CPAP for Flail Chest
By Bryan E. Bledsoe, DO, FACEP

May 2005, MERGINET—My good friend, Keith Wesley, MD, really sold me on the role of continuous positive airway pressure (CPAP) in EMS. I have seen many patients avoid intubation through use of CPAP. I think it should be an EMT skill. A recent Turkish study compared CPAP to intermittent positive pressure ventilation (IPPV) in the management of flail chest. IPPV has been the standard or care.

The researchers studied 52 mechanically ventilated patients with flail chest. These were randomly divided into two treatment groups: one group (n=27) was intubated (ET) and ventilated with IPPV (standard treatment) and the other (n=25) received CPAP via a face mask. The CPAP group also received patient controlled analgesia (PCA).

They found that nosocomial (hospital-acquired) infections were more common in the intubated group (48 percent) compared to the CPAP group (18 percent). The mean pO2 was significantly higher for the first 2 days in the ET group. No differences in ICU stay were noted. Overall, 80 percent of the CPAP group survived, while only 67 percent of the ET group survived.

They concluded that CPAP in the setting of flail chest led to lower mortality and a lower nosocomial infection rate, but had a similar oxygenation and length of ICU stay compared to intubation and IPPV. They suggested that CPAP should be a first-line treatment for flail chest.

To me, this seems intuitive. CPAP is effective and proven in CHF. Increasing intra-thoracic pressures improved CHF and will also help to minimize the detrimental effect of a flail segment. I, too, think CPAP should be first-line therapy for flail chest in the prehospital setting.

Reference
Gunduz M, Unlugenic H,Ozalevi M, Inanoglu K, Akman H. “A comparative study of continuous positive airway pressure (CPAP) and intermittent positive pressure ventilation (IPPV) in patients with flail chest.” Emergency Medicine Journal. 2005;22:325-329.
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