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The Egyptian Society of Chest Diseases and Tuberculosis
ORIGINAL ARTICLE
a
Department of Chest Diseases, Faculty of Medicine, Zagazig University, Egypt
b
Department of Anesthiology, Faculty of Medicine, Zagazig University, Egypt
KEYWORDS Abstract Introduction: The use of positive pressure ventilation has decreased the overall morbid-
Chest trauma; ity and mortality associated with blunt chest trauma, but invasive mechanical ventilation (IMV) is
Noninvasive positive associated with many complications. The role of noninvasive ventilation (NIV) for the management
pressure ventilation; of patients with blunt chest trauma has not been well established. The aim of this study was to com-
CPAP; pare the efciency of CPAP versus BiPAP in avoiding IMV.
BiPAP Patients and method: This study was carried out in the period between April 2011 and April
2103, on 40 patients admitted to ICU with blunt chest trauma with acute respiratory distress that
had deteriorated despite aggressive medical management. Patients were randomly assigned to
receive either continuous positive airway pressure ventilation (CPAP) (group 1) n = 15, Bi-level
positive airway pressure ventilation (BiPAP) (group 2) n = 15 or IMV (group 3) n = 10.
Results: Improvement in gas exchange and relieve of respiratory distress was noticed in the three
studied groups after the start of assisted ventilation. Four patients in group 1 (26.7%) and three
patients in group 2 (20%) required endotracheal intubation. There was no signicant difference
in the length of stay in ICU between the three groups (10 5 days in group 1, 11 4 in group
2 and 10 6 in group 3. Pneumonia developed in one patient in group 1 (6.6%) and in 2 patients
in group 2 (13.3%) and in 3 patients in group 3 (30.3%). Pneumothorax developed in one patient in
group 1 (6.6%) and in no patients in group 2 (0%) and in one patient in group 3 (10%). As regards
mortality no mortalities were observed in groups 1 and 2 but one patient in group 3 (10%) died.
Conclusion: Both CPAP and BiPAP are safe and efcient techniques in managing respiratory
failure and reducing the incidence of intubation in patients with blunt chest trauma.
2014 The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier
B.V. All rights reserved.
Introduction aim of this study was to compare NIV (CPAP and BiPAP)
with invasive mechanical ventilation (IMV) in management
Chest trauma is one important factor for total morbidity and of patients with blunt chest trauma and to compare efciency
mortality in traumatized emergency patients. The lethality of of CPAP versus BiPAP in avoiding intubation and IMV.
isolated chest traumas is about 58%. Up to 25% of all deaths
caused by trauma are related to chest injuries [1], and mortality Patients and method
dramatically increases as a function of increased chest trauma
force [2]. This clinical study was carried out on 40 patients admitted to
Chest injuries often occur in combination with other severe intensive care unit with blunt chest trauma (either isolated
injuries, such as extremity, head, brain and abdominal injuries chest trauma or as a part of polytrauma) in the period
[1]. The impact of a blunt trauma is typically conducted to between April 2011 and April 2013. The inclusion criteria
many different intrathoracic structures; hence nearly all organs were acute respiratory distress that had deteriorated despite
of the thoracic cavity can be involved in chest trauma. The aggressive medical management, including severe dyspnea at
most common types of damage that result from chest trauma rest, a respiratory rate greater than 35 breaths per minute;
include injuries to the ribs, lung contusion, hematoma of the and the partial pressure of arterial oxygen (PaO2) less
chest wall, pleural effusion, pneumothorax and haemothorax 60 mmHg while the patient was breathing oxygen through a
[3]. Venturi mask with FiO2 up to 60%; and active contraction
of the accessory muscles of respiration or paradoxical
Pathophysiological aspects abdominal motion.
Patients with any of the following were excluded: tracheal
Respiratory impairment: damage to the osseous structure of intubation indicated for any other reason, contraindication
the thorax by rib and sternum fractures destabilizes the rib for non-invasive ventilation (active gastro-intestinal hemor-
cage and impairs spontaneous breathing mechanics substan- rhage, low level of consciousness, multiorgan failure, airway
tially; this condition is amplied by pain, which further reduces control problems, hemodynamic instability), traumatic brain
breathing function. Direct traumatic damage to the lung leads injury, facial trauma, skull base fracture, orbit base fracture,
to an extravasation of protein-rich uid with an altered surfac- cervical injury with specic treatment contraindicating a facial
tant composition [4]. Disturbance of diffusion, the reduction of mask [10].
compliance and functional residual capacity, ventilationper- All patients were subjected to
fusion mismatch and intrapulmonary shunt develop with sub-
sequent reduced oxygenation and elevated PaCO2 levels [5,6]. - Complete medical history.
After severe chest trauma, intrapulmonary shunting can also - Clinical examination.
be caused by a disruption of pulmonary capillaries and extrav- - Laboratory investigations (renal and hepatic function tests,
asation into the alveolar spaces. Aspiration of blood and/or serum electrolytes, blood sugar ,complete blood count,
gastric contents, fat embolism to the lung due to long bone arterial blood gas analysis, and microbiological investiga-
fractures and systemic inammatory response syndrome may tions when pneumonia was suspected).
additionally exacerbate respiratory decits and may lead to - Radiological investigations (plain X ray and computed
acute respiratory distress syndrome (ARDS) [7]. tomography on the chest for all patients and for other body
Cardiovascular impairment: a reduction in normal parts as indicated).
intraventricular lling by tension pneumothorax, pericardial - The Injury Severity Scale (ISS): was evaluated as the mea-
tamponade or massive hemorrhage may result in a sure of anatomic injury for six body regions: (1) the head-
life-threatening reduction in cardiac output. Moreover, neck, (2) the face, (3) the thorax, (4) the abdomen-pelvis,
intracardiac structural damage or heart contusions with (5) the extremities and (6) the external. The ISS was calcu-
concomitant arrhythmias are additional contributors to lated as the sum of the squares of the highest abbreviated
reduced cardiac output [6]. injury scale grade in each of the three most severely injured
Management of patients with blunt chest trauma focuses on body regions [14].
interventions such as the stabilization of fractures, pulmonary - Simplied acute physiologic score (SAPS) was calculated,
toilet, effective physiotherapy, and early and adequate pain this score takes into account 14 variables (age, heart rate,
control [8,9]. These patients are at high risk for developing systolic blood pressure, body temperature, respiratory rate
respiratory failure [10] with reports of up to 20% of patients or need for ventilatory support, urinary output, white-cell
with blunt chest trauma developing acute lung injury (ALI) count, hematocrit, Glasgow coma score, and serum glu-
or acute respiratory distress syndrome (ARDS) [8]. Intubation cose, potassium, sodium, bicarbonate, and urea nitrogen
rates range from 23% to 75% and depend on the severity of concentrations). A range of 04 is assigned for each vari-
the trauma, the degree of the underlying lung disease, and able (range of possible scores, 056). Higher scores indicate
the intensity of initial management and monitoring [8,11]. a higher risk of death [15].
The use of positive pressure ventilation has decreased the over-
all morbidity and mortality associated with blunt chest Patients were randomized to receive CPAP (group 1)
trauma, but endotracheal intubation and mechanical ventila- n = 15 (11 males, 4 females with mean age 31.8 13.8),
tion are associated with a high risk of nosocomial pneumonia BiPAP (group 2) n = 15 (10 males, 5 females with mean age
and prolonged mechanical ventilation [12].The role of nonin- 31.8 13.1), and patients who met inclusion criteria but did
vasive ventilation (NIV) for the management of patients with not show cooperation received IMV (group 3) n = 10 (7 males,
blunt chest trauma has not been well established [13]. The 3 females with mean age 30.6 12.7).
Continuous versus Bi-level positive airway pressure ventilation in blunt chest trauma 205
40
35
30
25
group1
20
group2
group3 15
10
0
one hour aer base line
Figure 1 Ratio of partial pressure of arterial oxygen to the Figure 4 Respiratory rate at the base line and after 1 h of
fraction of inspired oxygen (PaO2:FiO2) at the base line and after mechanical ventilation in the studied patient groups.
1 h of mechanical ventilation in the studied patient groups.
Table 2 Change in mean PaO2:FiO2, RR, HR before and after MV in each group.
Before After Paired t P
Group 1 Mean PaO2:FiO2 216.9 32.9 299 50.2 5.9 0.00
RR 34.2 2.3 23.4 1.8 17.2 0.00
HR 119 2.4 104.6 4.7 14.4 0.00
Group 2 Mean PaO2:FiO2 217.1 38.2 292 58.9 4.5 0.00
RR 34.3 2.3 23.3 2.5 21.7 0.00
HR 118.8 2.4 104 4.3 20.2 0.00
Group 3 Mean PaO2:FiO2 221.7 33.2 322 23.4 11.7 0.00
RR 34.2 2.1 24.4 2.4 25.2 0.00
HR 118.1 2 102.1 3.1 21 0.00
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447.
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