Ann Thorac Surg 1996;62:284-286
© 1996 The Society of Thoracic Surgeons
Case Report
Successful Reconstruction of a Complex Traumatic Carinal Disruption
Joseph R. Newton, Jr, MD,
Ravi Sharma, MD,
Hormoz Azar, MD,
Mark C. Rummel, MD,
L. Delano Britt, MD
Division of Cardiothoracic Surgery, Sentara Norfolk General Hospital, Norfolk, Virginia
Accepted for publication February 1, 1996.
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Abstract
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Complex traumatic tracheobronchial disruption often results in mortality or prolonged morbidity. This case report highlights a successful strategy for diagnosis and management of an unusually extensive carinal disruption in a patient with multiple trauma.
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Introduction
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The patient was a 20-year-old male Army private who became entangled in the propeller blade of an amphibious vessel. The only external injury was a broad contusion across the anterior torso that represented the blade impact site. However, respiratory distress, massive subcutaneous emphysema, and hypotension were present. Intubation, bilateral chest tube placement, and abdominal exploration due to a positive peritoneal lavage were performed emergently. Severe lacerations of the liver, spleen, and pancreas led to a left hepatic segmentectomy, distal pancreatectomy, and splenectomy.
In the immediate postoperative period, large continuous air leaks from both chest tubes suggested the possibility of a tracheobronchial disruption, which quickly was confirmed by flexible bronchoscopic examination. The patient was returned urgently to the operating room and by repeat bronchoscopy (rigid and flexible) an attempt was made to selectively intubate the left main bronchus for secure airway control. Although generally desirable, this was not possible due to the extensive carinal disruption and the concern for extending the injury. A standard right posterolateral thoracotomy was performed with a single-lumen endotracheal tube in the proximal trachea. Ventilation remained adequate because mediastinal soft tissues maintained approximate airway continuity.
When the posterior mediastinal pleural was opened an extensive carinal disruption was noted and, as expected, orotracheal ventilation ceased to be effective. A sterile flexible armored tube and anesthesia circuit that had been previously prepared and brought across the operative field was expeditiously placed into the left main bronchus directly to secure one-lung ventilation. By working around the endobronchial tube, detailed inspection now revealed a stellate "burstlike" fracture of the distal trachea and carina (Fig 1
). Both the left and right main bronchi were discontinuous from the trachea, and the membranous and cartilaginous portions of the distal trachea were both lacerated for a distance of 7 and 3 cm, respectively. Minimal, but necessary, debridement was carried out. Dissection was carefully performed to expose about 0.5 cm of airway wherever a laceration existed with care taken to maintain the integrity of the lateral airway blood supply. The reconstruction was completed by careful reapproximation of each laceration using interrupted 4-0 Vicryl sutures (Ethicon, Somerville, NJ) with knots tied externally. Orotracheal ventilation was resumed. Before chest closure, the repair was tested under saline solution to ensure an airtight seal and then meticulously buttressed with an intercostal muscle pedicle. Bronchoscopy was performed to clear secretions and to confirm a widely patent repair. The endotracheal tube was left in the trachea just below the vocal cords as immediate extubation was not considered feasible after these two extensive surgical procedures.
The patient was extubated on the first postoperative day; however, within 24 hours he required reintubation due to the development of adult respiratory distress syndrome. Subsequently, he was weaned from the ventilator and extubated on postoperative day 32. Secretions were cleared by multiple bronchoscopies to avoid blind endotracheal suctioning against the suture lines. Follow-up bronchoscopy 2 months postoperative revealed a widely patent distal trachea and right and left main bronchial openings without stenosis or granulation. Currently he is asymptomatic (Army active duty) at 2-year follow-up.
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Comment
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Complex and extensive carinal disruption as described in this case is unusual, and relatively few cases have been reported in the literature [1]. Treatment has included primary repair with or without cardiopulmonary bypass or repair and pneumonectomy. Associated injuries often result in a high mortality, making the isolated tracheobronchial injury mortality rate difficult to determine, but it has been estimated to be between 25% and 30% [1–4].
More than 80% of all (both complex and simple) tracheobronchial injuries secondary to blunt trauma are within 2.5 cm of the carina, and several theories have attempted to explain the mechanism of injury. The most accepted theory suggests that impact occurs when the glottis is closed, resulting in an abrupt increase in airway pressure and wall tension in the large-diameter airways [2, 5], resulting in a "blow-out" type injury.
Patients with tracheobronchial injury present commonly with dyspnea (90%), subcutaneous and mediastinal emphysema (66%), and pneumothorax (60%). Cyanosis with respiratory embarrassment from flail chest, tension pneumothorax, and hemoptysis are seen less frequently [2, 5, 6].
When tracheobronchial injury is suspected, chest tube insertion generally results in a large continuous air leak and may fail to fully reexpand the lung. Complete transection of the airway with minimal communication between the bronchus and pleural cavity may result in a small pneumothorax with pneumomediastinum. These injuries, especially if isolated to a single main bronchus, may be undiscovered and tracheobronchial healing may occur by granulation, with eventual stricture formation. Occasionally these patients may present late with stenosis, wheezing, or pulmonary suppuration, and only in retrospect is the history of chest trauma obtained.
The timely diagnosis of tracheobronchial injury requires a high index of suspicion, an understanding of the mechanism of injury, and knowledge of the expected clinical presentation and radiographic signs. Flexible bronchoscopy is used to establish the diagnosis [1, 5], but the capability of rigid bronchoscopy needs to be immediately available if required for adequate suctioning of blood and debris to improve visualization and secure an airway [6].
Tracheobronchial tears should be treated operatively to secure the airway and to allow a primary reconstruction before infection, granulation, or extensive scarring occurs. Tears of the thoracic trachea, carina, or right bronchus are best approached by a right thoracotomy, whereas isolated left bronchial tears are approached through the left chest. Intubation of the dependent lung with a long single-lumen flexible endotracheal tube [7] facilitates thoracotomy. Double-lumen tubes are generally too rigid and tubes with bronchial blockers may extend an injury. Once the chest is open, sterile transthoracic intubation of the dependent bronchus is carried out. Dissection around the airway should be minimized to avoid jeopardizing the blood supply. Repair is performed by primary single-layer anastomosis with interrupted absorbable sutures (4-0 Vicryl). The suture line should be reinforced with pericardial fat or a pedicle of intercostal muscle [2, 7]. Immediate extubation in the operating room is ideal to minimize positive airway pressure on the suture line. Follow-up bronchoscopy is routine. Early operative repair will lead to excellent airway results in more than 95% of cases [1, 2]. When the diagnosis of tracheobronchial disruption is delayed, late stricture formation can be treated by isolated sleeve resection of the stenosis and end-to-end reconstruction [7].
Complex tracheobronchial disruption secondary to blunt trauma is an uncommon injury, yet associated mortality and morbidity are high. The diagnosis should be suspected based on mechanism of injury and clinical and radiographic findings with bronchoscopy to confirm the diagnosis. Early operative reconstruction is the mainstay of treatment. Long-term follow-up indicates that most patients maintain full parenchymal function and resume a fully functional lifestyle, as demonstrated by our active-duty Army private.
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Footnotes
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Address reprint requests to Dr Newton, Mid-Atlantic Cardiothoracic Surgeons, Ltd, 400 W Brambleton Ave, Suite 200, Norfolk, VA 23510-1193.
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References
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- Symbas PN, Justicz AG, Ricketts RR. Rupture of the airways from blunt trauma: treatment of complex injuries. Ann Thorac Surg 1992;54:177–83.[Abstract/Free Full Text]
- Kirsh MM, Orringer MB, Behrendt DM, Sloan H. Management of tracheobronchial disruption secondary to nonpenetrating trauma. Ann Thorac Surg 1976;22:93–101.
- Bertelson S, Howitz P. Injuries of the trachea and bronchi. Thorax 1972;27:188–94.[Abstract/Free Full Text]
- Grover FL, Ellestad C, Arom KV, Root HD, Cruz AB, Trinkle JK. Diagnosis and management of major tracheobronchial injuries. Ann Thorac Surg 1979;28:384–91.[Abstract/Free Full Text]
- Urschel HC Jr, Razzuk MA. Management of acute traumatic injuries of the tracheobronchial tree. Surg Gynecol Obstet 1973;136:113–7.[Medline]
- Roxburgh JC. Rupture of tracheobronchial tree. Thorax 1987;42:681–8.[Abstract/Free Full Text]
- Newton JR, Grillo HC, Mathisen DJ. Main bronchial sleeve resection with pulmonary conservation. Ann Thorac Surg 1991;52:1272–80.[Abstract/Free Full Text]
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J. Thorac. Cardiovasc. Surg.,
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115(5):
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Abstract
Introduction
