Phase 2: Summary of Comments

Group 4: Thoracic Injuries

• Clinical algorithm for the management of intubated and non-intubated patients following thoracic injuries
  
  
• Best practice recommendations

Best practice recommendations

Expert Opinion
No studies were identified for the management of intubated patients following injuries to the chest wall. Activities regarded as important by the majority of responders in patients following thoracic surgery include positioning of patient upright ASAP; include at least shoulder ROM activities and DBE’s; clearing of secretions (Reeve et al 2007) and early mobilization (Gosselink et al 2008). In the presence of a flail chest, movement can potentially be inhibited. Ensure sufficient pain management and humidification (Reeve et al 2007; Simon et al 2006).

AGREEMENT: 4/4

Back to Top

Recommendation

An aggressive physiotherapy program including DBE and mobilization might be instituted in non intubated patients following thoracic trauma ASAP after insertion of ICD, while ensuring sufficient pain management. RECOMMENDATION 1: The implementation of this program ASAP after ICD insertion decreased the LOS in two studies (Senekal et al 1995; Ngubani et al 1999) and decreased the number of physiotherapy interventions needed in one study (Ngubani et al 1999). Implementing this strategy in non intubated patients thus has potential economic advantages without increasing the burden. However the potential harm is not clear. The recommendation is based on LOW QUALITY EVIDENCE: Two RCT’s (Senekal et al 1995; Ngubani et al 1999 and one observational study (Varela et al 2006). The quality of the evidence from the RCT’s were downgraded due to high risk of bias (refer to table 2); and imprecision of sample and data. There was insufficient cause to upgrade the observational study due to indirectness (thoracic surgery population) and the limited effect size (RR 0.56).

POSTED COMMENTS:

• Agree “Might” should read “should” Lack of evidence is not evidence of absence
• Agree but positioning for deep breathing exercises and active coughing and education to empower the patient to comply to home/ward programmes
• Pain management in addition to the formulation is very important

Recommendation 2 :

The early initiation of periodic CPAP in patients that are awake; hemodynamically stable and have sustained unilateral injuries to the chest wall might be considered before intubation. WEAK RECOMMENDATION: The implementation of CPAP decreased survival and nosocomial infection rate but did not decrease LOS (Gunduz et al 2005). The cost could potentially be affected because of high cost of intubation but has not been measured. Potential harm is not clear. Based on LOW QUALITY EVIDENCE one RCT (Gunduz et al 2005) was downgraded due to high risk of bias and imprecision of sample size and data

POSTED COMMENTS:

• Agree – can be bilateral too! Did CPAP decrease or increase survival and time off ventilator??? I accept that it decreases complications. (Bolliger study!) Just check the wording
• Agree and include education to motivate and empower the patient

Back to Top