Intensive Care Medicine

, Volume 39, Issue 7, pp 1171–1180 | Cite as

Noninvasive ventilation in chest trauma: systematic review and meta-analysis

  • D. ChiumelloEmail author
  • S. Coppola
  • S. Froio
  • C. Gregoretti
  • D. Consonni
Systematic Review



Single studies of Noninvasive Ventilation (NIV) in the management of acute respiratory failure in chest trauma patients have produced controversial findings. The aim of this study is to critically review the literature to investigate whether NIV reduces mortality, intubation rate, length of stay and complications in patients with chest trauma, compared to standard therapy.


We performed a systematic review and meta-analysis of randomized controlled trials, prospective and retrospective observational studies, by searching PubMed, EMBASE and bibliographies of articles retrieved. We screened for relevance studies that enrolled adults with chest trauma who developed mild to severe acute respiratory failure and were treated with NIV. We included studies reporting at least one clinical outcome of interest to perform a meta-analysis.


Ten studies (368 patients) met the inclusion criteria and were included for the meta-analysis. Five studies (219 patients) reported mortality and results were quite homogeneous across studies, with a summary relative risk for patients treated with NIV compared with standard care (oxygen therapy and invasive mechanical ventilation) of 0.26 (95 % confidence interval 0.09–0.71, p = 0.003). There was no advantage in mortality of continuous positive airway pressure over noninvasive pressure support ventilation. NIV significantly increased arterial oxygenation and was associated with a significant reduction in intubation rate, in the incidence of overall complications and infections.


These results suggest that NIV could be useful in the management of acute respiratory failure due to chest trauma.


Noninvasive ventilation Chest trauma Acute respiratory failure Meta-analysis Outcomes 


Conflicts of interest

Dr. Gregoretti received fees for lectures from Vivisol, SapoLife and Covidien. He also received fees for consultancies from Covidien and Smith Medical.


  1. 1.
    Pinilla JC (1982) Acute respiratory failure in severe blunt chest trauma. J Trauma 22:221–226CrossRefPubMedGoogle Scholar
  2. 2.
    Clark GC, Schecter WP, Trunkey DD (1988) Variables affecting outcome in blunt chest trauma: flail chest vs. pulmonary contusion. J Trauma 28:298–304CrossRefPubMedGoogle Scholar
  3. 3.
    LoCicero J III, Mattox KL (1989) Epidemiology of chest trauma. Surg Clin North Am 69:15–19PubMedGoogle Scholar
  4. 4.
    Shorr RM, Crittenden M, Indeck M et al (1987) Blunt thoracic trauma. Analysis of 515 patients. Ann Surg 206:200–205CrossRefPubMedGoogle Scholar
  5. 5.
    Wanek S, Mayberry JC (2004) Blunt thoracic trauma: flail chest, pulmonary contusion, and blast injury. Crit Care Clin 20:71–81CrossRefPubMedGoogle Scholar
  6. 6.
    Ziegler DW, Agarwal NN (1994) The morbidity and mortality of rib fractures. J Trauma 37:975–979CrossRefPubMedGoogle Scholar
  7. 7.
    Becher RD, Colonna AL, Enniss TM et al (2012) An innovative approach to predict the development of adult respiratory distress syndrome in patients with blunt trauma. J Trauma Acute Care Surg 73:1229–1235CrossRefPubMedGoogle Scholar
  8. 8.
    Martin M, Salim A, Murray J et al (2005) The decreasing incidence and mortality of acute respiratory distress syndrome after injury: a 5-year observational study. J Trauma 59:1107–1113CrossRefPubMedGoogle Scholar
  9. 9.
    Hudson LD, Milberg JA, Anardi D et al (1995) Clinical risks for development of the acute respiratory distress syndrome. Am J Respir Crit Care Med 151:293–301CrossRefPubMedGoogle Scholar
  10. 10.
    Navarrete-Navarro P, Rodriguez A, Reynolds N et al (2001) Acute respiratory distress syndrome among trauma patients: trends in ICU mortality, risk factors, complications and resource utilization. Intensive Care Med 27:1133–1140CrossRefPubMedGoogle Scholar
  11. 11.
    Treggiari MM, Hudson LD, Martin DP et al (2004) Effect of acute lung injury and acute respiratory distress syndrome on outcome in critically ill trauma patients. Crit Care Med 32:327–331CrossRefPubMedGoogle Scholar
  12. 12.
    Salim A, Martin M, Constantinou C et al (2006) Acute respiratory distress syndrome in the trauma intensive care unit: morbid but not mortal. Arch Surg 141:655–658CrossRefPubMedGoogle Scholar
  13. 13.
    DuBose JJ, Putty B, Teixeira PG et al (2011) The relationship between post-traumatic ventilator-associated pneumonia outcomes and American College of Surgeons trauma centre designation. Injury 42:40–43CrossRefPubMedGoogle Scholar
  14. 14.
    Karmakar MK, Ho AM (2003) Acute pain management of patients with multiple fractured ribs. J Trauma 54:615–625CrossRefPubMedGoogle Scholar
  15. 15.
    Trinkle JK, Richardson JD, Franz JL et al (1975) Management of flail chest without mechanical ventilation. Ann Thorac Surg 19:355–363CrossRefPubMedGoogle Scholar
  16. 16.
    Rico FR, Cheng JD, Gestring ML et al (2007) Mechanical ventilation strategies in massive chest trauma. Crit Care Clin 23:299–315 xiCrossRefPubMedGoogle Scholar
  17. 17.
    Johnson JA, Cogbill TH, Winga ER (1986) Determinants of outcome after pulmonary contusion. J Trauma 26:695–697CrossRefPubMedGoogle Scholar
  18. 18.
    Richardson JD, Adams L, Flint LM (1982) Selective management of flail chest and pulmonary contusion. Ann Surg 196:481–487CrossRefPubMedGoogle Scholar
  19. 19.
    Antonelli M, Conti G, Riccioni L et al (1996) Noninvasive positive-pressure ventilation via face mask during bronchoscopy with BAL in high-risk hypoxemic patients. Chest 110:724–728CrossRefPubMedGoogle Scholar
  20. 20.
    Antonelli M, Conti G, Moro ML et al (2001) Predictors of failure of noninvasive positive pressure ventilation in patients with acute hypoxemic respiratory failure: a multi-center study. Intensive Care Med 27:1718–1728CrossRefPubMedGoogle Scholar
  21. 21.
    Mariani J, Macchia A, Belziti C et al (2011) Noninvasive ventilation in acute cardiogenic pulmonary edema: a meta-analysis of randomized controlled trials. J Card Fail 17:850–859CrossRefPubMedGoogle Scholar
  22. 22.
    Peter JV, Moran JL, Phillips-Hughes J et al (2006) Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: a meta-analysis. Lancet 367:1155–1163CrossRefPubMedGoogle Scholar
  23. 23.
    Lightowler JV, Wedzicha JA, Elliott MW et al (2003) Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: cochrane systematic review and meta-analysis. BMJ 326:185CrossRefPubMedGoogle Scholar
  24. 24.
    Keenan SP, Sinuff T, Cook DJ et al (2004) Does noninvasive positive pressure ventilation improve outcome in acute hypoxemic respiratory failure? A systematic review. Crit Care Med 32:2516–2523CrossRefPubMedGoogle Scholar
  25. 25.
    Antonelli M, Conti G, Rocco M et al (1998) A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. N Engl J Med 339:429–435CrossRefPubMedGoogle Scholar
  26. 26.
    Nourdine K, Combes P, Carton MJ et al (1999) Does noninvasive ventilation reduce the ICU nosocomial infection risk? A prospective clinical survey. Intensive Care Med 25:567–573CrossRefPubMedGoogle Scholar
  27. 27.
    Nava S, Hill N (2009) Non-invasive ventilation in acute respiratory failure. Lancet 374:250–259CrossRefPubMedGoogle Scholar
  28. 28.
    Uretzky G, Cotev S (1980) The use of continuous positive airway pressure in blast injury of the chest. Crit Care Med 8:486–489CrossRefPubMedGoogle Scholar
  29. 29.
    BTS Standards of Care Committee (2002) Non-invasive ventilation in acute respiratory failure. Thorax 57:192–211CrossRefGoogle Scholar
  30. 30.
    Egger M, Smith GD, Altman D (2001) Systematic reviews in health care: meta-analysis in context. BMJ Publishing Group, LondonCrossRefGoogle Scholar
  31. 31.
    Rothman KJ, Greenland S (2008) Modern epidemiology, 3rd edn. Lippincott Williams & Wilkins, PhiladelphiaGoogle Scholar
  32. 32.
    Higgins JP, Thompson SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med 21:1539–1558CrossRefPubMedGoogle Scholar
  33. 33.
    Beltrame F, Lucangelo U, Gregori D et al (1999) Noninvasive positive pressure ventilation in trauma patients with acute respiratory failure. Monaldi Arch Chest Dis 54:109–114PubMedGoogle Scholar
  34. 34.
    Gregoretti C, Beltrame F, Lucangelo U et al (1998) Physiologic evaluation of non-invasive pressure support ventilation in trauma patients with acute respiratory failure. Intensive Care Med 24:785–790CrossRefPubMedGoogle Scholar
  35. 35.
    Ferrer M, Esquinas A, Leon M et al (2003) Noninvasive ventilation in severe hypoxemic respiratory failure: a randomized clinical trial. Am J Respir Crit Care Med 168:1438–1444CrossRefPubMedGoogle Scholar
  36. 36.
    Hernandez G, Fernandez R, Lopez-Reina P et al (2010) Noninvasive ventilation reduces intubation in chest trauma-related hypoxemia: a randomized clinical trial. Chest 137:74–80CrossRefPubMedGoogle Scholar
  37. 37.
    Xirouchaki N, Kondoudaki E, Anastasaki M et al (2005) Noninvasive bilevel positive pressure ventilation in patients with blunt thoracic trauma. Respiration 72:517–522CrossRefPubMedGoogle Scholar
  38. 38.
    Bolliger CT, Van Eeden SF (1990) Treatment of multiple rib fractures. Randomized controlled trial comparing ventilatory with nonventilatory management. Chest 97:943–948CrossRefPubMedGoogle Scholar
  39. 39.
    Linton DM, Potgieter PD (1982) Conservative management of blunt chest trauma. S Afr Med J 61:917–919PubMedGoogle Scholar
  40. 40.
    Gunduz M, Unlugenc H, Ozalevli M et al (2005) A comparative study of continuous positive airway pressure (CPAP) and intermittent positive pressure ventilation (IPPV) in patients with flail chest. Emerg Med J 22:325–329CrossRefPubMedGoogle Scholar
  41. 41.
    Vidhani K, Kause J, Parr M (2002) Should we follow ATLS guidelines for the management of traumatic pulmonary contusion: the role of non-invasive ventilatory support. Resuscitation 52:265–268CrossRefPubMedGoogle Scholar
  42. 42.
    Hurst JM, DeHaven CB, Branson RD (1985) Use of CPAP mask as the sole mode of ventilatory support in trauma patients with mild to moderate respiratory insufficiency. J Trauma 25:1065–1068CrossRefPubMedGoogle Scholar
  43. 43.
    Munshi IA, DeHaven B, Kirton O et al (1999) Reengineering respiratory support following extubation: avoidance of critical care unit costs. Chest 116:1025–1028CrossRefPubMedGoogle Scholar
  44. 44.
    Papadakos PJ, Karcz M, Lachmann B (2010) Mechanical ventilation in trauma. Curr Opin Anaesthesiol 23:228–232CrossRefPubMedGoogle Scholar
  45. 45.
    Christensson P, Gisselsson L, Lecerof H et al (1979) Early and late results of controlled ventilation in flail chest. Chest 75:456–460CrossRefPubMedGoogle Scholar
  46. 46.
    Diethelm AG, Battle W (1971) Management of flail chest injury: a review of 75 cases. Am Surg 37:667–670PubMedGoogle Scholar
  47. 47.
    Chiumello D, Esquinas AM, Moerer O et al (2012) A systematic technical review of the systems for the continuous positive airway pressure. Minerva Anestesiol 78:1385–1393PubMedGoogle Scholar
  48. 48.
    Sferrazza Papa GF, Di Marco F, Akoumianaki E et al (2012) Recent advances in interfaces for non-invasive ventilation: from bench studies to practical issues. Minerva Anestesiol 78:1146–1153PubMedGoogle Scholar
  49. 49.
    Pisani L, Carlucci A, Nava S (2012) Interfaces for noninvasive mechanical ventilation: technical aspects and efficiency. Minerva Anestesiol 78:1154–1161PubMedGoogle Scholar
  50. 50.
    Jaber S, Jung B (2011) Postoperative non-invasive ventilation outside the ICU: do not go too far! Minerva Anestesiol 77:9–10PubMedGoogle Scholar
  51. 51.
    Antonelli M, Moro ML, Capelli O et al (1994) Risk factors for early onset pneumonia in trauma patients. Chest 105:224–228CrossRefPubMedGoogle Scholar
  52. 52.
    Masip J, Roque M, Sanchez B et al (2005) Noninvasive ventilation in acute cardiogenic pulmonary edema: systematic review and meta-analysis. JAMA 294:3124–3130CrossRefPubMedGoogle Scholar
  53. 53.
    Agarwal R, Aggarwal AN, Gupta D (2010) Role of noninvasive ventilation in acute lung injury/acute respiratory distress syndrome: a proportion meta-analysis. Respir Care 55:1653–1660PubMedGoogle Scholar
  54. 54.
    Nava S, Schreiber A, Domenighetti G (2011) Noninvasive ventilation for patients with acute lung injury or acute respiratory distress syndrome. Respir Care 56:1583–1588CrossRefPubMedGoogle Scholar
  55. 55.
    Chiumello D, Pelosi P, Carlesso E et al (2003) Noninvasive positive pressure ventilation delivered by helmet vs. standard face mask. Intensive Care Med 29:1671–1679CrossRefPubMedGoogle Scholar
  56. 56.
    Tyburski JG, Collinge JD, Wilson RF et al (1999) Pulmonary contusions: quantifying the lesions on chest X-ray films and the factors affecting prognosis. J Trauma 46:833–838CrossRefPubMedGoogle Scholar
  57. 57.
    Peter JV, Moran JL, Phillips-Hughes J et al (2002) Noninvasive ventilation in acute respiratory failure—a meta-analysis update. Crit Care Med 30:555–562CrossRefPubMedGoogle Scholar
  58. 58.
    Joshi N, Localio AR, Hamory BH (1992) A predictive risk index for nosocomial pneumonia in the intensive care unit. Am J Med 93:135–142CrossRefPubMedGoogle Scholar
  59. 59.
    Tejada AA, Bello DS, Chacon VE et al (2001) Risk factors for nosocomial pneumonia in critically ill trauma patients. Crit Care Med 29:304–309CrossRefGoogle Scholar
  60. 60.
    Agarwal R, Aggarwal AN, Gupta D et al (2005) Non-invasive ventilation in acute cardiogenic pulmonary oedema. Postgrad Med J 81:637–643CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2013

Authors and Affiliations

  • D. Chiumello
    • 1
    • 2
    Email author
  • S. Coppola
    • 1
  • S. Froio
    • 1
  • C. Gregoretti
    • 3
  • D. Consonni
    • 4
  1. 1.Dipartimento di Anestesia, Rianimazione (Intensiva e Subintensiva) e Terapia del DoloreFondazione IRCCS Ca’ Granda-Ospedale Maggiore PoliclinicoMilanItaly
  2. 2.Dipartimento di Fisiopatologia Medico-Chirurgica e dei TrapiantiUniversità degli Studi di MilanoMilanItaly
  3. 3.Dipartimento di Emergenza e Accettazione, CTO-Maria AdelaideCittà della Salute e della ScienzaTurinItaly
  4. 4.Unità Operativa di EpidemiologiaFondazione IRCCS Ca’ Granda-Ospedale Maggiore PoliclinicoMilanItaly

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