OPERATIVE CHEST-WALL STABILIZATION IN FLAIL CHEST - OUTCOMES OF PATIENTS WITH OR WITHOUT PULMONARY CONTUSION

Background: The aim of operative chest wall stabilization in patients with flail chest and respiratory insufficiency is to reduce ventilator time and avoid ventilator associated complications. The purpose of th is retrospective study was to analyze the indications and outcomes of operative chest wall stabilization in defined groups of patients susta ining flail chest with and without pulmonary contusion. Methods: The h ospital records of 405 patients with multiple trauma (Injury Severity Score > 17) between 1988 and 1994 were reviewed. Forty-two patients su stained flail chest. Twenty of these underwent operative chest wall st abilization for the following indications: 1) flail chest with indicat ion for thoracotomy due to intrathoracic injury (n = 6); 2) flail ches t without pulmonary contusion (n = 9); 3) paradoxical movement of a ch est wall segment in the weaning period from the respirator (n = 3); an d 4) severe deformity of the chest wall (n = 2). For the purpose of an alysis the patients were separated into groups: group 1: operative che st wall stabilization in flail chest without pulmonary contusion (n = 10); group 2: operative chest wall stabilization in flail chest with p ulmonary contusion (n = 10); group 3: flail chest without pulmonary co ntusion and without chest wall stabilization (n 18); group 4: flail ch est with pulmonary contusion and without chest wall stabilization (n 4 ). Data were coded for time of operation, duration of ventilatory supp ort, and complications. Results: There were no significant differences in age, severity of injury and extent of injury between groups 1, 2, and 3 (p < 0.42). Group 4 was excluded for statistical analysis becaus e of the small number of patients. Patients in group I required a shor ter ventilatory support time compared to patients in group 3 (6.5 +/- 7.0 versus 26.7 +/- 29.0 days) and group 2 (p < 0.02). In group 2 (ven tilator time 30.8 +/- 33.7 days) early extubation was only possible in patients being operated on for chest wall instability during weaning from the ventilator. One patient in group 1, three patients in group 2 and five patients in group 3 developed pneumonia with further disturb ance of gas exchange. All patients in group 1 survived; deaths in grou p 2 were attributed to massive hemorrhage in two and septic multiorgan failure in one patient. Four patients in group 3 died of head injury, one of acute respiratory distress syndrome, one of severe hemorrhage, and one of multiple organ failure. Conclusions: In patients with flai l chest and respiratory insufficiency without pulmonary contusion, ope rative chest wall stabilization permits early extubation. Patients wit h pulmonary contusion do not benefit from chest wall stabilization. Se condary operative chest wall stabilization in these patients is indica ted when progressive collapse of the chest wall is evident during wean ing from the ventilator. (J Am Cell Surg 1998;187: 130-138. (C) 1998 b y the American College of Surgeons)