Adherence to Chest Wall Trauma Guidelines Reduces Critical Care Burden Across Ventilation Phenotypes: A Two-Era Cohort Study

Abstract Purpose To determine whether a structured, guideline-informed chest wall trauma pathway was associated with lower ICU burden, and whether this differed by the indication for ventilation. Methods We retrospectively compared ICU-managed patients at a single center in Era 1 (2013–2017; mainly nonoperative care) and Era 3 (2023–2025; after pathway implementation), excluding the COVID-19-affected transitional Era 2. The primary outcome, restricted mean ICU time through day 28, was analyzed by adjusted pseudo-observation regression. Ventilation phenotype (chest-wall related vs extrathoracic) was the predefined effect modifier; surgical stabilization of rib fractures (SSRF) was modeled as a time-dependent exposure. Results Among 181 ICU-managed patients, median ICU stay was 7 days in both eras, but Era 3 was associated with 3.42 fewer adjusted ICU days (95% CI, − 5.96 to − 0.88; p = 0.008) despite more severe thoracic injury. The reduction was − 6.23 days with chest-wall related ventilation (n = 67; p = 0.001) and − 2.29 days with extrathoracic ventilation (n = 100; p = 0.170); the era × phenotype interaction was significant for ventilator days (p = 0.040) but not ICU time (p = 0.067). SSRF associations were also phenotype-dependent (interaction p = 0.003 for ICU time, p = 0.010 for ventilator days); in the chest-wall related phenotype, SSRF was associated with faster ICU exit (HR, 2.50; p = 0.014), faster ventilator liberation (HR, 3.35; p = 0.002) and less pneumonia (46.7% vs 75.7%; p = 0.022). Blinded phenotype re-adjudication (κ = 0.84) did not materially change the interaction estimates. Conclusion The pathway was associated with lower adjusted ICU burden, concentrated in patients ventilated because of chest wall injury. It cannot be attributed to SSRF alone, and ventilation phenotype merits prospective evaluation.