Back To Search Results

Lung Torsion

Editor: Fatima Anjum Updated: 8/17/2023 10:36:06 AM

Introduction

Lung torsion is a rare condition that is classically seen when there is a disruption in the thoracic cavity. Common causes of lung torsion include thoracotomy, lung transplantation, and trauma. However, spontaneous cases have also been reported.[1]

Lung torsion is a life-threatening disease that requires a timely diagnosis because lung rotation can cause vascular compromise and airway obstruction, resulting in lung tissue necrosis. With immediate management, the affected lung or pulmonary lobe can be salvaged. Overall, lung torsion has a poor prognosis due to misdiagnosis and delay in treatment. If detorsion occurs and the lung is fixed in place, then it can recover to full function. This article will review the etiology, epidemiology, clinical manifestations, diagnosis, and management of lung torsion. 

Etiology

Register For Free And Read The Full Article
Get the answers you need instantly with the StatPearls Clinical Decision Support tool. StatPearls spent the last decade developing the largest and most updated Point-of Care resource ever developed. Earn CME/CE by searching and reading articles.
  • Dropdown arrow Search engine and full access to all medical articles
  • Dropdown arrow 10 free questions in your specialty
  • Dropdown arrow Free CME/CE Activities
  • Dropdown arrow Free daily question in your email
  • Dropdown arrow Save favorite articles to your dashboard
  • Dropdown arrow Emails offering discounts

Learn more about a Subscription to StatPearls Point-of-Care

Etiology

A history of intrathoracic procedures is common in patients with lung torsion, although spontaneous etiologies are also known.[1] The causes of lung torsion in adults include the following: 

  • Thoracic or abdominal trauma[2]
  • Lung transplantation[3][4]
    • Unilateral
    • Bilateral
  • Video-assisted thoracoscopic surgery (VATS) procedure[5]
  • Thoracentesis[6]
  • Thoracic Procedures[7]
    • Transesophageal operation[8]
    • Aorta repair[9]
    • Transthoracic correction of hiatal hernia[10]
    • Transthoracic needle aspiration
    • Transabdominal surgical diaphragmatic hernia
  • Spontaneous etiology
    • Pneumothorax[1]
    • Pleural effusion
    • Lobar atelectasis[11]
    • Pulmonary sequestration[12]
    • Diaphragmatic hernia[8] 

Commonly known causes of lung torsion in pediatric patients include the following: 

  • Blunt thoracic and abdominal trauma[12]
  • Tracheoesophageal repair[13]
  • Thoracotomy for hiatal hernia[14]
  • Ductus arteriosus closure[15]

Epidemiology

Lung torsion is rare, with the incidence reported to be 0.089% to 0.3% in one case series.[16] In this case study, lung torsion was found in 62.4% of patients post-operatively, 8.3% after trauma, and in 29.4% of patients, lung torsion occurred spontaneously. [16]

It was found that 21.6% of lung torsion cases occurred after VATS and 78.4% after thoracotomy. The case series also reviewed the site of lung torsion most commonly involved. In the study, 74.4% of lung torsions occurred after a right upper lobe lobectomy. The right middle lobe was the most common site (29.4% of patients after thoracic surgery). The incidence among genders was not significantly different. The case series reported that 58.3% of the cases occurred among males, and 41.7% occurred among females.[16]

Pathophysiology

Lung torsion is a result of a disruption in the thoracic cavity. This can vary from thoracotomy, pleural effusion, pneumothorax, trauma, or anything that can disturb the vasculature or lung tissue. Fluid accumulation from pleural effusion, inflammatory infiltrates from atelectasis, opacities from pneumonia, or other invasive procedures can compress the lung, vasculature, or airways. It may cause the lung to rotate and obstruct the pulmonary vessels. The large space in the thoracic cavity is a risk factor that allows mobility for the lung or lobes to rotate after segmentectomy or lobectomy. Even complete fissures without pleural adhesions or long bronchovascular vessels can cause lung torsion.[4][10][1][11][12][13][17]

Lung torsion results in either part of the lobe or the entire lobe twisting along an axis. This results in the obstruction of the bronchovascular tree, which eventually compromises the pulmonary arterial and venous circulation along with the bronchial circulation. It is found that if the lobe is rotated more than 180 degrees, the bronchovascular pedicle would be acutely obstructed, resulting in atelectasis followed by pulmonary infarction and necrosis. Bronchovascular obstruction will decrease arterial oxygen content as the lung will not get enough blood supply.[13]

Hypoxemia may result from intrapulmonary shunting, alveolar hyperventilation, and a mismatch of ventilation/perfusion (V/Q). Intrapulmonary shunting occurs if lobular veins are partially obstructed in an unventilated lung with some venous return. Alveolar hypoventilation occurs because the bronchus is kinked, decreasing the airflow from the airway to the bronchus. This may also increase airway secretions adding to the obstruction. If ventilation/perfusion mismatch occurs, there is partial bronchial obstruction but no venous return to the lobe because of complete vascular obstruction. Without proper oxygen requirements, the lung tissue can become non-viable. If the lung is not operated on early, the lung tissue can become necrotic.[13][18][19][20]

Histopathology

Histopathology of the rotated lung reveals visceral pleural fibrosis of the affected lung, and the tissue is filled with alveolar macrophages.[18]

History and Physical

No specific clinical signs or physical exam findings suggest lung torsion as the diagnosis. Nonspecific clinical signs include fever, chest pain, shortness of breath, and cough.[16] The most common symptom, however, are dyspnea, fever, and chest pain, respectively.[16] Most of these symptoms appear 4 to 14 days after a thoracic procedure, trauma, or any other triggering effect. Some patients were even asymptomatic and showed no clinical signs.

Physical exam findings can reveal hypoxia, respiratory discomfort, and tachypnea.[13][16][21][18][1] Radiological imaging, however, is required to confirm the diagnosis of lung torsion.[22]

Evaluation

Initial laboratory work can show leukocytosis, but it's not always present. Arterial blood gas may appear normal and not reflect the hypoxia; therefore, the diagnosis is made through radiologic imaging.[2]

An x-ray can show worsening consolidation, and sometimes abruption of the pulmonary artery may be seen. Anatomic abnormalities and pulmonary opacities can also be seen in x-ray imaging. Serial x-rays can show consolidation progression, especially if pneumonia is superimposing on lung torsion.[16][23][24]

Bronchoscopy can also reveal findings indicating lung torsion. In previous case studies, bronchoscopy revealed obstruction where the bronchoscope could not advance into the bronchus due to the narrowing of the passageway. The bronchial stenosis and a "fish mouth" orifice or noting twisting or extrinsic compression could be seen through bronchoscopy. Early identification of lung torsion using bedside bronchoscopy can preserve the lung tissue without needing a pneumonectomy.[25] However, bronchoscopy does not always reveal narrowing or diagnose lung torsion; therefore, a computed tomography (CT) scan is required to confirm the diagnosis.[16][18][26]

A CT scan can show obstruction of bronchial arteries, lobar opacification, or atelectasis and lobular collapse. Vascular and bronchial structures can appear stenosed, blocked, or inverted on imaging and may be seen as the "antler sign."[27] 

Obstruction in the airway can reveal tracheobronchial tree narrowing of the affected bronchus. The lung can rotate at various angles; however, one case series has shown that the lobe was rotated about 180 degrees in most cases. Follow-up CT scans can indicate a change in the position of the lesions as the lung torsion progresses. The presence of an "antler sign" on the chest CT scan with contrast, in addition to evidence of bronchial obstruction or abnormal fissure orientation, indicates lung torsion and requires confirmation by performing reconstructions of 3-dimensional views of the CT scan.[27]

CT angiography can show abrupt truncation and pulmonary artery obstruction. These images have also revealed interlobular septal thickening in the displaced lobe and venous congestion. Sometimes abnormal lobe displacement can reveal a fissure. If the lung tissue has become necrotic, imaging will reveal the loss of parenchymal and pulmonary vascular sites.[16][26][18][27]

Treatment / Management

Patients that are treated early on before necrosis occurs can have viable tissue saved. Case studies show that patients who underwent detorsion of the rotated lung could have full function returned with the lung re-expanding. Once the lungs go through detorsion, they must be fixed between the involved lung and the surrounding tissue with sutures or staples.

If the lung can't go through detorsion or if detorsion fails, then lobectomy must occur. Detorsion must be performed within the first few hours of diagnosis to save a viable lung. Any longer, the lung may already have irreversible ischemic damage, where it may be safer to perform a resection without detorsion. This would prevent the inflammatory markers that build up during the torsion from leaking out into the rest of the body and causing multiorgan failure.

For the damaged tissue, it is best to keep the lung rotated until the pulmonary veins have been clamped to prevent the systemic release of the inflammatory markers. Once safely clamped, a clinical decision can be made whether the lung can go through detorsion or if resection should occur. 

Delayed treatment can also cause a clot to form, resulting in pulmonary embolism or stroke. Heparin drip can be used as a prophylactic measure to prevent this complication. Conservative management was found to have recurrent pneumonia, eventually leading to death. Very few cases had complications of pneumonia, air leaks, or emphysema after fixation. Most procedures occurred without any complications intra-operatively and post-operatively.[18][28][29][30](B2)

Differential Diagnosis

Studies have found that misdiagnosis occurred in 18.3% of patients with lung torsion. Most differentials can be excluded by CT scan, CT angiography, or bronchoscopy from abnormal lobular placement. Diagnosis is confirmed with the vascular and airway obstructions seen on the CT scans. Differential diagnosis of lung torsion includes several possibilities, including those below.[13][14][16][31][32] 

  • Hemothorax
  • Hemorrhage
  • Pneumonia (infectious versus aspiration)
  • Contusion (after sub-lobar resection; can appear like airspace consolidation that resolves after a few days)
  • Lung gangrene
  • Parenchymal infection
  • Atelectasis
  • Tumor
  • Loculated effusion
  • Emphysema
  • Inadvertent ligation of the hilum
  • Diaphragmatic herniation
  • Leakage of the anastomosis site 

Prognosis

Prognosis is poor if lung torsion management is delayed or the patient becomes septic resulting in ischemia of the lung tissue. The mortality rate was found to be as high as 8.3%.[16] Higher mortality rates were associated with whole lung torsion compared to lobar torsion.[16] 

Studies have found similar survival rates among repositioning and direct repositioning. Indirection resection had higher mortality. Mortality from lung torsion was found to be highest in trauma patients at 22.2%, followed by thoracic surgery at 8.8% and spontaneous lung torsion at 3.1%.[16][33] 

Complications

Correction of lung torsion is an emergent surgical procedure with many associated complications, including those listed below.[13][34][35][36][37][38] 

  • Pneumonia
  • Cerebrovascular accident
  • Necrosis of the lung tissue
  • Hemorrhage
  • Vocal cord injury
  • Bronchopleural fistulae
  • Pulmonary embolism
  • Post-thoracic surgery noncardiogenic pulmonary edema
  • Atelectasis
  • Bronchospasm
  • Respiratory failure
  • Air leak including pneumothorax, pneumomediastinum, pneumopericardium
  • Emphysema 

Deterrence and Patient Education

Patients should be advised to avoid any blunt trauma to the thoracic or abdominal cavity after having a thoracic procedure to minimize the risk of postoperative lung torsion.

Pearls and Other Issues

Lung torsion is a diagnosis that can be made from a chest x-ray, CT scan, or bronchoscopy. Lung torsion is confirmed with a CT scan and is a life-threatening pathology. Bronchovascular and airway compromise occurs. If not treated in a timely fashion, then necrosis of the lung can occur. Detorsion of the lung or lobectomy is the treatment option.

If a thoracic procedure occurs, pneumopexy of the lung lobe should be performed to prevent lung torsion. After lobectomy or segmentectomy, the remaining lobe should be stapled or sutured so it stays fixed; however, this is not commonly practiced as a component of prophylactic treatment. A postopertive follow-up would require monitoring for air leaks. Practitioners should consider heparin drip for prophylactic prevention of pulmonary embolism.

Enhancing Healthcare Team Outcomes

If a thoracic procedure, such as VATS or lobectomy, is performed, stapling the lung or pneumopexy of the lobe should be considered to prevent lung torsion. Lung torsion is a diagnosis that must be made promptly and classically through radiologic imaging. Once a diagnosis is made, contacting the thoracic surgical team to salvage the lung is imperative. Coordination and rapid, effective communication among interprofessional care team members, including clinicians and surgeons, radiologists, nurses, and surgical assistants, are essential to ensure a timely diagnosis and correction of this potentially fatal condition. 

References


[1]

Kita Y, Go T, Nii K, Matsuura N, Yokomise H. Spontaneous torsion of the right upper lung lobe: a case report. Surgical case reports. 2017 Dec:3(1):37. doi: 10.1186/s40792-017-0313-3. Epub 2017 Feb 22     [PubMed PMID: 28229432]

Level 3 (low-level) evidence

[2]

Oliveira C, Zamakhshary M, Abdallah MR, Miller SF, Langer JC, Wales PW, Dasgupta R. Lung torsion after tracheoesophageal fistula repair: a case report and review of literature. Journal of pediatric surgery. 2007 Nov:42(11):E5-9     [PubMed PMID: 18022425]

Level 3 (low-level) evidence

[3]

Alberti D, Borsellino A, Migliazza L, Brena ML, Sonzogni A, Cheli M, Colombo A, Locatelli G. Pulmonary torsion after cardiac surgery in two infants: review of pediatric literature. Journal of pediatric surgery. 2004 Nov:39(11):1719-23     [PubMed PMID: 15547841]

Level 3 (low-level) evidence

[4]

Felson B. Lung torsion: radiographic findings in nine cases. Radiology. 1987 Mar:162(3):631-8     [PubMed PMID: 3809475]

Level 3 (low-level) evidence

[5]

DAUGHTRY DC. Traumatic torsion of the lung. The New England journal of medicine. 1957 Feb 28:256(9):385-8     [PubMed PMID: 13419007]


[6]

PARKS RE. Traumatic torsion of the lung. Radiology. 1956 Oct:67(4):582-3     [PubMed PMID: 13370873]


[7]

Schena S, Veeramachaneni NK, Bhalla S, Gutierrez FR, Patterson GA, Kreisel D. Partial lobar torsion secondary to traumatic hemothorax. The Journal of thoracic and cardiovascular surgery. 2008 Jan:135(1):208-9, 209.e1-2. doi: 10.1016/j.jtcvs.2007.08.053. Epub     [PubMed PMID: 18179946]

Level 3 (low-level) evidence

[8]

Tanaka Y, Nishio W, Hokka D, Kawamura S, Shimada E, Okumura S. Acute torsion of the left lower lobe caused by chronic traumatic hernia of the diaphragm. The Journal of thoracic and cardiovascular surgery. 2010 Feb:139(2):e4-6. doi: 10.1016/j.jtcvs.2008.05.061. Epub 2008 Sep 14     [PubMed PMID: 19660255]

Level 3 (low-level) evidence

[9]

Fu JJ, Chen CL, Wu JY. Lung torsion: survival of a patient whose hemorrhagic infarcted lung remained in situ after detorsion. The Journal of thoracic and cardiovascular surgery. 1990 Jun:99(6):1112-4     [PubMed PMID: 2359330]

Level 3 (low-level) evidence

[10]

Gicking J, Aumann M. Lung lobe torsion. Compendium (Yardley, PA). 2011 Apr:33(4):E4     [PubMed PMID: 21870341]

Level 3 (low-level) evidence

[11]

Stephens G, Bhagwat K, Pick A, McGiffin D. Lobar torsion following bilateral lung transplantation. Journal of cardiac surgery. 2015 Feb:30(2):209-14. doi: 10.1111/jocs.12476. Epub 2014 Dec 3     [PubMed PMID: 25470330]

Level 3 (low-level) evidence

[12]

Chrysou K, Gioutsos K, Filips A, Schmid R, Schmid RA, Kocher GJ. Spontaneous right whole-lung torsion secondary to bronchial carcinoma: a case report. Journal of cardiothoracic surgery. 2016 Jul 14:11(1):107. doi: 10.1186/s13019-016-0506-z. Epub 2016 Jul 14     [PubMed PMID: 27417315]

Level 3 (low-level) evidence

[13]

David A, Liberge R, Corne F, Frampas E. Whole-lung torsion complicating double lung transplantation: CT features. Diagnostic and interventional imaging. 2016 Sep:97(9):927-8. doi: 10.1016/j.diii.2016.05.010. Epub 2016 Jul 12     [PubMed PMID: 27421675]


[14]

Irie M, Okumura N, Nakano J, Fujiwara A, Noguchi M, Kayawake H, Yamashina A, Matsuoka T, Kameyama K. Spontaneous whole-lung torsion after massive pleural effusion and atelectasis. The Annals of thoracic surgery. 2014 Jan:97(1):329-32. doi: 10.1016/j.athoracsur.2013.04.133. Epub     [PubMed PMID: 24384188]

Level 3 (low-level) evidence

[15]

Oddi MA, Traugott RC, Will RJ, Simmons RA, Treasure RL, Schuchmann GF. Unrecognized intraoperative torsion of the lung. Surgery. 1981 Mar:89(3):390-3     [PubMed PMID: 7466631]

Level 3 (low-level) evidence

[16]

Dai J, Xie D, Wang H, He W, Zhou Y, Hernández-Arenas LA, Jiang G. Predictors of survival in lung torsion: A systematic review and pooled analysis. The Journal of thoracic and cardiovascular surgery. 2016 Sep:152(3):737-745.e3. doi: 10.1016/j.jtcvs.2016.03.077. Epub 2016 Apr 13     [PubMed PMID: 27209019]

Level 1 (high-level) evidence

[17]

Cable DG, Deschamps C, Allen MS, Miller DL, Nichols FC, Trastek VF, Pairolero PC. Lobar torsion after pulmonary resection: presentation and outcome. The Journal of thoracic and cardiovascular surgery. 2001 Dec:122(6):1091-3     [PubMed PMID: 11726883]

Level 2 (mid-level) evidence

[18]

Taira N, Kawasaki H, Takahara S, Furugen T, Atsumi E, Ichi T, Kushi K, Yohena T, Kawabata T. Postoperative Lung Torsion With Retained Viability: The Presentation and Surgical Indications. Heart, lung & circulation. 2018 Jul:27(7):849-852. doi: 10.1016/j.hlc.2017.06.733. Epub 2017 Jul 27     [PubMed PMID: 28867177]


[19]

Falcoz PE, Hoan NT, Le Pimpec-Barthes F, Riquet M. Severe hypoxemia due to intrapulmonary shunting requiring surgery for bronchioloalveolar carcinoma. The Annals of thoracic surgery. 2009 Jul:88(1):287-8. doi: 10.1016/j.athoracsur.2008.12.031. Epub     [PubMed PMID: 19559250]


[20]

Karbing DS, Panigada M, Bottino N, Spinelli E, Protti A, Rees SE, Gattinoni L. Changes in shunt, ventilation/perfusion mismatch, and lung aeration with PEEP in patients with ARDS: a prospective single-arm interventional study. Critical care (London, England). 2020 Mar 23:24(1):111. doi: 10.1186/s13054-020-2834-6. Epub 2020 Mar 23     [PubMed PMID: 32293506]


[21]

Duan L, Chen X, Jiang G. Lobar torsion after video-assisted thoracoscopic lobectomy: 2 case reports. The Thoracic and cardiovascular surgeon. 2012 Mar:60(2):167-9. doi: 10.1055/s-0030-1271182. Epub 2011 Jun 21     [PubMed PMID: 21695674]

Level 3 (low-level) evidence

[22]

Eba S, Tanaka R, Watanabe Y, Hirama T, Notsuda H, Suzuki T, Oishi H, Niikawa H, Noda M, Sakurada A, Okada Y. [Assessment of Computed Tomography Sagittal Images for Early Diagnosis of Pulmonary Torsion after Lung Resection]. Kyobu geka. The Japanese journal of thoracic surgery. 2021 Mar:74(3):191-195     [PubMed PMID: 33831871]


[23]

Moser ES Jr, Proto AV. Lung torsion: case report and literature review. Radiology. 1987 Mar:162(3):639-43     [PubMed PMID: 3544030]

Level 3 (low-level) evidence

[24]

Chen CH, Hung TT, Chen TY, Liu HC. Torsion of right middle lobe after a right upper lobectomy. Journal of cardiothoracic surgery. 2009 Apr 16:4():16. doi: 10.1186/1749-8090-4-16. Epub 2009 Apr 16     [PubMed PMID: 19368736]

Level 3 (low-level) evidence

[25]

Vallabhajosyula S, Blackmon SH. Left Lower Lobe Pulmonary Torsion. The Annals of thoracic surgery. 2016 Oct:102(4):e361. doi: 10.1016/j.athoracsur.2016.04.064. Epub     [PubMed PMID: 27645983]


[26]

Hennink S, Wouters MW, Klomp HM, Baas P. Necrotizing pneumonitis caused by postoperative pulmonary torsion. Interactive cardiovascular and thoracic surgery. 2008 Feb:7(1):144-5     [PubMed PMID: 18042566]

Level 3 (low-level) evidence

[27]

Hammer MM, Madan R. Clinical and imaging features in lung torsion and description of a novel imaging sign. Emergency radiology. 2018 Apr:25(2):121-127. doi: 10.1007/s10140-017-1563-x. Epub 2017 Oct 13     [PubMed PMID: 29030781]


[28]

Kutlu CA, Olgac G. Pleural flap to prevent lobar torsion: A novel technique. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. 2006 Dec:30(6):943-4     [PubMed PMID: 17052913]


[29]

Uramoto H, Takenoyama M, Hanagiri T. Simple prophylactic fixation for lung torsion. The Annals of thoracic surgery. 2010 Dec:90(6):2028-30. doi: 10.1016/j.athoracsur.2010.07.040. Epub     [PubMed PMID: 21095357]

Level 2 (mid-level) evidence

[30]

Higashiyama M, Takami K, Higaki N, Kodama K. Pulmonary middle lobe fixation using TachoComb in patients undergoing right upper lobectomy with complete oblique fissure. Interactive cardiovascular and thoracic surgery. 2004 Mar:3(1):107-9     [PubMed PMID: 17670190]


[31]

Kim EA, Lee KS, Shim YM, Kim J, Kim K, Kim TS, Yang PS. Radiographic and CT findings in complications following pulmonary resection. Radiographics : a review publication of the Radiological Society of North America, Inc. 2002 Jan-Feb:22(1):67-86     [PubMed PMID: 11796900]


[32]

Thomas PA. The lung torsion dilemma: Detorsion without resection or resection without detorsion? The Journal of thoracic and cardiovascular surgery. 2016 Sep:152(3):746. doi: 10.1016/j.jtcvs.2016.04.063. Epub 2016 Apr 28     [PubMed PMID: 27179842]


[33]

Kelly MV 2nd, Kyger ER, Miller WC. Postoperative lobar torsion and gangrene. Thorax. 1977 Aug:32(4):501-4     [PubMed PMID: 929493]

Level 3 (low-level) evidence

[34]

Larsson S, Lepore V, Dernevik L, Nilsson F, Selin K. Torsion of a lung lobe: diagnosis and treatment. The Thoracic and cardiovascular surgeon. 1988 Oct:36(5):281-3     [PubMed PMID: 3273364]

Level 3 (low-level) evidence

[35]

Apostolakis E, Koletsis EN, Panagopoulos N, Prokakis C, Dougenis D. Fatal stroke after completion pneumonectomy for torsion of left upper lobe following left lower lobectomy. Journal of cardiothoracic surgery. 2006 Sep 12:1():25     [PubMed PMID: 16968544]

Level 3 (low-level) evidence

[36]

Hendriks J, Van Schil P, De Backer W, Hauben E, Vanmaele R, Van Marck E. Massive cerebral infarction after completion pneumonectomy for pulmonary torsion. Thorax. 1994 Dec:49(12):1274-5     [PubMed PMID: 7878570]

Level 3 (low-level) evidence

[37]

Sengupta S. Post-operative pulmonary complications after thoracotomy. Indian journal of anaesthesia. 2015 Sep:59(9):618-26. doi: 10.4103/0019-5049.165852. Epub     [PubMed PMID: 26556921]


[38]

Sakai M, Kurimori K, Saeki Y, Kitazawa S, Kobayashi K, Iguchi K, Sato Y. Video-assisted thoracoscopic conservative repair of postoperative lobar torsion. The Annals of thoracic surgery. 2014 Nov:98(5):e119-21. doi: 10.1016/j.athoracsur.2014.07.080. Epub 2014 Oct 30     [PubMed PMID: 25441831]

Level 3 (low-level) evidence