Rib fractures are among the most common injuries identified in blunt trauma patients. Morbidity increases with increasing age and increasing number of rib fractures. The use of noninvasive ventilation has been shown to be helpful as a rescue technique avoiding intubation in patients who have become hypoxemic but little data with regard to its use to prophylactically prevent worsening respiratory status are available. We developed a chest trauma protocol for our "elderly" (>45 years) trauma patients and sought to determine whether this would improve pulmonary outcomes. We retrospectively reviewed our elderly chest trauma patients one year before (CTRL) and nine months after implementation (STU) of the chest trauma protocol. The protocol consisted of intravenous narcotics, oral nonsteroidal anti-inflammatory drugs, prophylactic noninvasive ventilation, and measurements of incentive spirometry. In the control year, there were 176 patients meeting study criteria, whereas 140 met the criteria in the STU group. The CTRL group had 11 unplanned ICU admissions (rate 0.063), six unplanned intubations (rate 0.034), and eight patients diagnosed with pneumonia (rate 0.045). These rates decreased in the STU group to two unplanned ICU admissions (0.014, P = 0.044), one unplanned intubation (rate 0.007, P = 0.138), and no patients with pneumonia (0.0, P = 0.010). Our chest trauma protocol has significantly decreased adverse pulmonary events in our older blunt chest trauma population with multiple rib fractures. This protocol has become our standard procedure for patients older than 45 years admitted with rib fractures.