Document Type: Review Article

Authors

Department of Cardiovascular and Thoracic Surgery, Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Soura, Kashmir, India.

Abstract

Lung contusion is an entity involving injury to the alveolar capillaries, without any tear or cut in the lung tissue. This results in accumulation of blood and other fluids within the lung tissue. The excess fluid interferes with gas exchange leading to hypoxia. The pathophysiology of lung contusion includes ventilation/perfusion mismatching, increased intrapulmonary shunting, increased lung water, segmental lung damage, and a loss of compliance. Clinically, patient’s presents with hypoxiemia, hypercarbia and increase in laboured breathing. Patients are treated with supplemental oxygen and mechanical ventilation whenever indicated. Treatment is primarily supportive. Computed tomography (CT) is very sensitive for diagnosing pulmonary contusion. Pulmonary contusion occurs in 25–35% of all blunt chest traumas.

Keywords

  1. Cohn SM. Pulmonary contusion: Review of the clinical entity. J Trauma 1997;42(5):973-79.
  2. Karmy-Jones R, Jurkovich GJ. Blunt chest trauma. Curr Probl Surg 2004;41(3):211-380.
  3. Croce MA, Fabian TC, Davis KA, Gavin TJ. Early and late acute respiratory distress syndrome: two distinct clinical entities. J Trauma 1999;46(3):361-6; discussion 366-8.
  4. Antonelli M, Moro ML, Capelli O, De Blasi RA, D’Errico RR, Conti G, et al. Risk factors for early onset of pneumonia in trauma patients. Chest 1994;105(1):224-8.
  5. Hoff SJ, Shotts SD, Eddy VA, Morris JA Jr. Outcome of isolated pulmonary contusion in blunt trauma patients. Am Surg 1994;60(2):138-42..
  6. Oppenheimer L, Craven KD, Forkert L, Wood LD. Pathophysiology of pulmonary contusion in dogs. J Appl Physiol 1979;47(4):718-28.
  7. Garzon AA, Seltzer B, Karlson KE. Physiopathology of crushed chest injuries. Ann Surg 1968;168(1):128-36.
  8. Raoof S, Goulet K, Esan A, Hess DR, Sessler CN. Severe hypoxemic respiratory failure: Part 2--nonventilatory strategies. Chest 2010;137(6):1437-48.
  9. Wrigge H, Zinserling J, Neumann P, Muders T, Magnusson A, Putensen C, et al. Spontaneous breathing with airway pressure release ventilation favors ventilation in dependent lung regions and counters cyclic alveolar collapse in oleic-acid-induced lung injury: A randomized controlled computed tomography trial. Crit Care 2005;9(6):R780-9.
  10. Borges JB, Okamoto VN, Matos GF, Caramez MP, Arantes PR, Barros F, et al. Reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome. Am J Respir Crit Care Med 2006;174(3):268-78.
  11. Tyburski JG, Collinge JD, Wilson RF, Eachempati SR. Pulmonary contusions: quantifying on chest X- ray films and the factors affecting prognosis. J Trauma 1999;46(5):833-8.
  12. Yamamoto L, Schroeder C, Morley D, Beliveau C. Thoracic trauma: The deadly dozen. Crit Care Nurs Q 2005;28(1):22-40..
  13. Moloney JT, Fowler SJ, Chang W. Anesthetic management of thoracic trauma. Curr Opin Anaesthesiol 2008;21(1):41-6.
  14. Hwang JCF, Hanowell LH, Grande CM. 7 Peri-operative concerns in thoracic trauma. Baillière’s Clinical Anaesthesiology 1996;10(1):123-53.
  15. Miller DL, Mansour KA. Blunt traumatic lung injuries. Thorac Surg Clin 2007;17(1):57-61, vi.
  16. Wanek S, Mayberry JC. Blunt thoracic trauma: Flail chest, pulmonary contusion, and blast injury. Crit Care Clin 2004;20(1):71-81.
  17. Mick NW, Peters JR, Egan D, Nadel ES. Chest trauma. Blueprints Emergency Medicine. 2nd edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2006: 76.
  18. Coyer F, Ramsbotham J. Respiratory health breakdown. In Chang E, Daly J, Eliott D. Pathophysiology Applied to Nursing. Marrickville, NSW: Mosby Australia; 2004: 154-155.
  19. Boyd AD. Lung injuries. In Hood RM, Boyd AD, Culliford AT. Thoracic Trauma. Philadelphia: Saunders; 1989: 153-155.
  20. Gavelli G, Canini R, Bertaccini P, Battista G, Bnà C, Fattori R. Traumatic injuries: Imaging of thoracic injuries. Eur Radiol 2002;12(6):1273-94.
  21. Cohn SM, Dubose JJ. Pulmonary contusion: an update on recent advances in clinical management. World J Surg 2010;34(8):1959-70.
  22. Wicky S, Wintermark M, Schnyder P, Capasso P, Denys A. Imaging of blunt chest trauma. Eur Radiol 2000;10(10):1524-38.
  23. Schild HH, Strunk H, Weber W, Stoerkel S, Doll G, Hein K, et al. Pulmonary contusion: CT vs plain radiograms. J Comput Assist Tomogr 1989;13(3):417-20.
  24. Kaewlai R, Avery LL, Asrani AV, Novelline RA. Multidetector CT of blunt thoracic trauma. Radiographics 2008;28(6):1555-70.
  25. Costantino M, Gosselin MV, Primack SL. The ABC’s of thoracic trauma imaging. Semin Roentgenol 2006;41(3):209-25..
  26. Maxson RT. Management of pediatric trauma: Blast victims in a mass casualty incident. Clinical Pediatric Emergency Medicine 2002;3(4):256-61.
  27. Bridges EJ. Blast injuries: From triage to critical care. Crit Care Nurs Clin North Am 2006;18(3):333-48.
  28. Allen GS, Cox CS Jr. Pulmonary contusion in children: Diagnosis and management. South Med J 1998;91(12):1099-106.
  29. Cohn SM, Zieg PM. Experimental pulmonary contusion: review of the literature and description of a new porcine model. J Trauma 1996;41(3):565-71.
  30. Livingston DH, Hauser CJ Trauma to the chest wall and lung. In Moore EE, Feliciano DV, Mattox KL. Trauma. 5th edition. McGraw-Hill Professional; 2003: 525-528.
  31. Sattler S, Maier RV. Pulmonary contusion. In Karmy-Jones R, Nathens A, Stern EJ. Thoracic Trauma and Critical Care. Berlin: Springer; 2002: 159-160 and 235-243.
  32. Bailey BJ, Johnson JT, Newlands SD, Head and Neck Surgery--Otolaryngology. Hagerstown, MD: Lippincott Williams & Wilkins; 2006: 929.
  33. Piantadosi CA, Schwartz DA. The acute respiratory distress syndrome. Ann Intern Med 2004;141(6):460-70.
  34. Ward PA. Acute lung injury: how the lung inflammatory response works. Eur Respir J Suppl 2003;44:22s-23s.
  35. Raghavendran K, Davidson BA, Woytash JA, Helinski JD, Marschke CJ, Manderscheid PA, et al. The evolution of isolated, bilateral lung contusion from blunt chest trauma in rats: cellular and cytokine responses. Shock 2005;24(2):132-8.
  36. McAuley DF, Frank JA, Fang X, Matthay MA. Clinically relevant concentrations of beta2-adrenergic agonists stimulate maximal cyclic adenosine monophosphate-dependent airspace fluid clearance and decrease pulmonary edema in experimental acid-induced lung injury. Crit Care Med 2004;32(7):1470-6..
  37. Julien M, Hoeffel JM, Flick MR. Oleic acid lung injury in sheep. J Appl Physiol 1986;60(2):433-40.
  38. Seitz DH, Perl M, Mangold S, Neddermann A, Braumüller ST, Zhou S, et al. Pulmonary contusion induces alveolar type 2 epithelial cell apoptosis: role of alveolar macrophages and neutrophils. Shock 2008;30(5):537-44.
  39. Liener UC, Knöferl MW, Sträter J, Barth TF, Pauser EM, Nüssler AK, et al. Induction of apoptosis following blunt chest trauma. Shock 2003;20(6):511-6.
  40. Knöferl MW, Liener UC, Seitz DH, Perl M, Brückner UB, Kinzl L, et al. Cardiopulmonary, histological, and inflammatory alterations after lung contusion in a novel mouse model of blunt chest trauma. Shock 2003;19(6):519-25.
  41. Martin TR, Hagimoto N, Nakamura M, Matute-Bello G. Apoptosis and epithelial injury in the lungs. Proc Am Thorac Soc 2005;2(3):214-20.
  42. Hoth JJ, Hudson WP, Brownlee NA, Yoza BK, Hiltbold EM, Meredith JW, et al. Toll-like receptor 2 participates in the response to lung injury in a murine model of pulmonary contusion. Shock 2007;28(4):447-52.
  43. Hoth JJ, Wells JD, Brownlee NA, Hiltbold EM, Meredith JW, McCall CE, et al. Toll-Like receptor 4-dependent responses to lung injury in a murine model of pulmonary contusion. Shock 2009;31(4):376-81.
  44. Epler GR. Bronchiolitis obliterans organizing pneumonia. Arch Intern Med 2001;161(2):158-64.
  45. Popper HH. Bronchiolitis obliterans. Organizing pneumonia. Verh Dtsch Ges Pathol 2002;86:101-6.
  46. Majeski EI, Paintlia MK, Lopez AD, Harley RA, London SD, London L. Respiratory reovirus 1/L induction of intraluminal fibrosis, a model of bronchiolitis obliterans organizing pneumonia, is dependent on T lymphocytes. Am J Pathol 2003;163(4):1467-79.
  47. Aufmkolk M, Fischer R, Voggenreiter G, Kleinschmidt C, Schmit-Neuerburg KP, Obertacke U. Local effect of lung contusion on lung surfactant composition in multiple trauma patients. Crit Care Med 1999;27(8):1441-6.
  48. Raghavendran K, Davidson BA, Knight PR, Wang Z, Helinski J, Chess PR, et al. Surfactant dysfunction in lung contusion with and without superimposed gastric aspiration in a rat model. Shock 2008;30(5):508-17.
  49. Strohmaier W, Trupka A, Pfeiler C, Thurnher M, Khakpour Z, Gippner-Steppert C, et al. Bilateral lavage with diluted surfactant improves lung function after unilateral lung contusion in pigs. Crit Care Med 2005;33(10):2286-93.
  50. Raghavendran K, Davidson BA, Huebschmann JC, Helinski JD, Hutson AD, Dayton MT, et al. Superimposed gastric aspiration increases the severity of inflammation and permeability injury in a rat model of lung contusion. J Surg Res 2009;155(2):273-82.
  51. Keough V, Pudelek B. Blunt chest trauma: Review of selected pulmonary injuries focusing on pulmonary contusion. AACN Clin Issues 2001;12(2):270-81.
  52. Klein Y, Cohn SM, Proctor KG. Lung contusion: Pathophysiology and management. Current Opinion in Anaesthesiology 2002;15(1):65-68.
  53. Bastos R, Calhoon JH, Baisden CE. Flail chest and pulmonary contusion. Semin Thorac Cardiovasc Surg 2008;20(1):39-45.
  54. Sutyak JP, Wohltmann CD, Larson J. Pulmonary contusions and critical care management in thoracic trauma. Thorac Surg Clin 2007;17(1):11-23, v.
  55. Kishen R, Lomas G. Thoracic trauma. In Gwinnutt CL, Driscoll P. Trauma Resuscitation: The Team Approach. Informal Healthcare; 2003: 55-64.
  56. Allen GS, Coates NE. Pulmonary contusion: A collective review. Am Surg 1996;62(11):895-900.
  57. Prentice D, Ahrens T. Pulmonary complications of trauma. Crit Care Nurs Q 1994;17(2):24-33.
  58. Ullman EA, Donley LP, Brady WJ. Pulmonary trauma emergency department evaluation and management. Emerg Med Clin North Am 2003;21(2):291-313.
  59. Johnson SB. Tracheobronchial injury. Semin Thorac Cardiovasc Surg 2008;20(1):52-7.
  60. Donnelly LF. CT of Acute pulmonary infection/trauma. In Strife JL, Lucaya J. Pediatric Chest Imaging: Chest Imaging in Infants and Children. Berlin: Springer; 2002: 123.
  61. Stern EJ, White C. Chest Radiology Companion. Hagerstown, Lippincott Williams & Wilkins; 1999: 80.
  62. Wiot JF. The radiologic manifestations of blunt chest trauma. JAMA 1975;231(5):500-3.
  63. Donnelly LF, Klosterman LA. Subpleural sparing: a CT finding of lung contusion in children. Radiology 1997;204(2):385-7.
  64. Cohn SM, Dubose JJ. Pulmonary contusion: as update on recent advances in clinical management. World J Surg 2010;34(8):1959-70.
  65. Wylie J, Morrison GC, Nalk K, Kornecki A, Kotylak TB, Fraser DD, et al. Lung contusion in children--early computed tomography versus radiography. Pediatr Crit Care Med 2009;10(6):643-7.
  66. Deunk J, Poels TC, Brink M, Dekker HM, Kool DR, Blickman JG, et al. The clinical outcome of occult pulmonary contusion on multidetector-row computed tomography in blunt trauma patients. J Trauma 2010;68(2):387-94.
  67. Soldati G, Testa A, Silva FR, Carbone L, Portale G, Silveri NG. Chest ultrasonography in lung contusion. Chest 2006;130(2):533-8.
  68. Hyacinthe AC, Broux C, Francony G, Genty C, Bouzat P, Jacquot C, et al. Diagnostic accuracy of ultrasonography in the acute assessement of common thoracic lesions after trauma. Chest 2012;141(5):1177-83.
  69. Rocco M, Carbone I, Morelli A, Bertoletti L, Rossi S, Vitale M, et al. Diagnostic accuracy of bedside ultrasonography in the ICU: feasibility of detecting pulmonary effusion and lung contusion in patients on respiratory support after severe blunt thoracict rauma. Acta Anaesthesiol Scand 2008;52(6):776-84.
  70. Soldati G, Testa A, Silva FR, Carbone L, Portale G, Silveri NG. Chest ultrasonography in lung contusion. Chest 2006;130(2):533-8.
  71. Soldati G, Copetti R, Sher S. Sonographic interstitial syndrome: the sound of lung water. J Ultrasound Med 2009;28(2):163-74.
  72. Tovar JA. The lung and pediatric trauma. Semin Pediatr Surg 2008;17(1):53-9.
  73. Garay S, Kamelar D. Pathophysiology of trauma-associated respiratory failure. In Hood RM, Boyd AD, Culliford AT. Thoracic Trauma. Philadelphia: Saunders; 1989: 328-332.
  74. Wagner RB, Slivko B, Jamieson PM, Dills MS, Edwards FH. Effect of lung contusion on pulmonary hemodynamics. Ann Thorac Surg 1991;52(1):51-7; discussion 57-8.
  75. Cullen ML. Pulmonary and respiratory complications of pediatric trauma. Respir Care Clin N Am 2001;7(1):59-77.
  76. Cooper GJ. Protection of the lung from blast overpressure by thoracic stress wave decouplers. J Trauma 1996;40(3 Suppl):S105-10.
  77. Lucid WA, Taylor TB. Thoracic trauma. In Strange GR. Pediatric Emergency Medicine: A Comprehensive Study Guide. New York: McGraw-Hill; 2002: 92-100.
  78. Pettiford BL, Luketich JD, Landreneau RJ. The management of flail chest. Thorac Surg Clin 2007;17(1):25-33.
  79. Yamamoto L, Schroeder C, Morley D, Beliveau C. Thoracic trauma: The deadly dozen. Crit Care Nurs Q 2005;28(1):22-40.
  80. Dueck R. Alveolar recruitment versus hyperinflation: A balancing act. Curr Opin Anaesthesiol 2006;19(6):650-4.
  81. Anantham D, Jagadesan R, Tiew PE. Clinical review: Independent lung ventilation in critical care. Crit Care 2005;9(6):594-600.
  82. Smith M, Ball V. Thoracic trauma. Cardiovascular/Respiratory Physiotherapy. St. Louis: Mosby; 1998: 221.
  83. Trinkle JK, Furman RW, Hinshaw MA, Bryant LR, Griffen WO. Pulmonary contusion. Pathogenesis and effect of various resuscitative measures. Ann Thorac Surg 1973;16(6):568-73.
  84. Ciesla ND. Chest physical therapy for patients in the intensive care unit. Phys Ther 1996;76(6):609-25.
  85. Yalçinkaya I, Sayir F, Kurnaz M, Cobanoğlu U. Chest Trauma: Analysis of 126 Cases. Ulus Travma Derg 2000;6(4):288-91.
  86. Moomey CB Jr, Fabian TC, Croce MA, Melton SM, Proctor KG. Cardio-pulmonary function after pulmonary contusion and partial liquid ventilation. J Trauma 1998;45(2):283-90.
  87. Miller PR, Croce MA, Bee TK, Qaisi WG, Smith CP, Collins GL, et al. ARDS after pulmonary contusion: accurate measurement of contusion volume identifies high-risk patients. J Trauma 2001;51(2):223-8; discussion 229-30.
  88. Cobanoglu U, Melek M, Edirne Y. Diagnosis of pulmonary contusion by CXR is associated with higher morbidity and mortality rates. Indian J Thorac Cardiovasc Surg 2010;26:24-9.
  89. Luce JM. Acute lung injury and the acute respiratory distress syndrome. Crit Care Med 1998;26(2):369-76.
  90. Midla GS. Extracorporeal circulatory systems and their role in military medicine: a clinical review. Mil Med 2007;172(5):523-6.
  91. Hirschl RB, Pranikoff T, Wise C, Overbeck MC, Gauger P, Schreiner RJ, et al. Initial experience with partial liquid ventilation in adult patients with the acute respiratory distress syndrome. JAMA 1996;275(5):383-9.
  92. Haitsma JJ, Bartels K, Papadakos PJ. Opening up to lung recruitment, pulmonary contusion and derecruitment-the role of inflammation. Crit Care & Shock 2006;9(2):42-6.
  93. Brun-Buisson C, Minelli C, Bertolini G, Brazzi L, Pimentel J, Lewandowski K, et al. Epidemiology and outcome of acute lung injury in European intensive care units. Results from the ALIVE study. Intensive Care Med 2004;30(1):51-61.
  94. Schreiter D, Reske A, Stichert B, Seiwerts M, Bohm SH, Kloeppel R, et al. Alveolar recruitment in combination with sufficient positive end expiratory pressure increases oxygenation and lung aeration in patients with severe chest trauma. Crit Care Med 2004;32(4):968-75.
  95. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000;342(18):1301-8.
  96. Nelson S, Bagby GJ, Bainton BG, Wilson LA, Thompson JJ, Summer WR. Compartmentalization of intraalveolar and systemic lipopolysaccharide-induced tumor necrosis factor and the pulmonary inflammatory response. J Infect Dis 1989;159(2):189-94.
  97. Ghofrani HA, Rosseau S, Walmrath D, Kaddus W, Kramer A, Grimminger F, et al. Compartmentalized lung cytokine release in response to intravascular and alveolar endotoxin challenge. Am J Physiol 1996;270(1 Pt 1):L62-8.
  98. Tutor JD, Mason CM, Dobard E, Beckerman RC, Summer WR, Nelson S. Loss of compartmentalization of alveolar tumor necrosis factor after lung injury. Am J Respir Crit Care Med 1994;149(5):1107-11.
  99. Dehoux MS, Boutten A, Ostinelli J, Seta N, Dombret MC, Crestani B, et al. Compartmentalized cytokine production within the human lung in unilateral pneumonia. Am J Respir Crit Care Med 1994;150(3):710-6.
  100. dos Santos CC, Zhang H, Slutsky AS. From bench to bedside: bacterial growth and cytokines. Crit Care 2002;6(1):4-6.
  101. Ferring M, Vincent JL. Is outcome from ARDS related to the severity of respiratory failure? Eur Respir J 1997;10(6):1297-300.
  102. Vignesh T, ArunKumar AS, Kamat V. Outcome in patients with blunt chest trauma and pulmonary contusions. Indian Journal of Critical Care Medicine 2004;8(2):73-7.
  103. Holcomb JB, McMullin NR, Kozar RA, Lygas MH, Moore FA. Morbidity from rib fractures increases after age 45. J Am Coll Surg 2003;196(4):549-55.
  104. Bongard FS, Lewis FR. Crystalloid resuscitation of patients with pulmonary contusion. Am J Surg 1984;148(1):145-51.
  105. Notter RH, Schwan AL, Wang Z, Waring AJ. Novel phospholipase-resistant lipid/peptide synthetic lung surfactants. Mini Rev Med Chem 2007;7(9):932-44.
  106. Wang Z, Chang Y, Schwan AL, Notter RH. Activity and inhibition resistance of a phospholipase-resistant synthetic exogenous surfactant in excised rat lungs. Am J Respir Cell Mol Biol 2007;37(4):387-94.