Pulmonary contusion
Pulmonary contusion is a bruising (contusion) of the lung which occurs as a result of chest trauma. The injury causes bleeding into the tissue of the lung but is not a pulmonary laceration, which is a frank tear in the lung tissue. Contusion causes an accumulation of fluid (edema) and blood in the alveoli (the air sacs where gases are exchanged) and the interstitial space of the lung.[1] Pulmonary contusion may interfere with gas exchange in the lungs[2] and can therefore result in hypoxia (inadequate oxygen levels), pneumonia, or acute respiratory distress syndrome. The severity can range from mild to potentially deadly.[3]
Lung contusions, which may be caused by blunt or penetrating trauma, were first described during World War II in people who had suffered blast injuries. In civilians, the injury is most often due to motor vehicle accidents. Pulmonary contusions rarely occur in isolation and are usually accompanied by other traumatic injuries. Signs and symptoms include indications that the body is not receiving enough oxygen, such as cyanosis, and direct effects of the physical trauma such as chest pain and coughing up blood. Clues from the injurious event, physical examination and chest radiography are used in the diagnosis of the injury.[4]
The contusion commonly heals on its own with supportive care, but may be associated with complications requiring intensive care. The presence or absence of pulmonary contusion plays a key role in determining whether an individual will die or suffer ill effects as the result of an injury.[5] The most common serious injury to occur in association with thoracic trauma, pulmonary contusion is found in 30–75% of severe cases of chest injury[6] and in 25–35% of all blunt chest trauma.[7] Of people who have multiple injuries with an injury severity score of over 15, pulmonary contusion occurs in about 17%.[8] It is also the most common chest injury in children,[9] who are at especially high risk for the injury because their compliant chest walls allow force to be transmitted to the lung rather than being absorbed by the chest wall.[10]
Signs and symptoms
Signs and symptoms of pulmonary contusion include respiratory distress, low blood oxygen saturation, chest pain, coughing,[1] and shortness of breath.[11] The area around the contusion may be tender.[10] Up to half of people with pulmonary contusion have hemoptysis (coughing up blood or bloody sputum).[1] People with severe contusions may have bronchorrhea (the production of watery sputum), and a reduction in cardiac output (the volume of blood pumped by the heart).[5] Hypotension (low blood pressure) and cyanosis (bluish color of the skin and mucous membranes indicative of hypoxemia, or inadequate blood oxygen) are commonly associated with pulmonary contusion,[6] and tachypnea (rapid breathing) and tachycardia (a rapid heart rate) are other signs.[12] With severe contusions, breath sounds may be decreased, or abnormal breath sounds called rales may be present.[6] These two signs, as well as wheezing, may be present for 24 hours.[1]
The more severe the injury, the more quickly symptoms become apparent.[5] People with mild contusions may have no symptoms at all; as many as half of pulmonary contusions are asymptomatic at the initial presentation.[13] Symptoms of severe contusions may occur by three or four hours after the injury.[5] Pulmonary contusion develops over 24 hours,[9] and tends to worsen slowly over a few days.[14] Hypoxemia typically becomes progressively worse 24 to 48 hours after injury.[15] However, deterioration may also be rapid.[6] Since difficulty breathing may take time to develop, and there may initially be no signs or symptoms, whenever someone suffers an injury involving force sufficient to cause pulmonary contusion, it is assumed that the injury may have occurred.[16]
Associated injuries
Pulmonary contusion requires a large amount of force to cause and its presence can therefore be used to gauge the severity of an injury.[17] Thus, a person who has been injured with enough force to have suffered a pulmonary contusion is likely to have other types of injuries as well.[16] As many as 75% of pulmonary contusions are accompanied by other chest injuries, such as rib fracture, hemothorax, pneumothorax, and flail chest;[18] when flail chest occurs, it is usually associated with internal chest injury, especially pulmonary contusion.[19] Pulmonary contusion may also be associated with injuries to the chest wall such as bruising[9] and fracture of the sternum,[3] and is frequently found underlying fracture sites.[20] However, in children, the lungs may be contused without associated rib fractures because the chest wall is flexible, and bones may bend rather than break.[15]
Pulmonary lacerations, in which lung tissue is torn or cut, may also result from blunt and penetrating forces in the same injury that causes a pulmonary contusion and may be associated with the latter injury.[4][6] The presence of a contusion may mask that of a laceration on chest X-ray.
Causes
Pulmonary contusion usually occurs when the moving chest strikes an object and decelerates rapidly;[1] about 70% of cases result from motor vehicle collisions, and falls are another cause.[4] The injury can also be caused by explosions; the organs most vulnerable to blast injuries are those that contain gas, such as the lungs.[8]
In addition to blunt trauma, penetrating trauma can also cause pulmonary contusion.[16] Penetration by a rapidly moving projectile is accompanied by a shock wave capable of causing a contusion, which usually surrounds the path along which the projectile traveled through the tissue.[3] However, except with shotgun wounds, pulmonary contusions that accompany gun and knife wounds are not usually severe enough to have a major effect on outcome,[17] and penetrating trauma causes less widespread lung damage than does blunt trauma.[4]
The physical mechanisms behind pulmonary contusion are poorly understood, but three possible mechanisms have been suggested: the spalling effect, the implosion effect, and the inertial effect.[4] In the spalling effect, lung tissue bursts or is sheared where the shock wave meets the lung tissue.[8] The spalling effect occurs where gas meets liquid, areas with large differences in density.[8] After the shock wave passes, the gas in the lung may expand beyond its original volume and may tear alveoli; this is the implosion effect.[4][21] In the inertial effect, differences in the rates of acceleration or deceleration cause the alveoli to be sheared from the bronchial structures, which have a different density.[4] The inertial effect is similar to diffuse axonal injury in head injury.[13]
The amount of energy that is transferred to the lung is determined in a large part by the compliance of the chest wall.[3] Children have more flexible chests because they have more elastic ribs and less ossification of their intercostal cartilage than adults do.[10] Therefore, their chest walls can bend, absorbing less of the energy from the injurious force and transmitting more of it to the underlying organs.[10][22] The more bony chest walls of adults absorb the force themselves rather than transmitting it.[22] Thus children commonly get pulmonary contusions without fractures overlying them, while elderly people are more likely to suffer fractures than pulmonary contusions because the bones are more likely to break than to bend.[3]
Pathophysiology
The injury is characterized by microhemorrhages, tiny bleeds associated with the traumatic separation of alveoli from airway structures and blood vessels.[3] The force involved in the trauma tears the membrane between alveoli and capillaries.[3] With more severe trauma, there is a greater amount of edema, bleeding, and tearing of the alveoli.[4] In contusions, injured capillaries leak fluid into the tissues around them.[19] In pulmonary contusions, the capillary alveolar membrane and small blood vessels may be damaged and leak blood and fluids into the alveoli and interstitial space.[5] Fluid leakage may fill the alveoli with proteins, and alveoli may collapse as a result of the edema and bleeding.[3]
An area of bleeding is commonly surrounded by an area of edema.[3] According to animal studies, blood initially collects in the interstitial space, and then edema occurs by an hour or two after injury.[21] Lung water increases over the first 72 hours after injury.[8] Damage to the lung tissue usually peaks by a day after the injury and clears up within a week.[8]
Components of blood in the lung cause inflammation.[9] Monocytes enter the area as part of the inflammatory process.[3] In response to inflammation, the lungs produce excess mucous, which can plug parts of the lung and lead to their collapse.[3]
Pulmonary contusion can cause uninjured parts of the lung to consolidate, alveoli to collapse, and atelectasis to occur.[20] The alveoli in the injured area thicken over a period of hours after the injury, and may become consolidated.[3] A decrease in the amount of surfactant produced may also contribute to the collapse and consolidation of alveoli.[7]
Contused lungs become stiff, losing compliance.[1] Since the lungs are less compliant, more pressure may be needed when ventilating the patient to fill the lungs with the same volume of air.[20] Pulmonary contusion causes a mismatch between ventilation and perfusion, thereby causing hypoxemia.[14] The ratio of ventilation to perfusion is normally about one, but in pulmonary contusion, there is not enough oxygen available to saturate the hemoglobin, and the blood leaves the lung without being fully oxygenated; the ventilation/perfusion ratio is less than one.[23] Intrapulmonary shunting increases and may contribute to the mismatch between ventilation and perfusion.[20] The vascular resistance increases in the contused part of the lung, leading to a decrease in the amount of blood that flows into it.[24] The larger the area of the injury, the more severe respiratory compromise is likely to be.[4] As the mismatch between ventilation and perfusion grows, blood oxygen saturation is reduced.[23] If it is severe enough, a mismatch in ventilation and perfusion cannot be corrected just by giving supplemental oxygen; thus it is an important cause of death in people who suffer trauma.[23]
Pulmonary contusions usually occur near solid structures in the chest such as the liver, the heart, and the ribs.[5] The pulmonary bruising usually occurs at the site of impact, but, as with traumatic brain injury, a contrecoup contusion may occur at the site opposite the impact as well.[3]
Diagnosis
To diagnose pulmonary contusion, health professionals use radiography, information about the event that caused the injury, and information from a physical examination.[4]
Chest X-ray is useful for detecting pulmonary contusion and may be used to confirm a diagnosis that is made using clinical signs.[8] However, though chest radiography is an important part of the diagnosis, it is not very sensitive in detecting the injury early on.[4][20] In a third of cases, pulmonary contusion is not visible on the first chest radiograph performed.[25] It takes an average of six hours for the opacification typical of pulmonary contusion to show up on a chest X-ray,[25] the injury may not be apparent on chest X-ray for 12–24 hours,[1] and the extent of damage may not be apparent until 24-48 hours after the injury.[9] Signs of pulmonary contusion detectable by radiography are usually gone by 10 days after the injury.[4]
A classic pulmonary contusion sign is a "patchy infiltrate" seen on chest X-ray.[16] This sign occurs due to bleeding into the alveoli.[6] Areas of the chest X-ray may also appear opaque.[20] The contusion does not typically follow the anatomical boundaries of the lobes or segments of the lung.[26] Lung contusion may look similar in an X-ray to aspiration,[22] and the presence of hemothorax or pneumothorax may obscure the injury on X-ray.[17]
CT scanning is more sensitive to pulmonary contusion than chest X-ray is.[6][19] CT may help determine the presence and size of pulmonary contusions, but those that are visible only on CT and not with chest X-ray are usually not severe enough to be important to the patient's health.[9] CT may also be helpful in determining which patients need mechanical ventilation;[8] a larger area of lung that appears contused on CT scan increases the likelihood of the need for ventilation.[22] CT scans may also help differentiate between pulmonary contusions and pulmonary hematomas, which can be hard to tell apart otherwise.[27] Pulmonary hematomas, collections of blood within the lung parenchyma, are thought to develop in between 4 and 11% of pulmonary contusions.[6] Unlike contusions, pulmonary hematomas usually form a mass by two days post-injury.[27] They do not usually cause shunting of blood or interfere with gas exchange, but do increase the risk of infection and abscess formation.[6]
Laboratory findings may also be used in the diagnosis of pulmonary contusion; for example, arterial blood gasses may show insufficient oxygen and excessive carbon dioxide even in someone receiving supplemental oxygen.[20] However, as with other signs, blood gas levels may be normal early in the course of the injury.[16]
Treatment
There is no treatment to speed the healing of a pulmonary contusion;[18] supportive care is the main treatment given.[25] In most cases, the injury does not require surgical intervention.[10] Treatment aims to prevent respiratory failure, ensure that the sufferer receives adequate oxygenation,[7][16] prevent additional injury, and provide supportive care while waiting for the contusion to heal.[18] Decreasing the work necessary to breathe is another part of treatment.[20] Since the condition of people with pulmonary contusion may worsen, they are monitored closely.[19] Monitoring involves keeping track of oxygen saturation[1] and heart and respiratory function.[4] Patients may need nothing more than supplemental oxygen and close monitoring.[16] The oxygen may be warmed and humidified.[23]
Continuous positive airway pressure using a mask fitted tightly to the face may be used to improve oxygenation, but carries the risk of complications such as causing air to enter the stomach and aspiration of stomach contents.[14]
People with signs of inadequate respiration or oxygenation may need to be intubated[25] and mechanically ventilated.[1] Intubation is reserved for when respiratory problems occur,[8] but most significant contusions do require intubation, and it may be done early on.[14] People with pulmonary contusion who are especially likely to need ventilation include those with prior severe lung disease or kidney problems; the elderly; those with a lowered level of consciousness; those with low blood oxygen or high carbon dioxide levels, and those who are going to be operated on and need anesthesia.[23]
High inflation pressures may be needed to oxygenate the blood adequately;[19] lungs that become stiff as the result of pulmonary contusion or its complications such as acute respiratory distress syndrome may need higher pressures to receive normal amounts of air.[14] Positive end-expiratory pressure (PEEP) can prevent alveoli from collapsing on exhalation.[20] PEEP is considered necessary for patients who are ventilated; however, if the pressure is too great it can expand the size of the contusion[4] and injure the lung.[18]
Another important part of treatment is pulmonary toilet,[1][15] use of deep breathing, drainage, and other methods to remove material such as mucus and blood from the airways. Caregivers clear the airway of secretions using suction and encourage the patient to cough and breathe deeply.[25] Chest physical therapy may also be used for the treatment of pulmonary contusion.[22][28] Chest physical therapy makes use of techniques such as breathing exercises, stimulating coughing, suctioning, percussion, movement, vibration, and drainage to rid the lungs of secretions, increase oxygenation, and expand collapsed parts of the lungs.[28]
The administration of fluid therapy for pulmonary contusion is controversial.[23] Excessive fluid in the circulatory system can worsen a pulmonary contusion, but hypovolemia resulting from insufficient fluid has an even worse impact.[9] People who have lost too much blood are at risk of going into shock; for these people, fluid resuscitation is necessary.[23] While fluids have historically been withheld, a lot of the evidence supporting this course of action came from animal studies, not studies with human patients.[9] It is not recommended that fluid therapy be withheld for pulmonary contusion patients who have other injuries.[15] For people who do require large amounts of intravenous fluid, a catheter may be placed in the pulmonary artery to measure the pressure within it.[6]
Pain control is another aspect of care; chest wall injuries may make breathing painful and cause the patient to hypoventilate (breathe inadequately).[20] Insufficient expansion of the chest may lead to atelectasis and may further reduce the oxygenation of the blood.[20] Analgesics can be given to reduce pain.[1]
Animal studies have had conflicting findings on whether steroids increase blood oxygenation and reduce the size of a pulmonary contusion, however they may increase risk for infection and so are not recommended.[8]
People who develop pneumonia as the result of pulmonary contusion are given antibiotics.[4] No studies have yet shown a benefit of using antibiotics as a preventative measure before infection occurs, though some doctors do recommend prophylactic antibiotic use even without scientific evidence of its benefit.[10] However, antibiotics can cause the development of antibiotic resistant strains of bacteria, so their use without a clear need is normally discouraged.[8]
Prognosis and complications
Pulmonary contusion usually resolves by itself[16] but can be associated with long-term respiratory disability.[8] In most cases, pulmonary contusion goes away by five to seven days after the injury without permanent complications.[29] However, severe complications such as acute respiratory distress syndrome (ARDS) may develop.[16] ARDS develops in both lungs in about 50–60% of people with significant pulmonary contusions.[9] One study found that 17% of people with pulmonary contusions alone developed ARDS, while 78% of people with at least two additional injuries developed the condition.[6] A larger contusion is associated with an increased risk of developing ARDS; in one study, 82% of people with a contusion of 20% or more of the lung area developed ARDS, while only 22% of people with less than 20% did so.[25] It is less common for ARDS to develop as a result of pulmonary contusion in children than in adults.[10]
Pneumonia, another potential complication, develops in as many as 20% of people with contused lungs.[10] Contused lungs are less able to remove fluids than uninjured lungs, and bacteria may grow in blood that collects in the alveolar spaces.[9] Contused lungs are less able to rid themselves of bacteria.[8] Intubation and mechanical ventilation further increase the risk of developing pneumonia.[3] As with ARDS, the chances of developing pneumonia increase with the size of the contusion.[25]
Atelectasis and respiratory failure are other potential complications.[9] Longer-term complications include pulmonary fibrosis and loss of lung volume; chronic lung disease may be correlated with the size of the initial injury.[3] One study found that six months after the injury, pulmonary contusion patients had disabling dyspnea associated with fibrosis and reduced oxygenation and functional residual capacity.[8] Dyspnea may persist for an indefinite period.[25] Pulmonary contusion may interfere with an individual's ability to return to work.[3]
Epidemiology
It is difficult to determine the mortality rate of pulmonary contusion because the injury rarely occurs by itself.[4] Usually, deaths of people with pulmonary contusion result from other injuries, commonly traumatic brain injury.[3] The mortality rate of pulmonary contusion is estimated to range from 14–40%, depending on the severity of the contusion itself and on associated injuries.[5] One study found that 35% of people with multiple significant injuries including pulmonary contusion die.[4] In another study, 11% of people with just pulmonary contusions died, while 22% of those with pulmonary contusion associated with other injuries died.[6] Pulmonary contusion is thought to contribute directly to the death in a quarter to a half of multitrauma deaths.[3]
Pulmonary contusions are thought to contribute significantly in about a quarter of deaths resulting from vehicle collisions.[17] An increase in the number of airbags installed in modern cars may be decreasing the incidence of pulmonary contusion.[6]
Since their chest walls are more flexible, children are more vulnerable to lung contusion than adults are,[16] and the injury is more common in children than in adults for that reason.[21] Thus children suffer double the number of pulmonary contusions as adults as a result of forceful impacts, yet have proportionately fewer rib fractures.[10] Pulmonary contusion is equally serious in children and adults.[10]
History
In 1761, Giovanni Battista Morgagni was first to describe a lung injury that was not accompanied by injury to the chest wall overlying it.[8] When explosives were used in war in the early 20th century, more began to be written about lung injury.[8] Studies by D.R. Hooker in 1918 and 1919 showed that lung hemorrhage was an important part of injury due to explosives.[8]
Pulmonary contusion was first described during World War II in people who had been injured in explosions;[3] Buford and Burbank described what they called "wet lung", in which the bronchopulmonary tree accumulated fluid and was simultaneously less able to remove fluid.[8] In the 1960s, the condition began to be more widely recognized in a non-combat context, and symptoms and typical findings with imaging techniques such as X-ray were described.[8] In 1975, a group led by J.K. Trinkle showed that the respiratory insufficiency that occurs in flail chest is most often due to pulmonary contusion, not to the "paradoxical motion" of the flail segment of the chest wall.[24]
See also
References
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Yamamoto L, Schroeder C, Morley D, Beliveau C (2005). "Thoracic trauma: The deadly dozen". Critical Care Nursing Quarterly. 28 (1): 22–40. PMID 15732422.
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Bailey BJ, Johnson JT, Newlands SD, Calhoun KS, Deskin RW (2006). Head and Neck Surgery—Otolaryngology. Hagerstwon, MD: Lippincott Williams & Wilkins. p. 929. ISBN 0-7817-5561-1. Retrieved 2008-04-21.
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Sattler S, Maier RV (2002). "Pulmonary contusion". In Karmy-Jones R, Nathens A, Stern EJ (ed.). Thoracic Trauma and Critical Care. Berlin: Springer. pp. 159-160 and 235-243. ISBN 1-4020-7215-5. Retrieved 2008-04-22.
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Ullman EA, Donley LP, Brady WJ (2003). "Pulmonary trauma emergency department evaluation and management". Emergency Medicine Clinics of North America. 21 (2): 291–313. doi:10.1016/S0733-8627(03)00016-6. PMID 12793615.
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Gavelli G, Canini R, Bertaccini P, Battista G, Bnà C, Fattori R (2002). "Traumatic injuries: imaging of thoracic injuries". European Radiology. 12 (6): 1273–1294. doi:10.1007/s00330-002-1439-6. PMID 12042932.
{{cite journal}}: Unknown parameter|month=ignored (help)CS1 maint: multiple names: authors list (link) - ^ a b c d e f g h i j k l m Miller DL, Mansour KA (2007). "Blunt traumatic lung injuries". Thoracic Surgery Clinics. 17 (1): 57–61. doi:10.1016/j.thorsurg.2007.03.017. PMID 17650697.
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Moloney JT, Fowler SJ, Chang W (2008). "Anesthetic management of thoracic trauma". Current Opinion in Anaesthesiology. 21 (1): 41–46. doi:10.1097/ACO.0b013e3282f2aadc. PMID 18195608.
{{cite journal}}: Unknown parameter|month=ignored (help)CS1 maint: multiple names: authors list (link) - ^ a b c d e f g h i j k l m n o p q r s Cohn SM (1997). "Pulmonary contusion: Review of the clinical entity". Journal of Trauma. 42 (5): 973–979. PMID 9191684.
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Mick NW, Peters JR, Egan D, Nadel ES, Walls R, Silvers S (2006). "Chest trauma". Blueprints Emergency Medicine. Second edition. Philadelphia, PA: Lippincott Williams & Wilkins. p. 76. ISBN 1-4051-0461-9.
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Costantino M, Gosselin MV, Primack SL (2006). "The ABC's of thoracic trauma imaging". Seminars in Roentgenology. 41 (3): 209–225. doi:10.1053/j.ro.2006.05.005. PMID 16849051.
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Livingston DH, Hauser CJ (2003). "Trauma to the chest wall and lung". In Moore EE, Feliciano DV, Mattox KL (ed.). Trauma. Fifth Edition. McGraw-Hill Professional. pp. 526–528. ISBN 0071370692. Retrieved 2008-04-26.
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Sutyak JP, Wohltmann CD, Larson J (2007). "Pulmonary contusions and critical care management in thoracic trauma". Thoracic Surgical Clinics. 17 (1): 11–23. doi:10.1016/j.thorsurg.2007.02.001. PMID 17650693.
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{{cite book}}: CS1 maint: multiple names: editors list (link) - ^ a b c d e f g h i j k Keough V, Pudelek B (2001). "Blunt chest trauma: Review of selected pulmonary injuries focusing on pulmonary contusion". AACN Clinical Issues. 12 (2): 270–281. PMID 11759554.
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Matthay RA, George RB, Light RJ, Matthay MA, ed. (2005). "Thoracic trauma, surgery, and perioperative management". Chest Medicine: Essentials of Pulmonary and Critical Care Medicine. Hagerstwon, MD: Lippincott Williams & Wilkins. p. 578. ISBN 0-7817-5273-6. Retrieved 2008-04-21.
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Sartorelli KH, Vane DW (2004). "The diagnosis and management of children with blunt injury of the chest". Seminars in Pediatric Surgery. 13 (2): 98–105. doi:doi:10.1053/j.sempedsurg.2004.01.005. PMID 15362279.
{{cite journal}}: Check|doi=value (help); Unknown parameter|month=ignored (help) - ^ a b c d e f g Kishen R, Lomas G (2003). "Thoracic trauma". In Gwinnutt CL, Driscoll P (ed.). Trauma Resuscitation: The Team Approach. Informa Healthcare. pp. 55–56, 63–64. ISBN 1-85996-009-X. Retrieved 2008-05-03.
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Bastos R, Calhoon JH, Baisden CE (2008). "Flail chest and pulmonary contusion". Seminars in Thoracic and Cardiovascular Surgery. 20 (1): 39–45. doi:10.1053/j.semtcvs.2008.01.004. PMID 18420125.
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Wanek S, Mayberry JC (2004). "Blunt thoracic trauma: Flail chest, pulmonary contusion, and blast injury". Critical Care Clinics. 20 (1): 71–81. doi:10.1016/S0749-0704(03)00098-8. PMID 14979330.
{{cite journal}}: Unknown parameter|month=ignored (help) - ^ Donnelly LF (2002). "CT of Acute pulmonary infection/trauma". In Strife JL, Lucaya J (ed.). Pediatric Chest Imaging: Chest Imaging in Infants and Children. Berlin: Springer. p. 123. ISBN 3-540-43557-3. Retrieved 2008-05-01.
- ^ a b Shields TW (2005). General Thoracic Surgery. Philadelphia, PA: Lippincott Williams & Wilkins. p. 959. ISBN 0-7817-3889-X. Retrieved 2008-04-21.
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Ciesla ND (1996). "Chest physical therapy for patients in the intensive care unit" (PDF). Physical Therapy. 76 (6): 609–625. PMID 8650276.
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External links
- National Guideline Clearinghouse. Practice management guideline for pulmonary contusion - flail chest
- Trauma.org: Pulmonary contusion