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Surgical Stabilization of Internal Pneumatic Stabilization?A Prospective Randomized Study of Management of Severe Flail Chest PatientsHideharu Tanaka,MD,Tetsuo Yukioka,MD,Yoshihiro Yamaguti,MD,Syoichiro Shimizu,MD,Hideaki Goto,MD,Hiroharu Matsuda,MD,and Syuji Shimazaki,MDBackground:We compared the clin-ical efficacy of surgical stabilization and internal pneumatic stabilization in severe flail chest patients who required pro-longed ventilatory support.Methods:Thirty-seven consecutive severe flail chest patients who required mechanical ventilation were enrolled in this study.All the patients received iden-tical respiratory management,including end-tracheal intubation,mechanical ven-tilation,continuous epidural anesthesia, analgesia,bronchoscopic aspiration,pos-tural drainage,and pulmonary hygiene. At5days after injury,surgical stabiliza-tion with Judet struts(S group,n؍18)or internal pneumatic stabilization(I group, n؍19)was randomly assigned.Most re-spiratory management was identical be-tween the two groups except the surgical procedure.Statistical analysis using two-way analysis of variance and Tukey’s testwas used to compare the groups.Results:Age,sex,Injury SeverityScore,chest Abbreviated Injury Score,number of rib fractures,severity of lungcontusion,and Pa O2/F IO2ratio at admis-sion were all equivalent in the two groups.The S group showed a shorter ventilatoryperiod(10.8؎3.4days)than the I group(18.3؎7.4days)(p<0.05),shorter in-tensive care unit stay(S group,16.5؎7.4days;I group,26.8؎13.2days;p<0.05),and lower incidence of pneumonia(Sgroup,24%;I group,77%;p<0.05).Percent forced vital capacity was higher inthe S group at1month and thereafter(p<0.05).The percentage of patients whohad returned to full-time employment at6months was significantly higher in the Sgroup(11of18)than in the I group(1of19).Conclusion:This study proved thatin severe flail chest patients,surgical sta-bilization using Judet struts has beneficialeffects with respect to less ventilatory sup-port,lower incidence of pneumonia,shorter trauma intensive care unit stay,and reduced medical cost than internalfixation.Moreover,surgical stabilizationwith Judet struts improved percent forcedvital capacity from the early phase aftersurgical fixation.Also,patients with sur-gical stabilization could return to theirprevious employment quicker than thosewith internal pneumatic stabilization,even in those with the same severity of flailchest.We therefore concluded that surgi-cal stabilization with Judet struts may bepreferably applied to patients with severeflail chest who need ventilator support.Key Words:Severe flail chest,Surgi-cal stabilization,Long-term follow-up.J Trauma.2002;52:727–732.T he therapeutic approach to flail chest has been exten-sively reported.Selected ventilation and tracheostomy have become standard treatment for patients with flail chest.However,it is well known that some patients with severe flail chest still require prolonged ventilation and may develop posttraumatic pneumonia.1In addition,long-term disability has been reported in one third of cases with con-servative treatment,and patients managed with internal pneu-matic stabilization could not return immediately to full-time employment.2,3Recently,beneficial effects of surgical stabilization in severe flail chest patients have been reported in European countries.4,5According to these results,surgical fixation shortened the duration of intubation and achieved early res-toration of chest wall deformity.However,clinical compari-sons between surgical stabilization and internal pneumatic stabilization in patients with the same severity of flail chest that need prolonged ventilation have been poorly docu-mented.Thus,this study was conducted to evaluate the clin-ical efficacy of surgical stabilization compared with internal pneumatic stabilization in patients with the same severity of flail chest.SUBJECTS AND METHODSPatient SelectionFrom April1992to March1998,148consecutive pa-tients who sustained traumatic flail chest were treated at the Level I Trauma and Critical Care Center,Kyorin University Hospital,Tokyo.Of these148patients,111were excluded for the following reasons:patients did not require mechanical ventilation;patients had fractures of fewer than six ribs; patients did not develop acute respiratory failure;patients had severe closed head injury(head Abbreviated Injury Scale scoreϾ3with unconsciousness)and/or spinal injury;ageϽ14years;consent not given;chronic preexisting heart,pul-Submitted for publication June23,2000.Accepted for publication December11,2001.Copyright©2002by Lippincott Williams&Wilkins,Inc.From the Department of Traumatology and Critical Care Medicine, Kyorin University,Tokyo,Japan.Presented at the56th Annual Meeting of the American Association for the Surgery of Trauma,September19–21,1996,Houston,Texas.Address for reprints:Hideharu Tanaka,MD,DMSc,Department of Traumatology and Critical Care Medicine,Kyorin University,6-20-2 Shinkawa,Mitaka City,Tokyo181-8611,Japan;email htanaka@.monary,hepatic,and/or renal disease;and questionnaire notcompleted.Finally,37patients were enrolled in this random-ized controlled study.GroupingAll the patients received identical treatment until studyconsent was obtained.In brief,all of the37patients requiredend-tracheal intubation in the emergency room or traumaintensive care unit(TICU)because of flail chest and acuterespiratory failure.The indications for mechanical ventilationwere presence of hypoxia and/or hypercarbia(Pa O2Ͻ60mm Hg,Pa CO2Ͼ50mm Hg)under40%inspired oxygen inha-lation;associated severe trauma with unconsciousness and/orshock state;and presence of airway obstruction or repeatedatelectasis.Thereafter,patients were transferred to the TICU andreceived continuous aggressive pulmonary physiotherapy in-cluding end-tracheal intubation,mechanical ventilation(pos-itive end-expiratory pressure ventilation with spontaneousintermittent mandatory ventilation mode with pressure sup-port ventilation),continuous epidural anesthesia,analgesiaadministration,bronchoscopic aspiration,postural drainage,respiratory physiotherapy,and administration of systemicantibiotics.At5days after injury,each patient was randomly as-signed to either the surgical stabilization group(S group)oran internal pneumatic stabilization group(I group)accordingto a randomization chart.Patients in both groups were treatedequally by the predesigned study protocol until surgery.Ta-ble1shows the patient demographics.All these parameterswere similar in the two groups(Table1).Surgical ProcedureEighteen patients underwent surgical fixation(S group).Surgical stabilization with Judet struts was performed within14days after injury.Most patients underwent surgery ataround1week.Several sizes of Judet struts and the fixationtool are shown in Figure1.Details of the surgical procedure were as follows(Fig.2).The approach to the ribs consists of a minimal postero-lateral and/or anterolateral skin incision over the fracturedarea.Essentially,large thoracotomy and incision are unnec-essary.To preserve respiratory function,respiratory assis-tance and intercostal muscles were minimally dissected(Fig.2A).Ribs between T1and T3,and T11and T12were not fixed.Ribs between T4and T10with a large dislocatedsegmental fracture were manually reduced with a metal hookinitially(Fig.2B).Judet struts were applied to the rib cageaccording to the fracture size(Fig.2C).After surgical stabi-lization,a continuous subcutaneous drainage tube was placed,and muscles and skin were sutured in the usual manner(Fig.2D).One to2days after surgery,until the patients woke up,ventilatory support was continued.When the influence of theanesthetic agent disappeared,the patients were extubatedwhen the following extubation criteria were achieved:ab-sence of hypoxia(Pa O2Ͼ80mm Hg,Pa CO2Ͻ50mm Hg under40%inspired oxygen inhalation);stable hemodynamicsand consciousness;respiratory rateϽ25breaths/min,underspontaneous breathing;spontaneous tidal volumeϾ12mL/kg;and no obstruction of the airway and no repeatedatelectasis.Internal Pneumatic StabilizationNineteen patients in the I group continued the samerespiratory management(positive end-expiratory pressureventilation with spontaneous intermittent mandatory ventila-tion mode with pressure support ventilation)until theyreached the extubation criteria(same as above).Also,mostrespiratory management was identical in the two groups;expect the surgical procedure.Follow-Up ProgramAs follow-up in both groups,patients were transferred toa general ward when they achieved a stable homodynamicand respiratory condition without any artificial organ support,according to our definition.After discharge from the hospital,patients’respiratory function and subjective complaints werefollowed in the outpatient clinic until12months after injury. Measured ParametersThe following parameters were compared between thetwo groups:severity of lung contusion,incidence of pneu-monia,incidence of tracheotomy,length of mechanical ven-tilation,length of TICU stay,total medical expense,long-term respiratory function by spirometry,subjective dyspnea,and questionnaire.Severity of Pulmonary ContusionSeverity of pulmonary contusion was evaluated by ascoring system,5in which infiltrate shadows involving lessTable1Group Demographics of Internal Pneumatic Stabilization Group and Surgical Stabilization Group*GroupSex(M/F)Age(yr)ISSNo.ofFracturesSite of Flail Segment PaO2/F IO2atAdmissionTubeThoracotomyAL PL Stove-In ChestSurgical(nϭ18)12/643Ϯ1233Ϯ118.2Ϯ3.31143223Ϯ6818/18 Internal(nϭ19)14/546Ϯ930Ϯ88.2Ϯ2.61433256Ϯ3419/19 p Value NS NS NS NS NS NS NS NS NS AL,anterolateral;PL,posterolateral;NS,not statistically significant.*The group demographics were all similar in the two groups;pϽ0.05between the two groups.MeanϮSD.than one lobe on the admission chest radiograph were con-sidered mild (1point),more than one lobe and/or both but less than one lung as moderate (2points),and large infiltrate shadows involving the bilateral lungs as severe (3points).Definition of PneumoniaPneumonia was diagnosed by the following criteria:pu-rulent expectorate or end-tracheal aspirate from which known pathogens were grown (Ͼ105/mL),continued high fever (Ͼ38°C),leukocytosis (Ͼ10,000/␮L),and recent infiltrate shadows on chest radiograph.Medical CostFor evaluation of total medical expense,all the medical costs during TICU stay were obtained on the basis of public health insurance.This health insurance issued by the Japa-nese Governmental Foundation covers the admission fee for the hospital examinations,food and drugs,and all doctors ’fees.Total medical cost was converted from yen to U.S.dollars,assuming $1.00for ¥110.SpirometrySpirometric measurement of percent forced vital capac-ity (%FVC)and forced expiratory volume at 1second were measured using a spirometer (Minato auto Spiro system 9,Minato Medical Science Co.,Osaka,Japan)in the TICU,general ward,and outpatient clinic at 1,2,3,and 4weeks;and at 2,3,6,and 12months after injury.QuestionnaireAlso,a questionnaire detailing chest pain,chest tight-ness,employment history,and subjective dyspnea was ad-ministered at 6and 12months after injury.Subjective dys-pnea was evaluated by the British Medical Research Gradation of Dyspnea.7Statistical AnalysisGroup values are expressed as mean ϮSD.Two-way analysis of variance with repeated measures was used to analyze the interactions between groups and time factors.Tukey ’s test was used to compare values between the groups at individual times.Student ’s t test and ␹2test (Yatescorrec-Fig.1.Judet struts of different sizes andlengths.Fig.2.Details of surgical procedure.Table 2Incidence of Pneumonia on Days 7and 21,Length of Mechanical Ventilation,Total Length of TICU Stay,and Incidence of Tracheostomy on Days 7and 21in Internal Pneumatic Stabilization and Surgical Stabilization GroupsPostoperative DayIncidence of Pneumonia Total Length (Days after Surgery)Tracheostomy D7(%)D21(%)Length of MechanicalVentilationLength of TICU StayD7D21Surgical 8.2Ϯ4.11/184/1810.8Ϯ3.416.5Ϯ7.40/183/18(n ϭ18)(5)(22)(2.5Ϯ3.2)(9.2Ϯ5.2)Internal NA3/1917/1918.3Ϯ7.426.8Ϯ13.25/1915/19(n ϭ19)(16)(90)p ValueNS Ͻ0.05Ͻ0.05Ͻ0.05NSϽ0.05D7,7days after injury;D21,21days after injury;NA,not available;NS,not significant.Mean ϮSD.Management of Severe Flail Chest Patientstion)were used to compare nonrepeated variables.Values of pϽ0.05were accepted as significant.RESULTSGroup DemographicsGroup demographics in both groups are shown in Table 2.Eighteen patients were treated by end-tracheal intubation and mechanical ventilation followed by surgical stabilization, and19patients were treated by internal pneumatic stabiliza-tion.Surgical stabilization was performed at8.2Ϯ4.1days. Incidence of Lung ContusionLung contusions were classified as mild,moderate,or severe,and were present in36%,27%,and36%,respec-tively,in the S group and in31%,38%,and31%,respec-tively,in the I group.Mean value of lung contusion score was identical in the two groups(I group,2.0Ϯ0.9;S group,2.0Ϯ0.8).Incidence of PneumoniaThe incidence of pneumonia in the S group and the I group was identical at7days after injury(I group,5%;Sgroup,16%).However,the incidence of pneumonia in the S group was significantly lower than that in the I group at21 days after injury(I group,90%;S group,22%;pϽ0.05). Length of Mechanical VentilationThe length of mechanical ventilation in the S group was significantly shorter than that in the I group(I group,18.3Ϯ7.4days;S group,10.8Ϯ3.4days;pϽ0.05)(Table1).In the S group,mechanical ventilation was performed for only 2.5Ϯ3.2days after surgery.Length of TICU StayAlso,the length of TICU stay in the S group was signifi-cantly shorter than that in the I group(I group,26.8Ϯ13.2days; S group,16.5Ϯ7.4days;pϽ0.05).Especially in the S group, patients stayed9.2Ϯ5.2days in the TICU after surgery. Tube ThoracotomyTube thoracotomy was performed in all patients because of an associated pneumothorax or hemothorax. TracheostomyEighteen patients eventually required tracheostomy:0 patients in the S group and5patients in the I group at7days after injury,and3patients in the S group and15patients in the I group at21days after injury(pϽ0.05).Total Medical ExpenseTotal medical expense in the S group($13,455Ϯ$5,840)was significantly lower than that in the I group ($23,423Ϯ$1,380)(pϽ0.05).SpirometryTube thoracotomy was performed in all the patientsbecause of an associated pneumothorax or hemothorax.%FVC in both groups had deteriorated equally(40–50%)at1to2weeks after injury.%FVC gradually increased through-out the study period in both groups.However,patients in theS group had statistically significantly better recovery thanpatients in the I group at3months and thereafter(Fig.3).There was no significant difference in forced expiratory vol-ume at1second between the groups.QuestionnaireA questionnaire including chest pain,chest tightness,em-ployment history,and subjective dyspnea was administered.Thirty-seven patients completed the questionnaire.Answers tothe questionnaire12months after injury showed significantly(p Ͻ0.05)more frequent complaints of persistent chest tightness, thoracic cage pain,and dyspnea on effort in the I group(Fig.4).Subjective dyspnea in37patients is described in Table3.Sub-jective dyspnea was more frequent in the I group.Significantlymore patients in the S group had returned to their previousfull-time employment at6months after injury(I group,1of19;S group,11of18;pϽ0.05)(Fig.5).At12months after injury,seven patients in the I group and two in the S group had notreturned to their previous jobs.The remaining28patients re-turned to their previous jobs.The ratio of patients who returnedto their previous full-time employment was identical in the twogroups(I group,12of19;S group,16of18;pϭNS),but only3patients in the I group returned to a high-activity job,whereas13patients in the S group returned to a high-activity job(pϽ0.05).Fig.3.FVC(meanϮSD)in the internal pneumatic stabilization group and the surgical stabilization group.%FVC had deterio-rated equally(40–50%)at1to2weeks after injury.Although %FVC gradually increased throughout the study period in both groups,patients in the surgical stabilization group had signifi-cantly better improvement than patients in the internal pneumatic stabilization group at3weeks and thereafter.*pϽ0.05between the two groups.The Journal of TRAUMA௡Injury,Infection,and Critical CareDISCUSSIONThe results of this study indicate that early surgical stabilization may have clinical advantages in terms of lower morbidity and lower medical cost compared with internal fixation.Also,fewer subjective complaints were found with respect to early improvement of respiratory function.Many more patients returned to full-time employment as a result of surgical stabilization.Flail chest,not by means of fracture of multiple rib,and also complex traumatic acute respiratory failure syndrome,results in severe rib fracture pain,lung contusion,and lung atelectasis.For the treatment of flail chest patients,surgical stabilization of the chest wall was introduced in the 1960s;however,over the past two decades,volume-limited ventila-tion with internal pneumatic stabilization has markedly re-duced mortality.This treatment allows less invasive manage-ment than surgical fixation and has become a popular treatment for flail chest.8–11However,ventilator-associated pneumonia often occurs in the injured lung because of pro-longed mechanical ventilation.14The duration of intubation may be strongly related to the incidence of pneumonia.12Our results suggested that the low incidence of pneumonia in patients with surgical stabilization results in a shorter dura-tion of intubation and fewer complications of pneumonia.Consequently,this may lead to shorter TICU stay and lower medical cost in surgical fixation patients.In our series,sur-gical fixation was performed along with modern respiratory management,which may be required for acute respiratory failure resulting from lung contusion,atelectasis,low vital capacity caused by rib cage deformity,and pain.In addition,it must be noted that end-tracheal intubation and mechanical ventilation are not always successful treat-ment for severe flail chest patients,and preventing chest cage deformity 13may result in sufficient recovery of respiratory function.12Only one third of patients could return to full-time employment after internal fixation as described by Lander-casper et al.2,3Newly developed surgical fixation tools have been de-signed for less invasive surgery and have also been reevalu-ated in several European countries.4,5According to these results,surgical fixation shortened the duration of intubation and restored chest wall deformity early.However,clinical comparisons between surgical and internal pneumatic stabi-lization in patients with identical severity of flail chest have been poorly documented.This study could provide an answer to this question.Among various methods of surgical rib fixation,4,5techniques practicable for patients with flail chest need to be quickly applied,convenient,and less invasive.The reason why we chose to use the Judet strut fixationtechniqueFig.4.Answers to questionnaire at 6and 12months after injury in the internal pneumatic stabilization group and the surgical stabili-zation group.Persistent chest tightness,thoracic cage pain,and dyspnea on effort were significantly more frequent complaints in patients in the internal pneumatic stabilization group than in the surgical stabilization group.*p Ͻ0.05between the two groups at admission.Table 3Subjective Dyspnea at 12Months after Injury*GroupNone (%)Slight (%)Moderate (%)Severe (%)Very Severe (%)Surgical group (n ϭ18)10(56)4(22)3(17)1(6)0(0)Internal group (n ϭ19)5(26)8(42)6(31)3(16)1(5)*Subjective dyspnea was more frequent in the Igroup.Fig. 5.Percent recovery of full-time employment at 6and 12months after injury in the internal pneumatic stabilization and surgical stabilization groups.In the S group,significantly more patients had returned to their previous full-time employment at 6months after injury (I group,1of 19;S group,11of 18).At 12months after injury,9of 19had returned to low-activity jobs in the I group and 3of 18in the S group.However,3of 19in the I group and 13of 18in the S group had returned to high-activity employ-ment (p Ͻ0.01).Management of Severe Flail Chest Patientsin this study was that it could be applied in a short time,and it is simple,convenient,and less invasive.Also,this plate could be applied without any pleural injury in our limited experience and preserved intercostal muscle function.14The results of this study indicated that application of Judet struts allows not only restoration of rib cage deformity but also preservation of intercostal muscle function.In addition,re-ducing chest pain and chest tightness may be related to improvement of respiratory function.This combination of surgical intervention and trauma intensive care may explain the reduced lower morbidity in our patients.Thus,it should be kept in mind that not only surgical intervention but also intensive care is critical in obtaining a good result in the treatment of severe flail chest.In conclusion,Judet strut surgical stabilization may be preferably applied for severe flail chest patients in whom prolonged ventilatory assistance is expected. ACKNOWLEDGMENTSWe express special thanks to Dr.Nakae for his skillful teaching on early stages of this study.We also thank Dr.Maemura for his help. REFERENCES1.Campbell DB.Trauma to the chest wall,lung,and major airways.Semin Thorac Cardiovasc Surg.1992;4:234–240.2.Beal SL,Oreskovich MR.Long-term disability associated with flailchest injury.Am J Surg.1985;150:324–326.ndercasper J,Cogbill-TH,Lindesmith LA.Long-term disabilityafter flail chest injury.J Trauma.1984;24:410–414.4.Glinz W.Problems caused by the unstable thoracic wall and bycardiac injury due to blunt injury.Injury.1986;17:322–326.5.Galan G,Penalver JC,Paris F,et al.Blunt chest injuries in1696patients.Eur J Cardiothorac Surg.1992;6:284–287.6.Freedland M,Wilson RF,Bender JS,Levison MA.The managementof flail chest injury:factors affecting outcome.J Trauma.1990;30:1460–1468.7.Snider GL,Kory RC,Lyons H.Grading of pulmonary functionimpairment by means of pulmonary function test.Chest.1967;52:270–271.8.Avery AE,Morch ET,Benson DW.Critically crushed chest:a newmethod of treatment with continuous mechanical hyperventilation to produce alkalotic apnea and internal pneumatic stabilization.J Thorac Surg.1956;32:291–308.9.Richardson JD,Adams L,Flint LM.Elective management of flailchest and pulmonary contusion.Ann Surg.1982;196:481–487.ler HA,Taylor GA,Harrison AW,et al.Management of flailchest.Can Med Assoc J.1983;129:1104–1107.ndreneau RJ,Hinson JM Jr,Hazelrigg SR,et al.Conservativemanagement of flail chest.J Indian Med Assoc.1990;88:186–187. 12.Fleming WH,Bowen JC.Early complications of long termrespiratory support.J Thorac Cardiovasc Surg.1972;64:729–738.13.Graeber GM,Cohen DJ,Patrick DH,et al.Rib fracture healing inexperimental flail chest.J Trauma.1985;25:903–908.14.Chihara K,Hitomi S,Kobayashi J,Kawarasaki S.Preservation andimprovement of chest wall function.Nippon Geka Gakkai Zasshi.1991;92:1363–1366.DISCUSSIONDr.Robert F.Wilson(Detroit,Michigan):The series presented by Dr.Tanaka and his associates bothers me quite a bit.It leaves out many patients with associated injuries,who are the ones most apt to need ventilator support.I wonder if the authors could comment on any data they might have on the patients they excluded.The61patients presented here were randomized into two groups prospectively over a10-year period,but only22 actually had a surgical fixation.The disparity in the numbers in the two groups should be explained,if possible.The scale for quantifying the amount of pulmonary contu-sion was also not clear.For example,a relatively mild bilateral infiltrates would be considered severe by their criteria.The Pa O2/F IO2ratio was particularly bothersome because the slides indicate a mean Pa O2/F IO2ratio of270for the ventilator group, whereas the abstract indicates a Pa O2/F IO2ratio of205for the ventilator group.Thus,the ventilator group,according to the abstract,had almost half of its patients with a Pa O2/F IO2ratio below200,which indicates a rather severe degree of pulmonary dysfunction at admission.Dr.Tanaka has indicated that they do not fixate all of the fractured ribs when they use the Judet plates, and perhaps he could provide more detail on the steps used during the surgical procedure.Although the results with ventilator therapy in this article seem suboptimal according to current standards,the results with surgical fixation seem remarkably good.The fact that almost no pneumonia was present by the time of the fixation, which was on day6Ϯ3.3,was surprising.I’m also not sure how all of their cases were fixated within1week if the average time of fixation was6.0Ϯ3.3days.If the average duration for ventilatory support was only7.8Ϯ1.3days in the fixated group,does this mean that the fixated patients were only on a ventilator for an average of1.8days after the ribs had surgical fixation?In the long-term follow-up,I can understand how the patients with surgical fixation would have a better forced vital capacity,but I have difficulty explaining a difference in peak expiratory flow rate,particularly if the forced expiratory volume at1second results were almost identical.Thank you for allowing me to discuss this interesting article.The Journal of TRAUMA௡Injury,Infection,and Critical Care。