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a General Thoracic Surgery, Department of Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
b Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
Accepted for publication July 24, 2007.
* Address correspondence to Dr Nishiumi, General Thoracic Surgery, Department of Surgery, Tokai University School of Medicine, Bohseidai, Isehara, Kanagawa, 259-1193, Japan (Email: nishiumi{at}is.icc.u-tokai.ac.jp).
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Abstract |
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Methods: Sites, methods, and outcomes of occlusion of the affected bronchus by endobronchial blocker used with a Univent endotracheal tube (Fuji Systems Corporation, Tokyo, Japan) in 35 patients (29 men, 6 women; mean age, 26 ± 13 years) with diffuse lung contusion, treated from 1988 to 2004, were analyzed.
Results: The right main bronchus was occluded in 7 patients, left main bronchus in 12, intermediate bronchial trunk in 9, and secondary bronchi in 7. Four patients who developed hypoxemia underwent differential ventilation. Bronchial occlusion was performed 118 ± 139 minutes after arrival and continued 26 ± 13 hours. Twenty-nine patients survived; 1 died of pulmonary abscess and 5 died due to brain injury.
Conclusions: Bronchial occlusion should be performed soon after trauma in patients with endobronchial bleeding. The Univent has three advantages in such patients: (1) it prevents the inflow of blood from the affected bronchus into the unaffected lung; (2) the tamponade effect of the endobronchial blocker stops bronchial bleeding; and (3) air embolus due to air flowing from the bronchus into the pulmonary veins can be prevented. Use of a tube for one-lung ventilation with which the trauma surgeon is familiar is advisable. The Uniblocker tube (Fuji Systems Corporation) allows occlusion of the affected bronchus without reinsertion of a single-lumen tracheal tube.
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Introduction |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Patients and Methods |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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During the period 1988 through 2005, 874 consecutive patients with blunt chest trauma were admitted to the Emergency and Critical Care Center of the Tokai University Hospital. During this period, bronchial occlusion was performed on the affected side with an endobronchial blocker attached to a Univent to treat any of three conditions: disruption of the intermediate bronchial trunk and lobe trunk (peripheral-type bronchial disruption), deep pulmonary laceration, and diffuse lung contusion. Intermediate bronchial trunk and lobe trunk bronchial disruption has been described elsewhere [4]. Five patients with such disruption underwent bronchial repair while the bronchus proximal to the site of injury was occluded with a Univent blocker during one-lung mechanical ventilation. In cases of deep pulmonary laceration, the visceral pleura and alveoli were disrupted and blood from injured pulmonary arterioles and venules flowed into both the airway and thoracic cavity. More than 500 mL of blood often filled the thoracic cavity. Thirty-seven patients with deep pulmonary laceration were treated first by bronchial occlusion and this was followed by immediate emergency thoracotomy and lobectomy [5]. Because the visceral pleura in patients with diffuse lung contusion was slightly damaged, blood from ruptured alveoli flowed into the segmental bronchus, lobar bronchus, and trachea. Patients with diffuse lung contusion suffered intrathoracic hemorrhage caused by combined chest wall injury, and the chest tube drainage volume was less than 500 mL during the first 2 hours after arrival. In addition, without central-type bronchial injury, these patients did not have mediastinal emphysema but there was slight air leakage through the chest tube.
We analyzed the medical records of 35 consecutive patients with diffuse lung contusion in whom bronchial occlusion on the affected side and mechanical ventilation were performed. These were 29 males and 6 females, 12 in their teens, 16 in their 20s, 3 in their 30s, 1 in his 40s, 2 in their 50s, and 1 in his 70s. Mean age was 26 ± 13 years. The cause of injury was a motorbike accident in 13 patients, other types of traffic accidents in 12, a fall in 9, and injury by a falling object in 1. Because endobronchial bleeding was an emergency situation we performed tracheal intubation and bronchial occlusion without obtaining the patients’ consent. After removal of the tracheal tube, the attending surgeon explained the medical procedures to the patient, whose life was saved after arrival at the hospital.
For these 35 patients, we analyzed vital signs upon admission, sites of bronchial occlusion, length of time from admission to the start of bronchial occlusion, duration of bronchial occlusion, measures taken to deal with hypoxemia, selection of the tube for one-lung ventilation, and outcomes.
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Results |
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When bronchial occlusion with an endobronchial blocker attached to a Univent was performed, the main bronchus on the affected side was occluded first. Endobronchial bleeding was seen on the right side in 16 patients and on the left side in 19. None had bilateral endobronchial bleeding. A serious thoracic injury was suspected in 23 patients, including 8 patients with hemoptysis upon arrival; tracheal intubation was performed with a Univent by an emergency room doctor, and blood from the airway expelled of the tube upon exhalation. Bronchial occlusion was then performed with a Univent blocker by a thoracic surgeon. When occlusion of the main bronchus on the injury side was achieved, blood gushing from the bronchus came under instant control. Patients who were transported by helicopter and patients who needed immediate tracheal intubation for shock and (or) disturbed consciousness underwent tracheal intubation with a single lumen tube by an emergency room doctor upon arrival. Tracheal reintubation with a Univent and bronchial occlusion were performed later by a thoracic surgeon. After bronchial occlusion, we confirmed the position of the Univent blocker by chest roentgenography. We used a fiber bronchoscope for one-lung ventilation through the Suction Safe (Kimura Medical Instrument Corp. Tokyo, Japan), and we absorbed aspirated blood that had flowed into the bronchus on the unaffected side from the bronchus on the affected side and fixed the position of the blocker in the bronchus on the injured side. Because blood obscured the apical lens of the electronic bronchoscope, we were not able to observe the trachea and bronchus.
Sites of occlusion with the Univent blocker are shown in Figure 1. The right main bronchus was occluded in seven patients and the left main bronchus in 12. In 9 patients with bleeding from the right middle and lower bronchial trunk, the intermediate bronchial trunk was occluded and mechanical ventilation was performed, involving the right upper lobe and the left lung. In 7 patients (1 patient with bleeding from the right upper bronchial trunk, 1 with bleeding from the left upper bronchial trunk, and 5 with bleeding from the left lower bronchial trunk), selective occlusion of the secondary bronchi was performed.
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Artificial respiration was initiated in continuous positive pressure ventilation (CPPV) mode with a tidal volume of 8 mL/kg, respiratory rate of 20 breaths/minute, fraction of inspired oxygen (FiO 2) of 1.0, inspiratory to expiratory time (I:E) rate of 1:1.5, and positive end-expiratory pressure of 5 cm H2O. In 4 patients (1 patient with bleeding from the right upper bronchial trunk and 3 with bleeding from the left upper and lower bronchial trunk) who developed hypoxemia after one-lung ventilation with a Univent, ventilation was performed separately for the right and left sides because of lung contusion on the nonoccluded side. Differential ventilation of the right and left sides with a Univent in a patient with bleeding from the right upper bronchial trunk is shown schematically in Figure 2. Because the Univent blocker has a straw-shaped opening, differential ventilation was performed by applying 5 cm H2O continuous positive airway pressure (CPAP) with FiO 2 of 1.0 to the right middle and lower lobes or the left upper and lower lobes.
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The duration of bronchial occlusion was 6 to 12 hours in 5 patients, 12 to 24 hours in 11, 24 to 36 hours in 11, and 36 to 48 hours in 8 (mean: 26 ± 13 hours). Before 2000, the mean duration of bronchial occlusion was 28 hours. During and after 2000, it was shortened to 20 hours on the basis of our experience that endobronchial bleeding could be stopped within 24 hours in most patients.
Twelve and 24 hours after the bronchial occlusion was released, bronchoscopy was performed to aspirate clots within the bronchi. If the abbreviated injury scale (AIS)–90 score for the head was less than 3, flail chest was not present, and injured organs other than in the chest were stable, the patient was weaned from the respirator, the tracheal tube was removed 2 to 3 days after the release of bronchial occlusion, and the patient was advised to practice forcefully discharging bloody sputum. Tracheotomy was performed in 12 patients; 4 showing signs of flail chest and 8 with a head AIS score of 3 or more. Mechanical ventilation was used for 9 days on average, including the period of bronchial occlusion with the Univent. The respirator was used for as long as 16 days in the 3 patients in whom internal fixation with CPPV was performed because of flail chest complications and 12 days in the 15 patients with a head AIS score of than 3 or more.
To prevent pneumonia, each patient was treated with antibiotics (second-generation cephalosporin) for 4 days. If signs of inflammation were noted on hospital day 5, the patient was treated with antibiotics to which bacteria isolated from the sputum immediately after admission were sensitive. Although 1 patient developed pulmonary abscess (described below), none of the patients developed severe pneumonia requiring mechanical ventilation.
Twenty-nine of the 35 patients survived, and 6 died within 30 days of hospitalization. Of the 29 surviving patients, 17 were discharged and 12 were transferred to a different hospital for rehabilitation. Average stay at our hospital was 65 days. The cause of death was brain injury (head AIS score greater than 4) in 5 patients and pulmonary abscess in 1. The patient who developed pulmonary abscess died. He was a 22-year-old man admitted to our hospital after a motor vehicle accident. To deal with bleeding from the left upper and lower bronchial trunks, the patient’s left main bronchus was occluded with a Univent beginning 75 minutes after arrival and continuing 29 hours. Endobronchial bleeding was thus controlled successfully. To deal with diffuse brain contusion, cranial decompression was achieved by craniotomy 4 hours after admission. Hypothermia at 34°C was established postoperatively and the patient was rewarmed at 48 hours. A chest X-ray film obtained on hospital day 3 revealed multiple traumatic pulmonary cysts in the left lower lobe. On hospital day 12, the pulmonary cysts were shown to be complicated by pulmonary abscess. On hospital day 16, the patient died of sepsis due to Staphylococcus aureus.
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Comment |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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In patients with endobronchial bleeding associated with blunt chest trauma, airway pressure can rise suddenly due to a combination of direct external force to the chest and closure of the glottis upon traumatic injury, resulting in the rupture of alveoli and development of hemorrhagic pulmonary cysts. Blood carried by the pulmonary circulation enters the bronchi from the injured alveoli and is forcefully expelled from the trachea toward the larynx during expiration. Chest trauma can be classified as diffuse pulmonary contusion (International Classification of Diseases [ICD]-9:862.21, 901.40) not accompanied by rupture of the visceral pleura or deep pulmonary laceration (ICD-9:861.31) accompanied by rupture of the visceral pleura. Deep pulmonary laceration can be complicated by 500 mL or more of intrathoracic blood during the first 2 hours after admission and hence requires emergency open thoracotomy and lobectomy [4]. In patients with diffuse pulmonary contusion, however, the visceral pleura remains intact and the lung surfaces are sealed, thus minimizing the volume of intrathoracic bleeding. For this reason, when dealing with diffuse pulmonary contusion, emergency lobectomy is not needed if suffocation due to endobronchial bleeding can be prevented.
Treatment of diffuse pulmonary contusion starts with insertion of a thoracic drainage tube, followed by tracheal intubation with a Univent. The blocker attached to the Univent is used to achieve bronchial occlusion at the right or left main bronchus or the intermediate bronchus, depending on the site of bleeding. We have identified the following four advantages of using a Univent for occlusion of the affected bronchus:
In patients with endobronchial bleeding, blood can be forcefully expelled into the trachea during respiration or as a result of reflexive coughing. In the past it was difficult to perform bronchoscopy in such patients, and the Univent blocker had to be inserted into the main bronchus on the affected side in a blind manner. Our technique for inserting the Univent blocker into the left main bronchus is shown in Figure 3 [9]. None of our patients have suffered cervical spine injury from this procedure.
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We believe that endobronchial bleeding from the injured alveoli in cases of diffuse lung contusion comes from the pulmonary circulation with low pressure and does not involve the bronchial artery circulation. After the safety of prolonged one-lung ventilation due to hypoxic pulmonary vasoconstriction was confirmed, we began to apply continuous occlusion of the bronchus on the affected side, using a Univent, until endobronchial bleeding could be controlled satisfactorily [6]. Because pressure in the pulmonary vessels is usually low and the pulmonary arterial blood flow on the bronchial occlusion side decreases to less than 50% by pulmonary vasoconstriction, endobronchial bleeding was successfully stopped within 18 to 36 hours in all patients by occlusion of the bronchus on the affected side.
When the absence of blood forcefully expelled from the bronchus distal to the occluded site was confirmed by bronchoscopy, bronchial occlusion with the Univent blocker was released. Clots within the bronchus on the affected side were then removed by aspiration with the bronchoscope, followed by withdrawal of the tracheal tube. After this treatment, patients were advised to forcefully discharge sputum by coughing, to eliminate blood remaining within the airway and thereby prevent pneumonia. Traumatic pulmonary cysts were often seen in patients who underwent bronchial occlusion. However, most of these cysts disappeared in one to two years. For patients in whom bacterial infection develops within the cysts, leading to a pulmonary abscess, we believe immediate pneumonectomy is indicated.
Bahk and colleagues [10] recommended the use of a double-lumen tube for tracheal intubation in patients with chest trauma. We see the following problems with such use of a double-lumen tube in patients with endobronchial bleeding:
Characteristics of the two types of one-lung ventilation tubes used for the treatment of chest trauma are summarized in Table 1. The Univent is superior to a double-lumen tube in terms of achieving a rapid effect (shorter time until the start of bronchial occlusion or differential ventilation), ease of bronchoscope manipulation, tamponade effect in the affected bronchi, prevention of air embolus, and feasibility of selective bronchial occlusion. However, in terms of securing the airway at the tracheal bifurcation in chest trauma patients or in those with a disrupted right main bronchus, a double-lumen tube is superior to the Univent. Differential ventilation for the right and left sides is also easier with a double-lumen tube. However, as shown in Figure 2, differential ventilation is also possible with the Univent if the blocker lumen is used in combination with CPAP or high-frequency jet ventilation.
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Of auxiliary tubes to be attached to the lumen of a single-lumen tracheal tube for the purpose of one-lung ventilation, the Uniblocker received particular attention in 2004 [11]. In the past, if a patient with chest trauma developed endobronchial bleeding after tracheal intubation with a single-lumen tube, the single-lumen tube had to be withdrawn and intubation had to be repeated with a Univent tube. If tracheal intubation is repeated in patients presenting with hemoptysis securing the airway is delayed, thus risking death due to hypoxemia. The Uniblocker tube allows bronchial occlusion to a degree similar to that possible with the Univent but without requiring reinsertion of the tracheal tube.
Massive endobronchial bleeding associated with blunt chest trauma can be managed conservatively with the use of a Univent. However, patients with endobronchial bleeding associated with blunt chest trauma often have multiple injuries involving organs outside the thoracic region. Conservative treatment of endobronchial bleeding with a Univent can be carried out in tandem with the diagnosis and treatment of accompanying severe injuries of the chest and other regions, and it is expected to contribute to saving the lives of patients with severe multiple organ injuries.
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