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Ann Thorac Surg 1999;67:834-836
© 1999 The Society of Thoracic Surgeons

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Case Reports

Surgical management and follow-up of a complex tracheobronchial injury

^a Cardiothoracic Surgery, Section of Pediatric Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
^b General Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
^c Otolaryngology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA
^d Anesthesiology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA

Accepted for publication August 13, 1998.

Address reprint requests to Dr Hammon, Jr, Department of Cardiothoracic Surgery, Wake Forest University Medical Center, Medical Center Blvd, Winston-Salem, NC 27157-1096

	Abstract

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Tracheobronchial trauma is an uncommon condition with potentially devastating consequences. Appropriate pre-, intra-, and postoperative management is mandatory for a satisfactory functional outcome. We report a case of extensive tracheobronchial injury secondary to blunt trauma, which was managed successfully with emergent surgical repair and careful endoscopic follow-up. We review the important management decisions made in this case.

	Introduction

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Tracheobronchial injury after blunt trauma may involve the trachea or bronchi from the level of the cricoid cartilage to the division of the lobar bronchi. It is a rare entity that is frequently lethal, particularly when there is a delay in diagnosis. We report the management and follow-up of a 4-year-old boy who was ejected from a vehicle and suffered an extremely complex tracheobronchial injury.

	Case report

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A 4-year-old boy, an unrestrained back seat passenger, was ejected from a vehicle after a head-on collision. He arrived at an outside emergency department with a Glasgow coma score of 3, hypotensive, and tachycardic. He was intubated immediately and rapidly became impossible to oxygenate and ventilate resulting in cardiopulmonary arrest. After successful resuscitation, a chest roentgenogram revealed a left pneumothorax. With the insertion of a left chest tube, a small amount of blood returned and a small air leak was noted. All other roentgenograms, including cervical spine films and a computed tomographic scan of the head and abdomen, were negative.

Upon arrival to our tertiary care facility, he had a Glasgow coma score of 10 and had developed a right pneumothorax. A 22F chest tube was inserted into the right pleural space; a persistent air leak was present. Aside from facial lacerations and chest wall contusions with diminished breath sounds over the right chest, there were no other pertinent physical findings. Suspecting a tracheobronchial injury, he underwent urgent fiberoptic bronchoscopy and was noted to have a disrupted trachea and a moderate amount of blood emanating from the trachea. He was taken to the operating room to repair a suspected tracheobronchial injury.

The chest was entered through a right, fifth interspace posterolateral thoracotomy. There was a large amount of mediastinal air present. In fact, when the mediastinum was entered, it became impossible to ventilate the patient. We noted that the trachea was completely avulsed from the carina and both mainstem bronchi were avulsed from the carina such that there was no continuity between the trachea and either mainstem bronchi, or the two mainstem bronchi with each other (Fig 1 ). In addition, the membranous portion of the trachea was split from the level of the cricoid cartilage to the carina, we attempted to intubate the left mainstem bronchus, but were unsuccessful in establishing adequate ventilation due to a combination of extensive injury and extensive bloody secretions. A sterile No. 4 noncuffed endotracheal tube was inserted into the right mainstem bronchus, thus permitting us to ventilate the patient while repairing the extensive injury.

View larger version (54K): [in this window] [in a new window]   Fig 1. Representation of the tracheobronchial tree upon initial inspection. Complete disruption of the bronchi from the trachea with selective intubation of right mainstem bronchus, plus a tear in the membranous trachea.

View larger version (31K): [in this window] [in a new window]   Fig 2. Reconstruction of carina with selective intubation of right mainstem bronchus and repair of membranous tear.

View larger version (42K): [in this window] [in a new window]   Fig 3. Repair completed with pericardial patch closing the anterior defect.

	Comment

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The incidence of tracheobronchial trauma is low compared with that of other intrathoracic injuries after blunt trauma. Bertelson and Howitz [1], reviewing postmortem findings in 1,178 patients dying after blunt chest trauma in Denmark, found the incidence of tracheobronchial injury to be 2.8%. From 1970 to 1990, just 183 cases of rupture of the airways were reported in the literature. Of these, 8% were complex injuries as described in this report [2].

Commonly called tracheobronchial disruption, several mechanisms have been postulated to explain the transverse (between tracheal rings), longitudinal (along membranous segment), or complex (more than one site or combination) tracheobronchial injury that occurs after blunt trauma [3, 4]. It can only be speculated, but it appears in this case that a combination of mechanisms was operative in creating such an extensive injury.

There are a variety of signs and symptoms that result from isolated tracheobronchial injury and depends on whether there is free communication between the site of injury and the pleura [5]. Davies and Hopkins [6], reporting on tracheobronchial trauma, recognized two groups of patients with distinct clinical patterns. In the first group, there is immediate communication between the site of disruption and the pleural space. In the second group, there is little or no communication between the airway and the pleural space, and the injury is sealed off by the mediastinal tissue. In this case, the boy became unstable with positive pressure ventilation as this disrupted the mediastinal tissue that contained the tracheal injury. This should be an early indicator of severe tracheobronchial injury. It is important to have an accurate bronchoscopic assessment of the location and length of injury before repair, as this will determine the necessary exposure. In this patient, bronchoscopic examination verified the presence of an injury, but greatly underestimated the severity. We chose a right thoracotomy because the disruption identified was near the carina.

In every instance of major airway injury, there must be extremely close cooperation between the surgeon and the anesthesiologist. The possibility of using double ventilation with intrathoracic placement of an endobronchial tube must be considered. High frequency jet ventilation is another option, both intra- and postoperatively. There are several operative principles that should be adhered to for successful outcome, including adequate debridement of devitalized tissue allowing mucosa-to-mucosa repair and limiting posterolateral dissection to preserve blood supply and to avoid injury to the recurrent laryngeal nerves. In the event that extensive damage or avulsion has occurred and there is tissue loss, viable tissue including pericardium can be used to complete the repair, as in this patient [7]. Frequent bronchoscopic examinations should be anticipated and may help with timing of extubation. If granuloma form, bronchoscopic fiberoptic laser removal is effective [8]. Long-term follow-up of these injuries is mandatory to monitor growth and development of the reconstructed trachea.

	References

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1. Bertelson S., Howitz P. Injuries to the trachea and bronchi. Thorax 1972;27:188-194.[Abstract/Free Full Text]
2. Symbas P.N., Justicz A.G., Ricketts R.R. Rupture of the airways from blunt trauma: treatment of complex injuries. Ann Thorac Surg 1992;54:177-183.[Abstract]
3. Deslauriers J., Beaulieu M., Archambault G., et al. Diagnosis and long-term follow-up of major bronchial disruptions due to nonpenetrating trauma. Ann Thorac Surg 1982;33:32-36.[Abstract]
4. Mills S.A., Johnston F.R., Hudspeth A.S., et al. Clinical spectrum of blunt tracheobronchial disruption illustrated by seven cases. J Thorac Cardiovasc Surg 1982;84:49-58.[Abstract]
5. Schonberg S. Bronchial rupturen bei thoarax kompression. Klin Wochenschr 1912;49:2218-2223.
6. Davies D., Hopkins J.S. Patterns in traumatic rupture of the bronchus. Injury 1973;4:261-266.[Medline]
7. Mathisen D.J., Grillo H. Laryngotracheal trauma. Ann Thorac Surg 1987;43:254-262.[Abstract]
8. Rimell F.L., Shapiro A.M., Mitskavich M.T. Pediatric fiberoptic laser rigid bronchoscopy. Otolaryngol 1996;114:413-417.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Scot C. Schultz Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Schultz, S. C. Articles by Nelson, J. M. Search for Related Content PubMed PubMed Citation Articles by Schultz, S. C. Articles by Nelson, J. M.