Page 109 - JSOM Spring 2023

An Ongoing Series

Admission Forced Vital Capacity Adds a Predictive Physiologic Tool
to Triage Patients Suffering Rib Fractures

A Prospective Observation Trial

Luke R. Johnston, MD *; Jason Nam, MD ; Alexander P. Nissen, MD ;
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Justin J. Sleeter, MD ; James K. Aden, PhD ; Alexander Mills, DO ; Valerie G. Sams, MD 7
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ABSTRACT
Background: Patients with rib fractures are at high risk for Introduction
morbidity and mortality. This study prospectively examines
bedside percent predicted forced vital capacity (% pFVC) in Blunt chest trauma is associated with a high risk of both mor-
predicting complications for patients suffering multiple rib bidity and mortality. Specifically, in patients with traumatic
fractures. The authors hypothesize that increased % pFVC is rib fractures, complications can arise secondary to pain and
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associated with reduced pulmonary complications. Methods: inadequate ventilation. The ability to predict appropriate
Adult patients with ≥3 rib fractures admitted to a level I trauma level of care and intervention is critical to helping prevent poor
center, without cervical spinal cord injury or severe traumatic outcomes.
brain injury, were consecutively enrolled. FVC was measured
at admission and % pFVC values were calculated for each pa- To minimize morbidity and mortality, managing patients with
tient. Patient were grouped by % pFVC <30% (low), 30–49% multiple rib fractures requires significant healthcare resources
(moderate), and ≥50% (high). Results: A total of 79 patients including ICU monitoring, ventilator management, respiratory
1–3
were enrolled. Percent pFVC groups were similar except for therapy intervention, and pain management protocols. Both
pneumothorax being most frequent in the low group (47.8% acute complications and long-term disability can occur be-
1–3
vs. 13.9% and 20.0%, p = .028). Pulmonary complications cause of these very common injuries. Recent studies indicate
were infrequent and did not differ between groups (8.7% vs. that the morbidity and lost productivity in patients suffering
5.6% vs. 0%, p = .198). Discussion: Increased % pFVC was thoracic trauma is substantial, even in the relatively young and
associated with reduced hospital and intensive care unit (ICU) those with minimal injuries. For example, patients with rib
length of stay (LOS) and increased time to discharge to home. fractures are significantly more disabled at 30 days postinjury
Percent pFVC should be used in addition to other factors to when compared with patients with chronic medical illness and
risk stratify patients with multiple rib fractures. Bedside spi- lose an average of 70 days of work or usual activity during
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rometry is a simple tool that can help guide management in their acute recovery.
resource-limited settings, especially in large-scale combat op-
erations. Conclusion: This study prospectively demonstrates Furthermore, there is a direct impact on operational medicine.
that % pFVC at admission represents an objective physiologic In the wars of Iraq and Afghanistan, even with the improve-
assessment that can be used to identify patients likely to re- ment of body armor, a study found that 10% of combat casu-
quire an increased level of hospital care. alties sustained thoracic injuries. The mortality rate for such
thoracic injuries was exceedingly high at 10.5%. Flail chest
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was tied for the leading cause of highest mortality, and pul-
Keywords: chest trauma; rib fracture; forced vital capac- 6
ity; pulmonary function test; risk stratification; prolonged monary contusion was the most common injury insult. US
casualty care; prolonged field care; bedside spirometry military surgeons performed in-theater thoracic surgery, which
amounted to 2.5% of all combat surgical procedures between
2002 and 2016. Even after survival and recovery, there are
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*Correspondence to luke.r.johnston.mil@mail.mil
1 LCDR Luke R. Johnston is a physician affiliated with the US Navy and the Department of Surgery, Uniformed Services Health University of the
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Health Sciences, Bethesda, MD. MAJ Jason Nam is a physician affiliated with the US Army and the Division of Pulmonary, Allergy, and Critical
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Care Medicine, Duke University School of Medicine, Durham, NC. MAJ Alexander P. Nissen, CPT Justin J Sleeter, and CPT Alexander Mills
are physicians affiliated with the US Air Force and the Department of General Surgery, Memorial Hermann Hospital, the University of Texas
Health Science Center at Houston, Houston, TX. Dr James K. Aden is a scientist affiliated with the Department of General Surgery, Memorial
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Hermann Hospital, the University of Texas Health Science Center at Houston, Houston, TX. Dr Valerie G. Sams is a physician affiliated with
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the US Air Force and the Departments of Surgery, Division of Trauma and Surgical Critical Care, Brooke Army Medical Center, Fort Sam Hous-
ton, TX.
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