Ann Thorac Surg 2002;73:1948-1949
© 2002 The Society of Thoracic Surgeons
Case report
Bronchial transection resulting from trivial blunt chest trauma
Sreedhar Reddy, MSa,
Piroze Davierwala, MCha,
Pawan Kumar, MSa,
Nityanand Thakur, MSa,
Packirisamy Babu, MSa,
Anil Tendolkar, MSa*
a Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, India
Accepted for publication December 5, 2001.
* Address reprint requests to Prof Tendolkar, Department of Cardiovascular and Thoracic Surgery, LTMM College and LTMG Hospital, Sion, Mumbai 400022, India
e-mail: atendolkar{at}yahoo.com
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Abstract
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A 3-year-old boy with a trivial blunt chest injury presented with a massive bronchopleural leak without any hilar vascular injury. On emergency exploration he had a complete transection of the right main bronchus. An end-to-end anastomosis of the transected bronchial ends was performed. At 1-month clinical and radiologic follow-up, the anastomosis had healed well.
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Introduction
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Blunt trauma to the chest resulting in rupture of trachea and major bronchi is rare [1]. Furthermore, rupture of the right main bronchus in the pediatric age group is exceptional [2]. We present a case of trivial chest trauma in a 3-year-old boy resulting in isolated right main bronchus injury without associated hilar vascular injury.
A 3-year-old boy was brought to us with a history of blunt injury to the chest. A tin roof sheet, with a dimensional size of approximately 1.25 m x 0.75 m (4 x 2 feet) and a weight of approximately 2 kg, fell onto the boy’s back when he was sleeping in the prone position. The boy was apparently asymptomatic for the first 24 hours but became breathless later and was brought to our hospital. On clinical examination he was tachypneic. There was no evidence of any external injury or subcutaneous emphysema over the chest or anywhere over the body as to suggest child abuse. Clinical examination was suggestive of right-sided pneumothorax. The chest roentgenogram showed a right-sided pneumothorax with complete collapse of the right lung. There was no evidence of fractured ribs. On insertion of an intercostal drain on the right side, there was a massive and persistent air leak, even on tidal respiration. A postintercostal drain insertion roentgenogram showed no expansion of the lung (Fig 1).
The patient’s dyspnea worsened over a couple of hours and was accompanied by a continuous drop in oxygen saturation. The patient was taken up for an emergency exploratory thoracotomy with a presumptive diagnosis of ruptured bronchus.
Single lung ventilation was achieved by a single lumen endotracheal tube with occlusion of the right main bronchus with a 4 French embolectomy catheter. On opening the pleura after a right posterolateral thoracotomy, a complete transection of the right main bronchus was noted. The proximal bronchial stump was 1.5 cm in length beyond the mediastinal pleural reflection. The distal stump was 5 mm proximal to the origin of the upper lobe bronchus. A small contusion of the upper lobe was noted. The other hilar structures were normal and there was no free fluid in the pleural cavity.
Both the transected ends were mobilized without compromising their blood supply. Intraoperative endobronchial suction through the transected distal stump was performed. The bronchial continuity was established by an end-to-end anastomosis using 4-0 polypropylene simple interrupted sutures, maintaining as little tension as possible. Care was also taken not to occlude the right upper lobe bronchus. An intercostal pedicle flap was placed over the bronchial anastomosis.
Postoperatively, there was no air leak on positive pressure as well as on spontaneous ventilation. On extubation the air entry was bilaterally equal, although an immediate postoperative roentgenogram showed haziness in the right upper zone (Fig 2)
suggesting acute pneumonitis of the upper and middle lobes. This cleared over the next 10 days with intravenous antibiotics and rigorous chest physiotherapy.
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Comment
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The pathophysiologic basis of a bronchial rupture includes three mechanisms: (1) a decrease in the anteroposterior diameter of the thorax, (2) sudden increase in intrabronchial pressure with a closed glottis, and (3) rapid deceleration [3]. As the child was sleeping in the prone position, obviously the first mechanism appeared to be the cause in this case. Tracheobronchial injuries are not diagnosed immediately in 25% to 68% of patients [4]. Two distinct clinical presentations may occur: (1) with free communication between the bronchus and the pleura and (2) with little or no communication. Trivial nature of injury raised a strong possibility of child abuse. Being the only child of the parents, a male, and a total lack of any obvious external injury, ruled out the possibility of child abuse. It is surprising that dyspnea developed in the patient 24 hours later, in spite of a free communication. It is possible that the presentation started as little or no communication and later changed to free communication between the bronchus and the pleura. Bronchoscopy, which is an established tool for the confirmation of diagnosis, was not possible because of the nonavailability of an adequate size pediatric bronchoscope. In our patient the bronchial rupture was within 2 cm of origin of the right main bronchus, a classic site described in literature [5]. Surgical repair should follow as soon as the condition of the patient permits [5]. In this case the surgical repair was the option made on an emergency basis, taking into account the clinical picture, roentgenogram, and deteriorating oxygen saturations of the patient. We used monofilament nonabsorbable interrupted sutures (polypropylene) to repair the bronchus, although monofilament absorbable suture material is considered to be the best. Acute pneumonitis that occurred in our patient on postoperative day 2 could have been caused by either infection or reventilation with increase of perfusion after tracheobronchial reconstruction [6]. With improvement in anesthetic and surgical techniques, the prognosis of tracheobronchial ruptures mainly depends on the initial control of respiratory failure and complications.
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References
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Abstract
Introduction
