Implementation of a Respiratory Therapy-Driven Protocol to Monitor Rib Fracture Patients

Background: Effective management of blunt thoracic trauma includes optimization of pulmonary hygiene, including lung expansion therapy. Intermittent noninvasive positive pressure therapy (CPAP 10 cm H2O) for patients with rib fractures has been used at our institution with the goal of preventing or alleviating atelectasis and preventing respiratory-related complications. The decision to initiate therapy was based on the provider’s clinical judgment. In January 2023, we implemented a respiratory therapist (RT)-driven lung expansion therapy assessment pathway for rib fracture patients. Pulmonary function tests (PFTs) were used to select patients for hyperinflation therapy. Serial measurements (Q 6 h x 24 h) of vital capacity (VC) and negative inspiratory force (NIF) were then used to determine the duration of the therapy, as well as for monitoring patients who were not initially initiated on lung expansion therapy. Methods: The data were extracted from the medical records of patients admitted to trauma surgery service at Mayo Clinic Hospital, Rochester between January 2022 and January 2024 with a diagnosis of rib fractures. Patients were divided into 2 groups: pre-protocol group (patients admitted before January 11, 2023), and a post-protocol implementation group including patients admitted on January 11, 2023, or later. Results: There were 477 patients in the pre-protocol and 440 patients in the post-implementation group. There was a slight decrease in the proportion of patients initiated on lung expansion therapy post-implementation (43% vs 39%, P = .16); average days on CPAP per patient decreased post-implementation from 2.7 ± 11 to 1.7 ± 4 (P = .09). There was no difference in the proportion of patients requiring ventilatory support (12% vs 14%, P = .33) or patients diagnosed with pneumonia during hospital stay (7% vs. 7.5%, P = .93) (Table 1). Combined pre and post-protocol initiation data points indicate little variability in repeated VC assessments during the first 24 h of hospital admission (Figure 1). Conclusions: There appears to be a decrease in lung expansion therapy use following the implementation of an RT-driven PFT-based protocol without an increase in adverse outcomes. A prospective trial may be required to determine if subsequent VC measurements are beneficial in the assessment for the requirement for lung expansion therapy after the initial patient assessment.