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Ann Thorac Surg 1998;65:182-186
© 1998 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Management of Major Tracheobronchial Injuries: A 28-Year Experience

Division of Thoracic Surgery, Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA

Accepted for publication June 30, 1997.

Dr Johnson, Division of Thoracic Surgery, Department of Surgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78284-7841.

	Abstract

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Background. Tracheobronchial injuries are rare but potentially life threatening. Their successful diagnosis and treatment often require a high level of suspicion and surgical repairs unique to the given injury.

Methods. We reviewed our experience with 32 patients with tracheobronchial injuries treated over the past 28 years.

Results. Forty-one percent (13/32) of the injuries were due to blunt trauma and 59% (19/32), to penetrating trauma. Most penetrating injuries were located in the cervical trachea (74%), whereas blunt injuries were more commonly located close to the carina (62%). Fifty-nine percent of the patients required urgent measures to secure the airway. Penetrating injuries were usually diagnosed by clinical findings or at surgical exploration. The diagnosis of blunt injuries was more difficult and required a high index of suspicion and the liberal use of bronchoscopy. The majority of the injuries were repaired primarily using techniques specific to the injury, and most patients returned to their normal activity soon after discharge.

Conclusions. A high level of suspicion and the liberal use of bronchoscopy are important in the diagnosis of tracheobronchial injury. A tailored surgical approach is often necessary for definitive repair.

	Introduction

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Tracheobronchial injury (TBI) is rare but potentially life threatening. It requires early diagnosis, skillful airway management, and prompt surgical repair. The diagnosis of TBI secondary to blunt trauma is not always straightforward and initially can be missed in patients with multiple injuries.

Our recent experience with some complex airway injuries led us to review our experience with TBI during the past 28 years. A retrospective chart review was performed of all patients identified with TBI to determine the clinical presentation, identify methods of diagnosis, describe the techniques of airway management and surgical repair, and define morbidity and mortality.

	Material and Methods

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
We reviewed records at the University Hospital at San Antonio of patients who were identified as having tracheal, bronchial, or tracheobronchial injury from 1968 to 1996. Age, sex distribution, clinical findings, diagnostic methods, cause and location of injuries, associated injuries (if present), airway management, surgical treatment, and outcome are reported.

	Results

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Thirty-two patients with TBI were identified. Twenty-four (75%) were male and 8 (25%), female with a median age of 21 years (range, 18 months to 64 years). Three patients (9%) were less than 10 years old. There were 13 blunt injuries (41%)—10 motor vehicle accidents, 1 fall, 1 rope injury, and 1 water-ski accident—and 19 (59%) penetrating injuries—13 gunshot wounds and six stab wounds.

Physical Findings
The most common physical findings are diagramed in Fig 1. Of the 17 patients with injury to the cervical trachea, 4 (24%) had air escaping from the neck wound, and a diagnosis was made immediately. All 8 patients with injury to the mediastinal trachea and all 4 patients with injury to the main bronchus were documented to have a "massive air leak" after placement of a tube thoracostomy. Two patients had only a "minimal air leak," and only 1 (7%) of 15 patients with a distal bronchial injury (and an associated pneumothorax) failed to have any air leak after placement of a tube thoracostomy.

View larger version (28K): [in this window] [in a new window]   Common physical findings in patients with tracheobronchial injury.

View larger version (20K): [in this window] [in a new window]   More frequent roentgenographic findings in patients with tracheobronchial injury.

View larger version (22K): [in this window] [in a new window]   Abnormal bronchoscopic findings in patients with tracheobronchial injury.

Operative Management
Twenty-four patients (75%) underwent surgical treatment within 2 hours after injury, and 7 patients (22%), between 2 and 8 hours after injury. Only 1 patient who was transferred to our institution 2 days after sustaining a blunt TBI underwent surgical exploration 4 days after injury.

Penetrating Injuries
There were 14 injuries to the cervical trachea secondary to penetrating trauma: six stab wounds and eight gunshot wounds. All of these patients were approached through collar incisions except 1 who was wounded at the base of the neck posterior to the manubrium. This patient had an associated right pneumothorax and was approached through a median sternotomy to provide exposure to both the superior mediastinum and the right hemithorax. He was found to have a through-and-through lesion at the level of the seventh cartilage with an associated esophageal perforation and severe avulsion of the right upper lobe bronchus. The tracheal injury was closed primarily with interrupted 3-0 Prolene (Ethicon, Somerville, NJ), and the esophageal perforation was also repaired primarily in a two-layer fashion using 3-0 polyglactin 910 (Vicryl; Ethicon) with insertion of a pleural flap between the two injuries. A right upper lobectomy was necessary secondary to a severely avulsed right upper lobe. A pleural flap was used to protect the stapled bronchial stump.

Three patients with stab wounds between the second and fourth tracheal cartilage were treated by debridement and tracheostomy tube placement directly through the injury. Ten patients with through-and-through injuries between the second and fifth rings underwent debridement and primary repair with interrupted 3-0 or 4-0 monofilament nonabsorbable suture. Tracheostomy was performed distal to the injury in 2 of these patients to protect the repair against high airway pressures and provide pulmonary toilet. Three of the patients with cervical tracheal through-and-through lesions had associated esophageal perforations that were treated with primary repair and interposition of a local muscle flap.

Five penetrating injuries to the intrathoracic trachea were secondary to gunshot wounds. Two patients were hypotensive despite aggressive fluid resuscitation in the emergency department, and a median sternotomy approach was used for suspected intrapericardial injury. Three other patients had an associated right pneumothorax, and a right thoracotomy was used. Of these 5 patients, 4 had through-and-through injuries that were debrided and repaired primarily with interrupted 3-0 or 4-0 nonabsorbable monofilament suture. In 1 of these 4 patients, an associated esophageal injury was found. This was debrided and primarily closed. A pleural flap was then interposed between the posterior wall of the trachea and the anterior esophageal wall. Another patient was found to have a stellate longitudinal avulsion of the anterior wall of the mediastinal trachea (entrance wound) extending from the eighth ring down to the carina. The posterior exit wound to the membranous portion of the trachea was debrided and repaired primarily with interrupted 4-0 Prolene. The avulsed anterior wall was debrided and repaired primarily with figure-of-eight 3-0 Prolene sutures. A pleural flap was sutured loosely with 3-0 Vicryl anteriorly (Fig 4). After the repair was completed, a pulmonary wedge resection of a severely injured right upper lobe was performed.

View larger version (22K): [in this window] [in a new window]   Longitudinal tear in mediastinal trachea down to right main bronchus. The injury is repaired with figure-of-8 nonabsorbable sutures, and the repair is protected with a pleural flap.

Three patients had partial tracheal rupture: 2, of the mediastinal trachea, and 1, of the cervical trachea. Both patients with injury to the mediastinal trachea (posterior to the manubrium) underwent a median sternotomy. Primary repair was performed using figure-of-8 3-0 or 4-0 nonabsorbable monofilament suture. The cervical tracheal injury was approached through a collar incision and also repaired primarily using interrupted 3-0 Prolene.

Five (39%) of the 13 patients had avulsions of the right main bronchus. All of these injuries were located within 2.5 cm of the carina, and all were diagnosed by bronchoscopy before exploration through a right thoracotomy. Two patients had severe stellate avulsions of the distal trachea and right bronchus. Because of the extensive injury to the right main bronchus and the necessity to use part of the bronchus to close the distal trachea, a right pneumonectomy was performed. The proximal posterior right main bronchus was then used to create a flap to allow closure of the distal trachea (Fig 5). The 3 other patients had clean avulsions of the mainstem bronchus. These were repaired primarily using interrupted 4-0 Prolene and were buttressed with pleural flaps.

View larger version (24K): [in this window] [in a new window]   Severe avulsion of mediastinal trachea and main bronchus requiring right pneumonectomy. The pneumonectomy is performed, and the membranous portion of the main bronchus is used to create a flap to repair the avulsed mediastinal trachea.

View larger version (22K): [in this window] [in a new window]   Transection of left bronchus at bifurcation. A left upper lobectomy is completed, as the left upper lobe bronchus was not viable. The left lower lobe is anastomosed to the left main bronchus after resection of the nonviable bronchus.

Six patients sustained postoperative complications, for an overall morbidity rate of 19%. The complications included pneumonia in 3, suture granuloma in 2, and wound infection in 1. After discharge from the hospital, 28 of the 30 patients returned to previous levels of activity. One patient never recovered to baseline status because of the severity of the closed head injury, and the second patient was seen 6 months postoperatively because of dyspnea with heavy exercise. This patient had sustained extensive avulsion of the anterior tracheal wall from the eighth ring down to the carina (see Fig 4). Flexible bronchoscopy revealed tracheal stenosis with granuloma formation at the site of the injury. Laser fulguration of the granuloma and subsequent balloon dilation were performed with good results.

Two patients, both of whom had sustained multiple blunt injuries, died, for an overall mortality rate of 6%. One death was secondary to a severe closed head injury, and the other was due to fulminant intraabdominal sepsis and shock.

	Comment

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Until 1927 when Krinitzki [1] reported the case of a human long-term survivor, TBI had been considered to be inevitably fatal. In 1947, the cases of 2 patients with TBI were reported by Kinsella and Johnstrud [2]. Twelve years later, Hood and Sloan [3] presented a series of 7 patients and reviewed 91 other cases from the world literature. In a series published in 1961, Shaw and co-workers [4] began to advocate primary repair of the trachea over delayed closure. The true incidence of TBI is difficult to establish, as a large proportion (30% to 80%) of these patients will die before reaching the hospital [5]. However, it is estimated on the basis of autopsy reports that 2.5% to 3.2% of patients who die as a result of trauma may have associated TBI [6][7].

Lynn and Iyengar [7] reported that more than 80% of TBIs due to blunt trauma are located within 2.5 cm of the carina. This is similar to our series if we exclude 3 patients with cervical injuries that resulted from direct blows to the neck. There are several theories regarding the mechanism of blunt tracheobronchial disruption that may explain this [8][9][10]. The first hypothesis is that a direct impact to the chest decreases the anteroposterior diameter of the thorax while simultaneously increasing the transverse diameter. As the lungs always remain in contact with the chest wall because of the negative intrapleural pressure, they stretch laterally and produce a traction force at the carina. The second hypothesis is that a rapid deceleration causes shearing of the bronchus from its points of fixation near the cricoid and carina. The third hypothesis, which is consistent with Laplace’s law, is that the greatest wall tension generated within the tracheobronchial tree during periods of increased airway pressures, such as that occurring during compression of the chest wall against a closed glottis, is at the carina.

The initial assessment of the traumatized patient involves the traditional ABCs of resuscitation as outlined by the American College of Surgeons in the advanced-trauma life support guidelines [11]. Patients with tracheal or bronchial injuries make this initial assessment particularly crucial and challenging [12]. Almost two thirds of our patients were seen in the emergency department with some degree of respiratory difficulty and required emergent measures to secure and control the airway. Orotracheal intubation was the most frequent method used. In 2 of our patients with complete transection of the trachea, intubation was performed over a flexible bronchoscope as previously described [13]. We have shown that patients with cervical injuries and open neck wounds can be safely intubated through the open wound to secure the airway if necessary.

The initial physical findings in patients with TBI can be subtle. However, several abnormalities have previously been described that can alert the physician to the diagnosis. Tachypnea and subcutaneous emphysema (occurring in 59% and 81% of our patients, respectively) are common [1][13][14][15][16]. In our series, abnormalities found during bronchoscopy were similar to those reported recently [17][18]. Findings that led to the suspicion of injury included obstruction of the airway with blood and inability to visualize the more distal lobar bronchi because of collapsed mainstem bronchi. Visualization of the tear was confirmatory.

In our series, associated injuries were common and were related to the mechanism and location of the TBI. The most common associated injury related to penetrating TBI in our series was esophageal perforation, which is consistent with other reports [19][20].

Most cervical tracheal injuries were approached through a collar incision. In patients with injuries high in the mediastinal trachea or with suspected great-vessel injury, a median sternotomy was performed. When the injury was associated with a unilateral pneumothorax or when a bronchial injury was diagnosed preoperatively, an ipsilateral posterolateral thoracotomy was the incision of choice. For injuries to the mediastinal trachea not associated with a pneumothorax, our approach was through a right posterolateral thoracotomy (usually through the fourth intercostal space). Since the initial report by Shaw and colleagues [4], primary repair of the injured tracheobronchial tree has been encouraged [6][12][13][14][16]. In our series, most patients (78%) underwent primary repair of the tracheobronchial tree using tailored surgical techniques, as previously described. Early in the study, patients with contaminated stab wounds to the cervical trachea between the second and fourth rings were treated with exploration, debridement, and tracheostomy tube placement through the wound. The tracheostomy tube was downsized within 2 weeks of injury and eventually removed with no further treatment. This practice has been abandoned, and more recently we have treated these wounds with debridement and primary closure.

In conclusion, TBI encompasses a heterogeneous group of injuries that requires skillful airway management, careful diagnostic evaluation, and operative repairs that are often creative and necessarily unique to the given injury. An experienced surgeon with a high level of suspicion and the liberal use of bronchoscopy constitute the major tools necessary for a successful outcome in treating these injuries.

	Acknowledgments

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
We thank Dr Gregory J. Moorman for elaborating the illustrations that enhance the quality of the manuscript.

	References

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 

1. Krinitzki SI Zur Kasuistik einer vollstandigen Zerreißung des rechten Lufttrohrenastes. Virchows Arch 1927;266:815-819.
2. Kinsella TJ, Johnstrud LW Traumatic rupture of the bronchus. J Thorac Surg 1947;16:571-583.
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