Pathophysiologie, Diagnostik und Therapie der Lungenkontusion – Empfehlungen der interdisziplinären Arbeitsgruppe der Sektion NIS der DGU und DGT zur Thoraxtraumaversorgung

Zusammenfassung

Lungenkontusionen treten in aller Regel in Kombination mit weiteren Verletzungen auf und sprechen für eine hohe Krafteinwirkung. Vor allem bei polytraumatisierten Patienten werden Lungenkontusionen in hoher Anzahl nachgewiesen. Diese Verletzungen sind u. a. durch eine zeitliche Dynamik charakterisiert, die in der initialen Diagnostik Schwierigkeiten bereiten kann. Eine korrekte Einordnung des Verletzungsausmaßes in das Gesamtgeschehen und entsprechende diagnostische und therapeutische Schritte sind für das Erreichen einer Ausheilung essenziell. Das übergeordnete Ziel aller therapeutischen Maßnahmen ist es, dabei die Lungenfunktion bestmöglich zu erhalten und assoziierte Komplikationen wie die Entwicklung einer Pneumonie oder eines ARDS (Acute Respiratory Distress Syndrome) zu vermeiden.

Die vorliegende Arbeit der interdisziplinären Arbeitsgruppe „Thoraxtrauma“ der Deutschen Gesellschaft für Unfallchirurgie (DGU) und der Deutschen Gesellschaft für Thoraxchirurgie (DGT) basiert auf einer umfangreichen Literaturrecherche zu Grundlagen, Diagnostik und Behandlung der Lungenkontusion. Es konnten ausnahmslos Arbeiten mit niedrigem Evidenzgrad eingeschlossen werden. Die Empfehlungen der vorliegenden Arbeit entsprechen einem Konsens der interdisziplinären Arbeitsgruppe.

Zur initialen Diagnostik ist eine CT des Thorax mit Kontrastmittel empfohlen, das Ausmaß der Lungenkontusion korreliert mit dem Auftreten von Komplikationen. Eine konventionelle Aufnahme des Thorax kann initial die Verletzung unterbewerten, ist aber zur kurzfristigen Verlaufskontrolle geeignet.

Die Therapie der Lungenkontusion ist multimodal und symptomorientiert. Insbesondere die intensivmedizinische Betreuung mit einer lungenprotektiven Beatmung und adäquaten Lagerung sind Eckpfeiler der Behandlung. Soweit es die Nebenerkrankungen und der Zustand des Patienten zulassen, sollte eine nicht invasive Beatmung erwogen werden. Abhängig von der Lungenbeteiligung und dem Patientenzustand kann ferner eine ECMO-Therapie als Ultima Ratio erwogen werden. Insbesondere diese sollte nur an spezialisierten Kliniken durchgeführt werden, weswegen eine frühzeitige Patientenzuweisung oder eine frühe Verlegung im Rahmen von Netzwerkstrukturen antizipiert werden sollte.

Abstract

Pulmonary contusion usually occurs in combination with other injuries and is indicative of a high level of force. Especially in multiply injured patients, pulmonary contusions are frequently detected. The injury is characterised by dynamic development, which might result in difficulties in recognising the actual extent of the injury at an early stage. Subsequently, correct classification of the extent of injury and appropriate initiation of therapeutic steps are essential to achieve the best possible outcome. The main goal of all therapeutic measures is to preserve lung function as best as possible and to avoid associated complications such as the development of pneumonia or Acute Respiratory Distress Syndrome (ARDS).

The present report from the interdisciplinary working group “Chest Trauma” of the German Society for Trauma Surgery (DGU) and the German Society for Thoracic Surgery (DGT) includes an extensive literature review on the background, diagnosis and treatment of pulmonary contusion. Without exception, papers with a low level of evidence were included due to the lack of studies with large cohorts of patients or randomised controlled studies. Thus, the recommendations given in the present article correspond to a consensus of the aforementioned interdisciplinary working group.

Computed tomography (CT) of the chest is recommended for initial diagnosis; the extent of pulmonary contusion correlates with the incidence and severity of complications. A conventional chest X-ray may initially underestimate the injury, but is useful during short-term follow-up.

Therapy for pulmonary contusion is multimodal and symptom-based. In particular, intensive care therapy with lung-protective ventilation and patient positioning are key factors of treatment. In addition to invasive ventilation, non-invasive ventilation should be considered if the patient’s comorbidities and compliance allows this. Furthermore, depending on the extent of the lung injury and the general patient’s condition, ECMO therapy may be considered as an ultima ratio. In particular, this should only be performed at specialised hospitals, which is why patient assignment or anticipation of early transfer of the patient should be anticipated at an early time during the course.

Schlüsselwörter

Trauma - Lungenkontusion - Lungenverletzung

Keywords

trauma - lung contusion - chest - lung injury

Publication History

Received: 21 May 2022

Accepted after revision: 09 November 2022

Article published online:
30 January 2023

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