From the Guidelines
The treatment for flail chest should prioritize surgical stabilization of rib fractures (SSRF) within 48-72 hours from the traumatic injury, as it has been shown to reduce morbidity, mortality, and improve quality of life 1. The management of flail chest involves a multidisciplinary approach, including pain management, respiratory support, and surgical intervention. Initially, adequate pain control is essential using multimodal analgesia, including opioids and NSAIDs, and possibly regional anesthesia techniques such as epidural analgesia or intercostal nerve blocks. Respiratory support may include supplemental oxygen, incentive spirometry, chest physiotherapy, and in severe cases, mechanical ventilation.
- Key considerations in the treatment of flail chest include:
- Early surgical stabilization of rib fractures (SSRF) to restore chest wall integrity and improve pulmonary mechanics
- Addressing associated injuries, such as pneumothorax or hemothorax, which may require chest tube placement
- Preventing complications, such as pneumonia, through early mobilization, pulmonary hygiene, and appropriate antibiotic therapy when indicated
- Optimizing timing of SSRF, with evidence suggesting that early surgery (within 48-72 hours) is associated with better outcomes, including reduced duration of mechanical ventilation, shorter ICU and hospital stay, and decreased risk of tracheostomies and pneumonia 1.
- The benefits of SSRF in flail chest patients have been consistently demonstrated in recent studies, including reduced morbidity, mortality, and improved quality of life 1.
- It is essential to note that the optimal timing of SSRF remains debatable, but the current evidence supports early surgery (within 48-72 hours) as the preferred approach 1.
From the Research
Treatment Options for Flail Chest
- The treatment for flail chest typically involves stabilizing the chest wall and providing supportive care for respiratory and circulatory disturbances 2.
- Skeletal traction and intermittent positive pressure respiration are common methods used to stabilize the chest wall and manage respiratory issues 2.
- Internal pneumatic stabilization, which involves continuous positive pressure ventilation and positive end-expiratory pressure, can also be effective in relieving flail chest 3.
- In some cases, surgical stabilization may be necessary to repair the chest wall and improve respiratory function 4, 5.
Indications for Surgical Stabilization
- Surgical stabilization is typically indicated for patients with severe chest wall instability, persistent pain, and progressive decline in pulmonary function 4.
- It is also recommended for patients who are unable to be weaned from the ventilator due to the mechanics of flail chest 4.
- Open fixation is appropriate for patients who require thoracotomy for other concomitant injuries 4.
- However, surgical stabilization is not recommended for patients with severe pulmonary contusion, as the underlying lung injury and respiratory failure preclude early ventilator weaning 4.
Other Treatment Approaches
- Pressure control ventilation and minitracheotomy can be used to treat severe flail chest trauma, especially in patients who fail extubation and noninvasive mask treatment 6.
- Pneumatic stabilization can be combined with simple surgical stabilization to shorten the mechanical ventilation period and improve outcomes 3.
- Adequate analgesia and aggressive pulmonary toilet, including facemask oxygen, CPAP, and chest physiotherapy, are also important components of flail chest treatment 4.