Blast Lung Injury Severity Score

• Screening chest x-rays for asymptomatic patients is not recommended (Matthews et al 2015), as patients with blast lung injury (BLI) present either immediately or early with hypoxemia. Contrary to previous belief that the clinical picture of BLI may develop over 24 to 48 hours, studies have shown that patients do not present with a delay in manifestation of lung injury (Pizov et al 1999, Avidan et al 2005).
• Similarly, it was previously suggested that tympanic membrane (TM) rupture, the most common primary blast injury, was a marker for increased risk of development of BLI. Studies have shown that TM perforation is in fact poorly correlated with BLI (Leibovici et al 1999, Ballivet de Regloix 2017).
• Low inspiratory pressure with avoidance of positive end-expiratory pressure (PEEP) is ideal in BLI in order to avoid secondary barotrauma, arterial air embolism, or pneumothorax. However, patients with blast lung often have injury patterns similar to acute respiratory distress syndrome (ARDS) and require positive pressure ventilation (PPV) and PEEP.
• Other treatment considerations include avoiding aggressive intravenous hydration after physiology capture, as it can worsen pulmonary edema, and considering the need for a prophylactic thoracostomy tube before air transportation.

Intubated patients require the following ventilation management:

• Mild BLI patients will usually require volume-controlled or pressure support ventilation modes. PEEP requirement is ≤5 cm H₂O.
• Moderate BLI will use conventional ventilator modes, including inverse-ratio ventilation as needed. PEEP requirement is 5-10 cm H₂O.
• Severe BLI will use conventional ventilator modes and commonly require additional therapies such as nitric oxide, high-frequency jet ventilation, independent lung ventilation, or extracorporeal membrane oxygenation. PEEP requirement is >10 cm H₂O.