The Case

A 71-year-old man presents to the emergency department after a ground-level fall. He has a history of hypertension and benign prostatic hypertrophy. His vital signs are all normal, and he declines any pain medication. Investigations reveal rib fractures on the right side. Guidelines recommend admitting him, but he would like to go home.

Clinical Question

In patients 60 years of age and older and with three or more rib fractures, can spirometry identify those who can safely be discharged home from the emergency department?

Background

Older patients often present to the emergency department with traumatic rib fractures. These injuries can lead to life-threatening complications such as pneumonia, pneumothorax, and acute respiratory distress syndrome. The Western Trauma Association guidelines recommend admitting patients older than 65 years of age with two or more rib fractures to an ICU or other step-down monitored setting (see Figure 1).¹

There are some studies suggesting that early spirometry may be a useful prognostic indicator in patients with multiple rib fractures.² Spirometry measurements include forced vital capacity (FVC), peak expiratory flow (PEF), forced expiratory volume in 1 second (FEV1), and negative inspiratory force (NIF). While PEF has not been demonstrated to be closely correlated with patient outcomes, it remains possible that spirometry could be used to identify patients who could avoid unnecessary hospitalization and be discharged home.³ However, these studies were all limited by their retrospective observational nature.

Reference: Schuster KM, Sanghvi M, O’Connor R, et al. Spirometry not pain level predicts outcomes in geriatric patients with isolated rib fractures. J Trauma Acute Care Surg. 2020;89(5):947-954.

• Population: Patients 60 years of age and older admitted to the hospital with at least three rib fractures within 24 hours of injury.
• Exclusions: Injury occurred greater than 24 hours before presentation, significant additional musculoskeletal injury, or cognitive impairment and able to cooperate with testing.
• Exposure: Spirometry measuring (FVC, FEV1, and NIF).
• Comparison: Handgrip strength to assess frailty and pain measured on a visual analog scale (VAS).
• Outcomes:
  • Primary Outcomes: Discharge disposition and length of stay (LOS).
  • Secondary Outcomes: Mortality, pneumonia, intubation, unplanned transfer to higher level of care, and readmission (within 30 days).
  • Authors’ Conclusions

“Spirometry measurements early in the hospital stay predict ultimate discharge home, and this may allow immediate or early discharge. The impact of pain control on pulmonary function requires further study.”

Key Results

There were 346 patients over the age of 60 with isolated rib fractures requiring admission to the hospital. Of those, 260 met the exclusion criteria. This resulted in a cohort of 86 patients with a mean age of 77 years that was 50 percent female. Just over half (45 of 86) were admitted to the step-down unit, 19 of 86 (22 percent) to the ICU, and 22 of 86 (26 percent) to the surgical floor. The mechanisms of injury were falls (54 percent), motor vehicle collisions (45 percent), or motorcycle collisions (1 percent). The median number of fractured ribs was five. Pneumothorax was present in 5 percent and hemothorax in 4 percent of the patients included in the analysis. One patient out of 86 died (1.2 percent).