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Pulmonary contusion

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Pulmonary contusion
SpecialtyEmergency medicine Edit this on Wikidata

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 tiny air-filled sacs responsible for absorbing oxygen from the atmosphere) and the interstitial space (the space surrounding cells) of the lung.[1] This interferes with gas exchange in the lungs, leading to inadequate oxygen levels (hypoxia).[2]

Lung contusions are usually caused by blunt trauma, but a shock wave associated with penetrating trauma can also cause them. The injury gained recognition during World Wars I and II in soldiers who had suffered blast injuries. In civilians, the injury is most often due to motor vehicle accidents. 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.[3]

The contusion commonly heals on its own with supportive care, but may be associated with complications requiring intensive care including pneumonia and acute respiratory distress syndrome. The severity can range from mild to deadly.[4] Pulmonary contusions rarely occur in isolation; they are usually accompanied by other injuries.[5] The presence or absence of pulmonary contusion plays a key role in determining whether an individual will die or suffer serious ill effects as the result of an injury.[6] 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[7] and in 25–35% of all blunt chest trauma.[8] Of people who have multiple injuries with an injury severity score of over 15, pulmonary contusion occurs in about 17%.[9] Children are at especially high risk for the injury because the relative flexibility of their bones prevents the chest wall from absorbing force from an impact, causing it to be transmitted instead to the lung.[10]

Signs and symptoms

Signs and symptoms typical of pulmonary contusion include respiratory distress, signs of low blood oxygen saturation, and indications of accompanying injuries, such as pain in the chest wall. Shortness of breath may be associated with the injury,[11] and people with pulmonary contusion may not be able to tolerate exercise well.[12] Tachypnea (rapid breathing) and tachycardia (a rapid heart rate) are other signs.[13][14] With severe contusions, breath sounds may be decreased, or rales (an abnormal crackling sound in the chest accompanying breathing) may be present.[7] These two signs, as well as wheezing, may be present for 24 hours.[1] The area around the contusion may be tender.[10] Coughing is a sign of lung contusion, with coughing up blood or bloody sputum present in up to half of individuals with the injury.[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).[6] Hypotension (low blood pressure) and cyanosis (bluish color of the skin and mucous membranes indicative of hypoxemia, inadequate blood oxygen) are commonly associated with pulmonary contusion.[7]

The more severe the injury, the more quickly symptoms become apparent.[6] People with mild contusions may have no symptoms at all; as many as half of pulmonary contusions are asymptomatic at the initial presentation.[15] Symptoms of severe contusions may occur by three or four hours after the injury,[6] but pulmonary contusion tends to worsen slowly over a few days.[16] Hypoxemia typically becomes progressively worse 24 to 48 hours after injury.[17] However, deterioration may also be rapid.[7] Because signs and symptoms may take time to develop, it is assumed that pulmonary contusion may have occurred whenever someone suffers an injury involving force sufficient to cause it.[18]

Associated injuries

A CT scan of a pulmonary contusion (red arrow) accompanied by a rib fracture (blue arrow)

Since a large amount of force is required to cause pulmonary contusion, its presence can be used to gauge the severity of an injury.[19] 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.[18] As many as 75% of pulmonary contusions are accompanied by other chest injuries, such as rib fracture, hemothorax, pneumothorax, and flail chest.[5] Most instances of flail chest are associated with pulmonary contusion,[20][21] and the contusion, rather than the chest wall injury, is often the main cause for concern in treatment of people with these injuries.[22] The injury may be associated with indications of trauma to the chest wall such as bruising and fracture of the sternum.[23] Over half of fractures of the scapula are associated with pulmonary contusion.[20] A 2000 study found that the most common injuries to accompany pulmonary contusion were hemothorax and pneumothorax.[24] Lung contusion, which usually occurs near solid structures in the chest such as the liver, the heart, and the ribs,[6] is frequently found underlying fracture sites.[25] Pulmonary lacerations, in which lung tissue is torn or cut, may may result from the same blunt or penetrating forces that cause pulmonary contusion.[7] Lacerations can result in pulmonary hematomas, collections of blood within the lung parenchyma; these are thought to develop in between 4 and 11% of pulmonary contusions.[7] Unlike contusions, pulmonary hematomas usually form a mass by two days post-injury.[26] They do not usually cause shunting of blood or interfere with gas exchange, but do increase the risk of infection and abscess formation.[7]

Causes

Vehicle accidents are the most common cause of pulmonary contusion.

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[3] and sports injuries are other causes.[11] The injury can also be caused by explosions; the organs most vulnerable to blast injuries are those that contain gas, such as the lungs.[9] Blast lung is a term used to describe severe pulmonary contusion, bleeding or edema with damage to alveoli and blood vessels, or a combination of these.[27] It is the most common cause of death among vehicle occupants involved in accidents,[28] and among people who initially survive an explosion.[29]

In addition to blunt trauma, penetrating trauma can also cause pulmonary contusion.[18] 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.[4] However, pulmonary contusions that accompany gun and knife wounds are not usually severe enough to have a major effect on outcome,[19] and penetrating trauma causes less widespread lung damage than does blunt trauma.[3] An exception is shotgun wounds, which can seriously damage large areas of lung tissue through a blast injury mechanism.[19]

Mechanism

The alveoli

The physical mechanisms behind pulmonary contusion are poorly understood. However, it is known that lung tissue may be directly crushed, as when the chest wall bends inward in an impact.[30] Additionally, three possible mechanisms have been suggested: the inertial effect, the spalling effect, and the implosion effect.

  • The inertial effect results from the fact that different tissues have different densities, and therefore different rates of acceleration or deceleration.[3] The lighter alveolar tissue is sheared from the heavier hilar structures, an effect similar to diffuse axonal injury in head injury.[15]
  • In the spalling effect, lung tissue bursts or is sheared where a shock wave meets the lung tissue, at interfaces between gas and liquid.[9] The alveolar walls form such a gas-liquid interface with the air within the alveoli.[15][20] The spalling effect occurs in areas with large differences in density; particles of the denser tissue are spalled (thrown) into the less dense particles.[31]
  • The implosion effect is proposed to occur microscopically when the pressure in the airways increases sharply.[30] When a pressure wave passes through a tissue containing bubbles of gas, it first causes them to implode, then to rebound and expand beyond their original volume.[32] The air bubbles cause many tiny explosions, resulting in tissue damage;[32] the overexpansion of gas bubbles can stretch and tear alveoli.[33][34] This tearing of the capillary–alveolar membrane can cause alveoli to fill with blood, reducing the amount of surface area available for gas exchange.[35]

The bruising usually occurs on the lung directly under the site of impact, but, as with traumatic brain injury, a contrecoup contusion may occur at the site opposite the impact as well.[4] A blow to the front of the chest may cause bruising on the back of the lungs because a shock wave travels through the chest and hits the curved back of the chest wall, which reflects the energy back onto the back of the lungs, concentrating it (a similar mechanism may occur at the front of the lungs when the back is struck).[34]

The amount of energy that is transferred to the lung is determined in a large part by the compliance (flexibility) of the chest wall.[4] 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][36] An adult's more bony chest wall absorbs more of the force itself rather than transmitting it.[36] 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.[4][17] One study found that pulmonary contusions were accompanied by fractures 62% of the time in children and 80% of the time in adults.[34] When contusion is accompanied by a fracture, it is usually concentrated into a more specific location; the injury is more diffuse when there is no fracture.[34][21]

Pathophysiology

Bruising of the lung results in bleeding and fluid leakage into and edema of the lung tissues, which can become stiffened and lose their normal elasticity. As a result of these and other pathological processes that occur in the injury, pulmonary contusion progresses over time and can cause hypoxia (insufficient oxygen). The water content of the lung increases over the first 72 hours after injury, potentially leading to frank pulmonary edema in more serious cases.[9]

Bleeding and edema

Normally, oxygen and carbon dioxide diffuse across the capillary and alveolar membranes and the interstitial space (top). Fluid impairs this diffusion, resulting in less oxygenated blood (bottom).

In contusions, injured capillaries leak fluid into the tissues around them.[37] In pulmonary contusions, the force involved in the trauma tears the membrane between alveoli and capillaries.[4] As a result of damage to this capillary–alveolar membrane and small blood vessels, blood and fluids leak into the alveoli and interstitial space.[6] With more severe trauma, there is a greater amount of edema, bleeding, and tearing of the alveoli.[3] Pulmonary contusion is characterized by microhemorrhages (tiny bleeds) that occur when the alveoli are traumatically separated from airway structures and blood vessels.[4] An area of bleeding in the contused lung is commonly surrounded by an area of edema.[4] According to animal studies, blood initially collects in the interstitial space, and then edema occurs by an hour or two after injury.[33] For gas exchange to occur, carbon dioxide must diffuse across the epithelium of the capillaries, across the interstitial space, and across the alveolar epithelium; oxygen must diffuse the other direction. Fluid accumulation interferes with gas exchange,[38] and fluid leakage can cause the alveoli to fill with proteins and collapse due to edema and bleeding.[4]

Consolidation and collapse

Pulmonary contusion can cause uninjured parts of the lung to consolidate, alveoli to collapse, and atelectasis to occur.[25] Over a period of hours after the injury, the alveoli in the injured area thicken and may become consolidated.[4] A decrease in the amount of surfactant produced may also contribute to the collapse and consolidation of alveoli;[8] inactivation of surfactant increases the surface tension of alveoli.[34] Reduced production of surfactant can also occur in tissue surrounding the injury that was not originally injured.[30] When alveoli consolidate as a result of bleeding into them, it causes the pressure within the capillaries of the lungs to rise; this increased pressure can rise so high that blood and serum leak from the capillaries.[20] An intrapulmonary shunt can develop as a result of bleeding into the alveolar space and subsequent lung consolidation.[21] The vascular resistance increases in the contused part of the lung, leading to a decrease in the amount of blood that flows into it.[39]

Inflammation, which can result when components of blood enter the lung tissue due to contusion, can also cause parts of the lung to collapse. Macrophages, neutrophils, and other inflammatory cells and blood components can enter the lung tissue and release factors that lead to inflammation, increasing the likelihood of respiratory failure.[24] In response to inflammation, excess mucus is produced, potentially plugging parts of the lung and leading to their collapse.[4] Findings from animal studies indicate that even when only one side of the chest is injured, inflammation may also affect the other lung.[24] The uninjured lung and uninjured parts of the injured lung may develop changes including edema and thickening of the septa of the alveoli.[39] If this inflammation is severe enough, it can lead to dysfunction of the lungs like that seen in acute respiratory distress syndrome.[5]

Ventilation/perfusion mismatch

Pulmonary contusion causes a mismatch between ventilation and perfusion, which can in turn cause hypoxemia.[16][23] The [Ventilation/perfusion ratio|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.[40] As the mismatch between ventilation and perfusion grows, blood oxygen saturation is reduced.[40] The larger the area of the injury, the more severe respiratory compromise is likely to be.[3] If it is severe enough, a mismatch in ventilation and perfusion cannot be corrected just by giving supplemental oxygen; thus a large portion of people who die as the result of trauma die because of this problem.[40] Intrapulmonary shunting resulting from pulmonary contusion may contribute to a mismatch between ventilation and perfusion.[25] Insufficient inflation of the lungs, which can result from inadequate mechanical ventilation or an associated injury such as flail chest, can also contribute to the ventilation-perfusion mismatch.[34]

Diagnosis

Chest X-ray is an important diagnostic tool for pulmonary contusion.

To diagnose pulmonary contusion, health professionals use radiography, information about the event that caused the injury, and clues from a physical examination.[3] Laboratory findings may also be used; for example, arterial blood gasses may show insufficient oxygen and excessive carbon dioxide even in someone receiving supplemental oxygen.[25] However, as with other signs, blood gas levels may be normal early in the course of the injury.[18]

X-ray

Chest X-ray is the most common method used for detecting lung contusion[24] and may be used to confirm a diagnosis made using clinical signs.[9] Areas of the X-ray film may also appear opaque, due to bleeding and edema in the alveoli; most typically, this results in "nonsegmental consolidation," which is opacification of various portions of the lungs that are not connected to one another.[41] Consolidation appears on an X-ray film when the parts of the lung that are normally filled with air fill with material resulting from the pathological condition, such as blood.[42] The contusion is not typically restricted by the anatomical boundaries of the lobes or segments of the lung.[20][21][43] Instead of occurring in continuous lung segments, the damage occurs wherever the lung tissue interfaces with adjacent structures of different density (such as the ribs, the spine, or the heart).[41] The X-ray appearance of pulmonary contusion may appear similar to aspiration,[36] and the presence of hemothorax or pneumothorax may obscure the injury on a radiograph.[19]

Though chest radiography is an important part of the diagnosis, it is often not sensitive enough to detect contusion early after the injury.[25] In a third of cases, pulmonary contusion is not visible on the first chest radiograph performed.[12] It takes an average of six hours for the characteristic opacification to show up on a chest X-ray, and the contusion may not become apparent for 48 hours.[20][21] When a lung contusion is apparent on a chest X-ray shortly after an injury, it suggests that the trauma to the chest was severe and that a CT scan might reveal other, related injuries that may have been missed on an X-ray film.[44]

Computed tomography

Computed tomography (CT scanning) is more sensitive to pulmonary contusion than X-ray is,[7][37] and it may identify abdominal, chest, or other injuries that may accompany the contusion.[39] In one study, chest X-ray detected lung contusions in 16.3% of people with serious blunt trauma, while CT detected them in 31.2% of the same people.[45] Unlike X-ray, CT scanning can detect the contusion almost immediately after the injury.[21] It can also help determine the size of a contusion, which may be helpful in determining whether a patient needs mechanical ventilation; a larger volume of contused lung on CT scan increases the likelihood of the need for ventilation.[21] CT scans can also help differentiate between pulmonary contusions and pulmonary hematomas, which can be difficult to tell apart otherwise.[26] However, lung contusions that are visible on CT but not with chest X-ray are usually not severe enough to be important to the outcome or to affect treatment.[24]

Treatment

There is no treatment to speed the healing of a pulmonary contusion;[5] the main care is supportive.[12][16] In most cases, the injury does not require surgical intervention.[10][46] Attempts are made to discover injuries that may accompany the contusion,[9] to prevent additional injury, and to provide supportive care while waiting for the contusion to heal.[5] Monitoring, including keeping track of fluid balance, respiratory function, and oxygen saturation using pulse oximetry is also required, because respiratory function may progressively worsen.[22] Treatment of lung contusion aims to prevent respiratory failure and to ensure adequate oxygenation.[8][18] This includes decreasing the work necessary to breathe.[25] Supplemental oxygen is given, and it may be warmed and humidified.[40] When the contusion does not respond to other treatments, extracorporeal membranous oxygenation may be used; blood is pumped from the body into a machine that oxygenates it and removes carbon dioxide, and is then pumped back in.[47]

Ventilation

Mechanical ventilation may be required if pulmonary contusion causes inadequate oxygenation.

Continuous positive airway pressure (CPAP) may be used to improve oxygenation: air is blown into the airways during both inspiration and expiration at a prescribed pressure via a mask fitted tightly to the face.[5] However, the technique carries the risk of complications such as causing air to enter the stomach and aspiration of stomach contents, especially when level of consciousness.[16] CPAP has the advantage of being non-invasive, but invasive ventilation may be required for severe contusions.[14]

People with signs of inadequate respiration or oxygenation may need to be intubated[12] and mechanically ventilated.[1] Intubation is reserved for when respiratory problems occur,[9] but most significant contusions do require intubation, and it may be done early on in anticipation of this need.[16] 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.[40]

Pulmonary contusion or its complications such as acute respiratory distress syndrome may cause lungs to lose compliance (stiffen), so higher pressures to may be needed to give normal amounts of air[16] and oxygenate the blood adequately.[37] Positive end-expiratory pressure (PEEP), which delivers air at a given pressure at the end of the expiratory cycle, can prevent alveoli from collapsing on exhalation.[25] PEEP is considered necessary with mechanical ventilation; however, if the pressure is too great it can expand the size of the contusion[3] and injure the lung.[5]

Fluid therapy

The administration of fluid therapy in individuals with pulmonary contusion is controversial.[40] Excessive fluid in the circulatory system can worsen a pulmonary contusion, because it can cause fluid leakage from injured capillaries, which are more permeable than normal.[34][21] However, hypovolemia (low blood volume) resulting from insufficient fluid has an even worse impact, potentially causing hypovolemic shock; for people who have lost large amounts of blood, fluid resuscitation is necessary.[40] While fluids have historically been withheld from people with pulmonary contusion,[48] a lot of the evidence supporting this course of action came from animal studies, not clinical studies with humans.[9] It is not recommended that fluid therapy be withheld for pulmonary contusion patients who have other injuries.[17] Studies have had conflicting findings on whether fluid resuscitation is associated with increased pulmonary edema.[9] 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.[7] Measuring pulmonary artery pressure allows the clinician to give enough fluids to prevent shock without exacerbating edema.[49] Furosemide, a drug used in the treatment of pulmonary contusion, is a diuretic (i.e. it increases urine output, reducing excessive fluid in the system).[21] It can also relax the smooth muscle in the veins of the lungs, thereby decreasing pulmonary venous resistance and reducing the pressure in the pulmonary capillaries.[21]

Supportive care

Retaining secretions in the airways can worsen hypoxia[50] and lead to infections.[16] An important part of treatment is pulmonary toilet,[1][17] the 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 to breathe deeply.[12] Chest physical therapy may also be used for the treatment of pulmonary contusion.[36][51] Chest physical therapy makes use of techniques such as breathing exercises, stimulation of coughing, suctioning, percussion, movement, vibration, and drainage to rid the lungs of secretions, increase oxygenation, and expand collapsed parts of the lungs.[51] People who do develop infections such as pneumonia are given antibiotics.[3] 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.[9]

Pain control is another means to facilitate the elimination of secretions. Pain from a chest wall injury can also make coughing painful, making it more likely that mucus will accumulate in the airways.[52] Also, chest injuries may make breathing painful and contribute to hypoventilation (inadequate breathing) because the chest wall movement involved in breathing adequately is painful.[23][52] Insufficient expansion of the chest may lead to atelectasis and further reduce the oxygenation of the blood.[25] Analgesics (pain medications) can be given to reduce pain.[1] Injection of anesthetics into nerves in the chest wall, called nerve blockade, is another method used to decrease pain; this method has the advantage that does not depress respiration the way some pain medications can.[34]

Prognosis

Pulmonary contusion usually resolves by itself;[18] in most cases, it goes away by five to seven days after the injury without permanent complications.[53] Signs of pulmonary contusion detectable by radiography are usually gone by 10 days after the injury.[3] When the lesions are small, they normally do not increase the chances of death or poor outcome for people with blunt chest trauma; however, these chances increase with the size of the contusion.[24] Older people and those who have heart, lung, or kidney disease prior to the injury are more likely to have longer hospital stays and complications from the injury; a 2000 study found that complications occurred in 55% of people with heart or lung disease and 13% of those without.[24]

Pulmonary contusion may have long-term ill effects on respiratory function;[39][54] respiratory disability may interfere with an individual's ability to return to work.[4] Fibrosis of the lungs results in dyspnea and loss of functional residual capacity.[39] It can also permanently reduce the compliance of the lungs.[35] During the six months after the injury, up to 90% of people with pulmonary contusion suffer dyspnea,[20][21] and this difficulty breathing may persist for an indefinite period.[12] Functional residual capacity has been found to be reduced in most pulmonary contusion patients studied as late as four years after the injury.[21] Chronic lung disease may be correlated with the size of the initial injury.[4]

Complications

A chest X-ray of acute respiratory distress syndrome, a serious potential complication of pulmonary contusion

Pulmonary contusion can result in respiratory failure; about half of such cases occur within a few hours of the initial trauma.[21] Other severe complications, including infections and acute respiratory distress syndrome (ARDS) may result from the injury, occurring up to half of people with pulmonary contusions.[34] 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.[7] A larger contusion is associated with an increased risk; 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.[12] Pneumonia, another potential complication, develops in as many as 20% of people with pulmonary contusion.[10] Contused lungs are less able to remove bacteria than uninjured lungs, predisposing them to infection.[55] Intubation and mechanical ventilation further increase the risk of developing pneumonia.[4] As with ARDS, the chances of developing pneumonia increase with the size of the contusion.[12] Children and adults have been found to have similar rates of complication with pneumonia and ARDS.[34]

Epidemiology

It is difficult to determine the death rate (mortality) of pulmonary contusion because the injury rarely occurs by itself.[3] Usually, deaths of people with pulmonary contusion result from other injuries, commonly traumatic brain injury.[4] Therefore it it controversial whether pulmonary contusion with flail chest is a major factor in mortality on its own or whether it merely contributes to mortality in people with multiple injuries.[56] 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.[6] One study found that 35% of people with multiple significant injuries including pulmonary contusion die.[3] In another study, 11% of people with just pulmonary contusions died, while 22% of those with pulmonary contusion associated with other injuries died.[7] A flail chest accompanying lung contusion increases the morbidity and mortality to more than twice that of pulmonary contusion alone.[21] Pulmonary contusion is thought to contribute directly to the death in a quarter to a half of polytrauma deaths.[4]

Pulmonary contusions are thought to contribute significantly in about a quarter of deaths resulting from vehicle collisions.[19] As the number of auto accidents increased with the increase of use of vehicles, so did the number of chest injuries.[5] However an increase in the number of airbags installed in modern cars may be decreasing the incidence of pulmonary contusion.[7]

Since their chest walls are more flexible, children are more vulnerable to lung contusion than adults are,[18] and the injury is more common in children than in adults for that reason.[33] Children in forceful impacts suffer twice as many pulmonary contusions as adults with similar injury mechanisms, yet have proportionately fewer rib fractures.[10] Pulmonary contusion has been found in 53% of children with significant chest injuries (those requiring hospitalization).[57] The rates of certain types of injury mechanisms differ between children and adults; for example, children are more often hit by cars as pedestrians.[34] Differences in the bodies of children and adults also lead to different manifestations of pulmonary contusion and associated injuries; for example, children have less body mass, so the same force is likely to lead to more multisystem trauma.[34] Some differences in children's physiology might be advantageous (for example they are less likely to have other medical conditions), and thus it has been predicted that children would have a better outcome than adults.[58] However, despite these differences, children with pulmonary contusion have similar mortality rates to adults.[34]

History

Giovanni Battista Morgagni, credited with having first described lung trauma without chest wall trauma

In 1761, Giovanni Battista Morgagni was first to describe a lung injury that was not accompanied by injury to the chest wall overlying it.[9] A review article published in 1840 may have marked the first time an attempt was made to review the medical literature on the subject comprehensively.[59] However, it was not until the early 20th century that the injury and its clinical significance began to receive wide recognition.[56] Lung injury began to receive more attention in the medical literature during World War I.[9] With the use of explosives came a large number of casualties with no external signs of chest injury but with significant bleeding in the lungs.[56] Studies of World War I injuries by D.R. Hooker showed that pulmonary contusion was an important part of the concussive injury that results from explosions.[56]

Pulmonary contusion received further attention during World War II, when the bombings of Britain led to blast injuries and associated respiratory problems in both soldiers and civilians.[9] Also during this time, studies were carried out with animals placed at varying distances from a blast; they showed that protective gear could prevent lung injuries, suggesting that an impact to the outside of the chest wall was responsible for the internal lesions.[54] In 1945, Buford and Burbank described what they called "wet lung", in which the lungs accumulated fluid and were simultaneously less able to remove it.[9] Thus they attributed the respiratory failure often seen in blunt chest trauma in part to excessive fluid resuscitation, and the question of whether and how much to administer fluids has remained controversial ever since.[9]

During the Vietnam War, combat again provided the opportunity for study of pulmonary contusion; studies during this conflict played an important role in the development of the modern understanding of its treatment.[9] The condition also began to be more widely recognized in a non-combat context in the 1960s, and symptoms and typical findings with imaging techniques such as X-ray were described.[9] Before the 1960s, it was believed that the respiratory insufficiency seen in flail chest was due to "paradoxical motion" of the flail segment of the chest wall (the flail segment moves in the opposite direction as the chest wall during respiration), so treatment was aimed at managing the chest wall injury, not the pulmonary contusion.[47] For example, positive pressure ventilation was used to stabilize the flail segment from within the chest.[5] It was first proposed in 1965 that this respiratory insufficiency is most often due to injury of the lung itself rather than to the chest wall,[9] and a group led by J.K. Trinkle confirmed this hypothesis in 1975.[39] Hence the modern treatment prioritizes the management of pulmonary contusion.[56] Animal studies performed in the late 1960s and 1970s began to clarify the pathophysiological processes involved in pulmonary contusion.[54]

See also

References

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