Every year, over 60,000 older adults in the UK are hospitalised after a fall, and more than 20% of those admitted to major trauma centres have a chest injury. Rib fractures make it painful to breathe deeply, which can lead to lung collapse, poor secretion clearance, and pneumonia. Incentive spirometers—simple handheld devices that guide patients through sustained deep breaths—are widely used after surgery, but their effectiveness for older adults with rib fractures has never been tested in a robust trial. This trial will recruit 276 patients aged 65 and older from 12 UK trauma centres. Half will receive usual care plus an incentive spirometer; the other half will receive usual care alone. The primary outcome is whether the device reduces new pulmonary complications within five days. If the spirometer proves effective, it could become a cheap, low-tech tool to prevent serious lung infections in a vulnerable, growing population. If it does not, the trial will prevent unnecessary spending on a device that offers no benefit. Either way, the results could inform national guidelines from NICE and the Chest Wall Injury Society, shaping how thousands of older patients are treated each year.
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Research Question: For patients aged ≥ 65 years, does usual care and incentive spirometry after rib fracture reduce the incidence of pulmonary complications compared to usual care at 5 days? Background: Over 60,000 patients aged over 65 years are admitted to UK hospitals each year having sustained injury after a fall (22). In those admitted to Major Trauma Centres over 20% have sustained a chest injury (12). Pain from rib fractures, and underlying lung injuries, impacts the mechanics of breathing. This results in ineffective ventilation, lung collapse, and impaired cough/secretion clearance all of which increase the risk of pulmonary complications (24). Incentive spirometers are simple handheld devices that encourage patients to take sustained deep breaths to increase lung volume, optimise collateral ventilation and mobilise secretions. The use of incentive spirometers to prevent pulmonary complications has been evaluated extensively in the surgical population post-operatively but not in patients with rib fractures. The surgical literature has shown little to no benefit but is of poor methodological quality. It also lacks a focus on older adults who we believe could see greater benefit due to their higher risk of pulmonary complications. One small randomised controlled trial has compared incentive spirometry and usual care in patients with rib fractures and observed a significant reduction in pulmonary complication rates (8). Aims: To determine whether usual care and incentive spirometry is clinically effective compared to usual care for older adults admitted with rib fractures. Objectives: Primary: To compare the effect on pulmonary complications of usual care and incentive spirometry compared with usual care 5 days post randomisation. Secondary: To compare the effect on patient reported outcome measures of breathlessness and pain 5 days post randomisation. Methods: A prospective multicentre parallel group randomised controlled superiority trial. Participants will be recruited from 12 UK sites (Major Trauma Centres and Trauma Units). 276 older adults with rib fracture(s) will be randomised 1:1 to either usual care and incentive spirometry (intervention) or usual care (control). The primary outcome is onset of new pulmonary complications within 5 days of randomisation. Secondary outcomes explore the clinical effectiveness of incentive spirometry. Timelines for Delivery: Total 26 months. Set up – months 0-7; recruitment - months 8-19; follow-up - 20; analysis and dissemination - months -21-26. Anticipated impact and Dissemination: Results will be published in a high impact medical journal and disseminated through relevant conferences and professional physiotherapy networks. We will work with our PPI group, and expert advisory panel, to determine the most desirable means to communicate and share findings with participants, consultees and the public. If appropriate, we will seek for findings to be incorporated into relevant national guidelines (such as the Chest Wall Injury Society and NICE Rehabilitation after Trauma) to support practice change.
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