Chest wall stabilization in ventilator-dependent traumatic flail chest patients: who benefits?

Objectives: Traumatic flail chest is a potentially life threatening injury, often associated with prolonged invasive mechanical ventilation and intensive care unit stay. This study evaluates the usefulness and cost-effectiveness of surgical rib stabilization in patients with flail chest resulting in ventilator dependent respiratory insufficiency.

Methods: A retrospective study on a consecutive series of patients with flail chest with the need for mechanical ventilation was performed. Effectiveness of rib fixation was evaluated in terms of predictors for prolonged ventilation, cost-effectiveness and outcome.

Results: A total of 61 patients underwent flail chest stabilization using a locked titanium plate fixation system between July 2010 and December 2015 at our institution. 62% ( n  = 38) of patients could be weaned from the ventilator within the first 72 h after surgery. Multiple linear regression analysis revealed that closed head injury, bilateral flail chest, number of stabilized ribs and severity of lung contusion were the main independent predictors for prolonged mechanical ventilation (Odds ratio (OR) 6.88; 3.25; 1.52 and 1.42) and tracheostomy (OR 9.17; 2.2; 1.76 and 0.84 ), respectively. Furthermore cost analysis showed that already a two day reduction in ICU stay could outweigh the cost of surgical rib fixation.

Conclusions: Operative rib fixation has the potential to reduce ventilator days and ICU stay and subsequently hospital costs in selected patients with severe traumatic flail chest requiring mechanical ventilation. Especially associated closed head injury can adversely affect mechanical ventilation time. Furthermore the subgroups of patients sustaining a fall from a height and those with flail chest after cardiopulmonary re-animation seem to profit only marginally from surgical rib fixation.