Chest
Volume 97, Issue 4, April 1990, Pages 943-948
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Clinical Investigations in Critical Care
Treatment of Multiple Rib Fractures: Randomized Controlled Trial Comparing Ventilatory with Nonventilatory Management

https://doi.org/10.1378/chest.97.4.943Get rights and content

We studied the treatment of multiple rib fractures in NIC, comparing ventilatory with nonventilatory methods in 69 patients who were randomly allocated to one of the following two treatments: (1) a CPAP mask combined with regional analgesia (n = 36); or (2) endotracheal intubation and mechanical ventilation with PEEP (n = 33). Clinical outcome was as follows: mean duration of treatment, 4.5±2.3 days for the group with CPAP and 7.3±3.7 days for the intubated group (p = 0.0003); mean number of days spent in intensive care, 5.3±2.9 days and 9.5±4.4 days, respectively (p = <0.0001); mean period of hospitalization, 8.4±7.1 days and 14.6±8.6 days, respectively (p = 0.0019); and patients developing complications: 28 percent (10/36) and 73 percent (24/33), respectively. Infections caused the difference in 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 a CPAP mask combined with regional analgesia can shorten and simplify treatment in these patients, mainly through a decreased infection rate, when compared with intubation and mechanical ventilation, and we recommend this treatment in patients similar to our sample.

Section snippets

Population

Between January 1988 and March 1989, 70 patients admitted to our respiratory ICU with multiple rib fractures in NIC were sequentially randomized pairwise24 to either CPAP mask treatment combined with regional analgesia or to endotracheal intubation and ventilation. Informed consent was obtained. The study had been approved by the University of Stellenbosch Faculty of Medicine Ethics Committee. Patients with NIC were enrolled in the study according to the criteria listed in the following

RESULTS

Of the 70 patients entered into the trial, one in the group with CPAP had to be excluded because serial chest x-ray films showed fewer than four rib fractures. Finally, 36 patients were treated by CPAP mask, and 33 by endotracheal intubation and mechanical ventilation. The groups were comparable in respect to sex, age, grade of dyspnea prior to the injury, preexisting pulmonary disease, smoking habits, the FVC before onset of treatment, and the PaO2 with 40 percent oxygen by mask on admission (

DISCUSSION

In this study, we conducted a randomized controlled trial to compare treatment by CPAP mask combined with regional analgesia to endotracheal intubation and mechanical ventilation with PEEP in patients with multiple rib fractures in NIC. In our sample, we could demonstrate that treatment by CPAP mask proved to be much shorter and had fewer complications than intubation and mechanical ventilation.

Previous studies showed that NIC with multiple rib fractures could be managed without intubation of

ACKNOWLEDGMENTS

We thank Prof. R. Stewart and Mrs. J. Barnes for reviewing the article, Prof. D. Kotze for statistical analysis, and E. Badenhorst and B. Karg for compiling the manuscript.

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      Moreover, when compared to mechanical ventilation in two RCTs, CPAP was reported to have lower mortality and pneumonia rates by up to 28% and 34% respectively [24,29]. In one of the aforementioned RCTs comparing CPAP to mechanical ventilation (MV), the patients received regional analgesia as well as CPAP, which was not provided to the comparison mechanical ventilation group, which may have affected their results [24]. However, the second RCT of 43 patients with five or more rib fractures also reported lower pneumonia and mortality rates [29].

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    Manuscript received July 20; revision accepted October 2

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