Journal of Postgraduate Medicine
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Year : 1981  |  Volume : 27  |  Issue : 2  |  Page : 120-122A  

Management of flail chest by intermittent positive pressure respiration (IPPR).

KM Nadkarni, DD Dasgupta, RA Bhalerao 

Correspondence Address:
K M Nadkarni

How to cite this article:
Nadkarni K M, Dasgupta D D, Bhalerao R A. Management of flail chest by intermittent positive pressure respiration (IPPR). J Postgrad Med 1981;27:120-122A

How to cite this URL:
Nadkarni K M, Dasgupta D D, Bhalerao R A. Management of flail chest by intermittent positive pressure respiration (IPPR). J Postgrad Med [serial online] 1981 [cited 2020 Oct 26 ];27:120-122A
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Severe blunt injury to the chest wall resulting in multiple fracture ribs with a flail chest and hemo/pneumothorax can present as an acute respiratory emergency.

In the less severe cases, paradoxical respiration may lead to gradual progressive hypoxemia and atelectasis. Other infective chest complications may then supervene.

Immediate tacheostomy with controlled positive pressure respiration on a respirator is the only sure way to avoid mortality and stabilise the thoracic cage in a favourable position for healing of fractures.


Case 1:

A 24 year old male was admitted in a gasping state to the emergency surgical ward with a history of vehicular accident. Examination showed the patient to be markedly tachypnoeic and cyanosed with a pulse rate of 140 per minute and respiratory rate of 48 per minute. Local examination revealed multiple fractures of ribs (2nd to 9th) with a significant flail and paradoxical movement of the left chest. Plain radiograph of the chest showed multiple fractures of ribs on the left side with a hemopneumothorax.[Fig. 1] The patient also had a compound fracture of the left humerus and left tibia-fibula. Arterial blood gas analysis showed p02-54 mm. Hg., pCO2 30 mm. Hg., pH-7.43 and SaO2,-88%. Immediate endotracheal intubation was followed by tracheostomy, intercostal drainage of hemo and pneumothorax by a Malecot's catheter connected to under water bottle, and IPPR on a Bird's respirator with oxygen under a pressure of 15-20 lbs/sq. inch. On respirator, blood gas analysis after 24 hours showed p02-110, mm. Hg. pC02 34, mm. Hg. pH-7.38 and Sa02 98%. The patient was kept on IPPR for a period of 3 weeks. Any attempt at weaning off the respirator produced a fall in p02, (59 mm. 11g.) within 4 hours. The patient was also given antibiotics, humidification in a nebuliser, chest physiotherapy and the orthopedic problems were dealt with. Repeat X-rays of the chest showed good lung expansion. [Fig. 2] The intercostal drain was removed after one week. At the end of 3 weeks the paradoxical movement diminished and the patient was gradually weaned off the respirator whilst monitoring blood gases. After 6 weeks the patient was completely off the respirator, had very minimal deformity of the chest wall visible and p02 was normal. Pulmonary function tests (PFT) done after 3 months were within normal limits.

Case 2:

A 28 year old male patient was admitted following a railway accident. He had 4 ribs fractured on the left side (2nd to 6th) at multiple sites with flail segment. He also had a degloving injury to the left lower limb. Although the patient was reasonably comfortable without cyanosis with a pulse of 120/mt. and respiration of 36/mt., the patient was hyperventilating and had a visible paradoxical movement of the left upper chest. X-ray chest confirmed the fracture ribs with a small hemothorax. Arterial blood gas analysis showed p02 48, mm. Hg. pCO2-32, mm. Hg. pH-7.4 and SaO2-80%. A tracheostomy was immediately performed and connected to IPPR and an intercostal drain was introduced, to drain the hemothorax which was removed after 3 days. On respirator, arterial blood gases 24 hours later showed pO2-100 mm. Hg., pCO2- 34 mm. Hg., pH-74, Sa02 97%. Patient was on IPPR for 2 weeks. During the third week, the patient was gradually weaned off the respirator without any hypoxemia.

Degloving injury was simultaneously treated by skin grafting. A minimal cosmetic deformity persisted. Pulmonary function tests done after 3 months were normal.


Flail chest is a surgical emergency and several methods are available for its stabilisation, viz. surgical stabilisation, treatment in a respirator (physiologic stabilisation) or a combination of both.[2] A number of studies have been done on the treatment of flail chest.[1], [3], [5] Avery and associates,[1] in 1956, first reported good results from treatment using a respirator and since then this method has been widely accepted. Promptitude of treatment is important and immediate tracheostomy and therapy with IPPR should be started as soon as instability of chest wall with paradoxical respiration is detected and before the onset of hypoxia, atelectasis and other chest complications.[2] The treatment should be continued for a minimum period of 3-6 weeks until the chest is stable enough to take over ventilation. IPPR produces satisfactory ventilation and helps the fractured ribs to unite in the position of inspiration, thereby reducing the deformity and improving the late results on pulmonary function.[2] It is necessary to drain the hemo/pneumo thorax by intercostal drainage before starting IPPR to permit full expansion of the lung.

In comparable series not treated early with IPPR, greater than 24% mortality is reported.[5], [6] It is, therefore, not advisable to wait for respiratory insufficiency to manifest.[2] Some authors[6] underline the risk of infection with IPPR and recommend treatment with mechanical ventilation only when absolutely necessary. However, with proper antibiotics, physiotherapy and respirator care, infection can be dealt with.

Advocates of other therapeutic principles[4], [6] recommend open reduction of rib fractures with osteofixation instead of IPPR. We have not attempted surgical fixation in any of our cases and we consider IPPR as the best method for improving early and late results in cases of flail chest with paradoxical movements.


We are thankful to Dr. C. K. Deshpande, M.D., F.R.C.P., Dean K.E.M. Hospital, for permitting us to publish hospital data. We are also grateful to our anaesthetist colleagues for their help in respirator management.


1Avery, E. E., Morch, E. T. and Benson, D. W.: Critically crushed chests; a new method of treatment with continuous mechanical hyperventilation to produce alkalotic apnea and internal pneumatic stabilisation. J. Thorac. Surg., 32: 291-311, 1956.
2Christensson, .P., Gisselsson, L., Lacerof, H., Malm, A. and Ohlsson, N.: Early and late results of controlled ventilation in flail chest. Chest, 75: 456-460, 1979.
3Howell, J. F., Crawford, E. S. and Jordan, G. L. Jr.: The flail chest; an analysis of 100 patients. Amer. J. Surg. 106: 628-635, 1963.
4Paris, F., Tarazona, V., Blasco, E., Canto, A., Cassillas, M., Pastor, J., Paris, M. and Montero, R. S.: Surgical stabilisation of traumatic flail chest. Thorax, 30: 521-527, 1975.
5Relihan, M., and Litwin, M. S.: Morbidity and mortality associated with flail chest injury: A review of 85 cases, J. Trawriw., 13: 663-671, 1973.
6Shackford, S. R., Smith, D. E., Zarins, C. K., Rice, C. L. and Virgillo, R. W.: The management of flail chest: a comparison of ventilatory and non ventilatory treatment. Amer. J. Surg., 132: 759-762, 1976.

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