From the Guidelines
The best next step in managing a trauma patient with COPD, respiratory distress, and a flail chest is to secure the airway and provide adequate oxygenation through endotracheal intubation and mechanical ventilation. This patient requires immediate airway management due to the combination of underlying COPD, which already compromises respiratory function, and the flail chest, which causes paradoxical chest wall movement and impairs effective breathing mechanics. The patient's current oxygen saturation of 92% on a nonrebreather mask, as well as the presence of respiratory distress and flail chest, necessitate careful consideration of oxygen therapy to avoid excessive oxygen use, which can lead to respiratory acidosis in patients with COPD, as highlighted in the BTS guideline for oxygen use in adults in healthcare and emergency settings 1.
After intubation, ventilator settings should be adjusted to accommodate the patient's COPD, typically using lower tidal volumes (6-8 mL/kg ideal body weight), longer expiratory times, and permissive hypercapnia if necessary. Pain control is essential and can be achieved with intravenous opioids such as fentanyl (25-50 mcg IV every 1-2 hours as needed) or morphine (2-4 mg IV every 2-4 hours as needed), possibly supplemented with regional anesthesia techniques like intercostal nerve blocks or epidural analgesia for more effective pain relief. Adequate pain management allows for better chest expansion and coughing, which helps prevent atelectasis and pneumonia. Bronchodilators such as albuterol (2.5 mg via nebulizer every 4-6 hours) should be continued to manage the underlying COPD.
The recent Canadian Thoracic Society guideline on pharmacotherapy in patients with stable COPD 1 emphasizes the importance of personalized management plans to improve symptoms, health status, and prevent acute exacerbations, but it does not directly address the acute management of trauma patients with COPD and flail chest. However, the principles of avoiding excessive oxygen use and managing the patient's underlying pulmonary disease are consistent with the recommendations for stable COPD management. Chest stabilization may be necessary in severe cases, though this is typically considered after initial resuscitation and stabilization. This approach prioritizes addressing the immediate life-threatening respiratory compromise while accounting for the patient's underlying pulmonary disease.
Key considerations in the management of this patient include:
- Avoiding excessive oxygen use to prevent respiratory acidosis
- Adjusting ventilator settings to accommodate the patient's COPD
- Providing adequate pain control to improve chest expansion and prevent complications
- Continuing bronchodilators to manage the underlying COPD
- Considering chest stabilization in severe cases after initial resuscitation and stabilization.
From the Research
Assessment and Management of Trauma Patient
The patient presents with a history of COPD, hypertension, and respiratory distress after a motor vehicle collision, and is found to have a flail chest. The best next step in management would involve:
- Securing the airway, as the patient is already on a nonrebreather mask but may require further intervention due to the severity of the injury and the presence of COPD 2, 3
- Considering the patient's COPD history, noninvasive positive pressure ventilation (NIPPV) may be beneficial in reducing the need for invasive mechanical ventilation and aiding in weaning 4
- Careful attention to ventilatory settings to avoid dynamic hyperinflation and acid-base disturbances, should invasive mechanical ventilation be required 4, 5
Ventilatory Strategy
When deciding on a ventilatory strategy, it is essential to consider the patient's lung-protective needs, particularly in the context of acute respiratory distress syndrome (ARDS) or severe lung injury. Ultra-lung-protective ventilation strategies may be beneficial in certain cases, but the risks and benefits must be carefully weighed, especially when considering extracorporeal support 6.
Airway Management
Airway management is critical in emergency situations, and endotracheal intubation is often the gold standard. However, alternative procedures and a well-planned algorithm are essential in case of difficulties or failures 2. The patient's airway should be secured promptly to prevent further complications, and the chosen method should be guided by the patient's specific needs and the clinician's expertise 3.