Pulmonary laceration

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Pulmonary laceration
Lung lacerations.JPG
Coronal CT scan showing lucencies (pale areas in radiography) in the lung caused by pulmonary lacerations on the left of the image (black arrows)
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A pulmonary laceration is a chest injury in which lung tissue is torn or cut. [1] An injury that is potentially more serious than pulmonary contusion, pulmonary laceration involves disruption of the architecture of the lung, [2] while pulmonary contusion does not. [3] Pulmonary laceration is commonly caused by penetrating trauma but may also result from forces involved in blunt trauma such as shear stress. A cavity filled with blood, air, or both can form. [2] The injury is diagnosed when collections of air or fluid are found on a CT scan of the chest. Surgery may be required to stitch the laceration, to drain blood, or even to remove injured parts of the lung. The injury commonly heals quickly with few problems if it is given proper treatment; however it may be associated with scarring of the lung or other complications.

Contents

Presentation

Complications

Complications are not common but include infection, lung abscess, and bronchopleural fistula (a fistula between the pleural space and the bronchial tree). [4] A bronchopleural fistula results when there is a communication between the laceration, a bronchiole, and the pleura; it can cause air to leak into the pleural space despite the placement of a chest tube. [4] The laceration can also enlarge, as may occur when the injury creates a valve that allows air to enter the laceration, progressively expanding it. [4] One complication, air embolism, in which air enters the bloodstream, is potentially fatal, especially when it occurs on the left side of the heart. [5] Air can enter the circulatory system through a damaged vein in the injured chest and can travel to any organ; it is especially deadly in the heart or brain. [5] Positive pressure ventilation can cause pulmonary embolism by forcing air out of injured lungs and into blood vessels. [5]

Causes

Pulmonary laceration is a common result of penetrating trauma but may also be caused by blunt trauma; broken ribs may perforate the lung, or the tissue may be torn due to shearing forces [5] that result from different rates of acceleration or deceleration of different tissues of the lung. [6] Violent compression of the chest can cause lacerations by rupturing or shearing the lung tissue. [4] Pulmonary laceration may result from blunt and penetrating forces that occur in the same injury and may be associated with pulmonary contusion. [7] [8] Lacerations of the lung tissue can also occur by compression of the alveoli against the ribs or spine. [4] As with contusions, pulmonary lacerations usually occur near solid structures in the chest such as ribs. [2] Pulmonary laceration is suspected when rib fractures are present. [9]

Pathophysiology

A CT scan of a pneumothorax, a chest injury that may accompany pulmonary laceration Pneumothorax CT.jpg
A CT scan of a pneumothorax, a chest injury that may accompany pulmonary laceration

A pulmonary laceration can cause air to leak out of the lacerated lung [10] and into the pleural space, if the laceration goes through to it. [8] Pulmonary laceration invariably results in pneumothorax (due to torn airways), hemothorax (due to torn blood vessels), or a hemopneumothorax (with both blood and air in the chest cavity). [11] Unlike hemothoraces that occur due to pulmonary contusion, those due to lung laceration may be large and long lasting. [12] However, the lungs do not usually bleed very much because the blood vessels involved are small and the pressure within them is low. [5] Therefore, pneumothorax is usually more of a problem than hemothorax. [8] A pneumothorax may form or be turned into a tension pneumothorax by mechanical ventilation, which may force air out of the tear in the lung. [12]

The laceration may also close up by itself, which can cause it to trap blood and potentially form a cyst or hematoma. [8] Because the lung is elastic, the tear forms a round cyst called a traumatic air cyst that may be filled with air, or blood and air, and that usually shrinks over a period of weeks or months. [13] Lacerations that are filled with air are called pneumatoceles, and those that are filled with blood are called pulmonary hematomas. [14] In some cases, both pneumatoceles and hematomas exist in the same injured lung. [12] A pneumatocele can become enlarged, for example when the patient is mechanically ventilated or has acute respiratory distress syndrome, in which case it may not go away for months. [12] Pulmonary hematomas take longer to heal than simple pneumatoceles and commonly leave the lungs scarred. [14]

Over time, the walls of lung lacerations tend to grow thicker due to edema and bleeding at the edges. [1]

Diagnosis

A chest X-ray of a right sided pulmonary contusion associated with flail chest and subcutaneous emphysema. Contusion may mask pulmonary laceration on chest X-ray. Pulmonary contusion.jpg
A chest X-ray of a right sided pulmonary contusion associated with flail chest and subcutaneous emphysema. Contusion may mask pulmonary laceration on chest X-ray.

Pulmonary laceration may not be visible using chest X-ray because an associated pulmonary contusion or hemorrhage may mask it. [1] [9] As the lung contusion clears (usually within two to four days), lacerations begin to become visible on chest X-ray. [3] CT scanning is more sensitive and better at detecting pulmonary laceration than X-rays are, [1] [5] [12] [15] and often reveals multiple lacerations in cases where chest X-ray showed only a contusion. [12] Before CT scanning was widely available, pulmonary laceration was considered unusual because it was not common to find with X-ray alone. [12] On a CT scan, pulmonary lacerations show up in a contused area of the lung, [9] typically appearing as cavities filled with air or fluid [16] that usually have a round or ovoid shape due to the lung's elasticity. [4]

Hematomas appear on chest radiographs as smooth masses that are round or ovoid in shape. [1] Like lacerations, hematomas may initially be hidden on X-ray by lung contusions, but they become more apparent as the contusion begins to heal. [1] Pneumatoceles have a similar shape to that of hematomas but have thin, smooth walls. [17] Lacerations may be filled completely with blood, completely with air, or partially with both. [4] Lacerations filled with both blood and air display a distinctive air-fluid level. [4] A single laceration may occur by itself, or many may be present, creating an appearance like Swiss cheese in the radiography of the lung. [4]

Pulmonary laceration is usually accompanied by hemoptysis (coughing up blood or of blood-stained sputum). [12]

Thoracoscopy may be used in both diagnosis and treatment of pulmonary laceration. [8]

A healing laceration may resemble a lung nodule on radiographs, but unlike pulmonary nodules, lacerations decrease in size over time on radiographs. [4]

Classification

In 1988, a group led by R.B. Wagner divided pulmonary lacerations into four types based on the manner in which the person was injured and indications found on a CT scan. [18] In type 1 lacerations, which occur in the mid lung area, the air-filled lung bursts as a result of sudden compression of the chest. [18] Also called compression-rupture lacerations, type 1 are the most common type and usually occur in a central location of the lung. [1] They tend to be large, ranging in size from 2–8 cm. [19] The shearing stress in type 2 results when the lower chest is suddenly compressed and the lower lung is suddenly moved across the vertebral bodies. [18] [19] Type 2, also called compression-shear, [1] tends to occur near the spine and have an elongated shape. [19] Type 2 lacerations usually occur in younger people with more flexible chests. [6] Type 3, which are caused by punctures from fractured ribs, occur in the area near the chest wall underlying the broken rib. [18] Also called rib penetration lacerations, type 3 lacerations tend to be small [1] and accompanied by pneumothorax. [18] Commonly, more than one type 3 laceration will occur. [19] Type 4, also called adhesion tears, [1] occur in cases where a pleuropulmonary adhesion had formed prior to the injury, in which the chest wall is suddenly fractured or pushed inwards. [19] They occur in the subpleural area and result from shearing forces at sites of transpleural adhesion. [6]

Treatment

As with other chest injuries such as pulmonary contusion, hemothorax, and pneumothorax, pulmonary laceration can often be treated with just supplemental oxygen, ventilation, and drainage of fluids from the chest cavity. [20] A thoracostomy tube can be used to remove blood and air from the chest cavity. [21] About 5% of cases require surgery, called thoracotomy. [11] Thoracotomy is especially likely to be needed if a lung fails to re-expand; if pneumothorax, bleeding, or coughing up blood persist; or in order to remove clotted blood from a hemothorax. [11] Surgical treatment includes suturing, [11] stapling, oversewing, and wedging out of the laceration. [8] Occasionally, surgeons must perform a lobectomy, in which a lobe of the lung is removed, or a pneumonectomy, in which an entire lung is removed. [11]

Prognosis

Full recovery is common with proper treatment. [20] Pulmonary laceration usually heals quickly after a chest tube is inserted and is usually not associated with major long-term problems. [8] Pulmonary lacerations usually heal within three to five weeks, [12] and lacerations filled with air will commonly heal within one to three weeks but on occasion take longer. [1] However, the injury often takes weeks or months to heal, and the lung may be scarred. [2] Small pulmonary lacerations frequently heal by themselves if material is removed from the pleural space, but surgery may be required for larger lacerations that do not heal properly or that bleed. [21]

See also

Related Research Articles

<span class="mw-page-title-main">Thorax</span> Frontal part of an animals body, between its head and abdomen

The thorax or chest is a part of the anatomy of humans, mammals, and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main divisions of the creature's body, each of which is in turn composed of multiple segments.

<span class="mw-page-title-main">Pneumothorax</span> Abnormal collection of air in the pleural space

A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve is formed by an area of damaged tissue, and the amount of air in the space between chest wall and lungs increases; this is called a tension pneumothorax. This can cause a steadily worsening oxygen shortage and low blood pressure. This leads to a type of shock called obstructive shock, which can be fatal unless reversed. Very rarely, both lungs may be affected by a pneumothorax. It is often called a "collapsed lung", although that term may also refer to atelectasis.

<span class="mw-page-title-main">Pleurisy</span> Disease of the lungs

Pleurisy, also known as pleuritis, is inflammation of the membranes that surround the lungs and line the chest cavity (pleurae). This can result in a sharp chest pain while breathing. Occasionally the pain may be a constant dull ache. Other symptoms may include shortness of breath, cough, fever, or weight loss, depending on the underlying cause. Pleurisy can be caused by a variety of conditions, including viral or bacterial infections, autoimmune disorders, and pulmonary embolism.

<span class="mw-page-title-main">Chest tube</span> Type of surgical drain

A chest tube is a surgical drain that is inserted through the chest wall and into the pleural space or the mediastinum in order to remove clinically undesired substances such as air (pneumothorax), excess fluid, blood (hemothorax), chyle (chylothorax) or pus (empyema) from the intrathoracic space. An intrapleural chest tube is also known as a Bülau drain or an intercostal catheter (ICC), and can either be a thin, flexible silicone tube, or a larger, semi-rigid, fenestrated plastic tube, which often involves a flutter valve or underwater seal.

<span class="mw-page-title-main">Thoracotomy</span> Surgical procedure

A thoracotomy is a surgical procedure to gain access into the pleural space of the chest. It is performed by surgeons to gain access to the thoracic organs, most commonly the heart, the lungs, or the esophagus, or for access to the thoracic aorta or the anterior spine. A thoracotomy is the first step in thoracic surgeries including lobectomy or pneumonectomy for lung cancer or to gain thoracic access in major trauma.

<span class="mw-page-title-main">Chest radiograph</span> Projection X-ray of the chest

A chest radiograph, called a chest X-ray (CXR), or chest film, is a projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures. Chest radiographs are the most common film taken in medicine.

<span class="mw-page-title-main">Hemothorax</span> Blood accumulation in the pleural cavity

A hemothorax is an accumulation of blood within the pleural cavity. The symptoms of a hemothorax may include chest pain and difficulty breathing, while the clinical signs may include reduced breath sounds on the affected side and a rapid heart rate. Hemothoraces are usually caused by an injury, but they may occur spontaneously due to cancer invading the pleural cavity, as a result of a blood clotting disorder, as an unusual manifestation of endometriosis, in response to Pneumothorax, or rarely in association with other conditions.

Hemopneumothorax, or haemopneumothorax, is the condition of having both air (pneumothorax) and blood (hemothorax) in the chest cavity. A hemothorax, pneumothorax, or the combination of both can occur due to an injury to the lung or chest.

<span class="mw-page-title-main">Blunt trauma</span> Physical trauma caused to a body part, either by impact, injury or physical attack

Blunt trauma, also known as blunt force trauma or non-penetrating trauma, is physical trauma or impactful force to a body part, often occurring with road traffic collisions, direct blows, assaults, injuries during sports, and particularly in the elderly who fall. It is contrasted with penetrating trauma which occurs when an object pierces the skin and enters a tissue of the body, creating an open wound and bruise.

<span class="mw-page-title-main">Chest injury</span> Medical condition

A chest injury, also known as chest trauma, is any form of physical injury to the chest including the ribs, heart and lungs. Chest injuries account for 25% of all deaths from traumatic injury. Typically chest injuries are caused by blunt mechanisms such as direct, indirect, compression, contusion, deceleration, or blasts caused by motor vehicle collisions or penetrating mechanisms such as stabbings.

<span class="mw-page-title-main">Focused assessment with sonography for trauma</span> Fluid accumulation screening

Focused assessment with sonography in trauma is a rapid bedside ultrasound examination performed by surgeons, emergency physicians, and paramedics as a screening test for blood around the heart or abdominal organs (hemoperitoneum) after trauma. There is also the extended FAST (eFAST) which includes some additional ultrasound views to assess for pneumothorax.

<span class="mw-page-title-main">Penetrating trauma</span> Type of injury

Penetrating trauma is an open wound injury that occurs when an object pierces the skin and enters a tissue of the body, creating a deep but relatively narrow entry wound. In contrast, a blunt or non-penetrating trauma may have some deep damage, but the overlying skin is not necessarily broken and the wound is still closed to the outside environment. The penetrating object may remain in the tissues, come back out the path it entered, or pass through the full thickness of the tissues and exit from another area.

<span class="mw-page-title-main">Pulmonary contusion</span> Internal bruise of the lungs

A pulmonary contusion, also known as lung contusion, is a bruise of the lung, caused by chest trauma. As a result of damage to capillaries, blood and other fluids accumulate in the lung tissue. The excess fluid interferes with gas exchange, potentially leading to inadequate oxygen levels (hypoxia). Unlike pulmonary laceration, another type of lung injury, pulmonary contusion does not involve a cut or tear of the lung tissue.

<span class="mw-page-title-main">Subcutaneous emphysema</span> Medical condition

Subcutaneous emphysema occurs when gas or air accumulates and seeps under the skin, where normally no gas should be present. Subcutaneous refers to the subcutaneous tissue, and emphysema refers to trapped air pockets. Since the air generally comes from the chest cavity, subcutaneous emphysema usually occurs around the upper torso, such as on the chest, neck, face, axillae and arms, where it is able to travel with little resistance along the loose connective tissue within the superficial fascia. Subcutaneous emphysema has a characteristic crackling-feel to the touch, a sensation that has been described as similar to touching warm Rice Krispies. This sensation of air under the skin is known as subcutaneous crepitation, a form of crepitus.

<span class="mw-page-title-main">Tracheobronchial injury</span> Damage to the tracheobronchial tree

Tracheobronchial injury is damage to the tracheobronchial tree. It can result from blunt or penetrating trauma to the neck or chest, inhalation of harmful fumes or smoke, or aspiration of liquids or objects.

<span class="mw-page-title-main">Diaphragmatic rupture</span> Tear in the thoracic diaphragm, usually caused by physical trauma

Diaphragmatic rupture is a tear of the diaphragm, the muscle across the bottom of the ribcage that plays a crucial role in breathing. Most commonly, acquired diaphragmatic tears result from physical trauma. Diaphragmatic rupture can result from blunt or penetrating trauma and occurs in about 0.5% of all people with trauma.

<span class="mw-page-title-main">Scapular fracture</span> Injury of the shoulder blade

A scapular fracture is a fracture of the scapula, the shoulder blade. The scapula is sturdy and located in a protected place, so it rarely breaks. When it does, it is an indication that the individual was subjected to a considerable amount of force and that severe chest trauma may be present. High-speed vehicle accidents are the most common cause. This could be anywhere from a car accident, motorcycle crash, or high speed bicycle crash but falls and blows to the area can also be responsible for the injury. Signs and symptoms are similar to those of other fractures: they include pain, tenderness, and reduced motion of the affected area although symptoms can take a couple of days to appear. Imaging techniques such as X-ray are used to diagnose scapular fracture, but the injury may not be noticed in part because it is so frequently accompanied by other, severe injuries that demand attention. The injuries that usually accompany scapular fracture generally have the greatest impact on the patient's outcome. However, the injury can also occur by itself; when it does, it does not present a significant threat to life. Treatment involves pain control and immobilizing the affected area, and, later, physical therapy.

<span class="mw-page-title-main">Pneumatocele</span>

A pneumatocele is a cavity in the lung parenchyma filled with air that may result from pulmonary trauma during mechanical ventilation.

A pulmonary hematoma is a collection of blood within the tissue of the lung. It may result when a pulmonary laceration fills with blood. A lung laceration filled with air is called a pneumatocele. In some cases, both pneumatoceles and hematomas exist in the same injured lung. Pulmonary hematomas take longer to heal than simple pneumatoceles and commonly leave the lungs scarred. A pulmonary contusion is another cause of bleeding within the lung tissue, but these result from microhemorrhages, multiple small bleeds, and the bleeding is not a discrete mass but rather occurs within the lung tissue. An indication of more severe damage to the lung than pulmonary contusion, a hematoma also takes longer to clear. Unlike contusions, hematomas do not usually interfere with gas exchange in the lung, but they do increase the risk of infection and abscess formation.

Tumor-like disorders of the lung pleura are a group of conditions that on initial radiological studies might be confused with malignant lesions. Radiologists must be aware of these conditions in order to avoid misdiagnosing patients. Examples of such lesions are: pleural plaques, thoracic splenosis, catamenial pneumothorax, pleural pseudotumor, diffuse pleural thickening, diffuse pulmonary lymphangiomatosis and Erdheim–Chester disease.

References

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