CPAP for flail segment

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vc85

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So I heard some medics talking about, and found some articles regarding CPAP being used in flail segment patients to "splint from the inside"

Has anyone done or seen it done? How concerned would you be about a pneumothorax, because I am having a hard time imagining an injury pattern where you would have a flail segment and not a high index of suspicion for a pneumo or hemopneumo
 
Yeah I would imagine it would be a hard sell. Maybe for a flight program doing IFT trauma flights after the patient has been imaged; or if point of care ultrasound/imaging advances
 
We're specifically contraindicated from using CPAP on chest trauma patients.
 
Its a huge risk that provides very little support if you're wrong and/or things go south. There is an increased risk of pneumo with a flail as you state, plus the changes in WOB may make it more uncomfortable for the patient (there may be decreased inhaled WOB but also an increase in exhaled WOB, depending on the case and device used).

You are using CPAP to "splint". Will this splint increase the potential for a pneumo to form?
 
If there is enough force to cause multiple displaced rib fractures, just assume there is a developing pneumothorax.
 
E tank said:
Bear in mind, though, the patients in this study with pneumothoraces would be known and have chest tubes.
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Yes. I don't think CPAP for flail segment has a role in prehospital medicine (or anywhere until pneumothorax is ruled out) until POCUS has been adopted and proficiency in prehospital use to detect pneumothorax had been reached.

Even then, the benefit of CPAP prehospitally is probably minimal, and the most benefit will be seen after admission.
 
NPO said:
Yes. I don't think CPAP for flail segment has a role in prehospital medicine (or anywhere until pneumothorax is ruled out)
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Not to put too fine a point on it, even with pneumothoraces, as long as there is functioning chest drainage, as far as that study goes, CPAP might not be a bad Idea in terms of what it is really meant for, that is among other things avoiding antelectasis and pneumonias in these patients.
 
E tank said:
Not to put too fine a point on it, even with pneumothoraces, as long as there is functioning chest drainage, as far as that study goes, CPAP might not be a bad Idea in terms of what it is really meant for, that is among other things avoiding antelectasis and pneumonias in these patients.
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We certainly use it for all of those reasons. The caveat, of course, is that NIPPV is really optimal for quickly-resolving problems, and these rib fracture/lung contusion patients will usually take days to get past the hump (they often don't even "peak" for a day or two). Continuous CPAP/BIPAP for days isn't awesome, although we sometimes give it a whirl. High-flow nasal cannula can be part of the mix as well.

If you can control pain, though, they can often do okay, as much of their respiratory trouble is from guarding and resulting poor pulmonary toilet. Good multimodal analgesia and perhaps a thoracic epidural sometimes means they'll do fine on a few liters by standard nasal cannula.

But yes, I'd be very wary of positive pressure if you couldn't first rule out (or decompress) pneumothorax.
 
Brandon O said:
We certainly use it for all of those reasons. The caveat, of course, is that NIPPV is really optimal for quickly-resolving problems, and these rib fracture/lung contusion patients will usually take days to get past the hump (they often don't even "peak" for a day or two). Continuous CPAP/BIPAP for days isn't awesome, although we sometimes give it a whirl. High-flow nasal cannula can be part of the mix as well.

If you can control pain, though, they can often do okay, as much of their respiratory trouble is from guarding and resulting poor pulmonary toilet. Good multimodal analgesia and perhaps a thoracic epidural sometimes means they'll do fine on a few liters by standard nasal cannula.

But yes, I'd be very wary of positive pressure if you couldn't first rule out (or decompress) pneumothorax.
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Vapotherm is a very nice option here and much better tolerated
 
Summit said:
Vapotherm is a very nice option here and much better tolerated
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Definitely has a role. But some people do need real PEEP.
 
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