Journal of Clinical Monitoring and Computing

, Volume 24, Issue 1, pp 73–81 | Cite as

Selective medicated (saline + natural surfactant) bronchoalveolar lavage in unilateral lung contusion. A clinical randomized controlled trial

  • Giuseppe A. Marraro
  • Carmelo Denaro
  • Claudio Spada
  • Marco Luchetti
  • Carla GiansiracusaEmail author



Open lung and low tidal volume ventilation appear to be a promising ventilation for chest trauma as it can reduce ARDS and improve outcome. Local therapy (e.g. BAL) can be synergic to remove from the lung the debris, mitigate inflammatory cascade and avoid damage spreading to not compromised lung areas.

Materials and methods

44 pulmonary contused patients were randomized to receive broncho-suction and volume controlled low tidal volume ventilation—VCLTVV (Control Group) or the same ventilation plus medicated (saline + surfactant) BAL (Treatment Group). Tidal volume <10 ml/kg, PEEP of 10-12 cm H2O and PaO2 60–100 mm Hg and PaCO2 35–45 mm Hg were used in both groups. BAL was performed using a fiberscope. 4 boluses of 25 ml saline with 2.4 mg/ml of surfactant were introduced into each contused lobe in which, subsequently, 240 mg of surfactant was instilled.


All patients survived. In the Control Group 18 patients developed pneumonia, 5 ARDS and days of intubation were 11.50 (3.83) compared to 5.05 (1.21) of Treatment Group in which OI and PaO2/FiO2 significantly improved from 36 h.


VCLTVV alone was not able to prevent ARDS and infection in the Control Group as the reduction of intubation. In the Treatment Group, VCLTVV and medicated BAL facilitated the removal of degradated lung material and recruited the contused lung regions, enabling the healing of the lung pathology.


lung contusion BAL ventilation ARDS surfactant 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Keel M, Meier C. Chest injuries—what is new? Curr Opin Crit Care. 2007;13:674–9.CrossRefPubMedGoogle Scholar
  2. 2.
    Sutyak JP, Wohltmann CD, Larson J. Pulmonary contusions and critical care management in thoracic trauma. Thorac Surg Clin. 2007;17:11–23.CrossRefPubMedGoogle Scholar
  3. 3.
    Bastos R, Calhoon JH, Baisden CE. Flail chest and pulmonary contusion. Semin Thorac Cardiovasc Surg. 2008;20:39–45.CrossRefPubMedGoogle Scholar
  4. 4.
    Wu J, Sheng L, Ma Y, et al. The analysis of risk factors of impacting mortality rate in severe multiple trauma patients with posttraumatic acute respiratory distress syndrome. Am J Emerg Med. 2008;26:419–24.CrossRefPubMedGoogle Scholar
  5. 5.
    Cohn SM. Pulmonary contusion: review on the clinical entity. J Trauma. 1997;42:973–9.CrossRefPubMedGoogle Scholar
  6. 6.
    Mizushima Y, Hiraide A, Shimazu T, et al. Changes in contused lung volume and oxygenation in patients with pulmonary parenchymal injury after blunt chest trauma. Am J Emerg Med. 2000;18:385–9.CrossRefPubMedGoogle Scholar
  7. 7.
    Brun-Buisson C, Minelli C, Bertolini G, et al. Epidemiology and outcome of the acute lung injury in European intensive care units. Results from the AIVE study. Intensive Care Med. 2004;30:51–61. (for the ALIVE Study Group).CrossRefPubMedGoogle Scholar
  8. 8.
    Miller PR, Croce MA, Kilgo PD, et al. Acute respiratory distress syndrome in blunt trauma: identification of independent risk factors. Am Surg. 2002;68:845–50.PubMedGoogle Scholar
  9. 9.
    Laudi S, Donaubauer B, Busch T, et al. Low incidence of multiple organ failure after major trauma. Injury. 2007;38:1052–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Wu J, Sheng L, Wang S, et al. Analysis of clinical risk factors associated with the prognosis of severe multiple-trauma patients with acute lung injury. J Emerg Med. 2009. doi: 10.1016/j.jemermed.2009.05.024.
  11. 11.
    Weinert CR, Gross CR, Kangas JR, et al. Health-related quality of life after acute lung injury. Am J Respir Crit Care Med. 1997;156:1120–8.PubMedGoogle Scholar
  12. 12.
    Raghavendran K, Notter RH, Davidson BA, et al. Lung contusion: inflammatory mechanisms and interaction with other injuries. Shock. 2009;32:122–30.CrossRefPubMedGoogle Scholar
  13. 13.
    Obertacke U, Neudeck F, Majetschak O, et al. Local and systemic reactions after lung contusion: an experimental study in the pig. Shock. 1998;10:7–12.CrossRefPubMedGoogle Scholar
  14. 14.
    Davis KA, Fabian TC, Croce MA, et al. Prostanoids: early mediators in the secondary injury that develops after unilateral pulmonary contusion. J Trauma. 1999;46:824–32.CrossRefPubMedGoogle Scholar
  15. 15.
    Muehlstedt SG, Richardson CJ, Lyte M, et al. Systemic and pulmonary effector cell function after injury. Crit Care Med. 2002;30:1322–6.CrossRefPubMedGoogle Scholar
  16. 16.
    Pallister I, Dent C, Topley N. Increased neutrophil migratory activity after major trauma: a factor in the etiology of acute respiratory distress syndrome? Crit Care Med. 2002;30:1717–21.CrossRefPubMedGoogle Scholar
  17. 17.
    Raghavendran K, Davidson BA, Knight PR, et al. Surfactant dysfunction in lung contusion with and without superimposed gastric aspiration in a rat model. Shock. 2008;30:508–17.CrossRefPubMedGoogle Scholar
  18. 18.
    Seitz DH, Perl M, Mangold S, et al. Pulmonary contusion induces alveolar type 2 epithelial cell apoptosis: role of alveolar macrophages and neutrophils. Shock. 2008;30:537–44.CrossRefPubMedGoogle Scholar
  19. 19.
    Pison U, Seeger W, Buchhorn R, et al. Surfactant abnormalities in patients with respiratory failure after multiple trauma. Am Rev Respir Dis. 1989;140:1033–9.PubMedGoogle Scholar
  20. 20.
    Seeger W, Elssner A, Gunter A, et al. Lung surfactant phospholipids associate with polymerizing fibrin: loss of surfactant activity. Am J Resp Cell Mol Biol. 1993;9:213–20.Google Scholar
  21. 21.
    Spragg RG, Smith RM. Pathology of the surfactant system of the mature lung. Am J Respir Crit Care Med. 1997;155:756–60.PubMedGoogle Scholar
  22. 22.
    Ware LB, Matthay MA. The acute respiratory distress syndrome. New Engl J Med. 2000;342:1334–49.CrossRefPubMedGoogle Scholar
  23. 23.
    Wu JS, Sheng L, Wang SH, et al. The impact of clinical risk factors in the conversion from acute lung injury to acute respiratory distress syndrome in severe multiple trauma patients. J Int Med Res. 2008;36:579–86.PubMedGoogle Scholar
  24. 24.
    Strohmaier W, Schalg C. Lung lavage with diluted surfactant is as effective as bolus treatment in a long-term aspiration model. Appl Cardiopul Pathophysiol. 1998;7:17–22.Google Scholar
  25. 25.
    Meister JC, Balaraman V, Ku T, et al. Lavage administration of dilute recombinant surfactant in acute lung injury in piglets. Pediatr Res. 2000;47:240–5.CrossRefPubMedGoogle Scholar
  26. 26.
    Baudouin SV. Exogenous surfactant replacement in ARDS—one day, someday, or never? New Engl J Med. 2004;351:853–5.CrossRefPubMedGoogle Scholar
  27. 27.
    Marraro G, Pesci A, Croce AM, et al. Bronchoalveolar lavage (BAL) with porcine derived surfactant in ARDS: hemodynamic and gas exchange assessment. Appl Cardiopul Pathophysiol. 2004;13(suppl):60–1.Google Scholar
  28. 28.
    Lewis JF, Brackenbury A. Role of exogenous surfactant in acute lung injury. Crit Care Med. 2003;31(suppl):S324–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Marraro GA, Luchetti M, Spada C, et al. Selective medicated (normal saline and exogenous surfactant) bronchoalveolar lavage in severe aspiration syndrome in children. Pediatr Crit Care Med. 2007;8:476–81.CrossRefPubMedGoogle Scholar
  30. 30.
    Tsangaris I, Galiatsou E, Kostanti E, et al. The effect of exogenous surfactant in patients with lung contusions and acute lung injury. Intensive Care Med. 2007;33:851–5.CrossRefPubMedGoogle Scholar
  31. 31.
    Marini JJ. The “open lung” compromise. Intensive Care Med. 2007;33:1114–6.CrossRefPubMedGoogle Scholar
  32. 32.
    Murray JF, Matthay MA, Luce JM, et al. An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis. 1988;138:720–3.PubMedGoogle Scholar
  33. 33.
    Baker SP, O’Neill B, Haddon W Jr, et al. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14:187–96.CrossRefPubMedGoogle Scholar
  34. 34.
    Osler T, Baker SP, Long W. A modification of the injury severity score that both improves accuracy and simplifies scoring. J Trauma. 1997;43:922–6.CrossRefPubMedGoogle Scholar
  35. 35.
    Moore EE, Malangoni MA, Cogbill TH, et al. Organ injury scaling IV: thoracic vascular, lung, cardiac and diaphragm. J Trauma. 1994;36:299–300.PubMedGoogle Scholar
  36. 36.
    Moore EE, Cogbill TH, Jurkovich GJ, et al. Organ injury scaling III: chest wall, abdominal vascular, ureter, bladder and urethra. J Trauma. 1992;33:337–9.PubMedCrossRefGoogle Scholar
  37. 37.
    Daly M, Miller PR, Carr JJ, et al. Traumatic pulmonary pathology measured with computed tomography and a semiautomated analytic method. Clin Imaging. 2008;32:346–54.CrossRefPubMedGoogle Scholar
  38. 38.
    Exadaktylos AK, Sclabas G, Schmid SW, et al. Do we really need routine computed tomography scanning in the primary evaluation of blunt chest trauma in patients with “normal” chest radiograph? J Trauma. 2001;51:1173–6.CrossRefPubMedGoogle Scholar
  39. 39.
    Miller PR, Croce MA, Bee TK, et al. ARDS after pulmonary contusion: accurate measurement of contusion volume identifies high-risk patients. J Trauma. 2001;51:223–30.CrossRefPubMedGoogle Scholar
  40. 40.
    Van Golde LMG, Batenburg JJ, Robertson B. The pulmonary surfactant system: biochemical aspects and functional significance. Physiol Rev. 1988;68:374–455.PubMedGoogle Scholar
  41. 41.
    Rooney SA. The surfactant system and lung phopholipid biochemistry. Am Rev Respir Dis. 1985;131:439–60.PubMedGoogle Scholar
  42. 42.
    Wright JR, Clements JA. Metabolism and turnover of lung surfactant. Am Rev Respir Dis. 1987;135:426–44.Google Scholar
  43. 43.
    Vezzol D, Marraro G, Luchetti M, et al. Bronchopulmonary lavage with Curosurf in ARDS. Biol Neonate. 2002;81(Suppl 1):99–140.Google Scholar
  44. 44.
    Cochrane GC, Revak SD. Surfactant lavage treatment in a model of respiratory distress syndrome. Chest. 1999;116:85S–7S.CrossRefPubMedGoogle Scholar
  45. 45.
    Balaraman V, Meister J, Ku TL, et al. Lavage administration of dilute surfactants after acute lung injury in neonatal piglets. Am J Respir Crit Care Med. 1998;158:12–7.PubMedGoogle Scholar
  46. 46.
    Gommers D, Eijking EP, So KL, et al. Bronchoalveolar lavage with a diluted surfactant suspension prior to surfactant instillation improves the effectiveness of surfactant therapy in experimental acute respiratory distress syndrome (ARDS). Intensive Care Med. 1998;24:494–500.CrossRefPubMedGoogle Scholar
  47. 47.
    Winswell TE, Smith RM, Katz LB, et al. Bronchopulmonary segmental lavage with surfaxin (KL(4)- surfactant) for acute respiratory distress syndrome. Am J Respir Crit Care Med. 1999;160:1188–95.Google Scholar
  48. 48.
    Vezzoli D, Marraro GA, Luchetti M, et al. Bronchopulmonary lavage with porcine-derived surfactant in acute lung injury. Acta Pharmacol Sin. 2002;23:117Google Scholar
  49. 49.
    Vezzol D, Marraro G, Luchetti M, et al. Bronchopulmonary lavage with Curosurf in acute respiratory di stress sindrome. Biol Neonate. 2002;81(Suppl 1):39Google Scholar
  50. 50.
    Strohmaier W, Marraro G. Surfactant treatment in the ICU: alternative interpretations of existing evidence. Pediatric Anesthesia. 2006;16:813–5.PubMedGoogle Scholar
  51. 51.
    Chuang-Stein C, Offen W. Analysis of clinical trials using SAS: a practical guide. Cary: SAS Institute Inc; 2005.Google Scholar
  52. 52.
    The NPAR1WAY Procedure. SAS/STAT(R) 9.2 User’s Guide. 2nd ed. SAS; 2009. Accessed Oct 2009.
  53. 53.
    Strohmaier W, Trupka A, Pfeiler C, et al. Bilateral lavage with diluted surfactant improves lung function after unilateral lung contusion in pigs. Crit Care Med. 2005;33:2286–93.CrossRefPubMedGoogle Scholar
  54. 54.
    Westphal M, Traber DL. Exogenous surfactant in acute lung injury: no longer a question? Crit Care Med. 2005;33:2431–3.CrossRefPubMedGoogle Scholar
  55. 55.
    Davidson TA, Caldwell ES, Curtis JR, et al. Reduced quality of life in survivors of acute respiratory distress syndrome compared with critically ill control patients. JAMA. 1999;281:354–60.CrossRefPubMedGoogle Scholar
  56. 56.
    Jackson JC, Mitchell N, Hopkins RO. Cognitive functioning, mental health, and quality of life in ICU survivors: an overview. Crit Care Clin. 2009;25:615–28.CrossRefPubMedGoogle Scholar
  57. 57.
    Hopkins RO, Jackson JC. Short- and long-term cognitive outcomes in intensive care unit survivors. Clin Chest Med. 2009;30:143–53.CrossRefPubMedGoogle Scholar
  58. 58.
    Herridge MS, Cheung AM, Tansey CM, et al. One-year outcomes in survivors of acute respiratory distress syndrome. N Engl J Med. 2003;348:683–93.CrossRefPubMedGoogle Scholar
  59. 59.
    Rubenfeld GD, Caldwell E, Peabody E, et al. Incidence and outcomes of acute lung injury. N Engl J Med. 2005;353:1685–93.CrossRefPubMedGoogle Scholar
  60. 60.
    Lachmann G, Robertson B, Vogel J. In vivo lung lavage ad an experimental model of the respiratory distress syndrome. Acta Anaesthesiol Scand. 1980;24:231–6.CrossRefPubMedGoogle Scholar
  61. 61.
    Marraro G, Bonati M, Ferrari A, et al. Perfluorocarbon broncho-alveolar lavage and liquid ventilation versus saline broncho-lveolar lavage in adult guinea pig experimental model of meconium inhalation. Intensive Care Med. 1998;24:501–8.CrossRefPubMedGoogle Scholar
  62. 62.
    Schurch S, Schurch D, Curstedt T, et al. Surface activity of lipid extract surfactant in relation to film area compression and collapse. J Appl Physiol. 1994;77:974–86.PubMedGoogle Scholar
  63. 63.
    Spragg RG, Lewis JF, Wurst W, et al. Treatment of acute respiratory distress syndrome with recombinant surfactant protein C surfactant. Am J Respir Crit Care Med. 2003;167:1562–6.CrossRefPubMedGoogle Scholar
  64. 64.
    McCormack FX, Whittsett JA. The pulmonary collectins, SP-A and SP-D, orchestrate innate immunity in the lung. J Clin Invest. 2002;109:707–12.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • Giuseppe A. Marraro
    • 1
  • Carmelo Denaro
    • 2
  • Claudio Spada
    • 1
  • Marco Luchetti
    • 1
  • Carla Giansiracusa
    • 1
    Email author
  1. 1.Anesthesia and Intensive Care DepartmentA.O. Fatebenefratelli and Ophthalmiatric HospitalMilanItaly
  2. 2.Anesthesia and Intensive Care DepartmentAzienda Ospedaliera “Cannizzaro”CataniaItaly

Personalised recommendations