Pulmonary contusion

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Pulmonary contusion
Classification and external resources
A chest X-ray of a right sided pulmonary contusion associated with flail chest and subcutaneous emphysema
ICD-10 S27.3
ICD-9 861.21, 861.31

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). Other potential complications include pneumonia and 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 serious 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 chest walls allow force to be transmitted to the lung rather than being absorbed by the chest wall.[10]

Contents

[edit] Signs and symptoms

Signs and symptoms of pulmonary contusion include respiratory distress, low blood oxygen saturation, chest pain, and coughing, with up to half of sufferers 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.[11] Shortness of breath may also be associated with the injury.[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 area around the contusion may be tender.[10]

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]

[edit] Associated injuries

A CT scan of a pneumothorax, a chest injury that may accompany pulmonary contusion
A CT scan of a pneumothorax, a chest injury that may accompany pulmonary contusion

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 pulmonary contusion.[19] A 2000 study found that the most common injuries to be associated with pulmonary contusion were hemothorax and pneumothorax.[20] 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.[21] Over half of fractures of the scapula are associated with pulmonary contusion.[19]

Pulmonary lacerations, in which lung tissue is torn or cut, may also be associated with pulmonary contusion.[4] Both injuries may result from blunt or penetrating forces that occur in the same traumatic event.[4][6] The presence of a contusion may mask that of a laceration on chest X-ray.

Pulmonary contusions usually occur near solid structures in the chest such as the liver, the heart, and the ribs.[5]

[edit] Causes

Vehicle accidents are the most common cause of pulmonary contusion.
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 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, 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] An exception is shotgun wounds, which can seriously damage large areas of lung tissue through a blast injury mechanism.[17]

[edit] Mechanism

The physical mechanisms behind pulmonary contusion are poorly understood. Lung tissue may be directly crushed, as when the chest wall bends inward in an impact.[22] Additionally, 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] The alveolar walls form such a gas-liquid interface with the air within the alveoli.[19]

The implosion effect is proposed to occur microscopically when the pressure in the airways increases sharply.[22] 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.[23] The result is many tiny explosions of the air bubbles, resulting in tissue damage;[23] the overexpansion of gas bubbles can stretch and tear alveoli.[4][24][25]

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 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.[3] 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.[25] A similar mechanism may occur at the front of the lungs when the back is struck.[25]

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][26] The more bony chest walls of adults absorb the force themselves rather than transmitting it.[26] 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][15] One study found that pulmonary contusions were accompanied by fractures 62% of the time in children and 80% of the time in adults.[25] 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.[25]

[edit] 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. In more serious cases, this leads to frank pulmonary edema.[8] Damage to the lung tissue usually peaks by a day after the injury and clears up within a week.[8]

[edit] Bleeding and edema

In contusions, injured capillaries leak fluid into the tissues around them.[27] Thus, in pulmonary contusions, damage to the capillary alveolar membrane and small blood vessels causes blood and fluids to leak into the alveoli and interstitial space.[5] Pulmonary contusion is characterized by microhemorrhages (tiny bleeds) that occur when the alveoli are traumatically separated 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] An area of bleeding in the contused lung 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.[24] The fluid accumulation interferes with gas exchange,[28] and fluid leakage can cause the alveoli to fill with proteins and collapse due to edema and bleeding.[3]

[edit] Consolidation

Pulmonary contusion can cause uninjured parts of the lung to consolidate, alveoli to collapse, and atelectasis to occur.[21] Over a period of hours after the injury, the alveoli in the injured area thicken and may become consolidated.[3] A decrease in the amount of surfactant produced may also contribute to the collapse and consolidation of alveoli;[7] inactivation of surfactant increases the surface tension of alveoli.[25] Reduced production of surfactant can also occur in tissue surrounding the injury that was not originally injured.[22] 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.[19] An intrapulmonary shunt can develop.[19] The vascular resistance increases in the contused part of the lung, leading to a decrease in the amount of blood that flows into it.[29]

Inflammation, which can result when components of blood enter the lung tissue due to contusion,[9] can also cause parts of the lung to collapse. Monocytes enter the area as part of the inflammatory process.[3] In response to inflammation, the lungs produce excess mucus, which can plug parts of the lung and lead to their collapse.[3] Findings from animal studies indicate that even when only one side of the chest is injured, inflammation may also affect the other lung.[20]

[edit] Ventilation/perfusion mismatch

Pulmonary contusion causes a mismatch between ventilation and perfusion, which can in turn cause 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.[30] Insufficient inflation of the lungs, which can result from inadequate mechanical ventilation or an associated injury such as flail chest, can contribute to the ventilation-perfusion mismatch.[25] As the mismatch between ventilation and perfusion grows, blood oxygen saturation is reduced.[30] 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.[30] Intrapulmonary shunting resulting from pulmonary contusion may contribute to a mismatch between ventilation and perfusion.[21] The larger the area of the injury, the more severe respiratory compromise is likely to be.[4]

[edit] Diagnosis

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

To diagnose pulmonary contusion, health professionals use information about the event that caused the injury, information from a physical examination, and radiography.[4] Chest X-ray is the most common method used for detecting it[20] and may be used to confirm a diagnosis made using clinical signs.[8] A classic sign of lung contusion is a "patchy infiltrate" seen on chest X-ray,[16] which occurs due to bleeding into the alveoli.[6] Areas of the chest X-ray may also appear opaque; this "opacification" results from bleeding and edema in the alveoli.[19] The contusion is not typically restricted by the anatomical boundaries of the lobes or segments of the lung; it may cross these boundaries.[19][31] The X-ray appearance of pulmonary contusion may appear similar to aspiration,[26] and the presence of hemothorax or pneumothorax may obscure the injury on a radiograph.[17]

Though chest radiography is an important part of the diagnosis, it is not very sensitive in detecting the injury early on.[4][21] In a third of cases, pulmonary contusion is not visible on the first chest radiograph performed.[32] It takes an average of six hours for the opacification typical of pulmonary contusion to show up on a chest X-ray, and the injury may not be apparent on the X-ray until 48 hours after the injury.[19] Signs of pulmonary contusion detectable by radiography are usually gone by 10 days after the injury.[4] When a lung contusion does show up 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 be missed on an X-ray film.[33]

CT scanning is more sensitive to pulmonary contusion than chest X-ray is.[6][27] CT may help determine the presence and size of pulmonary contusions,[9] but those that are visible only on CT and not with chest X-ray are usually not severe enough to be important to the patients' outcome.[20] CT may also be helpful in determining which patients need mechanical ventilation;[8] a larger volume of contused lung on CT scan increases the likelihood of the need for ventilation.[26] CT scans may also help differentiate between pulmonary contusions and pulmonary hematomas, which can be hard to tell apart otherwise.[34] 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.[34] 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.[21] However, as with other signs, blood gas levels may be normal early in the course of the injury.[16]

[edit] Treatment

Patients with inadequate oxygenation due to pulmonary contusion may need to be intubated and placed on a mechanical ventilator.
Patients with inadequate oxygenation due to pulmonary contusion may need to be intubated and placed on a mechanical ventilator.

There is no treatment to speed the healing of a pulmonary contusion;[18] supportive care is the main treatment given.[32] 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] (including by decreasing the work necessary to breathe),[21] prevent additional injury, and provide supportive care while waiting for the contusion to heal.[18] Since the injury may become progressively worse, patients are monitored closely.[27] Monitoring involves keeping track of oxygen saturation[1] (pulse oximetry) 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.[30]

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[32] 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.[30]

High inflation pressures may be needed to oxygenate the blood adequately;[27] 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.[21] 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.[32] Chest physical therapy may also be used for the treatment of pulmonary contusion.[26][35] 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.[35]

The administration of fluid therapy for pulmonary contusion is controversial.[30] Excessive fluid in the circulatory system can worsen a pulmonary contusion, because it can cause excess fluid leakage from injured capillaries, which are more permeable than normal.[25] However, 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.[30] 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] Measuring pulmonary artery pressure allows the clinician to give enough fluids to prevent shock without giving exacerbating edema.[36]

Pain control is another aspect of care; chest injuries may make breathing painful and contribute to hypoventilation (inadequate breathing).[21] Insufficient expansion of the chest may lead to atelectasis and may further reduce the oxygenation of the blood.[21] Analgesics can be given to reduce pain,[1] and nerve blocks can be used to decrease pain without depressing respiration.[25]

Animal studies have shown conflicting findings on whether glucocorticoids increase blood oxygenation and reduce the size of a pulmonary contusion. However they may increase the risk of 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]

[edit] Prognosis and complications

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

Pulmonary contusion usually resolves by itself[16] but can be associated with long-term respiratory disability.[8] For example, up to 90% of people with pulmonary contusion suffer dyspnea during the six months after the injury.[19] In most cases, pulmonary contusion goes away by five to seven days after the injury without permanent complications.[37] 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.[20] Older people and those who have heart or lung 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.[20]

Severe complications such as acute respiratory distress syndrome (ARDS) may result from the injury, occurring 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; 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.[32]

Pneumonia, another potential complication, develops in as many as 20% of people with pulmonary contusion.[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] 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.[32] Children and adults have been found to have similar rates of complication with pneumonia and ARDS.[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.[32] Pulmonary contusion may interfere with an individual's ability to return to work.[3]

[edit] 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 polytrauma 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.[24] Thus children suffer double the number of pulmonary contusions as adults as a result of forceful impacts, yet have proportionately fewer rib fractures.[10] 53% of children with significant chest injuries (requiring hospitalization) have pulmonary contusion.[38] Differences in the bodies of children and adults 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.[25] However, despite differences in the severity of injuries and other factors, children with pulmonary contusion have similar mortality rates to adults.[25]

[edit] 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.[29]

[edit] See also

[edit] References

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[edit] External links

v • d • e
Injuries, other than fractures, dislocations, sprains and strains (S00-T14, 850-929)
Head (head injury) and neck
Thorax (chest trauma)
Abdomen, lower back, lumbar spine and pelvis
Shoulder and upper arm
General
v • d • e
Chest trauma
Chest wall injuries and Fractures
Rib fracture, Flail chest, Sternal fracture, Clavicle fracture, Shoulder girdle fracture, Scapular fracture
Pulmonary and Respiratory system injuries
Pneumothorax, Hemothorax, Hemopneumothorax, Pulmonary contusion, pulmonary laceration, Tracheobronchial injury
Cardiac and Circulatory system injuries