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Ann Thorac Surg 2000;69:1563-1567
© 2000 The Society of Thoracic Surgeons

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Original articles: General thoracic

Acute injuries of the trachea and major bronchi: importance of early diagnosis

^a Department of Surgery, The University of Tennessee Medical Center at Knoxville, Knoxville, Tennessee, USA

Address reprint requests to Dr Cassada, Department of Surgery, The University of Tennessee Medical Center, Box U-11, 1924 Alcoa Hwy, Knoxville, TN 37920

	Abstract

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Background. Tracheobronchial injuries are encountered with increasing frequency because of improvements in prehospital care and early initiation of the Advanced Trauma Life Support protocol. We review our experience with these injuries with the hypothesis that the leading determinant of patient outcome is the time interval to diagnosis.

Methods. Patients with tracheobronchial injury were identified from the registry of our level 1 trauma center during a 10-year period ending December 1997. Clinical presentation, diagnostic evaluation, surgical management, and outcome were reviewed.

Results. Twenty patients with ten cervical tracheal injuries and ten intrathoracic tracheobronchial injuries were treated. The mechanism of injury involved blunt trauma in 11 and penetrating trauma in 9. All patients underwent surgical debridement and primary repair. Patients with isolated airway injuries were discharged home after a mean hospital stay of 6 days and had no early complications. Three patients had delayed diagnosis (> 24 hours), and all sustained complications including death (1 patient) and multiorgan system failure (2 patients). The overall mortality rate was 15%.

Conclusions. Operative management of tracheobronchial injuries can be achieved with acceptable mortality. Independent of mechanism or anatomic location of injury, delay in diagnosis is the single most important factor influencing outcome. Early recognition of tracheobronchial injury and expedient institution of appropriate surgical intervention are essential in these potentially lethal injuries.

	Introduction

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Tracheobronchial injuries (TBIs) are encountered with increasing frequency because of improvements in prehospital care and early initiation of the Advanced Trauma Life Support protocol. Many patients still die before reaching the hospital. In 1971, Ecker and associates [1] reported their study of blunt TBIs in Dallas County, TX and found that of 27 patients seen over a 10-year period, only 9 were alive on reaching the emergency room. Reviewing 1,178 postmortem reports of persons dying of trauma, Bertelsen and Howitz [2] found that only 33 (0.03%) had TBI and of them, 27 (82%) died almost immediately.

Earlier reports [3, 4] emphasized the importance of early diagnosis and treatment. More recently, Rossbach and associates [5], in their review of 32 patients with TBI over a 28-year period, found that a high index of suspicion and the liberal use of bronchoscopy were essential in the diagnosis of the occult injury. We reviewed our experience with these injuries with the hypothesis that the key determinant of patient outcome was the time interval to diagnosis.

	Material and methods

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Patients with TBI treated from January 1988 through December 1997 at The University of Tennessee Medical Center at Knoxville, a level 1 trauma center, were identified through the trauma registry. The prehospital, hospital, and autopsy records were reviewed for mechanism of injury, clinical presentation, associated injuries, radiographic and bronchoscopic findings, surgical management, and outcome. Outcome was evaluated in relation to potential risk factors including mechanism of injury, associated injuries, anatomic location of injury, and time interval between injury and diagnosis.

Univariate analysis was performed by ² test and Fisher’s exact test for categoric variables and Student’s t test for continuous variables. Multiple logistic regression was then performed to determine the independent factors related to outcome. A p value of less than 0.05 was considered significant.

	Results

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All injuries involved the upper airway between the cricoid cartilage and the secondary bronchial bifurcations. Of the 20 patients treated, 10 had cervical tracheal injuries, 9 had major bronchial lacerations, and 1 had intrathoracic tracheal injury. The mean age was 27 years (range, 8 to 45 years), and there were 14 male and 6 female patients (Table 1). Nineteen patients arrived from the scene of the incident, and 1 was transferred from another facility. Ten were transported to the trauma center by helicopter, 9 by ambulance, and 1 by automobile.

	Comment

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The usual principles of trauma care apply to the treatment of major airway injuries. Rapid physical assessment and management of bleeding and shock should be undertaken, with primary attention given to managing the airway [1, 2, 5, 8]. For a patient in respiratory distress, an endotracheal tube should be passed, if possible, over a flexible bronchoscope. In our series, 55% of the patients were seen with a secure airway and were breathing comfortably on supplemental oxygen. Elective blind intubation secondary to inability to stent over a potential cervical tracheal injury is therefore discouraged [8]. Complete disruption of a compensated upper-airway laceration by intubation can be a fatal error by the clinician who is inclined to immediately intubate the patient for airway injury. Baumgartner and associates [11] delivered this warning in 1997 in the case of a patient with complete tracheal transection with false intubation. Although their patient survived, the outcome is usually fatal.

The diagnosis of major airway injury depends first on a thorough history and physical examination with careful inspection of the site of injury, particularly in the case of penetrating trauma, for evidence of leaking air in the cervical region [5, 12]. A chest radiograph suggestive of TBI in a patient in stable condition necessitates prompt bronchoscopy in either the emergency department or the operating room in anticipation of surgical exploration. Bronchoscopy was used in 10 patients in our series (7 in the blunt injury group, 3 in the penetrating injury group) and confirmed the location and extent of injury in all.

Accurate interpretation of the chest radiograph is essential in the early diagnosis of occult upper-airway injury. In 1989, Unger and co-workers [3] found that the preponderant findings on chest radiograph included subcutaneous emphysema, pneumomediastinum, pneumothorax, and air surrounding the mainstem bronchi. Mediastinal and subcutaneous emphysema can be massive if pleural rupture occurs. All our patients had subcutaneous emphysema on presentation. In their series of 9 patients, Baumgartner and associates [4] found subcutaneous emphysema and dyspnea were the most consistent presenting features of TBI.

Once a diagnosis of major airway injury is made, the surgical management includes open debridement and repair to establish airway continuity [9, 13–15]. Most groups prefer nonabsorbable sutures, such as polypropylene, although some surgeons choose to use braided polyglactin sutures. In our series, both types of suture were used in interrupted through-and-through fashion with extraluminal knots (See Table 1). Clinical follow-up was inconsistent, and little data are available on subsequent development of hypertrophic granulation tissue. If there is irreparable damage to a major bronchus or massive pulmonary vascular injury, lobectomy or pneumonectomy may be the only surgical option to repair the airway, as was the case in 2 of our patients.

Kirsh and associates [3] postulated three specific patterns of TBI based on the mechanism of injury in blunt trauma. The first involves rapid compression of the chest and the anteroposterior diameter of the thorax with a simultaneous widening of the transverse diameter. This produces lateral motion resulting in traction on the trachea at the carina. The second mechanism involves an increase in the intratracheal pressure that occurs against a closed glottis. The intraluminal pressure then exceeds the tracheal elastic strength, which results in rupture at the membranous and cartilaginous junctions. In the third mechanism, rapid deceleration results in shearing forces at fixed points along the trachea, including the cricoid cartilage and the carina, leading to disruption. In our review, blunt upper-airway injuries occurred most frequently at the takeoff of the right mainstem bronchus (84%).

Three patients had delay in diagnosis, and all had septic complications with one resultant death. The delay in diagnosis was due to failure to consider the possibility of airway injury in a timely fashion. A prolonged period of hypoxia adversely affects all organ systems and can be only partially reversed by eventual restoration of the airway. A high level of suspicion with ready use of diagnostic techniques such as bronchoscopy is required to identify the occult injury.

In conclusion, operative management of TBIs can be achieved with acceptable mortality. Independent of mechanism or anatomic location of injury, delay in diagnosis is the single most important factor influencing outcome. Early recognition of TBI and expedient institution of appropriate surgical intervention are essential in these potentially lethal injuries.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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4. Baumgartner F., Sheppard B., de Virgilio C., et al. Tracheal and main bronchial disruptions after blunt chest trauma. Ann Thorac Surg 1990;50:569-574.[Abstract]
5. Rossbach M.M., Johnson S.B., Gomez M.A., Sako E.Y., Miller O.L.W., Calhoon J.H. Management of major tracheobronchial injuries. Ann Thorac Surg 1998;65:182-186.[Abstract/Free Full Text]
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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): Raymond A. Dieter, Jr George F. Schuchmann Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cassada, D. C. Articles by Enderson, B. L. Search for Related Content PubMed PubMed Citation Articles by Cassada, D. C. Articles by Enderson, B. L.