Multiple rib fractures usually cause significant pain and limited chest-wall excursion and thus restrict the patient’s ability to cough and breathe deeply. This results in poor clearance of secretions, atelectasis, and decreased functional residual capacity with the clinical correlates of this being hypoxia, ventilation-perfusion mismatches, and respiratory failure. In the elderly in particular, this results in increased length of ventilator days, intensive care unit (ICU) length of stay, and pneumonia rates. As few as three rib fractures have been associated with an approximate 20% mortality and a 30% risk of developing pneumonia in those more than 65 years of age. In fact, the risk of mortality increases to almost 35% and the pneumonia rate to greater than 50% when these patients sustain six or more rib fractures. However, patients age 45 and older with more than four rib fractures are also at a dramatically increased risk of pulmonary complications and death. Therefore, aggressive pulmonary toilet and adequate pain control (as evidenced by the ability to cough, breathe deeply, and reproducibly perform large inspiratory volumes on spirometry) should not be limited to the elderly trauma patient with rib fractures.