dd

good work mate. i'll stick with your numbers

1. you're right about shallow breathing in response to rib fracture pain... it's pretty much a guarantee here. his rate is high because his PaO2 has dropped as a result of the collapse.

in the short term, using a very high FiO2 and losing your nitrogen pressure in the alveoli is probably not going to be a great concern. i've never heard anyone even consider this in the acute situation. it doesn't help but i think the other forces/actions/effects involved are much, much greater. good thought though. probably wouldn't need to be as high as 100% for this man. he'll immediately feel a lot better and may then be more compliant with the rest of your treatment than if he remains hypoxic.

2. for rib fractures i like the epidural idea. sometimes you can do a local/regional nerve block. in any case you want something fairly strong but would be keen to avoid morphine for its respiratory drive suppressing action. fentanyl through an epidural, ideally a PCA version would probably be great.

i'm sure the medical staff would have already prescribed paracetamol for his temp (slight help for pain too) and will await a sputum sample from yourself to send for urgent culturing. he may be started on antibiotics by them prior to receiving a sample based on "most likely" pathogens causing his infection.

your ideas about need for analgesia are right on.... deeper breaths are going to be the key here. multiple knock-on effects. i don't think there'd be a huge improvement in his ABGs just with this, though everything helps.


3. certainly you'll want to turn him intermittently but in the immediate situation you'd be just wanting him on his left side. he may not tolerate lying dead flat, so head up a bit is perhaps better.

you'll want to position him like this to put that lung on stretch - distending forces can assist with opening up collapsed alveoli. there's also increased expansion of teh uppermost lung's adjacent chest wall. there's another treatment idea i have to combine with this (see below).

he could possibly tolerate lying on the fractured rib side, although i doubt it. he'd also be lying on his chest drain which (a) risks kinking it and (b) would probably be uncomfortable. until his collapse has resolved i wouldn't be putting him on that side. for pressure area care, i'd just switch between left s/l and supine. i'd treat him with head of bed flat or close to, but i wouldn't leave him down like that. i'd put the head of the bed up fairly high so he's in high side-lying or supine head up 60 degrees or so.

4. ACBT.... yes. let's now see what he can do with analgesia on board and in this position.
i don't do percussion on anyone other than patients with cf or bronchiectasis, ie those with large amounts of peripheral secretions with impaired clearance. otherwise i think it's a waste of time and the evidence for it is weak.
chest wall vibrations can work well and could be an option here although if he's in side-lying wouldn't work on the side that is down.

5. the fact that he's got a big smoking history doesn't necessarily mean anything about the characteristics of the secretions he has. it will probably mean he has increased secretions and perhaps the person who made up this scenario was thinking that reduced clearance of these secretions because of shallow breathing/pain etc has led to infection... sputum plugging... collapse ?

6. intubation? not yet
manual hyperinflation is not contraindicated - his HPTx has been drained. the drain is not bubbling, so you can use techniques that involve positive pressure. question here would be how? via a facemask? very uncomfortable. don't worry much about stating ventilator settings - that is indeed beyond what you need to know.
what would probably be ideal is intermittent positive pressure breathing (IPPB, examples include Bennett and Bird). not sure if you're familiar with this. it uses positive pressure on inspiration, but there is no peep. it can augment tidal volumes, reverse areas of atelectasis/collapse and mobilise secretions. even better, you can nebulise saline at the same time. this last bit won't be nearly as effective as using a standard nebuliser which you would consider if his secretions are tenacious. the fact that it uses positive inspiratory pressure goes perfectly with the positioning. in left side lying it will preferentially go to the uppermost lung which is just where you want it.

6a. non-invasive ventilation would be an option before invasive i think. cpap would be more appropriate than bipap. i'm sure you've got stuff to read on cpap. one problem is that cpap circuits are very rarely humidified and you can get impaction of secretions because of the high flowrates and dry air. i don't think this will be necessary if everything else works.

6b. suctioning if he can't do a strong huff/cough. you might consider inserting a nasopharyngeal airway if he's going to need repeated suctioning.

6c. yes, intubate if all this fails. in my experience patients with rib fractures that need intubation are ones who just cannot get adequate pain relief and slip into worsening atelectasis/secretion retention etc because they can't take deep breaths and/or cough effectively.

7. passive movements? why not active? he should be able to do active limb ex's in the bed on his own, though limit this whilst he's sydpnoeic. progress as soon as his chest problems have become less severe. if his gas exchange has improved a lot and his work of breathing is right down get him mobilising as able - use a walking aid, oxygen and your assistance as needed.