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Geriatric Rib Fractures – Spirometry or Pain Control for Dispo?

July 23, 2020

Written by Sam Parnell

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Bedside spirometry measurements, specifically the FEV1, can help predict outcomes for geriatric patients with isolated rib fractures and may be used to make decisions about admission and discharge. Pain control did not correlate with pulmonary function or predict discharge home.

Why does this matter?
Rib fractures are associated with significant morbidity and mortality in the geriatric population, and a recent algorithm developed by the Western Trauma Association recommends admitting most patients older than 65 with two or more rib fractures to a monitored setting. However, much of this correlation is likely related to concomitant injuries, and the evidence for geriatric patients with isolated rib fractures is limited. Multiple studies have suggested that pulmonary function tests such as incentive spirometry or FVC can help predict outcomes, but what role do these tests have for geriatric patients with isolated rib fractures? Will trauma surgery want to do spirometry and recommend early discharge in some cases, even from the ED?

Spirometry for geriatric rib fractures…like a breath of fresh air
This was a prospective observational study of 86 patients evaluating FVC, FEV1, NIF, pain level, and grip strength as predictors of outcome in patients ≥ 60 years of age with three or more isolated rib fractures. Complications such as pneumonia (2), unplanned ICU admission (3), and intubation (1) were rare. FVC, FEV1, and grip strength on day one predicted discharge to home, and both FEV1 and pain level on day one moderately correlated with the length of stay (LOS).

After adjusting for confounders, the FEV1 on day one was a significant predictor of both LOS and discharge home with a 3% increase in the odds of discharge home for every percent increase in FEV1 percent predicted (p=0.023). The only other predictor of home discharge that reached significance was younger age (p<0.001). Almost all patients with FEV1 greater than 60% of predicted were discharged home with a short LOS. For each patient, FVC, FEV1, and NIF did not change significantly over three days even though there was improvement in pain.

Interestingly, pain score had little impact on the potential for discharge home and was not associated with respiratory volumes, although improving pain was associated with shorter LOS.

Spirometry Not Pain Level Predicts Outcomes in Geriatric Patients with Isolated Rib Fractures. J Trauma Acute Care Surg. 2020 May 26. doi: 10.1097/TA.0000000000002795. [Epub ahead of print]

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