Non invasive Ventilation with Flail Chest

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Tim,

Do you know of any data published regarding NIPPV and flail chest?
Impressive anecdotal experience. Thanks for sharing.

Keith
On Tue, Jul 7, 2009 at 2:46 AM, Dr Timothy Hardcastle <
dr.tchardcastle at absamail.co.za> wrote:

> Hi Christine
>
> No "protocol" as such, just extensive experience (>300 major blunt chest
> trauma in the last 5 years) and therefore can give you some guidance that
> may assist you. (Maybe will help you to derive your own protocol). The
> reason I don't advocate a "protocol" here is that each patient is very
> individual in how they cooperate / cope with the support offered, so a
> general apporach is more relevant.
>
> Firstly: Flail chest is mainly a cause of pain, while underlying contusion
> is the cause of shunt and hypoxia, so analgesia is the first step; either
> epidural, or intercostal blocks,or combination opioid / non-opioid IV in
> suitable doses - PCA useful if patient able to cooperate. Aim for Ramsay
> 2-3 sedation level. If intercostal drain in-situ could even use
> intra-pleural catheter with bupivacaine.
>
> Secondly assess the extent of lung contusion - the worse the contusion the
> less likely non-invasive ventilation will work; rather intubate early and
> wean to extubate around day 5, then continue with non-invasive.
>
> If primarily rib fractures with limited severity of contusion, then early
> non-invasive ventilatory support is most appropriate: I start with a
> full-face mask, with portal for a naso-gastric tube to decompress the
> stomach - they all swallow air; use between 8 - 10 mmHg CPAP with a
> combination of additional pressure support adjusted to achieve internal
> splinting (minimal residual flail) or Vt of 6 - 8 ml/kg, whichever comes
> first. Aim for sats >92% or PaO2 of over 8kPa (68mmHg) as minimum. Titrate
> both CPAP and the PSV/ASB as required.
>
> Aim for a spontaneous resp rate less than 30 - more than this and they
> will tire - this group will require intubation and ventilation.
>
> Regular checks for developing VAP are essential. Screening wth ProCal is
> useful.
> Antibiotics are best avoided unless true infection is diagnosed.
> Prophylactic AB are not required for lung contusion.
>
> Hope this helps
> Tim
> Dr T C Hardcastle
> M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS (SA)
> Principal Specialist Trauma Surgeon /
> Honorary Lecturer University of KwaZulu-Natal Dept Surgery
> Deputy Director - IALCH Trauma Service
> Durban - South Africa
>
> > Has anyone have any protocols for managing traumatic chest injuries such
> > as a flail chest with non invasive ventilation?
> > --
> >
> > Chris Wilson
> >
> > Lecturer in Nursing
> >
> > Flinders University
> >
> > 82013354
> >
> > 0414253393
> >
> > --
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