Classification and Triage
Most lung injuries that require intervention will either need a chest tube, thoracotomy, or, rarely, a pneumonectomy.
Pneumathoraces can usually be treated with a chest tube.
Thoracotomies are rare and generally only required if a) chest tube output exceeds 1500cc (usually due to injury of the internal mammary or intercostal arteries and not due to the lung parenchyma itself – note that blood collected from the pleural space can be reinfused [McGhee A et al. J Accid Emerg Med 16: 451, 1999]) b) massive air leak ensues following large airway disruption c) mediastinal injury is suspected or d) hemodynamic instability is present and thought to be secondary to an intra-thoracic process.
Traditionally it was taught that chest trauma requiring a pneumonectomy was universally fatal, however Karmy-Jones et al. reported a series of 143 patients who required some form of lung resection, and found that while mortality increased with extent of resection (suture alone 9%; tractotomy 13%; wedge 30%; lobectomy 43%; pneumonectomy 50%), pneumonectomy still carried a 50% survival. [Karmy-Jones R et al. J Trauma 51: 1049, 2001]
Despite the obvious utility of a double lumen tube, the initial intubation should be accomplished with an 8.0 mm or larger endotracheal tube, which will allow for diagnostic bronchoscopy and subsequent tube exchange after the gastric contents have been removed.
Common causes of intraoperative and immediate postoperative death in lung-injured patients are blood loss and RV failure, the latter of which is initiated by the disproportionate increase in pulmonary vascular resistance (as compared to SVR) following blood loss [Long DM et al. J Trauma 8: 715, 1968], and which significantly complicates fluid management. There is not enough data to make a definitive recommendation regarding the management of RV failure in this setting, however increased preload is often helpful [Miller], but diuretics, pulmonary vasodilators, and nitric oxide [Nurozler F et al. Ann Thorac Surg 71: 364, 2001] have all been tried.