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. 2019 Apr 1;9(4):e023444. doi: 10.1136/bmjopen-2018-023444

Table 5.

Results of individual reviews that report a narrative synthesis for flail chest

Study details Included studies Outcomes assessed Narrative synthesis
Author
Unsworth et al 24
Year
2015
Country
Australia		 RCT=2
Granetzny (40)
Tanaka (37)
Marasco (46)
Non-randomised=6
Ahmed (64)
Althausen (50)
Doben (21)
De Moya (48)
Nirula (60)
Voggenreiter (42)
Total number of patients=408

  • Mortality

  • Pneumonia

  • Pneumothorax and haemothorax

  • Hospital length of stay

  • ICU stay

  • Costings

  • Treatment outcome

  • Significant decrease in mechanical ventilation requirements after surgical fixation. decreasing in ventilator-acquired pneumonia after surgical fixation.

  • Decrease in ICU-LOS, fewer days of mechanical ventilation and cost savings compared with non-operative management.

  • Decreased days of ventilator dependence and shorter ICU-LOS.

  • Lower incidence of pneumonia, a higher return to full time work at 6 months.

  • Less persistent pain at six and 12 months in those receiving surgery.

  • Significantly fewer days of mechanical ventilation and a shorter hospital and ICU-LOS.

  • The estimated cost savings ranged from US$10 000 to $A14 443 per patient with surgical rib fixation as a result of the decrease in ICU-LOS.

  • None of the studies were large enough to draw conclusions on the effect of this intervention on thromboembolism and death.
Author
de Lesquen et al 15
Year
2015
Country
France		 Meta-analysis=2
Leinicke nine studies (538 patients)
Slobogean 11 studies (732 patients)
RCT=3
Marasco (46)
Granetzny (40)
Tanaka (37)
Non-randomised=6
Ahmed (64)
Karev (40)
Voggenreiter (20)
Balci (64)
Nirula (60)
Althausen (50)
Total number of patients=421

  • Duration of IMV

  • LOS-ICU

  • Pneumonia

  • Mortality

 For flail chest, early surgical stabilisation can be considered in patients who would require mechanical ventilation for >48 hours.
(Grade B, extrapolated recommendations from level I evidences.)
Author
NICE12
Year
2010
Country
UK		 RCT=1
Tanaka (37)
Non-randomised=2
Voggenreiter (42)
Paris (29)
Case Series=4
Lardinois (66)
Mouton (23)
Menard (18)
Hellberg (10)
Total number of patients=225
Intervention group=173
Control group=52

  • Duration of IMV

  • Mortality

  • LOS ICU

  • Pneumonia

  • Lung function

  • Return to Employment

  • Sepsis

  • Pain or discomfort requiring removal of plates

 Surgical stabilisation with metal rib reinforcements aims to allow earlier weaning from mechanical ventilation, reduce acute complications and avoid chronic pain sometimes associated with permanent malformation of the chest wall. Kirschner wire may be used on its own, but this method of rib stabilisation is not covered by this guidance.
Author
Schulte et al 13
Year
2016
Country
UK		 Systematic review=1
Slobogean (753)
RCT=1
Marasco (23,23)
Non-randomised studies=9
Jayle (10,10)
Pieracci (35,35)
Zhang (24,15)
Wada (84,336)
Granhed (60,153)
Doben (10,11)
Xu (17,15)
Althausen (22,28)
De Moya (16,32)
Total number of patients=1712
Intervention group=301
Control group=658

  • Duration of IMV

  • Mortality

  • LOS hospital

  • LOS-ICU

  • Pneumonia

 Surgical stabilisation of flail chest in thoracic trauma patients has beneficial effects with respect to reduced ventilatory support, shorter intensive care and hospital stay, reduced incidence of pneumonia and septicaemia, decreased risk of chest deformity and an overall reduced mortality when compared with patients who received non-operative management.

ICU, intensive care unit; IMV, invasive mechanical ventilation; LOS, length of stay; NICE, National Institute for Health and Care Excellence; RCT, randomised controlled trial.