Application of the Nuss procedure for flail chest following cardiopulmonary resuscitation: a case report

Introduction

The Nuss procedure is a minimally invasive surgical procedure used for pectus excavatum (1). However, there are limited reports on its application in patients with multiple rib fractures resulting in flail chest. In this study, we describe the case of a patient who experienced ventricular fibrillation (VF) owing to acute myocardial infarction and underwent cardiopulmonary resuscitation (CPR), followed by the insertion of a Nuss bar to treat a flail chest caused by multiple rib fractures post-CPR. Van Wijck et al. compiled 74 studies of CPR-related injuries and examined 16,629 patients who underwent CPR. After CPR, 60% of patients sustained some kind of CPR-related injury. Rib fractures were the most common, accounting for 55% of cases (2).

The patient’s respiratory condition improved significantly after the procedure, but bilateral pneumothorax occurred following the removal of the Nuss bars. The Nuss procedure is an effective method of treatment for flail chest after CPR, but precautions are essential to prevent complications such as pneumothorax during bar removal. We present this case in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-25-23/rc).

Case presentation

A 72-year-old woman had presented to the emergency department with respiratory distress. She had collapsed at home owing to VF caused by acute myocardial infarction. Her daughter had performed CPR and she subsequently underwent cardiac catheterization and coronary artery stenting on the same day. Three weeks later, her ejection fraction recovered to 40%, but she was referred to our department owing to dyspnea caused by a flail chest following CPR. Being an elderly woman, the supporting tissues of the thorax had weakened, and she had a pronounced flail chest, a labored breathing pattern, and severe respiratory distress. In addition, even with the administration of 5 L/min of oxygen, she was still only able to maintain an SpO₂ of around 95%, therefore it was determined that surgery was indicated. Given the severity of the flail chest and the weakening of the supporting tissues of the thorax, it was deemed that reinforcement with a rib plate alone would be insufficient. Although there is the disadvantage that cardiac massage would become difficult, the cardiologist determined that cardiac function had stabilized after stent placement and that the likelihood of cardiac massage being necessary was extremely low, and therefore it was determined that repair using the Nuss method would be preferable.

Computed tomography (CT) revealed multiple fractures involving the second to sixth ribs bilaterally and a depression of the anterior chest wall (Figure 1). To address the dyspnea caused by the flail chest, two Nuss bars were inserted and fixed using the Nuss method under general anesthesia. Following the insertion, the patient’s respiratory condition improved, and she was discharged without oxygen therapy on postoperative day (POD) 43. The surgery was deemed effective because the patient’s respiratory distress improved significantly after surgery and oxygen administration could be discontinued.

Figure 1 Computed tomography scan after cardiopulmonary resuscitation. Multiple rib fractures (thin yellow arrows) in the second to sixth ribs bilaterally and a depression (thick yellow arrow) of the anterior chest wall are shown.

Eight months later, CT imaging showed improvement in the collapse of the anterior chest wall, and bone fusion was confirmed (Figure 2). During removal of the Nuss bar, it was difficult to obtain a sufficient view due to significant adhesions around the bar. After removal, the anterior chest wall collapse and flail chest improved (Figure 3), but bilateral pneumothorax developed (Figure 4A). Bilateral thoracic drains were inserted (Figure 4B), leading to resolution of the pneumothorax. The patient was discharged on POD 34. One year after CPR, the patient was living independently. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s), and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Figure 2 Chest X-ray and computed tomography after the Nuss procedure. Eight months after the insertion of the Nuss bars, the collapse of the anterior chest wall improved and the findings of bone fusion were confirmed.

Figure 3 Computed tomography after removal of the Nuss bars. Even after the Nuss bars were removed, the collapse of the anterior chest wall and the flail chest improved. The thick yellow arrow indicates the sternal depression.

Figure 4 Imaging findings after removal of the Nuss bars. (A) Chest X-ray after removal of the Nuss bars. Bilateral pneumothoraces after removal of the Nuss bars are shown. The thin yellow arrows indicate rib fractures. (B) Chest X-ray after improvement of the pneumothorax. Bilateral thoracic drains were inserted for bilateral pneumothoraces after removal of the Nuss bars.

Discussion

Sawyer et al. conducted a systematic review and meta-analysis comparing surgical and conservative treatment for rib fractures. Surgical fixation showed significantly better results in terms of intensive care unit (ICU) stay, mechanical ventilation, mortality, pneumonia, and tracheotomy. Subgroup analysis confirmed that surgical fixation was most effective in patients with flail chest and in patients who underwent surgical fixation within 72 hours (3). The usefulness of surgical treatment for flail chest, such as this case was demonstrated. In cases with significant thoracic instability that are difficult to control with conventional rib plate fixation alone, it may be appropriate to consider applying the Nuss procedure. However, since cardiac massage becomes difficult after the Nuss procedure, the application of this method must be carefully considered.

Dobroniak et al. analyzed 29 surgical treatment cases of flail chest after CPR, of which 4 (13.8%) died after surgery. Detailed preoperative preparation and surgical planning are essential. Open reduction and minimally invasive osteosynthesis using individually adjusted low-profile locking plates and/or intramedullary splints during surgery provides a minimally invasive surgical strategy. In addition, transsternal fixation of the bilateral fifth ribs can significantly restore physiological respiratory mechanics immediately after surgery and improve the success rate of weaning (4). Multiple fractures, including the bilateral fifth ribs and flail chest, may be more effectively treated with surgical treatment, and the site and degree of rib fractures, as well as the degree of flail chest and respiratory status, may be important factors in considering surgical indications.

Although reports of the Nuss technique for flail chest after CPR are rare, the report by Lee et al. (5) and this case demonstrated that the technique was minimally invasive and ensured high thoracic stability for flail chest after CPR. It is considered that this technique can be added as one of the treatment methods if the appropriate cases are carefully selected.

The Nuss procedure for pectus excavatum has been shown to improve respiratory status and is considered excellent, especially for the fixation of the anterior chest wall (6,7). However, pneumothorax is a common complication associated with the removal of the Nuss bar following the procedure for pectus excavatum and warrants attention (8). Camacho et al. reported that 9 of 40 (22.5%) patients who underwent Nuss bar removal for pectus excavatum experienced 10 complications: five patients had one bar removed, whereas the remaining four had two bars removed. The complications included two cases of wound dehiscence that healed without surgical intervention, two keloid scars (one requiring cosmetic surgery), two surgical site infections (both treated with antibiotics), two pneumothoraces (one accompanied by pleural effusion, which resolved spontaneously), and one case of severe bleeding controlled with angiography and endovascular embolization (8). Additionally, Skrzypczak et al. reported a significantly higher incidence of pneumothorax with two Nuss bars compared to one (9). In the present case, two Nuss bars were inserted, potentially increasing the risk of pneumothorax. Nakagawa et al. demonstrated that the procedure was minimally invasive and effective in their study of 10 cases of flail chest treated with the Nuss procedure (10).

However, at least two cases of sudden cardiac arrest following the Nuss procedure for pectus excavatum have been reported. Nakahara et al. emphasized the following considerations when applying the Nuss procedure for pectus excavatum (11).

• Fatal complications are likely caused by structural or functional cardiac changes induced by the Nuss bar. Therefore, detailed cardiac evaluations using electrocardiography and echocardiography should be performed preoperatively.
• The potential for arrhythmia during Nuss bar placement and removal necessitates careful monitoring. If arrhythmia occurs, the Nuss bar should be promptly removed.
• If complications are suspected, intraoperative transesophageal echocardiography should be performed to confirm whether they result from direct trauma or a compression of cardiac structures by the Nuss bar. It is important to note that chest compressions during CPR may be less effective after the insertion of the Nuss bar. Cases have been reported where CPR was performed while the Nuss bar in place, with varying outcomes. In this case, we conducted a thorough discussion with the cardiology department before inserting the Nuss bar. A stent was placed for the myocardial infarction that caused VF, and the patient’s hemodynamics was stabilized. Given the extremely low likelihood of cardiac arrest and the urgent need to improve the patient’s respiratory condition for rehabilitation, we proceeded with the Nuss procedure. Sawyer et al. reported that surgical treatment for multiple rib fractures and flail chest showed good postoperative outcomes within 72 hours. However, in this case, stabilization of cardiac function was the top priority, so surgical treatment using the Nuss method was performed 3 weeks after CPR, waiting for cardiac function to recover (3).

In the present study, minimally invasive improvement of the flail chest was achieved using the Nuss procedure in a high-risk patient after CPR. This is a rare reported case of a flail chest treated with the Nuss procedure post-CPR, resulting in a favorable long-term prognosis. However, the patient developed bilateral pneumothorax after Nuss bar removal. Inflammation associated with multiple rib fractures may predispose patients to pleural adhesions, increasing the risk of complications during removal. Careful attention to pleural adhesion detachment is essential when removing the chest wall plate, even with the addition of a thoracoscopic port.

Conclusions

To our knowledge, this is a rare report of the application of the Nuss procedure to flail chest after CPR. Although bilateral pneumothorax occurred after Nuss bar removal, the patient’s respiratory condition improved significantly after the procedure, resulting in a good prognosis. Even after the Nuss bars were removed, the collapse of the anterior chest wall and flail chest remained resolved.

Acknowledgments

We would like to thank Editage (http://www.editage.com) for the English language editing.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-25-23/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-25-23/prf

Funding: This case was supported by JSPS KAKENHI (22K09013) to Y.I.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-25-23/coif). Y.I. received funding from JSPS KAKENHI (22K09013). The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s), and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Nuss D, Kelly RE Jr, Croitoru DP, et al. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg 1998;33:545-52. [Crossref] [PubMed]
2. Van Wijck SFM, Prins JTH, Verhofstad MHJ, et al. Rib fractures and other injuries after cardiopulmonary resuscitation for non-traumatic cardiac arrest: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2024;50:1331-46. [Crossref] [PubMed]
3. Sawyer E, Wullschleger M, Muller N, et al. Surgical Rib Fixation of Multiple Rib Fractures and Flail Chest: A Systematic Review and Meta-analysis. J Surg Res 2022;276:221-34. [Crossref] [PubMed]
4. Dobroniak CC, Lesche V, Olgemöller U, et al. Surgical strategy for chest wall reconstruction secondary to cardiopulmonary resuscitation versus post-traumatic. Eur J Trauma Emerg Surg 2025;51:122. [Crossref] [PubMed]
5. Lee SK, Kim DH, Lee CH. Use of a pectus bar for surgical stabilization of cardiopulmonary resuscitation induced flail chest. J Card Surg 2020;35:2064-6. [Crossref] [PubMed]
6. Ke S, Duan H, Cai Y, et al. Thoracoscopy-assisted minimally invasive surgical stabilization of the anterolateral flail chest using Nuss bars. Ann Thorac Surg 2014;97:2179-82. [Crossref] [PubMed]
7. Kim JJ, Kim YH, Moon SW, et al. Nuss procedure for severe flail chest after blunt trauma. Ann Thorac Surg 2015;99:e25-7. [Crossref] [PubMed]
8. Camacho JP, Boudou R, Lobos PA, et al. Complications after Nuss bar removal procedure for pectus excavatum. Analysis and proposal of a safety protocol. Cir Pediatr 2024;37:55-60. [Crossref] [PubMed]
9. Skrzypczak PJ, Rozmiarek M, Dobiecki T, et al. A large single-center propensity score-matched cohort study on outcomes and complications based on the number of corrective bars used in the Nuss procedure. Sci Rep 2024;14:28285. [Crossref] [PubMed]
10. Nakagawa T, Masuda R, Yamada S, et al. Minimally invasive surgery for anterior flail chest injury in the acute phase: series of 10 cases. Gen Thorac Cardiovasc Surg 2023;71:403-8. [Crossref] [PubMed]
11. Nakahara O, Ohshima S, Baba H. Cardiopulmonary arrest during the Nuss procedure: case report and review. Acute Med Surg 2015;2:250-2. [Crossref] [PubMed]