treatment of multiple rib fractures. randomized controlled
TRANSCRIPT
DOI 10.1378/chest.97.4.943 1990;97;943-948 Chest
CT Bolliger and SF Van Eeden
nonventilatory managementcontrolled trial comparing ventilatory with Treatment of multiple rib fractures. Randomized
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*From the Respiratory Intensive Care Unit, Department (of internal
Medicine, Tygenheng Hospital, Cape Town, Soouith Africa.Manuscript received Juoly 20; revision accepted Octuher 2.
CHEST I 97 I 4 I APRIL 1990 943
Treatment of Multiple Rib Fractures*Randomized Controlled Trial ComparingVentilatory with Nonventilatory ManagementChris T Bolliger, M.D. ,B. Sc. ,Hon.;
and Stephan F Van Eeden, M.Med.
We studied the treatment of multiple rib fractures in NIC,
comparing ventilatory with nonventilatory methods in 69
patients who were randomly allocated to one ofthe following
two treatments: (1) a CPAP mask combined with regional
analgesia (n 36); or (2) endotracheal intubation and me-
chanical 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 = 0M003); 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 ofhospitalization, 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 CPA? 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.
(Chest 1990; 97:943-48)
NIC = nonpenetrating injury to the chest; ISS injury severityscore
T he treatment of multiple rib fractures in NIC has
undergone radical changes ouver the last three to
four decades and is still evolving. Whereas up until
the 1930s the stabilization of the chest wall wasachieved by sandbags, external compression, and
0 the utilization of different mechanical
devices such as wires, hooks, screws, or pins became
fashionable over the next 20 years. During the 1950s
the radically different concept of internal pneumatic
stabilization with positive-pressure breathing was de-
veloped.2’3 This technique required endotracheal in-
tubation and mechanical ventilation of the patient.
The evoolution O)f the understanding of the pathophys-
ioolo)glc effects of NIC directed the attentio)n froonl the
chest wall too the injury ofthe underlying king resulting
ill gas exchange disturbances and co)mplicatio)ns such
as the ARDS.4#{176}#{176}
Mechanical ventilatioun has since becoome an ac-
cepted foorm oof treatment for multiple rib fractures
and flail chests;�’� however, with the widespread use
of this invasive form of treatment, complications such
as respiratory t2 sepsis, I)arootrauma, and
tracheal stenoosis became evident.
Recently, there has been a return too mooninvasive
modes O)f treatment, such as ooptimal pain relief and
CPAP via a tightly fitting face mask too increase the
FRC.13.t4 The use of CPAP via a mask maintains the
principle ofinternal pneumatic stabilizatioon but avoids
the risks invoived with intubatioon and mechanical
ventilation. 05,06
Pain relief in mechanical ventilation dooes not pre-
sent prooblems, as the respiratoory depression due too
systemically administered analgesics is ooften initially
desired in patients on a ventilator; however, in a
patient breathing spo)ntaneously, any depression oof the
respiratory drive must be avoided. Therefore, sys-
temic analgesia is often replaced by local o� regioonal
means of pain relief. The main options are intercostal
nerve blocks or epidural analgesia. L7��
Previous studies have shoown the feasibility ouf nom-
ventilatory treatment of NIC, bitt they were either
retrospective,05 o)nly descriptive,aS oor lacked matching
or randoomization (or both) behveen the different
treatment 04, 05.22 We therefore coonducted a
randomized controolled trial too compare the use of a
CPAP nlask cumbined with regioonal analgesia too the
coonventiounal mode oof management of multiple rib
fractures, which is intubatioon and mechanical venti-
lation with PEEP. Our hypothesis was that in I)atietlts
with moderate too severe NIC, treatment with the
CPAP mask wo)illd he shorter and cause less coompli-
catio)ns than intubatioon and mechanical ventilatioun.
Pb;�ulation
MATERIALS ANI) METuons
Between Janutarv 1988 amid March 1989, 70 patiemots admitted to)
oouon respiratourv ICU with multiple nil) fractures in NIC were
sequentially randomized painwise� to) either CPAP mask treatment
coombined with regional analgesia our to) endotracheal inttohatioon and
Copyright © 1990 by American College of Chest Physicians on February 21, 2008 chestjournal.orgDownloaded from
944 Treatment of Multiple Rib Fractures (Bo!Iigeo Van Eeden)
ventilatioumi. Infourmed coonsent was oulotained. The study had been
approved by the University ouf Stellenhoosch Faculty ouf Medicine
Ethics Coommittee. Patients with NIC were ennoulled in the stiody
according too the criteria listed in the foollouwing tahuolation:
Incluosion (all oof the folloowimig):Moore than three rib fracturesAdmissioon too houspital within 24 hoours after injuryInsufficient coough mechanism dume to) pain or preexistingpnlmnonany disease (our both)
Excluision (any (of the fullousu’ing):Depressed level oof counscioousnessImportant facial injuries (excluding tolenance ouf CPAPmask)Fracttores too l)ase ouf skullSevere luong contusion (alveolar infiltrate umidenlying ribfractuores on admissioun chest x-ray film and PaO2-(8 kPaoun 40 percent (oxygen mask)Need for initial tipper laparotomy our other majoun surgery
Spinal injuryContraindications for regional aoialgesia (bleeding ten-dency)
PTVCCdUWS and Measun’ments
On admissioon to the ICU , all patients received the following
woorktop: detailed history regarding previoous coondition of the kings;
circumstances of injury; physical examination; and laboratory anal-
yses, includimig blood chemistry, full blouod cell count, chest x-ray
film, ECG, arterial blood gas levels on rooom air and 40 percent
ouxygen, amid FVC oubtained with a portable spirometen (the best o)f
three efforts was reponted).
The patients nandomly allocated too CPAP mask treatment under-
went the insertion of a luombar epidtoral catheten.#{176}-’� Pain relief was
oubtaimmed with louprenoorphine (Temgesic; Reckitt amid Colman), with
0. 1 too 0.3 rug per injectioon diluted in 10 to 20 ml of physioloogic
saline soltmtioun.’ The vooltome of the injectiorm was calcuolated by
muoltiplying the number of segments between the imisertion level (of
the epidural catheter and the level of the highest hnoken rib by 1.5
ml.� The pain level was assessed by the patient oun a straight line
fnom 0 (no paimi) too 10 (maximum pain) before amid after negioomial
analgesia. The ntomloer oof injections depended oon the patients’
needs, with the muinimuom interval being six houons. Altennativel�;
imitercoostal nerve blocks with htipivacaine hydnochloonide (Mancaine)
(maximum, 150 ing per douse) were used in patients with moudenate
NIC, le, unilateral nb fractures only. The patients were then placed
out) a freestanding CPAP mask system.
The patients assigned too emidotmacheal intuthatiomi and mechanical
ventilatioon were intubated amid connected too a respiratory (Siemens
9(X) C, CPAP Bird) amid received systemic pain reliefwith morphine
( ± 1 mmig/kg/day) and sedatioon with midazolam (Dormicum; Roche)
( ± 1.5 mg/kg/day) as mieeded. They were kept in the IMV mode.
The F1o2 amid level ouf CPAP were adjusted in both grouuips too
maiimtaimm adequoate oxvgenatioun (arterial oxygemi sattonatioun >90
percent amid arterial carbon dioxide pnessuone �6 kPa [45 mmii hgj).
All patiemits received aggressive physiootherapy daily and were
mouboilized as early as possible. The dionation oof treatment for both
groutips was at least 48 hoouns after admnissioon�’ and contintted until
the patient cooumld maimitaimi (1) a PaO2 greater than 8 kPa (60 mm
iig) oon 40 I�rcermt ouxygen, (2) a nespiratory rate ofless than 30/mm,
(3) FVC oof more than 15 mI/kg, and (4) hemoudynamic stability
(noormal pulse rate and bloood pressttre). Patients were discharged
fnom the ICU within 24 hotons after discoontinuoation of specific
treatment. The pain level, FVC, and arterial blood gas levels were
analyzed daily in all patients. Other examinations (white blooood cell
co)tttit, bacteriodogic samples, and chest x-ray films) were obtained
every third day or whemo indicated by the clinical cootorse (our booth).
Criteria for intubating and mechanically ventilating patients oms
the CPAP mask regimen were oone or mo�e oofthe foolloowing: (1) PaO2
less than 8 kPa (60 mm big) on 40 percent oxygen and CPAP of 10
cm H2O; (2) PaCO2 greaten than 6.5 kPa (48.8 mm hg) and rising;
(3) respiratory rate greater than 35/mm; (4) FVC less than 10 mI/kg;and (5) deterioration of level oof coonsciousness.
Variables were defined as follows: (1) dyspnea baseline dyspneaprior to injiory according too the NYHA classification; (2) preexisting
pulmoonary disease = any clinical symnptomns our previoouosly docu-
mented signs as well as nadiougraphic signs ouf preexisting puolmounany
disease; (3) smooker - cumnnent smoking of 5 our more cigarettes pen
day or daily pipe smouking, including ex-smo)kens from both gnoouops
wh(O ceased smouking less than six mounths prior too admission; (4)
hong conttosion = radiognaphic evidence ouf alveolar infiltrates
subjacent to the fractuored ribs within six hooumns (of injury; (5) blunt
abdominal trauma - contusion our niptione (our booth) (of internal
organs (diagnoosed clinically, s(unoognaplucally, our by laparootomy); (6)
acute bronchitis = punolent sputum (or bronchial washing) without
pulmoonary infiltrate, with positive culture oor 25 netotrophils pen
high-poower field (on both) with microorganisms on the Gram stain;
(7) pneumoonia = new puilmiinany infiltrate (not explained by any
outher neason) with at least two oof the folIoowing: purtmlent sputum,
raised temperature (>38.3#{176}C [100.9#{176}F]), raised white blood cell
oxount (> 12 x lOYcto mm and �80 percent neuotr(Ophils), and positive
sputum Gram stain on cultsore (or booth); (8) septicemia (all five oof
following) = (a) clinical evidence ouf infection, (b) fever (>38.3#{176}C
[100.9#{176}F], rectal) our hypothermia (<35.6#{176}C [96.1#{176}F], rectal), (c)
tachycardia (>90 beats per minute), (d) white bboood cell count
greaten than 20 x 10#{176}/cumm or less than 4 x 10#{176}/cumm, and (e) at
least one of the foollowing criteria four an altered perfusion state:
altered mentation (in relation to patient’s baseline), elevated lactate
level (>2 mm(ol/L), and ouliguria (ooutptot <30 ml or <0.5 mi/kg fon
at least one houn).�’
Statistical Analysis
We estimated the necessary sample size at 30 patients per gnotmp
in oorder too demomstrate a oomme-dav neductioumu ouf the ICU stay at the
95 percent c’oonfidemsce level. The dtoration of mechanical ventilati(on
was likely to be seven to) eight days according too our (OWn previous
recoords.
The criteria used too coompare oumtcoomes between the twoo methods
(of treatment were length of treatment (CPAP mask or mechanical
ventilatioon), duration ouf stay in the ICU , duiratioon of hoospitalizatkon,
and presence oofcomplicatiouns. The data were mion-mally distributed.
The statistical tests uosed were the Student�o f-test four countintoous
variables and X� test Ion categorical variables. Significant differences
were cxompared at the 95 percent level.
In additioon, booth grouips were stratified according to) smoking
histor�� evidence ouf preexisting pulmonary disease and grade of
dyspnea prioon too injuir) Analysis within and between the (woo grooups
for these pootential confotonders was performed by analysis of
variance.
RESU LTS
Of the 70 patients entered into the trial, one in the
group with CPAP had too 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 venti-
lation. 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 (Table 1).
The number of rib fractures, the proportions of
patients with hemothorax (pneumothorax), pulmonary
Copyright © 1990 by American College of Chest Physicians on February 21, 2008 chestjournal.orgDownloaded from
Patients with NICData (PAP !�Ilausk lmmtuoboautiomm io
No. ufpatieimts 36 3.3 . .
I)�uvs ouftreatumetmt 4.5 ± 2.3 7.3 ± :3.7 O.(XX)3*
Days iim intemmsive caro- 5.3 ± 2.9 9.5 ± 4.4 <0.0001*
I)avs immimospital 13.4 ± 7. 1 14.6 ± 8.6 0.0()19*
No. ofpatiemots ‘with 10 24 0.(X)2�
(.lonmplicati0001st
1)ata CPAP Mask Iiotuoboat�omi p \�tlute*
No. ofpatiemmts 36 3.3 . .
Sex (No. ofmnen) 26 22 NSf
Meami age 46.3 ± 15.7 47.8 ± 14.9 NS�
I)vspnea (� grade 2) 8 6 NSt
Pno.’existitog I)tillmio)rmarY 12 8 NSt
disease
Smnookers 28 22 NSt
FVC/L 1.53±0.63 1.48±0.66 NS�
PaO� with 40 loerco-mit
ooxvgeim boy mumask
kPa 15.7±4.2 14.2±3.4 NS�
mon Jig 117.8±31.5 106.5±25.5 . .
No. oufnib fractures 6.9±2.2 6.9±2.3 NS�
I Ienooutlmoorax (pioeuomnoothoorax) 16 i 7 NSt
Ptolnioomiarv coontutsiom 6 5 NSf
No. oofputietits with 15 14 NSt
additiounal fractures
Blumit abodoumminal traomnoa 2 7 NSfISS Score� 11.5±3.6 14.3±5.9 0.021t
The results ouf clinical ooutc(ome were as hollouovs
(Table 2): days 0)11 specific treatment, 4.5 ± 2.3 fur tile
grouup with CPAP and 7.3 ± 3.7 four the intubated grouup
(r = 0.0003); days spent ito the ICU, 5.3 ± 2.9 and9.5±4.4 days, respectively (p<O.(X)Ol); days of’ boos-
pitalizatioon, 8.4 ± 7. 1 and 14.6 ± 8.6 days, respectively
(i 0 . O() 19); amid 1)atieiits develiuping coOtill)l ications,28 Percent (10/36) and 73 1)ercelit (24133) (p = O.()02).
Details of the complications during the perioud in the
ICU are listed in Table 3. The average level ouf CPAP
delivered too the group receiving CPAP was 5.4 ± 1.3
dl H2O and to) the intul)ated grouup was 6.6 ± 2.3 cm
H2O (p>O.05).
One Patient iii tile group witil CPAP developed a
ni ttltifactorial respirato)rv failure (aicoohool �
lung collapse; l)tieitmflooliia) amid had tou i)e itituti)ated
and vetitilated for twou weeks befoore successful wean-
lug. Tivoo deaths ooccurred in the intui)ated group; a
74-year-old mnati with severe chroonic o)i)strtictive 1)tll-
niounary disease who had acute i)roonchitis at the tinie
oof injury died ouf’ respirators’ failure, and a 70-vear-ould
wouniato died suddenly in cardiac failure (tile autopsy
revealed a severe cardiac contusiom and suti)dtlral
Table 3-Complications in 69 Patients with N1C
3.
contusion, additional fractures o)utside the rib cage
(Fig 1), and, finally, blunt al)doominal trauma did not
show any significant differences between the two)
groups either. When using the ISS,t� we found values
of 11.5±3.6 amid 14.3±5.9, which were significantly
different at a 5 percent level (p = 0.02 12).
CPAP MASK INTUBATIONn:36 n::33
2110
� �
1_ � 104 I�ol � � Ii
o�
01 [
(�unplicatioti (PAP Niaslo intitloatiomi J) \altio�
No. ofpatiemmts 36 33 . .
Barotm’aumna
Pmiemmmmmotliorax 2 1 NS
Suoloc-utatmeomos emmmpiovso-mmia i 0 NS
Broumicimopleural fistula 0 2 NS
I mifectiomm
Acute hromicliitist 2 1 NS
Simmumsitis 0 1 NS
I.anytmgitis 0 2 NS
Pneui,moonmiat 5 i6 <0.(X)5
Septicetmmiat 0 3 NS
Other
Luomog coillapse 1 1 NS
Extraplo.ural hiemimatonia I 0 NSRespirator� failmore 1 1 NSl)eath 0 2 NS
Fictisu: 1 . liotal nomimiloer amool l(ucaliy.atunm offractuoro-s iii each treatt-o.l
gnoumj). Meamm mimitmmloerof rib fractuoro’sin lootlmgrouop ‘with (�PAP
muask aomd intmohated group was 6.9 (247/36 amid 228/33, respectively).
Table 1 -Clinical Characteristics on Admission of 69 Table 2-Comparison ofOutcome in 69 Patients with NIC
CHEST I 97 I 4 I APRIL, 1990 945
*NS not significamit.
tx2 analysis.
�t-test (mneamm ± SD).
§lnjuony severity store.
*t_test (moicaim ± SD).
tl)etaileol amialvsis iii Table 3.
:1:X2 anal\ sis.
*X.: amialvsis. NS, not significoimt.
tAs (lefimiO’(l un(ier nmethoools.
Copyright © 1990 by American College of Chest Physicians on February 21, 2008 chestjournal.orgDownloaded from
MORTALOTY
10 20 30 40 50 60
INJURY SEVERITY SCORE- �49 years O’��O50-69years � 70 years
FlcuRE 2. Injury severity scon&� four three different age groups.
Mean scores for grooump with CPAP groouop (11.5) amid intuhated group
(14.3) intersect at almoust identical mortality (percentage) regardless
of age.
946 Treatment of Multiple Rib Fractures (Bo!!igeo Van Eeden)
hematoma without signs o)f herniation oof the brain
stem, neither of which had been clinically apparent
on admission).
A stratified analysis within and between the two
groups showed that there was no significant difference
at the 5 percent level regarding ooutcome when co)m-
paring smookers and nonsmokers (p>O.O5), patients
with and without preexisting pulmonary disease
(p>O.O5), or dyspnea greater than or equal to grade 2
and dyspnea less than (p>O.OS).
In the group with CPAP, 23 patients were given an
epidural catheter, 12 received intercostal nerve blocks,
and one patient did no)t need further pain relief after
an initial intramuscular injection of diclofenac (Volta-
ren) in the emergency ward. Both analgesic methods
provided good pain relief, reducing the amount of pain
experienced by cooughing after the application of the
drug by an average oof 50 percent as assessed by the
patient on the linear scale; however, the twoo methoods
were no)t used eo�ually. Intercostal blocks were given
preferentially too patients with fewer fractures on oone
side oof the chest only. On the average, the epiditral
catheters were left in place for three days (range, two
to) seven days), the average to)tal nulilber oof injectioons
was 4.4, and the average t(otal doose o)f buprenoorphine
was 0.78 mg per patient. Noo complications were
observed.
Both treated groups received the same intensity of
chest physiotherapy, but due to the lack of initial
sedatioon and the absence ofan endotracheal tithe, the
patients in the group with CPAP could be mobilized
earlier and participated moore actively with the physi-
otherapist than the patients in the intutbated group.
DiscUSSION
In this study, we coonducted a randomized coontrolled
trial tcm compare treatment by CPAP mask combined
with regio)nal analgesia too endotracheal intubation and
mechanical ventilatioun with PEEP in patients with
multiple ru) fractures in NIC. In our sample, we could
demonstrate that treatment by CPAP mask prooved to
be much shorter and had fewer complicatioons than
intubatiom and mechanical ventilatioon.
Previous studies shoowed that NIC with multiple rib
fractures could be managed without intubatkon of the
patient, but in general the no)nventilated patients had
less severe chest trauma. With a randomized study,
we oobtained two treated groups which were well
matched for all parameters bitt for the ISS (Table 1).
The higher ISS score for the intubated group can be
accoounted for by greater incidence cfblunt abdomiinal
trauma (seven vs twoo in the group with CPAP), which
although on direct compariso)n was not different,
reached significance in the 155 due too the quadratic
nature of this score. Clinically, this difference was not
important, as the blunt abdominal trauma was less
severe than the chest trauma in all patients of both
grcoups and did noot influence the duration of treatment.
Two patients in the intutbated group underwent early
laparotoomies (one splenic rupture; one bladder rup-
ture), with an uneveniful postooperative course. Froum
Figure 2, it is apparent that although the ISS score
was 11.5 for the group with CPAP and 14.3 for the
intitbated grooup, both groups have similar mortality
regardless of age. The ISS pro)ved too be a goood index
(Of mortality, as both the deaths occurred in patients
70 years of age or older, whose risk of dying was
greater than that of younger patients for a given score
(Fig 2). The deaths were probably not related to the
mode oof treatment; however, the ISS was a relatively
poor indicatoor of the considerable morbidity in our
groups, whose major site of injury was the chest.
Apart from age and sex, we attached particular
importance to the condition of the lung prior to the
injury and obtained a detailed history of the degree of
dyspnea between grade 0 and 4 (NYHA), evidence of
preexisting pulmonary disease, and smoking status.
We used the FVC as a measurement of initial respi-
ratoory impairment and the Pa02 as an indicator of the
pulmo)nary gas exchange.
Our criteria for comparing outcomes between the
twoo groups were the duration of the different treat-
ments (specific treatment too increase FRC; stay in the
ICU; to)tal length oof hoospitalizatioon) and the rate of
connplications in each group. The results showed a
highly significant difference fcor all criteria, indicating
that treatment by CPAP mask combined with regional
analgesia shortened all periods co)nsiderably and
caused far fewer complicati.ons.
Comparisons with other studies were difficult, as
none ofthem used a severity score; however, Dittmann
et al� had two groups whose severity of chest trauma
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CHEST I 97 I 4 I APRIL, 1990 947
was comparable to) our population. Their periods in
the ICU, with 4.5 days foor the nonventilated amid 9.8
days for the ventilated group, were similar too omrs
(Table 2). The tootal length o)f hospitalizatioll in a stu(iy
by Trinkle et al#{176}�four their noollVelltilated group (9.3
days) compared well with that oofoour grouttp with CPAP
but not for the ventilated grooup (31 .3 days in their
study). Despite soume difficulties in comnparing the
studies mentitoned, the commoon message is that
nonventilatory treatment of NIC can shoorten hospi-
tahzati(on dramatically.
A detailed view ofour co)mplications (Table 3) which
occurred during the period in the ICU showed a very
low incidence cifpneumoothorax ,subcutaneous emphy-
sema, lung collapse, and bronchitis for both groups;
however, the number oof severe infectioons was much
more frequent in the intitbated group, with pneumonia
occurring in 48 percent (16/33 patients), compared
with 14 percent (5/36 patients) in the grooup with CPAP
Sinusitis, laryngitis, broonchopleural fistula, and septi-
cemia with positive bkRod culture oonly occurred in the
intubated and mechanically ventilated group. Tougether
with the pneumoonias, these complications were the
main factoors contributing to increased mo)rbidity and
therefore longer duration of each period of treatment
in this group. These findings agree well with the high
rate and the type of complications due to mechanical
ventilation reported in many studies. 02.04,15 Trinkle et
al#{176}�even reported an incidence of pneumoonia of 84
percent (16/19 patients) in their ventilated group.
Our overall rate of complications of 28 percent (10/
36) in the group with CPAP and of 73 percent (24/33)
in the intubated group, as well as the mortality of zero
in the group with CPAP and of 6 percent (2133) in the
intubated group, were comparable to the trial of
Trinkle et a1.#{176}�Their overall rate of complications in
the nonventilatory grooup was 21 percent and in the
ventilated group was 100 percent (19/19). Their moor-
tality was 0 and 21 percent, respectively. Complica-
tions due to the CPAP mask per se were negligible
(nasal pressure sores) and did not result in any discoon-
tinuation of the treatment.
The stratified analysis within and I)etWeen tour twoo
treated groups exchtded smoking, preexistitig pulmo-
nary disease, and degree ofdyspnea prior too injury aspossible confounders. This suggests that peouple with
impaired pulmonary function with mo)derate too severe
NIC can be treated without intiml)atio)n and mechanical
ventilation.
We see the successful outcome in our grooup with
nonventilatory treatment as a result ofthe coombination
ofCPAP by mask and regio)nal analgesia, booth of which
have been shown to be beneficial in NIC on their town.
The CPAP, by increasing the FRC, aims at the majoor
problem in NIC, which is contusion ofthe underlying
lung, with abnormalities in gas exchange.#{176}�’� Epidural
analgesia and interco)stal nerve blocks, oon the outher
hand, 1)rouxide pain reliefand allow early moobilizatioon
and aggressive chest physiotherapy �vith the patient’s
active Particil)atioulo. This, in tutrn, can po)tentiate the
increase in FRC� obtaitoed with CPAP�
Epidural analgesia usimig the luonohar approach for
tiloffacic 1)aili relief-52#{176}’ 1)ro)�’e(1 �‘er�’ satisfactoorv imi (our
trial. \Ve primarily useol this approuach, since in our
institution the nlajority ouf douctoors are trained oumily in
the luniixtr techni(Iue. Buprenourphiole prooveci too i)e
safe and effective in the epidural space. Most o)f (uttr
patients needed oonly oune too twou itijectiouns per 24
hoours too maintaito adeoiuate 1)ain relief. Clinically
important respiratory depression our catheter-related
coumplicatioons were noot oi)served.
\Ve coonclude that in patients with NIC xs’hoose main
site of injury is the chest and who doo n(ut meet am�y oof
the previoously mentiooned criteria four exchtsioumo, the
treatment ofchuice shooitld I)e the use (ofa CPAP mask
combined with regional analgesia, physioutherapy, amid
early mobilization. This treatment is coost-effective,
has less associated additioomial mnoorbidity, and shortens
hoospitalizatioon draniatically
ACKN()WI�EDG!’�1ENTS: ‘sVo thank Prof. H. Stewart amm(i Mrs. J.Barnes four reviewimmg the article. Prof. D. Kotzo’ four statisticalamoalvsis, amiol E. Bademmhoorst atid B. Karg four comimpilimig time niammu-script.
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East Coast Workshop in ElectrocardiographyThe Roogers heart Fooundation will sponsor this workshop May 30-Jume 3 at the Diploniat
Resort and Country Club, Hollvwoood, Floorida. For infornoatioon, contact: Rogers Heart
Foouondatiom, P0 Box 12588, St. Petersburg, 33733 (813:894-079(0).
Introduction to Occupational MedicineThis two-day coourse will be held Ma� 15-16 at the Marriott Hotel, Worcester, MA, spons(ored
b�’ the Occupational Health Program, University of Massachusetts Medical School, amid coo-
sponsored by the Harvard Educational Resource Center for Occupational Safety and Health.For infoormation: coontact Occupatiomoal Health Program, University of Massachusetts Medical
Center, 55 Lake Avenue North, Worcester 01655 (508:856-2322).
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DOI 10.1378/chest.97.4.943 1990;97;943-948 Chest
CT Bolliger and SF Van Eeden ventilatory with nonventilatory management
Treatment of multiple rib fractures. Randomized controlled trial comparing
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