"Kaas-series-3"- Understanding the etiopathogenesis of Kshataja-kaasa by Prof. Satyendra Ojha

अतिव्यवायभाराध्वयुद्धाश्वगजविग्रहैः।

रुक्षस्योरः क्षतं वायुःगृहीत्वा कासमावहेत् ।। 

स पूर्वं कासते शुष्कं ततः ष्ठीवेत् सशोणितम् । 

कण्ठेन रुजता-अत्यर्थं विरुग्णेनेव चोरसा ।। 

सूचीभिरिव तीक्ष्णाभिः तुद्यमानेन शूलिना । 

दुःख स्पर्शेन शूलेन भेदपीडाभितापिना ।। 

पर्वभेद ज्वर श्वास तृष्णा वैस्वर्य पीडितः । 

पारावत इवाकूजन् कासवेगात्क्षतोद्भवात् ।।

(च.चि.18/20-23) 

अयं च कासः साहसज यक्ष्मरुपे अपि उक्तो ज्ञेयः ।(आचार्य चक्रपाणि)

The features of kshataja kasa resembles with sahasaja rajyakshma.

A pulmonary contusion (or lung contusion) is a contusion (bruise) of the lung, caused by chest trauma. As a result of damage to capillaries, blood and other fluids accumulate in the lung tissue.
(रुक्षस्योरः क्षतं वायुःगृहीत्वा कासमावहेत् ।।) The excess fluid interferes with gas exchange, potentially leading to inadequate oxygen levels (hypoxia). Unlike pulmonary laceration, another type of lung injury, pulmonary contusion does not involve a cut or tear of the lung tissue.

A pulmonary contusion is usually caused directly by blunt trauma but can also result from explosion injuries or a shock wave associated with penetrating trauma.

Contusion involves hemorrhage in the alveoli (tiny air-filled sacs responsible for absorbing oxygen), but a hematoma is a discrete clot of blood not interspersed with lung tissue. A collapsed lung can result when the pleural cavity (the space outside the lung) accumulates blood (hemothorax) or air (pneumothorax) or both (hemopneumothorax). These conditions do not inherently involve damage to the lung tissue itself, but they may be associated with it. Injuries to the chest wall are also distinct from but may be associated with lung injuries.

सूचीभिरिव तीक्ष्णाभिः तुद्यमानेन शूलिना । 

दुःख स्पर्शेन शूलेन भेदपीडाभितापिना ।। 

 Chest wall injuries include rib fractures and flail chest, in which multiple ribs are broken so that a segment of the rib cage is detached from the rest of the chest wall and moves independently.

(पर्वभेद ज्वर श्वास तृष्णा वैस्वर्य पीडितः ।) 

Pulmonary laceration, in which lung tissue is torn or cut, differs from pulmonary contusion in that the former involves disruption of the macroscopic architecture of the lung, while the latter does not. When lacerations fill with blood, the result is pulmonary hematoma, a collection of blood within the lung tissue.

Falls, assaults, and sports injuries are other causes. Pulmonary contusion can also be caused by explosions; the organs most vulnerable to blast injuries are those that contain gas, such as the lungs. Blast lung is severe pulmonary contusion, bleeding, or edema with damage to alveoli and blood vessels, or a combination of these.

(ततः ष्ठीवेत् सशोणितम् ।)        

This is the primary cause of death among people who initially survive an explosion. Unlike other mechanisms of injury in which pulmonary contusion is often found alongside other injuries, explosions can cause pulmonary contusion without damage to the chest wall. 

In addition to blunt trauma, penetrating trauma can cause pulmonary contusion. Contusion resulting from penetration by a rapidly moving projectile usually surrounds the path along which the projectile traveled through the tissue. The pressure wave forces tissue out of the way, creating a temporary cavity; the tissue readily moves  back into place, but it is damaged. (अतिव्यवायभाराध्वयुद्धाश्वगजविग्रहैः।)
  Pulmonary contusions that accompany gun and knife wounds are not usually severe enough to have a major effect on outcome; penetrating trauma causes less widespread lung damage than blunt trauma. An exception is shotgun wounds, which can seriously damage large areas of lung tissue through a blast injury mechanism.

कासमात्ययिकं मत्वा क्षतजं त्वरया जयेत् । 

च.चि. 18/134 

Kshataja Kasa caused by exogenous factors need to be considered as emergency and be treated on grounds of maintaining basic parameters normal like fluid balance, electrolyte balance (bala) and later treatment should be like pittaj kasa as raktaj dushti (infection) is common in external injury. Further Pulmonary contusion is associated with complications including pneumonia and  acute respiratory distress syndrome, and it can cause long-term respiratory disability. (पर्वभेद ज्वर श्वास तृष्णा वैस्वर्य पीडितः ।) 

Pulmonary contusion can cause parts of the lung to consolidate, alveoli to collapse, and atelectasis (partial or total lung collapse) to occur. Consolidation occurs when the parts of the lung that are normally filled with air fill with material from the pathological condition, such as blood. Over a period of hours after the injury, the alveoli in the injured area thicken and may become consolidated. A decrease in the amount of surfactant  produced also contributes to the collapse and consolidation of alveoli; inactivation of surfactant increases their surface tension. Reduced production of surfactant can also occur in surrounding tissue that was not originally injured. 

Inflammation of the lungs, which can result when components of blood enter the tissue due to contusion, can also cause parts of the lung to collapse. Macrophages, neutrophils, and other inflammatory cells and blood components can enter the lung tissue and release factors that lead to inflammation, increasing the likelihood of respiratory failure.  In response to inflammation, excess  mucus  is produced, potentially plugging parts of the lung and leading to their collapse. Even when only one side of the chest is injured, inflammation may also affect the other lung. Uninjured lung tissue may develop edema, thickening of the septa of the alveoli, and other changes. If this inflammation is severe enough, it can lead to dysfunction of the lungs like that seen in acute respiratory distress syndrome. (पारावत इवाकूजन् कासवेगात्क्षतोद्भवात् ।।) Monitoring for complications such as  pneumonia and acute respiratory distress syndrome is of critical importance. Treatment aims to prevent respiratory failure and to ensure adequate blood oxygenation. Supplemental oxygen can be given and it may be warmed and humidified. When the contusion does not respond to other treatments, extracorporeal membranous oxygenation may be used, pumping blood from the body into a machine that oxygenates it and removes carbon dioxide prior to pumping it back in. 

The administration of fluid therapy in individuals with pulmonary contusion is controversial. Excessive fluid in the circulatory system (hypervolemia) can worsen hypoxia because it can cause fluid leakage from injured capillaries (pulmonary edema), which are more permeable than normal. However, low blood volume (hypovolemia) resulting from insufficient fluid has an even worse impact, potentially causing hypovolemic shock;  for people who have lost large amounts  of blood, fluid resuscitation is necessary. 

Supportive care

Retaining secretions in the airways can worsen hypoxia and lead to infections. Thus, an important part of treatment is pulmonary toilet, the use of suction, deep breathing, coughing, and other methods to remove material such as mucus and blood from the airways. Chest physical therapy makes use of techniques such as breathing exercises, stimulation of coughing, suctioning, percussion, movement, vibration, and drainage to rid the lungs of secretions, increase oxygenation, and expand collapsed parts of the lungs. People with pulmonary contusion, especially those who do not respond well to other treatments, may be positioned with the uninjured lung lower than the injured one to improve oxygenation. Inadequate pulmonary toilet can result in pneumonia.

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Prof. Satyendra Narayan Ojha  

MD PhD

(Kayachikitsa)
Director

Yashwant Ayu. College & P.G.Training&Research Center 

Kodoli, Kolhapur, Maharashtra, India.

Mobile No.- +91 9822177155     

email: drsnojha@rediffmail.com