Is incentive spirometry (IS) recommended for a patient with acute rib fractures and COVID-19 (Coronavirus disease 2019)?

Incentive Spirometry in Patients with Acute Rib Fractures and COVID-19

Incentive spirometry should NOT be recommended for patients with acute rib fractures and COVID-19 due to the risk of aerosol generation and potential for worsening respiratory mechanics.

Rationale for Avoiding Incentive Spirometry in COVID-19 with Rib Fractures

COVID-19 Considerations

• COVID-19 is an airborne disease that spreads through respiratory droplets and aerosols
• Procedures that encourage deep breathing and forceful exhalation may increase viral shedding and create aerosols
• The Difficult Airway Society and other anesthesia associations recommend minimizing aerosol-generating procedures in COVID-19 patients 1
• COVID-19 itself can cause respiratory muscle weakness and dysfunction, which may be exacerbated by painful breathing exercises 1

Rib Fracture Pain Management Priorities

• Pain from rib fractures leads to splinting, shallow breathing, poor cough, and secretion accumulation 2
• The primary focus should be on achieving adequate pain control rather than incentive spirometry
• Inadequate pain control with forced deep breathing can worsen respiratory mechanics and increase risk of respiratory failure 2

Alternative Approaches for Respiratory Care

Regional Anesthesia for Pain Control

• Regional anesthesia techniques should be the cornerstone of management:
  • Erector Spinae Plane Blocks (ESPB) - reduces opioid consumption with fewer side effects 2, 3
  • Serratus Anterior Plane Blocks (SAPB) - improves pain scores and respiratory function 2, 4
  • Thoracic Epidural or Paravertebral Blocks - for severe cases 2

Multimodal Analgesia

• Intravenous acetaminophen (1 gram every 6 hours) as first-line treatment 2
• NSAIDs for severe pain, considering potential adverse events 2
• Limited opioid use at lowest effective dose (hydromorphone preferred over morphine) 2
• Ketamine (0.3 mg/kg over 15 minutes) as an alternative to opioids 2

Safe Respiratory Support

• Gentle breathing exercises without forceful exhalation
• Application of ice packs to reduce pain 2
• Close monitoring for respiratory compromise, particularly in high-risk patients 2
• Early intervention for signs of respiratory deterioration

Risk Stratification and Monitoring

High-Risk Patients Requiring Closer Monitoring

• Age > 60 years
• Multiple rib fractures (≥3)
• Presence of flail chest
• Pulmonary contusions
• Pre-existing respiratory disease
• COVID-19 severity 1, 2

Follow-up Recommendations

• Follow-up within 2-3 weeks after hospital discharge 2
• Earlier follow-up for high-risk patients
• Evaluation of pain control, respiratory function, and functional status
• Assessment for signs of pneumonia or respiratory compromise

Conclusion

The combination of COVID-19 and rib fractures presents unique challenges for respiratory care. While incentive spirometry is traditionally used for rib fracture patients, its use in COVID-19 patients may increase viral transmission risk through aerosol generation. Instead, focus on optimal pain control through regional anesthesia techniques and multimodal analgesia, which will naturally improve respiratory mechanics without the risks associated with incentive spirometry.