Pulmonary laceration

A pulmonary laceration is a chest injury in which lung tissue is torn or cut.] Lacerations that are filled with air are called pneumatoceles, and those that are filled with blood are called pulmonary hematomas. In some cases, both pneumatoceles and hematomas exist in the same injured lung. 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. Pulmonary hematomas take longer to heal than simple pneumatoceles and commonly leave the lungs scarred.cite book |author=White C, Stern EJ |title=Chest Radiology Companion |publisher=Lippincott Williams & Wilkins |location=Hagerstown, MD |year=1999 |pages=80, 176 |isbn=0-397-51732-7 |oclc= |doi= |accessdate=2008-04-30 |url=http://books.google.com/books?id=keNyAl8AArUC&pg=PA176&dq=pulmonary+laceration&lr=&client=firefox-a&sig=wvrEbz3w48sBnRaXtSxF9E6DwzM#PPA80,M1]

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

Diagnosis

Pulmonary laceration may not be visible using chest X-ray because an associated pulmonary contusion or hemorrhage may mask it. As the lung contusion clears (usually within two to four days), lacerations begin to become visible on chest X-ray.cite journal |author=Wicky S, Wintermark M, Schnyder P, Capasso P, Denys A |title=Imaging of blunt chest trauma |journal=European Radiology |volume=10 |issue=10 |pages=1524–1538 |year=2000 |pmid=11044920 |doi= |url=] CT scanning is more sensitive and better at detecting pulmonary laceration than X-rays are,cite journal |author=Costantino M, Gosselin MV, Primack SL |title=The ABC's of thoracic trauma imaging |journal=Seminars in Roentgenology |volume=41 |issue=3 |pages=209–225 |year=2006 |month=July |pmid=16849051 |doi=10.1053/j.ro.2006.05.005 |url=] and often reveals multiple lacerations in cases where chest X-ray showed only a contusion. Before CT scanning was widely available, pulmonary laceration was considered unusual because it was not common to find with X-ray alone. On a CT scan, pulmonary lacerations show up in a contused area of the lung,cite book |author=Hopkins RL, Peden C, Ghandi S |chapter=Trauma radiology |title=Radiology for Anaesthesia and Intensive Care |publisher=Cambridge University Press |location=Cambridge, UK |year=2008 |pages=135 |isbn=0-521-69485-X |oclc= |doi= |accessdate= |url=http://books.google.com/books?id=9UDvpaw8d6YC&pg=PA133&dq=pulmonary+laceration&lr=&client=firefox-a&sig=DGLYopNn5ICNDT7nad_RdWxdrQg#PPA135,M1 ] typically appearing as cavities filled with air or fluidcite book |author=Donnelly LF |chapter=CT of Acute pulmonary infection/trauma |editor=Strife JL, Lucaya J |title=Pediatric Chest Imaging: Chest Imaging in Infants and Children |publisher=Springer |location=Berlin |year=2002 |pages= 123 |isbn=3-540-43557-3 |oclc= |doi= |accessdate= 2008-05-01 |url=http://books.google.com/books?id=o5FLRDJsOFgC&pg=PA124&dq=pulmonary+laceration&lr=&client=firefox-a&sig=2nK66fOXCjEiEMc3N7I8O83DcJE] that usually have a round or ovoid shape due to the lung's elasticity.

Hematomas appear on chest radiographs as smooth masses that are round or ovoid in shape. Like lacerations, hematomas may initially be hidden on X-ray by lung contusions, but they become more apparent as the contusion begins to heal. Pneumatoceles have a similar shape to that of hematomas but have thin, smooth walls. cite book |author=Schnyder P, Wintermark M |title=Radiology of Blunt Trauma of the Chest |publisher=Springer |location=Berlin |year=2000 |pages=62 |isbn=3-540-66217-0 |oclc= |doi= |accessdate= 2008-05-06 |url = http://books.google.com/books?id=Q4haCU0cX14C&pg=PA62&lpg=PA62&dq=pulmonary+laceration+type&source=web&ots=HUWMAZ1iXh&sig=-o9MQ09BCVfIrsoo2_xLbXm41VE&hl=en] Lacerations may be filled completely with blood, completely with air, or partially with both. Lacerations filled with both blood and air display a distinctive air-fluid level. A single laceration may occur by itself, or many may be present, creating an appearance like Swiss cheese in the radiography of the lung.

Pulmonary laceration is usually accompanied by hemoptysis (coughing up blood or of blood-stained sputum).cite journal |author=Gavelli G, Canini R, Bertaccini P, Battista G, Bnà C, Fattori R |title=Traumatic injuries: imaging of thoracic injuries |journal=European Radiology |volume=12 |issue=6 |pages=1273–1294 |year=2002 |month=June |pmid=12042932 |doi=10.1007/s00330-002-1439-6 |url=]

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

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

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.cite journal |author=Hara H, Yoshimura H |title=Traumatic lung injury |language=Japanese |journal=Kyobu Geka |volume=57 |issue=8 |pages=762–769 |year=2004 |month=July |pmid=15362557 |doi= |url=] A thoracostomy tube can be used to remove blood and air from the chest cavity.cite journal |author=Sartorelli KH, Vane DW |title=The diagnosis and management of children with blunt injury of the chest |journal=Seminars in Pediatric Surgery |volume=13 |issue=2 |pages=98–105 |year=2004 |month=May |pmid=15362279 |doi=doi:10.1053/j.sempedsurg.2004.01.005 |url=] About 5% of cases require surgery, called thoracotomy. 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. Surgical treatment includes suturing, stapling, oversewing, and wedging out of the laceration. 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.

Prognosis

Full recovery is common with proper treatment. Pulmonary laceration usually heals quickly after a chest tube is inserted and is usually not associated with major long-term problems. Pulmonary lacerations usually heal within three to five weeks, and lacerations filled with air will commonly heal within one to three weeks but on occasion take longer. However, the injury often takes weeks or months to heal, and the lung may be scarred. 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.

Complications

Complications are not common but include infection, pulmonary abscess, and bronchopleural fistula (a fistula between the pleural space and the bronchial tree). 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. The laceration can also enlarge, as may occur when the injury creates a valve that allows air to enter the laceration, progressively expanding it. One complication, air embolism, in which air enters the bloodstream, is potentially fatal, especially when it occurs on the left side of the heart. 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. Positive pressure ventilation can cause pulmonary embolism by forcing air out of injured lungs and into blood vessels.

ee also

*Pulmonary toilet

References