Chest
Volume 137, Issue 1, January 2010, Pages 74-80
Journal home page for Chest

Original Research
Critical Care Medicine
Noninvasive Ventilation Reduces Intubation in Chest Trauma-Related Hypoxemia: A Randomized Clinical Trial

https://doi.org/10.1378/chest.09-1114Get rights and content

Background

Guidelines for noninvasive mechanical ventilation (NIMV) recommend continuous positive airway pressure in patients with thoracic trauma who remain hypoxic despite regional anesthesia. This recommendation is rated only by level C evidence because randomized controlled trials in this specific population are lacking. Our aim was to determine whether NIMV reduces intubation in severe trauma-related hypoxemia.

Methods

This was a single-center randomized clinical trial in a nine-bed ICU of a level I trauma hospital. Inclusion criteria were patients with Pao2/Fio2<200 for >8 h while receiving oxygen by high-flow mask within the first 48 h after thoracic trauma. Patients were randomized to remain on high-flow oxygen mask or to receive NIMV. The interface was selected based on the associated injuries. Thoracic anesthesia was universally supplied unless contraindicated. The primary end point was intubation; secondary end points included length of hospital stay and survival. Statistical analysis was based on multivariate analysis.

Results

After 25 patients were enrolled in each group, the trial was prematurely stopped for efficacy because the intubation rate was much higher in controls than in NIMV patients (10 [40%] vs 3 [12%], P = .02). Multivariate analysis adjusted for age, gender, chronic heart failure, and Acute Physiology and Chronic Health Evaluation II at admission revealed NIMV as the only variable independently related to intubation (odds ratio, 0.12; 95% CI, 0.02–0.61; P = .01). Length of hospital stay was shorter in NIMV patients (14 vs 21 days P = .001), but no differences were observed in survival or other secondary end points.

Conclusion

NIMV reduced intubation compared with oxygen therapy in severe thoracic trauma-related hypoxemia.

Trial registration

clinicaltrials.gov; identifier: NCT 00557752.

Section snippets

Patients

This prospective randomized controlled study was conducted in a 700-bed level I trauma center that works as regional referral center for traumatic brain injury. From September 2005 to June 2008, we screened all patients admitted for severe thoracic trauma to our nine-bed closed trauma ICU without out-of-hospital intubation. The study was approved by the Institutional Review Board. Informed consent was obtained from patients or relatives in all cases.

Inclusion criteria were: age older than 18

Results

At the second interim analysis, after enrollment of 50 patients, a significantly reduced intubation rate in the NIMV group led the safety monitoring board to stop the study. The Consolidated Standards of Reporting Trials study flow is summarized in Figure 1. During the 3-year study period, 79 patients were screened, but only 50 were finally included in the study, 25 randomized to each treatment group. The baseline characteristics of patients in each group are summarized in Table 1. In the

Discussion

The major finding of this study is that early and continuous NIMV prevents intubation and reduces LOS in patients who develop severe hypoxia early in the course of thoracic trauma. It seems that the time course of oxygenation does not predict NIMV failure, as Pao2/Fio2 also improved in the first 24 h in the group of patients who were eventually intubated (see Fig 3). However, the difference in the Pao2/Fio2 ratio in NIMV vs control patients when comparing patients who were intubated with those

Acknowledgments

Author contributions: Dr Hernandez: contributed to the conception, coordination, design, and interpretation of the study and drafting, critical revision, reading, and approval of the manuscript.

Dr Fernandez: contributed to the conception, design, and interpretation of the study and drafting, critical revision, reading, and approval of the manuscript.

Dr Lopez-Reina: contributed to coordination, design, and interpretation of the study and critical revision, reading, and approval of the manuscript.

References (0)

Cited by (97)

  • Physiotherapy management of rib fractures

    2023, Journal of Physiotherapy
  • Thoracic trauma: Respiratory support

    2023, Praticien en Anesthesie Reanimation
  • High flow nasal cannula outside the ICU provides optimal care and maximizes hospital resources for patients with multiple rib fractures

    2022, Injury
    Citation Excerpt :

    Other studies have investigated HFNC and other forms of noninvasive respiratory support in patients with rib fractures [16,25-28,38]. In Spain, Hernandez et al. [38] showed reductions in the intubation of patients with severe thoracic trauma with the use of noninvasive mechanical ventilation. Just as in our study, falls and motor vehicle crashes were the most common trauma mechanisms in the Hernandez et al. study [38].

View all citing articles on Scopus

Funding/Support: This study was supported in part by Consejería de Sanidad de Castilla-La Mancha [Grant 06001-00 ICS Talavera] and Fundación de Investigación Médica Mutua Madrileña Automovilística [Grant 06/06/2004 n°65].

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).

View full text