Contemporary management of pulmonary contusions: a narrative review

Introduction

Background

Pulmonary contusion is defined as lung parenchymal injury without laceration to the lungs or pulmonary vasculature. Pulmonary contusion frequently occurs due to shearing forces sustained in blunt injury mechanisms, reverberation from penetrating chest wall injuries, and blast injuries, with the force of impact and mechanism of injury related to the likelihood of sustaining pulmonary contusions (1). It is a common finding following chest wall trauma, estimated to occur in as many as 50% of severe chest wall injuries sustained in combat and approximately 20% of non-military traumatic thoracic injuries with associated rib fractures (2,3). The pathophysiology of pulmonary contusions involves damage to alveolar capillaries, causing intraparenchymal fluid accumulation and subsequent pulmonary edema, increased ventilation/perfusion (V/Q) mismatch, and decreased lung compliance (4). Clinically, patients develop hypoxemia and hypercarbia and are at increased risk of developing pneumonia and acute respiratory distress syndrome (ARDS) requiring mechanical ventilation and intensive care unit (ICU)-level care (5). Historical pulmonary contusion-related mortality has been as high as 40% (6,7).

Rationale and knowledge gap

Pulmonary contusion diagnosis is challenging, as clinical and radiographic evidence of injury may manifest hours to days after the initial traumatic insult and rarely occurs in isolation (8,9). Variations in practice patterns persist due to limited prospective data, thus is it important to review the evolution of pulmonary contusion management and highlight current standards of care. As identification of patients at high risk of pulmonary contusion-related morbidity has become more sophisticated, earlier intervention is possible. Management of pulmonary contusions has evolved over several decades to focus on supportive care, non-invasive positive pressure ventilation, judicious fluid management, effective multimodal pain control, and optimization of patient positioning to minimize major fluid shifts, enhance oxygenation, and prevent further lung injury. In patients who require mechanical ventilation, lung protective ventilatory strategies are preferred to minimize worsening lung injury, ARDS, and pneumonia (10). Extracorporeal membrane oxygenation (ECMO) may be an important salvage therapy in appropriately selected patients (11,12).

Objective

This narrative review aims to synthesize the best evidence-based clinical practice methods for early identification and management of pulmonary contusions in the setting of chest wall injury. We present this article in accordance with the Narrative Review reporting checklist (available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-18/rc).

Methods

Methodology for this narrative review was based on the framework described by Gregory et al. (13). Source manuscripts published between January 1975 and February 11, 2025 were obtained by searching PubMed^® (National Library of Medicine, National Institutes of Health, Bethesda, MD, USA) using the keywords: pulmonary contusion, pulmonary contusion management, respiratory failure with pulmonary contusions, chest wall injury, trauma, and rib fractures (Table 1). Articles including pediatric patients and articles dated prior to 1970 were excluded. This search strategy identified 60 manuscripts. An artificial intelligence (AI) research tool (Elicit, Oakland, CA, USA) was also used to further screen for articles using the question: “How has the management of pulmonary contusions changed in the last 50 years?” The Elicit AI tool searched articles through the Semantic Scholar corpus and identified 545 papers and narrowed this selection to 25 of the most relevant articles based on population type, study design, sample size greater than 10 patients, and treatment outcomes.

Randomized control trials, retrospective studies, cross-sectional studies, case series, systematic reviews, and meta-analyses were included, and only studies published in English and French were considered. All articles generated from the PubMed and AI searches were screened by a single author and a total of 58 articles were included in this narrative review based on their relevance to pulmonary contusion management and chest trauma. The intended audience includes chest wall and trauma surgeons, intensivists, and other physicians caring for injured patients in inpatient settings. Institutional review board approval was not obtained as all manuscripts were publicly available.

Pathophysiology

Pulmonary contusions occur when a rapid transfer of kinetic energy disrupts the alveolar-capillary membrane and causes intra-alveolar hemorrhage and interstitial edema (4). Clinically, this manifests as pulmonary edema, V/Q mismatch, and impaired gas exchange. Resultant hypoxemia may be further exacerbated by both worsening intrapulmonary shunting and decreased lung compliance (14).

Respiratory insufficiency and failure due to pulmonary contusions typically manifest 24–48 hours post-injury. Over this relatively symptom-free interval, enhanced Toll-like receptor 4 (TLR-4) reactivity induces an exaggerated production of pro-inflammatory mediators, such as interleukin (IL)-6 and IL-8. When secondary insults like infection and/or surgical trauma are introduced, these pro-inflammatory mediators induce both local neutrophil infiltration and a systemic inflammatory response, which can rapidly progress to ARDS and multisystem organ failure (15).

Diagnostic approaches

Historically, plain chest radiographs (CXR) were the primary imaging modality used to detect pulmonary contusions. Tyburski et al. proposed a system for quantifying contusion lesion size on CXR, which correlated with clinical prognosis (16). This early version of the Pulmonary Contusion Score (PCS) awarded three points for every third of each lung involved on CXR, for a maximum score of 18 if both lungs were completely involved. Higher scores were associated with worse PaO₂:FiO₂ (P:F) ratios, which helped predict the need for mechanical ventilatory support. Unfortunately, CXR has limited diagnostic sensitivity, especially in the first several hours after injury.

Computed tomography (CT) has vastly improved diagnostic accuracy of pulmonary contusions and is thus considered the gold standard modality to assess contusion severity (Figure 1). CT detects contusions earlier and more precisely defines the lesion extent, volume, and distribution as compared to CXR (17,18). CT additionally determines the three-dimensional extent of pulmonary contusion, thus informing early clinical management strategies. Specifically, patients with higher contusion burdens should be considered for close inpatient observation (19). CT quantification of pulmonary contusion volumes may allow for early identification of patients at high risk of ARDS development and prolonged mechanical ventilation (20).

Figure 1 Computed tomography examples of pulmonary contusion. (A) Axial image of left lower lobe pulmonary contusion in patient with rib fractures. (B) Sagittal image of left upper and lower pulmonary contusion in patient with rib fractures with concomitant left hemothorax and right pneumothorax.

In fact, CT technology has become so advanced that some degree of pulmonary contusion is a frequently reported finding in thoracic injured patients (18). Data suggest that pulmonary contusions seen only on CT and not on CXR have limited significance in the absence of clinical signs and symptoms. As such, the use of CT as the default initial diagnostic modality should be reevaluated and perhaps replaced or supplemented by pulmonary ultrasound (18,21).

Pulmonary contusion scoring systems

Several chest trauma scoring systems (CTS) have been developed to help predict outcomes. Seok et al. compared the Thorax Trauma Severity Score (TTSS), CTS, Rib Fracture Score (RFS), Rib Score (RS), and the Abbreviated Injury Scale (AIS), and showed that TTSS and CTS are most predictive of clinical outcomes in all thoracic injured patients as well as those with pulmonary contusion [0.7, 95% confidence interval (CI): 0.651–0.788, and 0.687, 95% CI: 0.613–0.754, respectively] (22). In patients without pulmonary contusion, however, RFS was most predictive of respiratory complications. Notably, TTSS was the most comprehensive scoring system compared in this study, considering age, pulmonary contusion, rib fracture presence, and respiratory status as measured by P:F ratios. TTSS also best predicted mortality and yielded highly sensitive and specific thresholds for ARDS development in polytrauma patients (15). Specifically, ARDS risk is considered minimal with a TTSS score below 8, while a TTSS score of 13 or higher nearly guarantees ARDS development.

Higher utilization of chest CT has led to newer scoring systems to predict pulmonary contusion outcomes. As CT scans are more sensitive at detection of all-comer pulmonary injuries as compared to CXR, they correspondingly diagnose more pulmonary contusions. CT allows for three-dimensional reconstruction of the chest and superior characterization of pulmonary contusions (23). For example, the CT Volume Index (CTVI) score is calculated from the ratio of contused lung volume to total lung volume, both of which are accurately quantified using radiographic pixel analysis. CTVI scores >20% are associated with increased incidence of pneumonia, more ventilator days, longer ICU length of stay (LOS), and longer overall hospital LOS (HLOS). A similar study by Lee et al. in 2023, which defined moderate pulmonary contusion as <20% of the total lung volume and severe pulmonary contusion as ≥20% of the total long volume, found a statistically significant difference in pneumonia incidence between the two groups (5/35 vs. 23/38; P=0.008) (24). Eighty-two percent of patients with ≥20% contusion develop ARDS, compared to only 22% of patients with <20% contusion (25).

Although the use of CT may allow for more precise measurements of contusion volumes, such technology may not be widely available between hospitals or immediately accessible in the trauma bay to guide decision-making. As such, the PCS was developed to be performed by the trauma clinician reviewing CT imaging independent of the interpreting radiologist (26). PCS awards up to two points to each anatomic lung lobe (upper, middle, and lower lobes of the right lung and upper and lower lobes of the left lung). A score of 0 is given if no lobar contusions are present, 1 for <50% lobar contusion, and 2 for ≥50% lobar contusion, with a maximum possible cumulative score of 10. Patients with a PCS below 4 were unlikely to need prolonged mechanical ventilation with both a high specificity (93%) and negative predictive value (93%). Furthermore, patients with a PCS of 3 or less may be safely admitted to a non-ICU level of care.

Management strategies

Supportive care

Supportive care is the cornerstone of pulmonary contusion management and should begin promptly upon injury identification. Complementary fundamental measures include supplemental oxygen provision, supervised respiratory physiotherapy, independent pulmonary hygiene, and early mobilization as clinically feasible. As pulmonary contusions are dynamic lesions that classically progress over the 24–48 hours post-injury, supportive care must be proactive, closely monitored, and escalated if necessary. Serial clinical assessments should include respiratory rate, pulse oximetry, auscultation findings, and work of breathing. Any signs of clinical deterioration should prompt escalation in care level and imaging reassessment (14).

Interventions to provide supportive care can be combined, are often complementary, and can be escalated based on support need. Incentive spirometry and coughing exercises are critical to maintain alveolar ventilation and prevent atelectasis and pneumonia (4,14,27). Pulmonary toilet techniques, such as chest physiotherapy, flutter valves, and percussion therapy, all assist in clearing secretions and improving ventilation (28). In alert, cooperative patients, these interventions significantly reduce the risk of pneumonia. In intubated or obtunded patients, frequent suctioning and passive repositioning help reduce the incidence of ventilator-associated pneumonia (VAP) (29). Early mobilization has been shown to reduce both ICU LOS and the incidence of hospital-acquired infections. Hsieh et al. reported that the implementation of an early mobilization bundle in ICUs reduces ICU LOS by 10.3% and HLOS by 7.8% (30).

Overall, supportive management of pulmonary contusions should be individualized and adapted in real time to the patient’s clinical evaluation with heavy emphasis on frequent reassessment and multidisciplinary care coordination (31).

Oxygenation and ventilatory support

Hypoxemia in pulmonary contusion results from impaired gas exchange due to alveolar hemorrhage, interstitial edema, and atelectasis (4). Management strategies for optimizing oxygenation and ventilation have evolved from emphasis on positive pressure ventilation (32) towards lung-protective strategies (33). The goal of oxygenation and ventilatory support is to maintain adequate tissue oxygen delivery while minimizing iatrogenic barotrauma. For patients with mild hypoxemia (PaO₂ >60 mmHg, SpO₂ >92%), initial oxygen supplementation is provided via nasal cannula or simple face mask. In moderate cases, high-flow nasal cannula (HFNC) improves oxygenation, reduces respiratory rate, and enhances patient comfort (28). HFNC may also provide low levels of positive end-expiratory pressure (PEEP), thus supporting alveolar recruitment (28). Non-invasive ventilation (NIV) with either continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) may be employed in select patients with moderate to severe hypoxemia (P:F <200) who remain alert and hemodynamically normal. Early initiation of NIV strategies has been shown to improve gas exchange and decrease intubation rates (28). However, NIV is to be avoided in patients with facial trauma, copious secretions, and/or altered mental status due high aspiration risk.

Invasive mechanical ventilation becomes necessary in patients who exhibit signs of respiratory fatigue, refractory hypoxemia and/or hypercarbia, or deteriorating mental status. Lung-protective ventilatory strategies, modeled after ARDSNet protocols, are strongly preferred in these instances: low tidal volumes (6 mL/kg predicted body weight), plateau pressure <30 cmH₂O, and the lowest FiO₂ required to maintain PaO₂ >60 mmHg or SpO₂ >90% (10,33). PEEP titration is critical in these patients. Adequate PEEP prevents alveolar collapse and maintains oxygenation, but excessive levels may impair venous return and increase the risk of barotrauma. PEEP should be individualized based on lung compliance and oxygenation response. In patients with severe hypoxemia (PaO₂/FiO₂ <100) or worsening ARDS, prone positioning improves oxygenation by optimizing V/Q matching and enhancing alveolar recruitment and thus should be considered early in rapidly worsening or severe hypoxemic respiratory failure (10,34).

ECMO has emerged as a valuable adjunct in the management of severe pulmonary contusions, particularly in cases complicated by refractory hypoxemia or ARDS. While traditionally viewed with caution in trauma patients due to the risk of bleeding, accumulating evidence supports its early selective application in thoracic trauma with favorable outcomes. A comprehensive analysis of the Extracorporeal Life Support Organization (ELSO) registry by Jacobs et al. evaluated 85 bluntly injured patients with thoracic trauma and pulmonary contusion who underwent ECMO cannulation for end-stage respiratory failure between 1998 and 2014. Most were treated with veno-venous (VV) ECMO with an overall survival to discharge of 74.1%. Importantly, multivariate analysis identified both shorter ECMO duration and use of VV-ECMO as independent predictors of survival. Hemorrhagic complications occurred in 29.4% of cases, but did not significantly impact survival outcomes, even among patients with higher risk injury patterns, including intracranial hemorrhage and blunt solid organ injury (11).In a multicenter UK study, Kruit et al. retrospectively assessed 52 trauma patients managed with ECMO across national respiratory centers. Despite a 50% rate of bleeding complications, only a small subset required surgical intervention, and overall hospital mortality was low at 15%. Most notably, anticoagulation did not significantly exacerbate traumatic injuries or neurological complications. These findings suggest that ECMO can be safely employed in appropriately selected polytrauma patients, including those with significant neurological injuries (12).A recent large-scale retrospective cohort study utilizing the Trauma Quality Improvement Program (TQIP) database analyzing 14,106 patients with severe blunt thoracic trauma found that the use of VV-ECMO was associated with a significantly lower in-hospital mortality rate (22.3% vs. 37.3%, P<0.001), even amongst patients who did not meet ARDS criteria (26.9% vs. 40%, P<0.001). Although ECMO was associated with increased complications, including VAP and pulmonary embolism (PE), it also improved survival. Moreover, earlier ECMO initiation significantly reduced both ICU and overall HLOS (35). These cumulative findings highlight the evolving role of ECMO as a beneficial early intervention in the management of severe pulmonary contusions.

While bleeding risk remains a concern, particularly in patients requiring anticoagulation, technological advancements in ECMO such as heparin-sparing protocols have further expanded its feasibility. Early consideration and careful patient selection are paramount, especially in those with reversible lung injury, preserved neurologic function, and acceptable hemorrhagic risk.

Fluid management

Fluid resuscitation in pulmonary contusion requires a delicate balance between maintaining perfusion while avoiding alveolar edema exacerbation. Alveolar-capillary membrane damage permits fluid transudation into alveolar sacs, heightening the risk of hypoxemia and secondary lung injury if excessive intravenous fluids are administered (36). In the initial trauma setting, Advanced Trauma Life Support (ATLS) guidelines prioritize rapid assessment and early volume resuscitation. However, once hemorrhage control is achieved and hemodynamics are stabilized, focus must rapidly shift to conservative fluid administration (37). Early management included aggressive volume resuscitation, with Bongard et al. demonstrating hemodilution related to balanced resuscitation with salt solutions was not associated with increased size of pulmonary contusions (36). Current evidence favors goal-directed fluid therapy, which uses dynamic measures such as stroke volume variation (SVV), pulse pressure variation (PPV), and echocardiographic assessment to assess fluid responsiveness. Static parameters, such as central venous pressure (CVP), are less reliable in critically ill patients (38). Judicious fluid administration may decrease or eliminate the risk of underlying pulmonary contusion. Overzealous volume resuscitation can cause or worsen pulmonary edema and hypoxemia, and may result in prolonged mechanical ventilation with its associated morbidities. A cumulative positive fluid balance in the first 72 hours has been linked to increased rates of ARDS and mortality (38).

Adjuncts vasopressor support may be introduced early in fluid-refractory shock to maintain adequate mean arterial pressure (MAP) while minimizing fluid overload. The use of diuretics and even renal replacement therapy may be necessary in patients with significant fluid accumulation and oliguria. Daily fluid balance should be calculated and monitored closely. The transition from upfront resuscitation to timely de-escalation and eventual negative fluid balance is essential for recovery and prevention of further lung injury (39).

ICU monitoring

Patients with moderate to severe pulmonary contusions are at high risk for respiratory failure. This warrants ICU admission to allow for continuous physiological monitoring, serial laboratory evaluation, and early multidisciplinary coordination of respiratory, hemodynamic, and infectious risk management. Continuous pulse oximetry and capnography provide real-time feedback on oxygenation and ventilation. Arterial blood gases (ABGs) should be obtained at regular intervals and with any signs of clinical deterioration to assess gas exchange (26). Invasive mechanical ventilation not only allows for more complete control over oxygenation and ventilation, but additionally provides insight into an individual’s respiratory mechanics via real-time measurement and adjustment of parameters such as tidal volumes, plateau pressures, and static compliance. Decreasing compliance or increasing plateau pressures may indicate progression to ARDS or development of an occult pneumothorax. Hemodynamic monitoring may include continuous arterial pressure waveform analysis, CVP measurements, or more advanced modalities in unstable patients. Early identification of shock, sepsis, or cardiac dysfunction can direct prompt resuscitative or vasoactive interventions.

Proactive monitoring for hospital-acquired infections, particularly VAP, is vital. Protocols such as ventilator care bundles, head-of-bed elevation, scheduled chlorhexidine oral care, and sedation vacations have been shown to reduce VAP incidence and improve patient outcomes (30).

Pain management

Effective pain control is often a critical adjunct in patients with pulmonary contusion, especially for patients with associated rib fractures. Inadequate analgesia leads to splinting, hypoventilation, and impaired secretion clearance, and thus increases the risk of atelectasis, pneumonia, and respiratory failure (14,40). Systemic opioids, including intravenous morphine, hydromorphone, and fentanyl, are commonly used. However, opioids carry risks such as respiratory depression, sedation, ileus, and delirium (41). Titration to effect is critical, especially in elderly and/or hemodynamically unstable patients. To minimize opioid-related adverse effects, a multimodal analgesic strategy should be employed. Scheduling non-opioid medications such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) is an effective strategy (14). However, NSAIDs must be used cautiously in patients with renal impairment or coagulopathy (41). Additional adjuncts such as gabapentin and pregabalin may reduce opioid requirements, but can cause sedation and dizziness, particularly in elderly patients (41).

Regional anesthesia techniques may also be valuable for patients with thoracic trauma and concomitant pulmonary contusion. The most extensively studied modality is thoracic epidural analgesia, which provides superior pain relief, reduces pulmonary complications, improves ventilatory parameters, and facilitates early mobilization, particularly if employed early in a patient’s clinical trajectory. Epidural analgesia is particularly beneficial in patients with bilateral or flail chest injuries (41).

While individualized selection of a multimodal analgesic regimen is undoubtedly important, the frequency and means by which pain is reassessed is essential. Regular pain assessments using validated scales (e.g., visual analog scale, numeric rating scale) should guide analgesia adjustments (41). The integration of pain management into early mobilization and respiratory therapy protocols is critical to optimizing outcomes in pulmonary contusion care.

Anticoagulation

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and PE, is a well-recognized post-traumatic complication due to immobility, systemic inflammatory responses, and induction of a prothrombotic state (42). Prophylactic anticoagulation is therefore a critical component of comprehensive care, but must be carefully balanced against bleeding risks inherent to lung injury and polytrauma.

Pharmacologic prophylaxis with low molecular weight heparin (LMWH) is the mainstay of VTE prevention in trauma patients. It is preferred over unfractionated heparin due to more predictable pharmacokinetics, reduced risk of heparin-induced thrombocytopenia, and superior efficacy in preventing post-traumatic DVT (43). The standard prophylactic dose in trauma patients is 30 mg subcutaneously every 12 hours; however, dosing may need to be adjusted in obese patients or those with renal impairment (42). LMWH should be started as soon as feasible after injury. Mechanical prophylaxis, including intermittent pneumatic compression (IPC) devices and graduated compression stockings, should be implemented immediately, particularly in patients for whom anticoagulation is contraindicated or delayed. These measures should continue until pharmacologic prophylaxis is initiated and the patient is ambulating independently. Anticoagulation management in pulmonary contusion requires daily risk-benefit reassessment, coordination with hematology or trauma services, and adaptation to evolving clinical circumstances.

Bronchoscopy and pulmonary toilet

Airway management in pulmonary contusion is a critical aspect of supportive care, especially in patients with impaired clearance of secretions, blood, or debris resulting from parenchymal injury or concomitant trauma. Bronchoscopy plays an important diagnostic and therapeutic role in such cases, particularly when non-invasive airway clearance methods fail. Diagnostic indications for bronchoscopy include evaluation of persistent lobar collapse, radiologic opacities that do not respond to conservative therapies, and foreign body aspiration. In trauma patients, bronchoscopy is also valuable for identifying endobronchial blood clots or confirming tracheobronchial injuries, both of which may be radiographically occult (1). Therapeutic bronchoscopy allows for suctioning of lobar and segmental blood and mucus plugs to relieve atelectasis and restore V/Q matching. Bronchial lavage may also be completed to clear distal debris and obtain microbiologic cultures to guide antibiotic coverage if pneumonia is suspected (44). Bronchoscopy is particularly useful in patients with extensive pulmonary contusions and concurrent hemoptysis, where active bleeding can obscure airway patency and impair oxygenation. However, studies are limited in showing any mortality benefit to routine bronchoscopy (44).

Surgical management

Surgical intervention in the setting of pulmonary contusion is generally not directed at the pulmonary contusion itself, which is a non-anatomic injury that typically resolves with supportive care, but rather at associated injuries or secondary complications that are refractory to conservative management. Pulmonary contusions are frequently associated with hemothorax and/or pneumothorax due to concurrent chest wall and parenchymal injuries. When chest tube drainage fails to evacuate retained blood or when more than 1,500 mL of blood is initially drained or there is continued bleeding (>200 mL/h for 2–4 hours), thoracotomy or video-assisted thoracoscopic surgery (VATS) may be necessary for hemorrhage control and evacuation of retained hemothorax (14). VATS is increasingly preferred for its minimally invasive profile, allowing for removal of clotted hemothorax, identification and control of bleeding sources, and prevention of fibrothorax and empyema while minimizing superimposed postoperative pain (32). However, moderate to severe pulmonary contusions may prohibit single lung isolation to facilitate a VATS approach.

Pulmonary contusions also commonly accompany rib fractures, including flail chest. These injuries result in paradoxical chest wall motion, impaired ventilation, and increased work of breathing. Surgical stabilization of rib fractures (SSRF) has been shown to reduce mechanical ventilation duration, ICU and HLOS, and pneumonia incidence (40,45). Pulmonary contusions are not a contraindication to SSRF (46). Indications for SSRF include flail chest with respiratory compromise, severe rib fractures with significant displacement, failure of medical management with noninvasive support and optimal analgesia, and persistent pain impairing mobilization or pulmonary function. SSRF is ideally performed within 24–72 hours post-injury, but timing must be individualized based on pulmonary status, coagulopathy, and associated injuries. Early SSRF is associated with a shorter duration of mechanical ventilation, decreased ICU and HLOS, and lower rates of unplanned intubation, tracheostomy, and unplanned ICU admission (47,48).

Adjunctive therapies and controversies

Steroids

Corticosteroids have been hypothesized to mitigate the inflammatory response incited by pulmonary contusion and prevent progression to ARDS. However, retrospective studies have failed to demonstrate consistent reductions in both mortality and mechanical ventilation duration (49). Furthermore, there is major concern for potential for decreased bacterial clearance and subsequent increased pneumonia incidence. Therefore, routine corticosteroid administration is not recommended for treatment of pulmonary contusion (50). However, there is evidence-based support for use of steroids for severe pneumonia and could be considered in patients with pulmonary contusions who develop severe pneumonia (51). Future trials targeting specific phenotypes of lung injury may better elucidate potential subgroups that could benefit from supplemental corticosteroids.

Antibiotics

The role of antibiotics in the management of pulmonary contusion remains a subject of clinical debate. Pulmonary contusions are a recognized risk factor for the development of secondary pulmonary infections, particularly VAP in mechanically ventilated patients. However, prophylactic antibiotic use in the absence of clinical infection is not routinely recommended (50). Multiple studies have shown that empirical antibiotic administration does not reduce the incidence of pneumonia in trauma patients and may contribute to the development of multidrug-resistant organisms (50,52).

Prognosis and outcomes

Pulmonary contusion prognosis varies considerably depending on the degree of lung injury, presence and severity of polytraumatic injuries, preexisting comorbidities, and the timeliness and quality of supportive care. In isolated, mild pulmonary contusions, outcomes are generally favorable with complete radiologic and functional resolution within 7 to 10 days. However, in more severe cases—particularly those involving bilateral contusions, extensive parenchymal involvement, or concomitant thoracic injuries—the risk of complications and mortality increases substantially (1).

Key predictors of poor outcome include age >65 years, bilateral or large-volume pulmonary contusions on CT imaging, P:F ratio <200 at presentation, need for mechanical ventilation for >48–72 hours, high Injury Severity Score (ISS >25), associated traumatic brain injury or multiple long bone fractures, and the presence of shock or need for massive transfusion (26,53). Complications of pulmonary contusion include ARDS due to progressive inflammation, alveolar-capillary damage, and impaired gas exchange, pneumonia due to impaired clearance of secretions and prolonged intubation, sepsis and multiorgan failure (especially in polytrauma patients with prolonged ICU stay), and PE due to immobilization and a hypercoagulable state (54,55).

Long-term outcomes are variable. Most patients with mild-to-moderate contusions recover without significant sequelae. However, survivors of severe injury may experience persistent symptoms such as exertional dyspnea, chronic cough, reduced exercise tolerance, restrictive or obstructive changes on pulmonary function tests (PFTs), and radiographic scarring or fibrotic changes (56). Follow-up with a dedicated pulmonary specialist and post-discharge pulmonary rehabilitation can facilitate recovery and improve functional outcomes. PFTs are typically recommended at three to six months post-injury to assess for residual impairment (56).

Future directions

As the understanding of pulmonary contusion has evolved, research is increasingly focused on early identification, precision prognostication, respiratory support innovation, and long-term recovery. A data-driven, multidisciplinary approach integrating high-resolution imaging, molecular markers, and oxygenation and ventilatory optimization will likely guide future best practices in both civilian and military trauma care.

A popular focus of current clinical research relates to deep learning models and artificial intelligence tools for risk stratification. A study by Sarkar et al. trained a deep learning model to quantify pulmonary contusion as a percentage of total lung volume (Lung Contusion Index, or auto-LCI) and assess its relationship to clinical outcomes. They found that high auto-LCI values corresponded to increased risk of ARDS, longer ICU stay, and longer mechanical ventilation duration. Auto-LCI represents a precise metric that is potentially exploitable early in the treatment course of thoracic trauma to determine the risk of ARDS and other complications (57). This is one potential step in the ongoing development of more individualized therapies and treatment strategies.

Large-scale trauma registries and ICU datasets are being analyzed using machine learning to uncover predictors of poor outcomes, complications, and resource utilization (1,26). Integrating PCS with clinical scoring tools such as TTSS may result in better outcome prediction models. The convergence of imaging data, physiologic trends, and clinical scoring into unified digital dashboards may represent the next evolution in trauma critical care. Ongoing collaboration across trauma centers and prospective multicenter trials will be necessary to validate these innovations and better standardize pulmonary contusion management.

While acute management has received substantial attention, the long-term sequelae of pulmonary contusion remain poorly defined. Survivors of moderate-to-severe contusions may suffer from chronic, persistent dyspnea, abnormal spirometry, and radiographic fibrosis (2). Longitudinal cohort studies that incorporate serial PFTs, quality of life assessments, and imaging follow-up are essential to further characterize chronic impairment and guide post-discharge rehabilitation protocols. Structured pulmonary rehabilitation, inspiratory muscle training, and respiratory therapist-directed exercise regimens may play an increasing role in improving functional outcomes and reducing readmissions in this population (58).

Strengths and limitations

In this narrative review, we summarize evidence-based contemporary management of pulmonary contusions, including notable randomized control trials, retrospective reports, cross-sectional studies, and meta-analyses. While we aimed to provide a comprehensive overview and synthesis of historical and currently accepted practices for pulmonary contusion management, our study was limited to including 58 articles over the span of 50 years. Use of the Elicit AI tool is becoming more widely accepted as an adjunct mechanism to identify relevant articles, however, is limited through providing a maximum of 25 articles from its screening process. We expanded the inclusion of pertinent articles through an independent PubMed search, however, with the nature of a narrative review there is possibility of selection bias. The majority of studies included were retrospective in nature (n=35) and the average sample size was 6,000 patients (range, 18–148,000).

Conclusions

Pulmonary contusion remains a clinically significant sequela of blunt thoracic trauma, often heralding complex respiratory complications and prolonged hospitalization. Advancements in imaging, critical care monitoring, and multidisciplinary management strategies have significantly improved diagnostic accuracy and patient outcomes. Current management approaches emphasize early supportive care, judicious fluid management, multimodal pain control, and tailored ventilatory support as needed, with growing interest in adjunctive therapies and surgical interventions for severe or refractory cases. As our understanding of contusion pathophysiology evolves, there is a pressing need for standardized clinical guidelines and robust clinical trials to refine therapeutic algorithms and optimize long-term outcomes. Continued innovation in trauma systems, surgical stabilization techniques, and personalized care will be pivotal in shaping the future of pulmonary contusion management

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Christopher F. Janowak) for the series “Chest Trauma” published in Current Challenges in Thoracic Surgery. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-18/rc

Peer Review File: Available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-18/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-18/coif). The series “Chest Trauma” was commissioned by the editorial office without any funding or sponsorship. J.D.F. reported PI for investigator initiated clinical trials (Pacira, Varian), and PI for industry initiated clinical trials (Eclipse Regenysis), Consultant (Costa Surgical, Inc.). The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Zingg SW, Millar DA, Goodman MD, et al. The Association Between Pulmonary Contusion Severity and Respiratory Failure. Respir Care 2021;66:1665-72. [Crossref] [PubMed]
2. Ivey KM, White CE, Wallum TE, et al. Thoracic injuries in US combat casualties: a 10-year review of Operation Enduring Freedom and Iraqi Freedom. J Trauma Acute Care Surg 2012;73:S514-9.
3. Choi J, Tennakoon L, You JG, et al. Pulmonary contusions in patients with rib fractures: The need to better classify a common injury. Am J Surg 2021;221:211-5. [Crossref] [PubMed]
4. Oppenheimer L, Craven KD, Forkert L, et al. Pathophysiology of pulmonary contusion in dogs. J Appl Physiol Respir Environ Exerc Physiol 1979;47:718-28. [Crossref] [PubMed]
5. Miller C, Stolarski A, Ata A, et al. Impact of blunt pulmonary contusion in polytrauma patients with rib fractures. Am J Surg 2019;218:51-5. [Crossref] [PubMed]
6. Kollmorgen DR, Murray KA, Sullivan JJ, et al. Predictors of mortality in pulmonary contusion. Am J Surg 1994;168:659-63; discussion 663-4. [Crossref] [PubMed]
7. Elmali M, Baydin A, Nural MS, et al. Lung parenchymal injury and its frequency in blunt thoracic trauma: the diagnostic value of chest radiography and thoracic CT. Diagn Interv Radiol 2007;13:179-82.
8. Hosseini M, Ghelichkhani P, Baikpour M, et al. Diagnostic Accuracy of Ultrasonography and Radiography in Detection of Pulmonary Contusion; a Systematic Review and Meta-Analysis. Emerg (Tehran) 2015;3:127-36.
9. de Moya MA, Manolakaki D, Chang Y, et al. Blunt pulmonary contusion: admission computed tomography scan predicts mechanical ventilation. J Trauma 2011;71:1543-7. [Crossref] [PubMed]
10. Serpa Neto A, Cardoso SO, Manetta JA, et al. Association between use of lung-protective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a meta-analysis. JAMA 2012;308:1651-9. [Crossref] [PubMed]
11. Jacobs JV, Hooft NM, Robinson BR, et al. The use of extracorporeal membrane oxygenation in blunt thoracic trauma: A study of the Extracorporeal Life Support Organization database. J Trauma Acute Care Surg 2015;79:1049-53; discussion 1053-4. [Crossref] [PubMed]
12. Kruit N, Prusak M, Miller M, et al. Assessment of safety and bleeding risk in the use of extracorporeal membrane oxygenation for multitrauma patients: A multicenter review. J Trauma Acute Care Surg 2019;86:967-73. [Crossref] [PubMed]
13. Gregory AT, Denniss AR. An Introduction to Writing Narrative and Systematic Reviews - Tasks, Tips and Traps for Aspiring Authors. Heart Lung Circ 2018;27:893-8. [Crossref] [PubMed]
14. Griffard J, Kodadek LM. Management of Blunt Chest Trauma. Surg Clin North Am 2024;104:343-54. [Crossref] [PubMed]
15. Daurat A, Millet I, Roustan JP, et al. Thoracic Trauma Severity score on admission allows to determine the risk of delayed ARDS in trauma patients with pulmonary contusion. Injury 2016;47:147-53. [Crossref] [PubMed]
16. Tyburski JG, Collinge JD, Wilson RF, et al. Pulmonary contusions: quantifying the lesions on chest X-ray films and the factors affecting prognosis. J Trauma 1999;46:833-8. [Crossref] [PubMed]
17. Van Wijck SFM, Smith EF, Werner NL, et al. Evolution of Pulmonary Contusions in Patients With Severe Rib Fractures: Cause for Concern? Am Surg 2024;90:261-9. [Crossref] [PubMed]
18. Rodriguez RM, Friedman B, Langdorf MI, et al. Pulmonary contusion in the pan-scan era. Injury 2016;47:1031-4. [Crossref] [PubMed]
19. Deunk J, Poels TC, Brink M, et al. The clinical outcome of occult pulmonary contusion on multidetector-row computed tomography in blunt trauma patients. J Trauma 2010;68:387-94. [Crossref] [PubMed]
20. Mahmood I, El-Menyar A, Younis B, et al. Clinical Significance and Prognostic Implications of Quantifying Pulmonary Contusion Volume in Patients with Blunt Chest Trauma. Med Sci Monit 2017;23:3641-8. [Crossref] [PubMed]
21. Požgain Z, Kristek D, Lovrić I, et al. Pulmonary contusions after blunt chest trauma: clinical significance and evaluation of patient management. Eur J Trauma Emerg Surg 2018;44:773-7. [Crossref] [PubMed]
22. Seok J, Cho HM, Kim HH, et al. Chest Trauma Scoring Systems for Predicting Respiratory Complications in Isolated Rib Fracture. J Surg Res 2019;244:84-90. [Crossref] [PubMed]
23. Strumwasser A, Chu E, Yeung L, et al. A novel CT volume index score correlates with outcomes in polytrauma patients with pulmonary contusion. J Surg Res 2011;170:280-5. [Crossref] [PubMed]
24. Lee NH, Kim SH, Seo SH, et al. Prediction of respiratory complications by quantifying lung contusion volume using chest computed tomography in patients with chest trauma. Sci Rep 2023;13:6387. [Crossref] [PubMed]
25. Miller PR, Croce MA, Bee TK, et al. ARDS after pulmonary contusion: accurate measurement of contusion volume identifies high-risk patients. J Trauma 2001;51:223-8; discussion 229-30. [Crossref] [PubMed]
26. Toelle LJ, McNickle AG, Feery D, et al. The pulmonary contusion score: Development of a simple scoring system for blunt lung injury. Surg Pract Sci 2024;17:100247. [Crossref] [PubMed]
27. Cohn SM. Pulmonary contusion: review of the clinical entity. J Trauma 1997;42:973-9. [Crossref] [PubMed]
28. Anderson TN, Wang S, Free D, et al. The role of respiratory therapy in rib fracture management. Curr Probl Surg 2024;61:101664. [Crossref] [PubMed]
29. Ntoumenopoulos G, Presneill JJ, McElholum M, et al. Chest physiotherapy for the prevention of ventilator-associated pneumonia. Intensive Care Med 2002;28:850-6. [Crossref] [PubMed]
30. Hsieh SJ, Otusanya O, Gershengorn HB, et al. Staged Implementation of Awakening and Breathing, Coordination, Delirium Monitoring and Management, and Early Mobilization Bundle Improves Patient Outcomes and Reduces Hospital Costs. Crit Care Med 2019;47:885-93. [Crossref] [PubMed]
31. Richardson JD, Adams L, Flint LM. Selective management of flail chest and pulmonary contusion. Ann Surg 1982;196:481-7. [Crossref] [PubMed]
32. Roscher R, Bittner R, Stockmann U. Pulmonary contusion. Clinical experience. Arch Surg 1974;109:508-10. [Crossref] [PubMed]
33. Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000;342:1301-8. [Crossref] [PubMed]
34. Wang Y, Zeng C, Dong L, et al. Pulmonary contusion during the COVID-19 pandemic: challenges in diagnosis and treatment. Surg Today 2020;50:1113-6. [Crossref] [PubMed]
35. Zangbar B, Rafieezadeh A, Prabhakaran K, et al. Extracorporeal membrane oxygenation is associated with decreased mortality in non-acute respiratory distress syndrome patients following severe blunt thoracic trauma. J Trauma Acute Care Surg 2025;98:593-9. [Crossref] [PubMed]
36. Bongard FS, Lewis FR. Crystalloid resuscitation of patients with pulmonary contusion. Am J Surg 1984;148:145-51. [Crossref] [PubMed]
37. Vidhani K, Kause J, Parr M. Should we follow ATLS guidelines for the management of traumatic pulmonary contusion: the role of non-invasive ventilatory support. Resuscitation 2002;52:265-8. [Crossref] [PubMed]
38. Jin H, Tang LQ, Pan ZG, et al. Ten-year retrospective analysis of multiple trauma complicated by pulmonary contusion. Mil Med Res 2014;1:7. [Crossref] [PubMed]
39. Simon B, Ebert J, Bokhari F, et al. Management of pulmonary contusion and flail chest: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012;73:S351-61. [Crossref] [PubMed]
40. Prunet B, Bourenne J, David JS, et al. Patterns of invasive mechanical ventilation in patients with severe blunt chest trauma and lung contusion: A French multicentric evaluation of practices. J Intensive Care Soc 2019;20:46-52. [Crossref] [PubMed]
41. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 2012;116:248-73. [Crossref] [PubMed]
42. Ley EJ, Brown CVR, Moore EE, et al. Updated guidelines to reduce venous thromboembolism in trauma patients: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg 2020;89:971-81. [Crossref] [PubMed]
43. Linskey Dougherty MB, Josef AB, Kulaylat AS, et al. Early versus Late Prophylactic Anticoagulation in Trauma Patients with Pulmonary Contusions. Am Surg 2019;85:e216-9.
44. Marraro GA, Denaro C, Spada C, et al. Selective medicated (saline + natural surfactant) bronchoalveolar lavage in unilateral lung contusion. A clinical randomized controlled trial. J Clin Monit Comput 2010;24:73-81. [Crossref] [PubMed]
45. Vignesh T. ArunKumar AS, Kamat V. Outcome in patients with blunt chest trauma and pulmonary contusions. Indian J Crit Care Med 2004;8:73-7.
46. Van Wijck SFM, Pieracci FM, Smith EF, et al. Rib fixation in patients with severe rib fractures and pulmonary contusions: Is it safe? J Trauma Acute Care Surg 2022;93:721-6. [Crossref] [PubMed]
47. Lagazzi E, Rafaqat W, Argandykov D, et al. Timing matters: Early versus late rib fixation in patients with multiple rib fractures and pulmonary contusion. Surgery 2024;175:529-35. [Crossref] [PubMed]
48. Zhang Y, Tang X, Xie H, et al. Comparison of surgical fixation and nonsurgical management of flail chest and pulmonary contusion. Am J Emerg Med 2015;33:937-40. [Crossref] [PubMed]
49. Zingg SW, Gomaa D, Blakeman TC, et al. Oxygenation and Respiratory System Compliance Associated With Pulmonary Contusion. Respir Care 2022;67:1100-8. [Crossref] [PubMed]
50. Cohn SM, Dubose JJ. Pulmonary contusion: an update on recent advances in clinical management. World J Surg 2010;34:1959-70. [Crossref] [PubMed]
51. Dequin PF, Meziani F, Quenot JP, et al. Hydrocortisone in Severe Community-Acquired Pneumonia. N Engl J Med 2023;388:1931-41. [Crossref] [PubMed]
52. Balcı AE, Balcı TA, Eren Ş, et al. Unilateral Post-Traumatic Pulmonary Contusion: Findings of a Review. Surgery Today 2005;35:205-10. [Crossref] [PubMed]
53. Bilello JF, Davis JW, Cagle KM, et al. Predicting extubation failure in blunt trauma patients with pulmonary contusion. J Trauma Acute Care Surg 2013;75:229-33. [Crossref] [PubMed]
54. Janus TJ, Vaughan-Sarrazin MS, Baker LJ, et al. Predictors of pneumonia in trauma patients with pulmonary contusion. J Trauma Nurs 2012;19:139-47. [Crossref] [PubMed]
55. Landeen C, Smith HL. Examination of pneumonia risks and risk levels in trauma patients with pulmonary contusion. J Trauma Nurs 2014;21:41-9. [Crossref] [PubMed]
56. Kishikawa M, Yoshioka T, Shimazu T, et al. Pulmonary contusion causes long-term respiratory dysfunction with decreased functional residual capacity. J Trauma 1991;31:1203-8; discussion 1208-10. [Crossref] [PubMed]
57. Sarkar N, Zhang L, Campbell P, et al. Pulmonary contusion: automated deep learning-based quantitative visualization. Emerg Radiol 2023;30:435-41. [Crossref] [PubMed]
58. Rendeki S, Molnár TF. Pulmonary contusion. J Thorac Dis 2019;11:S141-51. [Crossref] [PubMed]