Noninvasive Ventilation in the Polytraumatized Patient
Trauma is the leading cause of death in persons younger than 44 years of age and is the fourth leading cause of death overall [1]. Approximately 140,000 trauma-related deaths occur in the United States annually. Chest trauma is the cause of death in up to
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Noninvasive Ventilation in the Polytraumatized Patient Marcin K. Karcz and Peter J. Papadakos
Keywords
Noninvasive ventilation • Trauma • Pulmonary contusion • Respiratory failure • Acute respiratory distress syndrome
8.1
Introduction
Trauma is the leading cause of death in persons younger than 44 years of age and is the fourth leading cause of death overall [1]. Approximately 140,000 trauma-related deaths occur in the United States annually. Chest trauma is the cause of death in up to one-fourth of patients with multiple-systems trauma. The most common traumatic injuries to the chest include rib fractures and flail chest, lung contusion, chest wall hematoma, pleural effusion, pneumothorax, and hematothorax [2]. Pulmonary contusion is especially common in patients sustaining multi-trauma, occurring in approximately 17 % of patients with multiple injuries [3]. Burford and Burbank [4] showed that posttraumatic respiratory failure was caused by an increased amount of interstitial and intra-alveolar fluids. They described it as “traumatic wet lung.” The authors recommended that aggressive pulmonary toilet, sufficient pain control, and positive airway pressure by mask be maintained to ensure adequate ventilation. Jensen et al. also reported successful M.K. Karcz, MD, MSc Department of Anesthesiology, University of Rochester, Rochester, NY, USA e-mail: [email protected] P.J. Papadakos, MD, FCCP, FCCM (*) Department of Anesthesiology, University of Rochester, Rochester, NY, USA Departments of Surgery and Neurosurgery, University of Rochester, Rochester, NY, USA Division of Critical Care Medicine, Departments of Anesthesiology, Surgery and Neurosurgery, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642, USA e-mail: [email protected] A.M. Esquinas (ed.), Noninvasive Ventilation in High-Risk Infections and Mass Casualty Events, DOI 10.1007/978-3-7091-1496-4_8, © Springer-Verlag Wien 2014
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treatment of thoracic trauma using continuous positive airway pressure (CPAP) by mask [5]. Subsequent to this trend-setting research, trauma management has been guided according to the mechanism of injury, its anatomical involvement, and the staging of the injury. It has mostly focused on fluid management, pulmonary toilet, control of chest wall pain, and surgical stabilization. Ventilator management has received little attention [6], which is reflected in a low-grade recommendation in the British Thoracic Society (BTS) guidelines for using noninvasive ventilation (NIV) in trauma patients [7]. The efficacy of NIV in the management of respiratory failure due to polytrauma is for the most part ambiguous mainly because of the lack of randomized controlled trials (RCTs) in this population. This chapter reviews current evidence demonstrating the role of NIV in polytrauma patients and suggests an approach for its application based on our own experience.
8.2
Epidemiology of Chest Trauma
Over the last few decades, the escalating number of blunt high-veloci
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