Dataset Information

Safety and efficacy of noninvasive ventilation in patients with blunt chest trauma: a systematic review.

ABSTRACT:

Introduction

This systematic review looks at the use of noninvasive ventilation (NIV), inclusive of noninvasive positive pressure ventilation (NPPV) and continuous positive pressure ventilation (CPAP), in patients with chest trauma to determine its safety and clinical efficacy in patients with blunt chest trauma who are at high risk of acute lung injury (ALI) and respiratory failure.

Methods

We searched the MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) databases. Pairs of reviewers abstracted relevant clinical data and assessed the methodological quality of randomized controlled trials (RCTs) using the Cochrane domain and observational studies using the Newcastle-Ottawa Scale.

Results

Nine studies were included (three RCTs, two retrospective cohort studies and four observational studies without a comparison group). There was significant heterogeneity among the included studies regarding the severity of injuries, degree of hypoxemia and timing of enrollment. One RCT of moderate quality assessed the use of NPPV early in the disease process before the development of respiratory distress. All others evaluated the use of NPPV and CPAP in patients with blunt chest trauma after the development of respiratory distress. Overall, up to 18% of patients enrolled in the NIV group needed intubation. The duration of NIV use was highly variable, but NIV use itself was not associated with significant morbidity or mortality. Four low-quality observational studies compared NIV to invasive mechanical ventilation in patients with respiratory distress and showed decreased ICU stay (5.3 to 16 days vs 9.5 to 15 days), complications (0% to 18% vs 38% to 49%) and mortality (0% to 9% vs 6% to 50%) in the NIV group.

Conclusions

Early use of NIV in appropriately identified patients with chest trauma and without respiratory distress may prevent intubation and decrease complications and ICU length of stay. Use of NIV to prevent intubation in patients with chest trauma who have ALI associated with respiratory distress remains controversial because of the lack of good-quality data.

SUBMITTER: Duggal A

PROVIDER: S-EPMC4057415 | biostudies-literature | 2013 Jul

REPOSITORIES: biostudies-literature

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Safety and efficacy of noninvasive ventilation in patients with blunt chest trauma: a systematic review.

Duggal Abhijit A Perez Pablo P Golan Eyal E Tremblay Lorraine L Sinuff Tasnim T

Critical care (London, England) 20130722 4

<h4>Introduction</h4>This systematic review looks at the use of noninvasive ventilation (NIV), inclusive of noninvasive positive pressure ventilation (NPPV) and continuous positive pressure ventilation (CPAP), in patients with chest trauma to determine its safety and clinical efficacy in patients with blunt chest trauma who are at high risk of acute lung injury (ALI) and respiratory failure.<h4>Methods</h4>We searched the MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (CENTRA ...[more]

PMID: 23876230

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Project description:BackgroundHigh-flow nasal cannula oxygen therapy (HFNC) is recommended by some scholars as an optimized respiratory support method for blunt chest trauma (BCT) patients. The basis of this recommendation is limited, however, and the efficacy of HFNC or noninvasive ventilation (NIV) in BCT patients has not yet been rigorously explored. This study aims to determine if HFNC is non-inferior to NIV in reducing treatment failure in moderate to severe BCT patients with acute respiratory failure.MethodsThis will be a prospective, open-label, multicenter, non-inferiority, randomized controlled trial. Moderate to severe BCT patients with acute respiratory failure (100mmHg < PaO2/FiO2 ≦ 200mmHg) who do not need immediate intubation will be randomized to HFNC or NIV within 48 h after trauma. The primary outcome is treatment failure, defined as invasive ventilation or a switch in respiratory support modality (from HFNC to NIV or vice-versa). Secondary outcomes include arterial blood gas analysis and vital signs at 2 and 12 h after initiating HFNC or NIV treatment, as well as patients' comfort scores, dyspnea scores, daily number of nursing airway care interventions, incidence of pneumonia or pneumothorax, facial skin breakdown, duration of NIV or HFNC, 28-day mortality, and total ICU and hospital lengths of stay. Based on an α error of 5% and a β error of 80%, with a non-inferiority limit of 9%, a sample size of 562 will be required to accomplish the trial goal, considering potential patient dropouts and nonparametric analysis.DiscussionWe hypothesize that HFNC will be non-inferior to NIV in reducing treatment failure in moderate to severe BCT with acute respiratory failure. The results should be useful for judging whether HFNC could be an effective alternative to NIV to treat moderate to severe BCT patients, especially for those who do not tolerate or have contraindications for NIV.Trial registrationChinese Clinical Trial Registry ChiCTR1800017313 . Registered on July 24, 2018.

Project description:BackgroundIn patients with multiple trauma, a supine chest radiography [chest X-ray (CXR)] is preferred over a erect CXR. However, this method has limitations in detecting post-traumatic pneumothorax. The use of chest computed tomography (CT) to detect traumatic pneumothorax is well known. However, pneumothorax that is not detected before a chest CT scan is known as an occult pneumothorax (OP), and it can cause serious complications in the patient. This study sought to evaluate the frequency and risk factors for OP in trauma patients.MethodsPatients who suffered thoracic trauma at the Level 1 Regional Trauma Center of Wonju Severance Christian Hospital between 2015 and 2022 were included in this study. All patients were at least 18 years old. The study reviewed all patients' supine CXR and chest CT images and classified them into five radiographic diagnoses: pneumothorax, rib fracture, subcutaneous emphysema, lung contusion, and pneumomediastinum.ResultsThe study included 1,284 patients, all with diagnoses of pneumothorax, rib fracture, subcutaneous emphysema, lung contusion, and pneumomediastinum following supine CXR and chest CT. The patient's average age was 58.3±15.2 years. Pneumothorax diagnosis on supine CXR had the lowest accuracy, at 46.7%, and the lowest sensitivity, at 12.7%. In univariate analysis, rib fracture, lung contusion, and subcutaneous emphysema on supine CXR were all found to be statistically significant regarding traumatic OP. In multivariate analysis, the risk factors for OP were lung contusion [odds ratio (OR), 1.440; 95% confidence interval (CI): 1.115-1.860; P=0.005] and subcutaneous emphysema (OR, 25.883; 95% CI: 13.155-50.928; P<0.001) on supine CXR.ConclusionsThe lung contusion and subcutaneous emphysema in supine CXR of trauma patients indicate the presence of OP. Therefore, if chest CT cannot be performed immediately due to unstable vital signs or other circumstances, recognizing the above radiological findings of traumatic pneumothorax may be necessary.

Project description:IntroductionThe diagnosis of cardiac contusion, caused by blunt chest trauma, remains a challenge due to the non-specific symptoms it causes and the lack of ideal tests to diagnose myocardial damage. A cardiac contusion can be life-threatening if not diagnosed and treated promptly. Several diagnostic tests have been used to evaluate the risk of cardiac complications, but the challenge of identifying patients with contusions nevertheless remains.Aim of the studyTo evaluate the accuracy of diagnostic tests for detecting blunt cardiac injury (BCI) and its complications, in patients with severe chest injuries, who are assessed in an emergency department or by any front-line emergency physician.MethodsA targeted search strategy was performed using Ovid MEDLINE and Embase databases from 1993 up to October 2022. Data on at least one of the following diagnostic tests: electrocardiogram (ECG), serum creatinine phosphokinase-MB level (CPK-MB), echocardiography (Echo), Cardiac troponin I (cTnI) or Cardiac troponin T (cTnT). Diagnostic tests for cardiac contusion were evaluated for their accuracy in meta-analysis. Heterogeneity was assessed using the I2 and the QUADAS-2 tool was used to assess bias of the studies.ResultsThis systematic review yielded 51 studies (n = 5,359). The weighted mean incidence of myocardial injuries after sustaining a blunt force trauma stood at 18.3% of cases. Overall weighted mean mortality among patients with blunt cardiac injury was 7.6% (1.4-36.4%). Initial ECG, cTnI, cTnT and transthoracic echocardiography TTE all showed high specificity (> 80%), but lower sensitivity (< 70%). TEE had a specificity of 72.1% (range 35.8-98.2%) and sensitivity of 86.7% (range 40-99.2%) in diagnosing cardiac contusion. CK-MB had the lowest diagnostic odds ratio of 3.598 (95% CI: 1.832-7.068). Normal ECG accompanied by normal cTnI showed a high sensitivity of 85% in ruling out cardiac injuries.ConclusionEmergency physicians face great challenges in diagnosing cardiac injuries in patients following blunt trauma. In the majority of cases, joint use of ECG and cTnI was a pragmatic and cost-effective approach to rule out cardiac injuries. In addition, TEE may be highly accurate in identifying cardiac injuries in suspected cases.

Project description:BackgroundThe benefit-risk ratio of prophylactic non-invasive ventilation (NIV) and high-flow nasal oxygen therapy (HFNC-O2) during the early stage of blunt chest trauma remains controversial because of limited data. The main objective of this study was to compare the rate of endotracheal intubation between two NIV strategies in high-risk blunt chest trauma patients.MethodsThe OptiTHO trial was a randomized, open-label, multicenter trial over a two-year period. Every adult patients admitted in intensive care unit within 48 h after a high-risk blunt chest trauma (Thoracic Trauma Severity Score ≥ 8), an estimated PaO2/FiO2 ratio < 300 and no evidence of acute respiratory failure were eligible for study enrollment (Clinical Trial Registration: NCT03943914). The primary objective was to compare the rate of endotracheal intubation for delayed respiratory failure between two NIV strategies: i) a prompt association of HFNC-O2 and "early" NIV in every patient for at least 48 h with vs. ii) the standard of care associating COT and "late" NIV, indicated in patients with respiratory deterioration and/or PaO2/FiO2 ratio ≤ 200 mmHg. Secondary outcomes were the occurrence of chest trauma-related complications (pulmonary infection, delayed hemothorax or moderate-to-severe ARDS).ResultsStudy enrollment was stopped for futility after a 2-year study period and randomization of 141 patients. Overall, 11 patients (7.8%) required endotracheal intubation for delayed respiratory failure. The rate of endotracheal intubation was not significantly lower in patients treated with the experimental strategy (7% [5/71]) when compared to the control group (8.6% [6/70]), with an adjusted OR = 0.72 (95%IC: 0.20-2.43), p = 0.60. The occurrence of pulmonary infection, delayed hemothorax or delayed ARDS was not significantly lower in patients treated by the experimental strategy (adjusted OR = 1.99 [95%IC: 0.73-5.89], p = 0.18, 0.85 [95%IC: 0.33-2.20], p = 0.74 and 2.14 [95%IC: 0.36-20.77], p = 0.41, respectively).ConclusionA prompt association of HFNC-O2 with preventive NIV did not reduce the rate of endotracheal intubation or secondary respiratory complications when compared to COT and late NIV in high-risk blunt chest trauma patients with non-severe hypoxemia and no sign of acute respiratory failure.Clinical trial registrationNCT03943914, Registered 7 May 2019.

Dataset Information

Safety and efficacy of noninvasive ventilation in patients with blunt chest trauma: a systematic review.

Introduction

Methods

Results

Conclusions

Publications

Safety and efficacy of noninvasive ventilation in patients with blunt chest trauma: a systematic review.

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