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Late sequelae of lung contusion
Injury (1989) 20,253-256
printed in Great Britain
253
Late sequelae of lung contusion Jan L. Svennevig, Jarle Vaage, Arne Westheim, Geir Hafsahl and Harald E. Refsum Departments
of Surgery and Radiology,
and Laboratory
of Clincial Physiology,
Twenty-four patients with severe lung contusion and multiple rib fhctures were studied at a mean 89 years (range 2-9 years) after iniuy. All patients had been in good health before the accident. After the acckient 15 (63 per cent) patients had rwpiratory symptoms such as dyspnoea at rest or moderate exercise (4), pain (8), cough or increased expectoration (II) and frequent bronchopulmonary infections (5). Three patients had changed their job because of respiratory disturbance. The average vital capacity, forced exp’ratoy volume in 1 s, maxkl voluntary ventilation anA CO transferfactor were reducd respectively to 87, 88, 82 and 83 per centof predicted values (PC 0.01) while total lung uapac@, residual volume and helium mixing time showed no definite changes (p > 0.05). Arterial blood gases at rest ana’ at maximum exercke showed slight changesonly. hkximal working capacity and ECG, as well as the vent&&y cost of&ate exercise were normal, where as the CO, recovery time after moderate exercise was slightly increused (F c 0.05). Overall there was a tenkncy towards poorer fimction in patients treated with artifuial ventilation. Chest radiographs were normal in 10 patients (42 per cent), and moderate changes were seen in 14 patients. Diaphragmatic movements were essentially normal in all patients. Severe injury to the chest causes frequent respiratory symptoms. However objective tests were only moderately reduced when compared with normal values. There was no unequivocal association between the subjective symptoms and the pulmona y function.
Introduction We have previously analysed early haemodynamics and gas exchange in patients subjected to severe injury of the chest resulting in lung contusion (Bugge-Asperheim et al., 1980; Svennevig et al., 1984). Only a few studies have been undertaken in order to assess the long-term sequelae (Rodewald and Harms, 1965; Davidson et al., 1969; Christensen et al., 197% Harming et al., 1981; Landscaper et al., 1984). Some studies indicate that severe injury to the chest results in long-term disability and impaired lung function, whereas others show no sequelae. The present study was undertaken in order to study the pulmonary function and working capacity of patients treated for severe lung contusion.
Material and methods The study comprised 24 patients, 22 men and 2 women, mean age 48 years (range 18-77 years), who had been 0 1989 Butterworth & Co (Publishers) Ltd 0020-1383/89/050253+l4
$03.00
Ullev&l Hospital, Oslo, Norway
treated for severe closed injury of the chest, mean 4.9 years (range 2-9 years) earlier. In all cases the primary injury resulted in multiple rib fractures (4-11 fractures) or flail chest, and in densities of the lung parer&ma beneath the lesion of the chest wall on chest radiographs, compatible with lung contusion (Pepe et al., 1982). Ten patients were treated on ventilators, median time on artificial ventilation being 6 days (range 4-60 days), while 14 patients could be managed on spontaneous ventilation, supported by extensive physiotherapy and relief of pain. Of the 24 patients 18 were multiply injured. However, only one patient had a severe head injury methylprednisolone, received Thirteen patients 30 mg/kg body weight 3 times during the first 16 h after the accident. The mean hospital stay was 41.8 days (range 9-165 days). All patients had been in good health before the accident, without any known chronic respiratory disease. Twenty patients were smokers. At follow-up all patients had to fill in a questionnaire: thereafter the patient underwent ambulatory examination and testing. Laboratory testing The bellows function, including vital capacity (VC), forced expiratory volume in 1 s (FEV,,) and maximal voluntary ventilation (MW) were determined with a low inertia, low resistance bell spirometer. The lung volumes, including total lung capacity (TLC), functional residual capacity (FRC) and residual volume (RV) were determined by the He-dilution technique, using a Godart Expirograph and He-analyser (Godart N.V., Bilthoven, Netherlands). The CO transfer factor of the lungs (TLCO) was determined with a HewlettPackard Single Breath Diffusion System (Hewlett-Packard Intercontinental, Palo Alto, Ca., USA). Blood gas analyses were performed with an IL 613 Blood Gas Analyser (Instrumentation Laboratory, Lexington, MA, USA). The pulmonary gas exchange at exercise was determined as described in detail by Erikson (1952), Andersen (1959) and Refsum (1972) using a closed-circuit double spirometer system (Erikson et al. 1951). The test subject was comfortably seated in a firmly padded armchair with head support and with a mechanically braked bicycle ergometer in front. The CO, output (VCO,), 0, uptake (VO,) and ventilation (V) were recorded continuously during 20 min of rest, 1 min of work (500 kpm or 4.9 kJ), and 20 min of recovery and rest.
254
Injury: the British Journal of Accident Surgery (1989) Vol. 20/No.
5
The CO, recovery time (CO,RT) was Petermined as the time it takes from the end of exercise till VCO, was reduced to the mean resting level plus 10 per cent. The extra ventilation (EV) was determined as the total ventilation for the last pre-exercise minute when the test subject put the feet on the ergometer pedals, 1 min of exercise and 10 min of recovery and rest, minus the resting values for an equally long period (12 min). All volumes are given at BTPS. The maximal working capacity (MWC) was determined on an electromagnetically braked bicycle ergometer (Siemens-Elema Ergometer Em 369, Stockholm, Sweden). The work load was started at 300 kpm and increased by 50 kpm every minute until exhaustion. ECG and blood pressure were recorded at rest, during exercise and during the first 5 min of the recovery period. The percentages of the expected normal lung functions were based on comparison with the normal values of Grimby and Ssderholm (1963) for bellows function and lung volumes, and of Cotes (1952) for TLCO. The measurements of exercise capacity were compared with the expected normal values reported by Nordenfelt et al. (1985). The level of significance of the differences between the mean observations were estimated by Student’s t test for paired observations.
and frequent bronchopulmonary infections (5). Three patients had changed their job because of respiratory disturbances, while three patients had disability pensions due to non-respiratory consequences of the accident. Twelve patients were still smokers. One patient had suffered a myocardial infarction; none of the patients had cardiac symptoms. Chest radiographs were normal in 10 patients (42 per cent); moderate changes were found in 14 patients (Table I). There was no association between radiographic findings and the patients’ complaints. Diaphragm movements were essentially normal in all patients. The bellows functions (VC, FEV,,,, MVV) were clearly reduced, in particular MW (Table ZI).Eight patients showed definitely reduced VC, while 6 and 10 patients, respectively, had reduced FEV,,O and MVV. The static lung volumes (TLC, FRC and RV) and their interrelationships, however, were essentially normal. TLC0 and Pao were also moder-
Resdts
Negative Thickening of pleura Deformity of chest wall Lung fibrosis Elevation of diaphragm Emphysema
Table I. Analysis of chest radiographs at follow-up of 24 patients
mean 4.9 years (range 2-9 years) after severe closed injury to the chest No. of patients
Result
At follow-up, mean 4.9 years (range 2-9 years) after the accident, 15 patients (63 per cent) had respiratory symptoms such as dyspnoea at rest or moderate exercise (4 patients), chest pain (B), cough and/or increased expectoration (II)
10 6 4 2 2 2
Table II. Pulmonary function in 24 patients mean 5.8 years (range 2-9 years) after severe closed injury of the chest.
Mean values f SEM Result
vc (1) FEV,, (I) FEV,,/VC (%) MW (I/min) TCL (I) FRC (I) RV (I) FRC/TLC (%) RV/TLC (%) He-mix t (min) TLC0 (mmol/kPa,min) Pace, (kPa) Pao, (kPa) Diaphragm movement right side (cm) Diaphragm movement left side (cm) l
P< 0.05:
l
4.01 f 0.20 3.02iO.18 74.4 zk1.8 118.0 k8.6 6.29*0.19 3.41 f0.14 1.91 *0.12 54.3 k1.6 30.5 f1.8 3.2 f0.3 8.22 f 0.12 5.4 l 0.1 11.2 *0.2 3.7 3.5
kO.3 f0.3
Percent of expected 87*3” 88*3” 102*2 82&5” 96zt.2 101*2 101 f4 105f3 103*4 111*7 83zt3” 102*1 95&2’ 101 f7 98*7
* P-C 0.01
Table III. Maximal work capacity and pulmonary gas exchange during and after a standard load of
500 kpm in 1 min. Mean values f SEM for 24 patients Result Maximal work capacity (kpm) Maximal heart rate (min) Ro, max work (kPa) m, max work (kPa) CO, recovery time (min) Extra ventilation (I) ‘:P
“P
1032zt40 161&3 5.0*0.1 12.8zt0.3 7.2&0.5 43.7 f 2.5
Percent of expected 98&3 100*2 95f3’ 108f2’ 118*6” 106f5
Svennevigetal.:Late sequelae of lung contusion
ately reduced, with definitely reduced values in six patients. With normal Pace,, the Pace,-Pao, relationship suggested moderate disturbances of the alveolar-arterial gas exchange. With regard to the cardiopulmonary function at exercise, maximal working capacity (MWC) and the heart rate at maximal work (HR,,,,) were completely normal. However, Pace, showed a slight decline, and Pao, a rise, as usual at maximal exercise in normal subjects (Table 10. The recovery time after exercise (CO,RT) for the whole group was increased, with increased values in eight patients. However, the ventilatory cost of exercise (EV) showed only a slight tendency to rise. Only 9 out of 24 patients felt that the injury had caused reduction in their working capacity, and 18 patients were able to return to their previous occupation. With regard to the association between respiratory symptoms and pulmonary function, three of the four patients complaining of dyspnoea had reduced VC, FEV,,, MW and TLCO, while one had normal values. None of these patients showed reduced Pao, or a rise in CO,RT and EV. On the other hand, three patients with the poorest pulmonary function of all, as judged from VC, FEV,,,, MW, TLCO, CO,RT, EV and MWC, had no major complaints. In general there was a clear tendency towards poorer function in the patients who had been treated with respirators; in particular the dynamic functions and the reaction to standard exercise showed clear differences. FEV,,O and MW were 80 f 5 per cent and 65 f 6 per cent of the expected in the respirator group, in contrast to 94f 4 per cent and 94 f 5 per cent, respectively, in the non-respirator group (PC 0.05;P < 0.001). EV and CO,RT were 122 f 9 per cent and 129 f 11 per cent in the respirator group, and 95 f 5 per cent and 1lOf 5 per cent in the non-respirator group (P-C 0.01, P-C 0.05). Also, MWC and HR,, were slightly lower in the respirator group (P
Discussion Today, more patients survive severe chest injury, compared with earlier reports (Svennevig et al., 1986). Few investigations exist on the long-term sequelae in these patients. The present study indicates that severe injury to the chest often causes respiratory symptoms such as pain dyspnoea, cough, increased expectoration and a tendency to infections of the upper airways. These findings are in agreement with earlier results (Davidson et al., 1969; Landscaper et al., 1984). Most of our patients were able to return to their previous occupation. In Landscaper’s (1984) follow-up investigation of 32 patients treated for flail chest, only 12 patients had returned to full-time employment. However, only 12 had experienced moderate or severe changes in their overall level of activity. There are conflicting reports on the value of resting blood gases; Rodewald and Harms (1965) found blood gases of more value than spirometry, while other authors found blood gas analyses of little value (Davidson et al., 1969;
255
Kummer et al., 1976; Christensen et al., 1979; Landscaper et al., 1984). Baumann (1968) found slight hypoxaemia at rest in 6 out of 32 patients. In the present study, there was no association between the minor changes in Pao and the subjective complaints. Also radiographs may be of little value. Diaphragmatic movements were normal in all our patients. In a kymographic study of 18 patients Christensen et al. (1979) found only minor changes. In the present study chest radiographs revealed deformity of the chest wall and thickening of the pleura in a few patients, in accordance with earlier reports (Davidson et al., 1969). Severe deterioration of the bellows function has been found after multiple fractures of the ribs (Braun, 1977). Baumann (1968) found a slight reduction of TLC in 10 of 32 patients, while bronchial obstruction was found in six patients. In patients treated for flail chest bellows function was abnormal in 57 per cent of patients, and 33 per cent exhibited at least a mild restrictive defect (Landscaper et al., 1984). However, in 35 patients tested 1-8 years after trauma causing flail chest, VC and FEV,, were found to be. significantly reduced in only three patients (Christensen et al., 1979). In only 5 of 35 patients studied with r3*Xe a significant reduction of the regional perfusion was seen (Christensen et al., 1979). In the present study MVV indicated a higher degree of functional deterioration than any of the other pulmonary function tests. The frequent respiratory symptoms can often not be confirmed by objective tests. In the present study only one in six patients had evidence of chest wall deformity and the mean values for FVC and FEV,,O showed small reductions for the group as a whole. The frequency of respiratory complaints was high, as also earlier reported by Davidson et al. (1969). However, orthopaedic and neurological sequelae more often seem to cause disablement (Davidson et al., 1969). In previous studies, applying the same pulmonary function tests, a close association has been observed between grade of dyspnoea and rise in the EV/MVV ratio, reflecting the increasing conflict between exertional ventilatory demands and ventilatory capacity (Refsum, 1972; Refsurn et al., 1989). In the present study, however, there was no similar, simple association between complaints and deterioration.
Conclusions The present study demonstrated a high frequency of minor to moderate respiratory symptoms years after severe chest injury. Chest radiographs were normal in the majority of the patients. Blood gas analyses and cardiopulmonary function at exercise were normal for the group as a whole, while the bellows function as measured with VC, FEV,,O and MVV was clearly reduced, especially in patients who had been treated on ventilators. However, there was no unequivocal association between the subjective complaints and the pulmonary function disturbances.
Acknowledgement We are grateful to Erik Fonstelien, statistical analysis.
MSc, for performing
the
References K. L. (1959) Rqiratoy i&covey from Muscular Eremke of .%ort Duration.Oslo: Oslo University Press, 102.
Andersen
256
Injury: the British Journal of Accident Surgery (1989) Vol. ZO/No. 5
Baumann P. C. (1968) Die Lungmfunktion nach schweren Thoraxvedetzungen. Pm.& 5 7,255. Braun U. (1977) Pattern of respiratory function in the late posttraumatic period after chest injury. Inferrsine Cure Med. 3, 186.
Bugge-Asperheim B., Svennevig J. L. and Birkeland S. (1980) Haemodynamic and metabolic consequences of lung contusion foollowing blunt chest trauma. Scmrd.J. Thorac. Curdiovax. Surg 14,295. Christensen P., Gisselsson L., Lecerof H. et al. (1979) Early and late results of controlled ventilation in fIaiI chest. Chest 75,456. Cotes J. E. (1952) Lung Fimth. London: Blackwell Scientific Publications, 603. Davidson I. A, Bargh W., Cm&hank A. N. et al. (1969) Crush injuries of the chest. A follow-up study of patients treated in an artificial ventilation unit. Thorax 24,563. Erikson H. (1952) Spirometry during a short exercise test for evaluation of pulmonary function. Stand. J. Clin. Lab. Invest. 3, 338.
Erikson H., SchoIander P. F. and Irving L. (1951) Apparatus for complete volumetric recording of the respiratory gaseous exchange. Sound.]].Clin. Lab. Invest.3, 228. Grimby G. and Sederhohn B. (1963) Spirometric studies in normaI subjects. Acfu A&d Scend. 173,199. Harming C. D., Ledingham E. and Ledingharn I. M. (1981) Late respiratory sequelae of blunt chest injury: a preliminary report. Thorax 36,204. Kurnmer F., Stacher G. and Vagacs H. (1976) Respiratorische F&&ion und kkischer Zustand von Patienten nach schweren Thoraxtraumen. Unfa~lheikmde 79,365.
Landscaper J., Cogbii T. and Lindesmith L. A. (1984) Long-term disability after flail chest injury. J. rrm 24, 410. Nordenfelt I., Adolfson L., Nilsson J. E. et aI. (1985) Reference values for exercise tests with contiiuous increase in load. Clin. Physiol. 5, 161. Pepe P. E., Potkin R., Reus D. H. et aI. (1982) CIinicaI predictors of the adult respiratory distress syndrome. Am. ]. Surg 144, 124. Refsurn H. E. (1972) Pulmonary gaseous exchange during and after exercise of short duration in silicosis. So&. 1. C/in. Lab lnvesf. [Suppl.] 29, 45. Refsum H. E., Naess-Andresen C. F. and Lange J. E. (1989) PuJrnonary function and gas exchange at rest and exercise in adolescent girls with mild idiopathic scoliosis during treatment with Boston thoracic brace. Spine (in press). RodewaId G. and Harms H. (1965) FunktioneIIe Spatergebnisse nach schweren Brustkorbtraumen. Zenfrulbl.C&r. 90, 1231. Svennevig J. L., Bugge-Asperheim B., Vaage, J. et aI. (1984) Corticosteroids in the treatment of blunt injury in the chest. lnjuy 16,SO. Svennevig J. L., Bugge-Asperheim B., Geiran 0. R. et aI. (1986) Prognostic factors in blunt chest trauma. Analysis of 652 cases. Ann. Chir. Gynaecol.75, 8.
Paper accepted 21 April 1989.
Reqwsfsfor reprints should be aalrd to: Jan L. Svennevig, Department of Surgery, UIIeva Hospital, 0407 Oslo 4, Norway.
printed in Great Britain
253
Late sequelae of lung contusion Jan L. Svennevig, Jarle Vaage, Arne Westheim, Geir Hafsahl and Harald E. Refsum Departments
of Surgery and Radiology,
and Laboratory
of Clincial Physiology,
Twenty-four patients with severe lung contusion and multiple rib fhctures were studied at a mean 89 years (range 2-9 years) after iniuy. All patients had been in good health before the accident. After the acckient 15 (63 per cent) patients had rwpiratory symptoms such as dyspnoea at rest or moderate exercise (4), pain (8), cough or increased expectoration (II) and frequent bronchopulmonary infections (5). Three patients had changed their job because of respiratory disturbance. The average vital capacity, forced exp’ratoy volume in 1 s, maxkl voluntary ventilation anA CO transferfactor were reducd respectively to 87, 88, 82 and 83 per centof predicted values (PC 0.01) while total lung uapac@, residual volume and helium mixing time showed no definite changes (p > 0.05). Arterial blood gases at rest ana’ at maximum exercke showed slight changesonly. hkximal working capacity and ECG, as well as the vent&&y cost of&ate exercise were normal, where as the CO, recovery time after moderate exercise was slightly increused (F c 0.05). Overall there was a tenkncy towards poorer fimction in patients treated with artifuial ventilation. Chest radiographs were normal in 10 patients (42 per cent), and moderate changes were seen in 14 patients. Diaphragmatic movements were essentially normal in all patients. Severe injury to the chest causes frequent respiratory symptoms. However objective tests were only moderately reduced when compared with normal values. There was no unequivocal association between the subjective symptoms and the pulmona y function.
Introduction We have previously analysed early haemodynamics and gas exchange in patients subjected to severe injury of the chest resulting in lung contusion (Bugge-Asperheim et al., 1980; Svennevig et al., 1984). Only a few studies have been undertaken in order to assess the long-term sequelae (Rodewald and Harms, 1965; Davidson et al., 1969; Christensen et al., 197% Harming et al., 1981; Landscaper et al., 1984). Some studies indicate that severe injury to the chest results in long-term disability and impaired lung function, whereas others show no sequelae. The present study was undertaken in order to study the pulmonary function and working capacity of patients treated for severe lung contusion.
Material and methods The study comprised 24 patients, 22 men and 2 women, mean age 48 years (range 18-77 years), who had been 0 1989 Butterworth & Co (Publishers) Ltd 0020-1383/89/050253+l4
$03.00
Ullev&l Hospital, Oslo, Norway
treated for severe closed injury of the chest, mean 4.9 years (range 2-9 years) earlier. In all cases the primary injury resulted in multiple rib fractures (4-11 fractures) or flail chest, and in densities of the lung parer&ma beneath the lesion of the chest wall on chest radiographs, compatible with lung contusion (Pepe et al., 1982). Ten patients were treated on ventilators, median time on artificial ventilation being 6 days (range 4-60 days), while 14 patients could be managed on spontaneous ventilation, supported by extensive physiotherapy and relief of pain. Of the 24 patients 18 were multiply injured. However, only one patient had a severe head injury methylprednisolone, received Thirteen patients 30 mg/kg body weight 3 times during the first 16 h after the accident. The mean hospital stay was 41.8 days (range 9-165 days). All patients had been in good health before the accident, without any known chronic respiratory disease. Twenty patients were smokers. At follow-up all patients had to fill in a questionnaire: thereafter the patient underwent ambulatory examination and testing. Laboratory testing The bellows function, including vital capacity (VC), forced expiratory volume in 1 s (FEV,,) and maximal voluntary ventilation (MW) were determined with a low inertia, low resistance bell spirometer. The lung volumes, including total lung capacity (TLC), functional residual capacity (FRC) and residual volume (RV) were determined by the He-dilution technique, using a Godart Expirograph and He-analyser (Godart N.V., Bilthoven, Netherlands). The CO transfer factor of the lungs (TLCO) was determined with a HewlettPackard Single Breath Diffusion System (Hewlett-Packard Intercontinental, Palo Alto, Ca., USA). Blood gas analyses were performed with an IL 613 Blood Gas Analyser (Instrumentation Laboratory, Lexington, MA, USA). The pulmonary gas exchange at exercise was determined as described in detail by Erikson (1952), Andersen (1959) and Refsum (1972) using a closed-circuit double spirometer system (Erikson et al. 1951). The test subject was comfortably seated in a firmly padded armchair with head support and with a mechanically braked bicycle ergometer in front. The CO, output (VCO,), 0, uptake (VO,) and ventilation (V) were recorded continuously during 20 min of rest, 1 min of work (500 kpm or 4.9 kJ), and 20 min of recovery and rest.
254
Injury: the British Journal of Accident Surgery (1989) Vol. 20/No.
5
The CO, recovery time (CO,RT) was Petermined as the time it takes from the end of exercise till VCO, was reduced to the mean resting level plus 10 per cent. The extra ventilation (EV) was determined as the total ventilation for the last pre-exercise minute when the test subject put the feet on the ergometer pedals, 1 min of exercise and 10 min of recovery and rest, minus the resting values for an equally long period (12 min). All volumes are given at BTPS. The maximal working capacity (MWC) was determined on an electromagnetically braked bicycle ergometer (Siemens-Elema Ergometer Em 369, Stockholm, Sweden). The work load was started at 300 kpm and increased by 50 kpm every minute until exhaustion. ECG and blood pressure were recorded at rest, during exercise and during the first 5 min of the recovery period. The percentages of the expected normal lung functions were based on comparison with the normal values of Grimby and Ssderholm (1963) for bellows function and lung volumes, and of Cotes (1952) for TLCO. The measurements of exercise capacity were compared with the expected normal values reported by Nordenfelt et al. (1985). The level of significance of the differences between the mean observations were estimated by Student’s t test for paired observations.
and frequent bronchopulmonary infections (5). Three patients had changed their job because of respiratory disturbances, while three patients had disability pensions due to non-respiratory consequences of the accident. Twelve patients were still smokers. One patient had suffered a myocardial infarction; none of the patients had cardiac symptoms. Chest radiographs were normal in 10 patients (42 per cent); moderate changes were found in 14 patients (Table I). There was no association between radiographic findings and the patients’ complaints. Diaphragm movements were essentially normal in all patients. The bellows functions (VC, FEV,,,, MVV) were clearly reduced, in particular MW (Table ZI).Eight patients showed definitely reduced VC, while 6 and 10 patients, respectively, had reduced FEV,,O and MVV. The static lung volumes (TLC, FRC and RV) and their interrelationships, however, were essentially normal. TLC0 and Pao were also moder-
Resdts
Negative Thickening of pleura Deformity of chest wall Lung fibrosis Elevation of diaphragm Emphysema
Table I. Analysis of chest radiographs at follow-up of 24 patients
mean 4.9 years (range 2-9 years) after severe closed injury to the chest No. of patients
Result
At follow-up, mean 4.9 years (range 2-9 years) after the accident, 15 patients (63 per cent) had respiratory symptoms such as dyspnoea at rest or moderate exercise (4 patients), chest pain (B), cough and/or increased expectoration (II)
10 6 4 2 2 2
Table II. Pulmonary function in 24 patients mean 5.8 years (range 2-9 years) after severe closed injury of the chest.
Mean values f SEM Result
vc (1) FEV,, (I) FEV,,/VC (%) MW (I/min) TCL (I) FRC (I) RV (I) FRC/TLC (%) RV/TLC (%) He-mix t (min) TLC0 (mmol/kPa,min) Pace, (kPa) Pao, (kPa) Diaphragm movement right side (cm) Diaphragm movement left side (cm) l
P< 0.05:
l
4.01 f 0.20 3.02iO.18 74.4 zk1.8 118.0 k8.6 6.29*0.19 3.41 f0.14 1.91 *0.12 54.3 k1.6 30.5 f1.8 3.2 f0.3 8.22 f 0.12 5.4 l 0.1 11.2 *0.2 3.7 3.5
kO.3 f0.3
Percent of expected 87*3” 88*3” 102*2 82&5” 96zt.2 101*2 101 f4 105f3 103*4 111*7 83zt3” 102*1 95&2’ 101 f7 98*7
* P-C 0.01
Table III. Maximal work capacity and pulmonary gas exchange during and after a standard load of
500 kpm in 1 min. Mean values f SEM for 24 patients Result Maximal work capacity (kpm) Maximal heart rate (min) Ro, max work (kPa) m, max work (kPa) CO, recovery time (min) Extra ventilation (I) ‘:P
“P
1032zt40 161&3 5.0*0.1 12.8zt0.3 7.2&0.5 43.7 f 2.5
Percent of expected 98&3 100*2 95f3’ 108f2’ 118*6” 106f5
Svennevigetal.:Late sequelae of lung contusion
ately reduced, with definitely reduced values in six patients. With normal Pace,, the Pace,-Pao, relationship suggested moderate disturbances of the alveolar-arterial gas exchange. With regard to the cardiopulmonary function at exercise, maximal working capacity (MWC) and the heart rate at maximal work (HR,,,,) were completely normal. However, Pace, showed a slight decline, and Pao, a rise, as usual at maximal exercise in normal subjects (Table 10. The recovery time after exercise (CO,RT) for the whole group was increased, with increased values in eight patients. However, the ventilatory cost of exercise (EV) showed only a slight tendency to rise. Only 9 out of 24 patients felt that the injury had caused reduction in their working capacity, and 18 patients were able to return to their previous occupation. With regard to the association between respiratory symptoms and pulmonary function, three of the four patients complaining of dyspnoea had reduced VC, FEV,,, MW and TLCO, while one had normal values. None of these patients showed reduced Pao, or a rise in CO,RT and EV. On the other hand, three patients with the poorest pulmonary function of all, as judged from VC, FEV,,,, MW, TLCO, CO,RT, EV and MWC, had no major complaints. In general there was a clear tendency towards poorer function in the patients who had been treated with respirators; in particular the dynamic functions and the reaction to standard exercise showed clear differences. FEV,,O and MW were 80 f 5 per cent and 65 f 6 per cent of the expected in the respirator group, in contrast to 94f 4 per cent and 94 f 5 per cent, respectively, in the non-respirator group (PC 0.05;P < 0.001). EV and CO,RT were 122 f 9 per cent and 129 f 11 per cent in the respirator group, and 95 f 5 per cent and 1lOf 5 per cent in the non-respirator group (P-C 0.01, P-C 0.05). Also, MWC and HR,, were slightly lower in the respirator group (P
Discussion Today, more patients survive severe chest injury, compared with earlier reports (Svennevig et al., 1986). Few investigations exist on the long-term sequelae in these patients. The present study indicates that severe injury to the chest often causes respiratory symptoms such as pain dyspnoea, cough, increased expectoration and a tendency to infections of the upper airways. These findings are in agreement with earlier results (Davidson et al., 1969; Landscaper et al., 1984). Most of our patients were able to return to their previous occupation. In Landscaper’s (1984) follow-up investigation of 32 patients treated for flail chest, only 12 patients had returned to full-time employment. However, only 12 had experienced moderate or severe changes in their overall level of activity. There are conflicting reports on the value of resting blood gases; Rodewald and Harms (1965) found blood gases of more value than spirometry, while other authors found blood gas analyses of little value (Davidson et al., 1969;
255
Kummer et al., 1976; Christensen et al., 1979; Landscaper et al., 1984). Baumann (1968) found slight hypoxaemia at rest in 6 out of 32 patients. In the present study, there was no association between the minor changes in Pao and the subjective complaints. Also radiographs may be of little value. Diaphragmatic movements were normal in all our patients. In a kymographic study of 18 patients Christensen et al. (1979) found only minor changes. In the present study chest radiographs revealed deformity of the chest wall and thickening of the pleura in a few patients, in accordance with earlier reports (Davidson et al., 1969). Severe deterioration of the bellows function has been found after multiple fractures of the ribs (Braun, 1977). Baumann (1968) found a slight reduction of TLC in 10 of 32 patients, while bronchial obstruction was found in six patients. In patients treated for flail chest bellows function was abnormal in 57 per cent of patients, and 33 per cent exhibited at least a mild restrictive defect (Landscaper et al., 1984). However, in 35 patients tested 1-8 years after trauma causing flail chest, VC and FEV,, were found to be. significantly reduced in only three patients (Christensen et al., 1979). In only 5 of 35 patients studied with r3*Xe a significant reduction of the regional perfusion was seen (Christensen et al., 1979). In the present study MVV indicated a higher degree of functional deterioration than any of the other pulmonary function tests. The frequent respiratory symptoms can often not be confirmed by objective tests. In the present study only one in six patients had evidence of chest wall deformity and the mean values for FVC and FEV,,O showed small reductions for the group as a whole. The frequency of respiratory complaints was high, as also earlier reported by Davidson et al. (1969). However, orthopaedic and neurological sequelae more often seem to cause disablement (Davidson et al., 1969). In previous studies, applying the same pulmonary function tests, a close association has been observed between grade of dyspnoea and rise in the EV/MVV ratio, reflecting the increasing conflict between exertional ventilatory demands and ventilatory capacity (Refsum, 1972; Refsurn et al., 1989). In the present study, however, there was no similar, simple association between complaints and deterioration.
Conclusions The present study demonstrated a high frequency of minor to moderate respiratory symptoms years after severe chest injury. Chest radiographs were normal in the majority of the patients. Blood gas analyses and cardiopulmonary function at exercise were normal for the group as a whole, while the bellows function as measured with VC, FEV,,O and MVV was clearly reduced, especially in patients who had been treated on ventilators. However, there was no unequivocal association between the subjective complaints and the pulmonary function disturbances.
Acknowledgement We are grateful to Erik Fonstelien, statistical analysis.
MSc, for performing
the
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Paper accepted 21 April 1989.
Reqwsfsfor reprints should be aalrd to: Jan L. Svennevig, Department of Surgery, UIIeva Hospital, 0407 Oslo 4, Norway.