severity score of greater than 15 and thoracic trauma score of greater than 3, there probably still is a role for endotracheal intubation in the pre-hospital setting.

2) In anything but the most severe trauma(as defined above), when the patient is able to maintain their own respiration (albeit with pain), good analgesia, PCA, epidurals, surgical fixation, and CPAP probably achieve a similar result to intubation in facilitating respiration and should be considered in preference if the patient can maintain respiration with these adjuvants. This will avoid the complications of endotracheal intubation.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Pressley, Fry, Philp et al. American Journal of Surgery. 204(6); 910-1; discussion 913-4, 2012 Dec. USA	649 patients. Scoring system based on age, number of fractures, presence of pulmonary contusion to predict outcome and need for intubation	Predicting outcome of patients with chest wall injury. Retrospective review. Patients with score less than 7 had lower mortality (4.2%) compared to higher scores (14.3%).	Score less than 7 predicted lower incidence of intubation (20%) compared to higher scores (40%).		Not a randomised controlled trial but retrospective review. Does not completely answer question if early intubation is what helped, but just that sicker patients are intubated. This we knew.
Harrington, Phillips, Machan et al. 2010 May; USA	1621 patients older than 50 with at least one rib fracture	Retrospective review with univariate and multivariate analysis (8 trauma centres)	On univariate analysis, increased mortality was associated with; admission to high volume trauma centres, CHF and intubation.	PCA and tracheostomy improved patient survival.	Not a RCT. Retrospective. Based on trauma data. Hence provides more epidemiological information. Naturally mortality will be higher in a patient who is intubated.
Richardson, Adams, and Flint 1982 Oct. USA	427 patients with blunt chest trauma.	Retrospective case review The 99 patients who required intubation and mechanical ventilation had a high mortality because of associated shock and head injury. signs of obvious respiratory distress were considered to be indications for endotracheal intubation.	The total mortality for the entire group of patients was 6.5%, with only 1.4% mortality caused by pulmonary injury. 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.		Not RCT. As per the previous study, we also know that patients who are intubated will be the sicker patients and so mortality will be higher. The study shows a relatively low mortality rate. The presence of a large flail segment without severe respiratory compromise or a large pulmonary contusion shown on chest radiograph were not considered significant indications for endotracheal intubation in this study hence it is not answering the questions asked of in my PICO. It nevertheless provides a guide that selective intubation in general is useful.
Bushby, Fitzgerald, and Cameron. 2005 Oct-Dec. Australia	336 adult trauma patient with ISS>15 and at least one thoracic anatomical score >3	Single centre retrospective case review with comparative statistical analysis.	The study population mortality was 42/322. There were 20 “unexpected survivors”. Chest decompression and/or endotracheal intubation were performed in 16/20 “unexpected survivors”. For patients sustaining severe thoracic blunt trauma, pre-hospital intubation and chest decompression appear to be associated with unexpected survival.		This is a particularly useful study for our PICO as it directly addresses the question that in patients with major blunt thoracic trauma (defined as thoracic anatomical score >3), intubation improves survival. One weak point is that the study aims to answer the question for both chest decompression and endotracheal intubation and hence does not allow separate analysis of the two factors. It would be unethical to deny patients one and not the other when clearly indicated though. It is reasonable to surmise that both interventions do improve unexpected survival in major thoracic trauma.
Gunduz, Unlugenc, and Ozalevli. 2005 May.	52 patients with flail chest who required mechanical ventilation	Prospective randomised controlled trial	Nosocomial infection was diagnosed in 10 of 21 patients in the ET group, but only in 4 of 22 in the CPAP group (p = 0.001). There were no significant differences in length of ICU stay between groups. Twenty CPAP patients survived, but only 14 of 21 intubated patients who received IPPV (p<0.01).	Non-invasive CPAP with PCA led to lower mortality and a lower nosocomial infection rate, but similar oxygenation and length of ICU stay.	The study numbers are small (52) but as a prospective randomised controlled trial, this study gives the greatest level of evidence. This study is directly looking at the improvement in mortality with early intubation in the specific population I was concerned with – flail chest. On the downside, the early intubation is being compared with CPAP with PCA rather than any other treatment so the results are not just a reflection of value added (or not) by early intubation but the efficacy of CPAP, which is not a question I am trying to answer.
Walz, Mollenhoff and Muhr 1998 July Germany	30 patients who suffered blunt chest trauma treated with CPAP by facemask.Initial CPAP of 7mbar with ASB (assisted spontaneous breathing) of 15mbar. FiO2 and CPAP/ASB levels were then gradually reduced until no longer needed	Prospective	The treatment was well accepted by all patients and common ventilation associated problems such as pneumonia did not occur.	In all patients, intubation and ventilation was avoided by CPAP	This was a prospective study and so gains significant power. There was no intubation arm of the study however but this was based on previous experiences hence ideally the study needs to be repeated with an intubation arm and a CPAP arm. This study does not directly answer the question whether intubation is indicated in the patient with multiple blunt chest trauma and flail chest, but by showing such could results with CPAP it indirectly does answer the question that intubation is not necessarily indicated. This was a small study of just 30 patients. Further, larger studies are needed.
Dehghan N., De Mestral C, Mckee M.d Feb 2014. Canada	The National trauma data bank was used for a retrospective analysis of the; injury patterns, management, and clinical outcomes associated with flail chest injuries between 2007 and 2009. Flail chest injury was identified in 3,467 patients	Retrospective analysis	Given the high rates morbidity and mortality in patients with a flail chest injury, alternate methods of treatment (to intubation and mechanical ventilation) need to be investigated with large randomized controlled trials. These include more consistent use of epidural catheters and surgical fixation.	77% were male and 54% had lung contusions. Mechanical ventilation was given in 59% for a mean of 12.1 days. Only 8% got epidural catheters and 0.7% surgical fixation of the chest wall. Complications included pneumonia (21%), ARDS(14%), sepsis (7%), and death(16%).	While this study included data about intubation and mechanical ventilation, it was a retrospective study looking at a host of issues. It is a retrospective review rather than a prospective randomised controlled trial. The study proves patients with a flail chest have a high mortality and morbidity and a lot of them are intubated and given mechanical ventilation. It also shows that augmentive treatments such as epidural catheter and surgical fixation are not used as much as they might be. Further prospective RCTs are needed to draw any more conclusions.

Comment(s)

These are conflicting studies. However, on the whole, I feel that the following conclusions can be drawn: 1)In patients with Major thoracic trauma, an injury severity score of greater than 15 and thoracic trauma score of greater than 3, there probably still is a role for endotracheal intubation in the pre-hospital setting. 2)In anything but the most severe trauma(as defined above), when the patient is able to maintain their own respiration (albeit with pain), good analgesia, PCA, epidurals, surgical fixation, and CPAP probably achieve a similar result to intubation in facilitating respiration and should be considered in preference if the patient can maintain respiration with these adjuvants. This will avoid the complications of endotracheal intubation.

Editor Comment

JS

Clinical Bottom Line

CPAP and good analgesia with PCA and epidural is enough to avoid intubation and its complications in most conscious and breathing patients who have multiple rib fractures.

References

1. Pressley, Fry, Philp et al. Predicting outcome of patients with chest wall injury. American Journal of Surgery. 2012 Dec. 204(6); 910-1; discussion 913-4,
2. Harrington, Phillips, Machan et al. Factors associated with survival following blunt chest trauma in older patients. results from a large regional trauma cooperative. Archives Surgery. 2010 May; 145(5);437-8;PMID: 20491160
3. Richardson, Adams, and Flint Selective management of flail chest and pulmonary contusion. Ann Surg. 196(4):481-7, 1982 Oct.
4. Bushby, Fitzgerald, and Cameron. Prehospital intubation and chest decompression is associated with unexpected survival in major thoracic blunt trauma. Emergency Medicine Australasia. 17(5-6);443-9, 2005 Oct-Dec.
5. Gunduz, Unlugenc, and Ozalevli. A comparative study of CPAP and IPPV in patients with flail chest. Emergency Medicine Journal 22(5):325-9, 2005 May.
6. Walz, Mollenhoff and Muhr CPAP augmented spontaneous respiration in thoracic trauma. An alternative to intubation Unfallchirurg. 101 (7):527-36,1998 July
7. Rucholtz, Waydhas, and Ose. Prehospital intubation in severe thoracic trauma without respiratory insufficiency. Journal of Trauma - Injury, Infection and Critical Care. 52 (5) (pp 879-886), 2002.
8. Dehghan N., De Mestral C, Mckee M.d Flail chest injuries: A review of outcomes and treatment practices from the national trauma data bank. Journal of trauma and acute care surgery February 2014, p 462–468