Pulmonary and Critical Care

Traumatic chest injury is a common complication of trauma. The chest wall, airways and lungs beautifully illustrate the interplay between anatomy, physiology and biochemistry. The pathophysiology of traumatic injury to the lung runs the gamut from the fairly simple concept of air around the lung in pneumothorax, through to a profound multi-system disorder associated with the acute respiratory distress syndrome, precipitated by lung contusions. The clinical approach to a pneumothorax includes the routine use of ultrasound in at-risk patients. Sensitivities and specificities are comparable to chest X-ray. Chest-X ray evaluation of pleural fluid in trauma, however, remains a key tool in determining the likely amount of fluid in the pleural space. The clinical approach to pleural fluid in the setting of a critically ill victim of trauma deviates from that of a non-trauma presentation; accessing the pleural space involves a careful balance of risks. Clinical features of pulmonary contusions range from pulmonary hemorrhage to diffuse cytokine storm. Evidence for empirical treatment with Tranexamic acid to treat or prevent pulmonary hemorrhage is currently lacking. Ventilatory strategies aimed at preventing progression to ARDS include protective ventilatory strategies and limitation of excess fluids. Treatment of established ARDS involves probing and early consideration of extracorporeal membrane oxygenation techniques. Future research directions include genotypeprediction of which patients will progress to multi-organ failure. Early recognition may assist in preventing progression to severe disease. Pulmonary rehabilitation involves effective nutrition and early ambulation. The avoidance of pulmonary-active medications may expedite recovery.