Ann Thorac Surg 2008;86:1020-1022. doi:10.1016/j.athoracsur.2008.02.095
© 2008 The Society of Thoracic Surgeons
Case Reports
Successful Repair of a Subtotal Rupture of Distal Tracheobronchial Tree With Complete Abridgment of the Right Bronchus in a 4-Year-Old Child
Sebastian Dango, MDa,*,
Wulf Sienel, MDa,
Karl-Heinz Kopp, MD, PhDb,
Bernward Passlick, MD, PhDa
a Department of Thoracic Surgery, University Hospital of Freiburg, Freiburg, Germany
b Department of Anesthesiology and Intensive Care Medicine, University Hospital of Freiburg, Freiburg, Germany
Accepted for publication February 18, 2008.
* Address correspondence to Dr Dango, Department of Thoracic Surgery, University Hospital Freiburg, Albert-Ludwigs-University Freiburg, Hugstetter Strasse 55, Freiburg, 79106, Germany (Email: sebastian.dango{at}uniklinik-freiburg.de).
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Abstract
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Accurate diagnosis of tracheobronchial injuries in children is difficult due to the paucity of clinical presentation and the variety of clinical symptoms. They are potentially life threatening in blunt chest trauma. We report here on a clinical case of a boy who was injured during outdoor activity. We describe intraoperative findings of the massive tracheobronchial lesion and its successful repair using a pericardial patch technique and postoperative recovery. Such a serious tracheobronchial injury with a positive outcome has not been reported so far. Clinical and technical steps are described and discussed.
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Introduction
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Ruptures of the tracheobronchial tree are uncommon and are potentially life threatening in blunt chest trauma in children [1–5]. Their accurate diagnosis is difficult due to the paucity of clinical presentation, and clinical symptoms depend on the size and location of the rupture [1, 4]. Diagnosis of bronchial ruptures is often delayed [2]. Tension pneumothorax, mediastinal and cervical emphysema, stridor, hemoptysis, and respiratory distress are common clinical symptoms [1, 4, 5]. Management is usually difficult and requires anesthesiologists, paediatricians, and surgeons, with the overall responsibility remaining with the thoracic surgeon [4, 5].
We report here on the case of a 4-year-old boy who was previously healthy and had been transferred to our hospital. While he was climbing on a scaffold, a metal part became disconnected, which forced the child to the ground from a height of 1.5 m. The loose object fell down and hit the ventral chest of the child lying on his back directly. When he was examined, his respiratory rate was 34/min with a fully developed state of shock (ie, blood pressure of 60/45 mm Hg, tachycardia of 184/min). Physical examination revealed a massive and progressive mediastinal and subcutaneous emphysema. No other injury could be detected. We performed a bronchoscopy-assisted intubation with a 4.5-mm endotracheal tube for respiratory stabilization, and sufficient oxygenation was achieved. Endotracheally, a massive amount of fresh blood was identified, indicating a tracheobronchial injury. An additional cervical and thoracic computed tomographic scan showed a complete abridgment of the right bronchus with subtotal rupture of the tracheal bifurcation (Fig 1).
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Fig 1. Computed tomographic scan performed in our trauma bay after admission. (A) Subtotal rupture of the tracheal bifurcation, including pars membranacea (arrow) with a massive subcutaneous emphysema. (B) Complete abridgment of the right main bronchus (long arrow) and presence of a pneumomediastinum (short arrow).
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After cardiorespiratory stabilization, the patient was taken to the operating room 6 hours after trauma. A right posterolateral thoracotomy was performed because the lesion of uncertain dimension was found in the lower tracheobronchial system. The left main bronchus was completely macerated up to the upper lobe and pars membranacea of the tracheal bifurcation could not be detectable. It appeared that the endotracheal tube was placed into the right main bronchus, which was completely smashed and disconnected. Furthermore, a completely destructed right upper lobe carina was detected. Due to deterioration of ventilation, digital replacement of the tube in the left main bronchus was necessary, resulting in sufficient oxygenation. Jet ventilation was not tolerated by the patient, because it resulted in severe desaturation.
Direct suture of the lesions was not feasible, only a patch technique seemed to be promising. A pericardial "Y"-form patch was prepared (Fig 2). Drawing back the endotracheal tube stepwise, the patch was placed and fixed. The macerated right tracheobronchial wall defect was closed and the right main bronchus was reconnected by patch plastic and direct suture, respectively, using 4.0 polydioxane sutures (Ethicon Inc, Norderstedt/Glashütte, Germany). An almost normal anatomical reconstruction was achieved. Application of an airway pressure up to 35 mm Hg was easily tolerated by the patch. The pericardial defect was repaired with a Gore-Tex membrane (Gore Inc, Munich, Germany). Coverage of the dorsal tracheal wall and main bronchus with surrounding lymph nodes and esophageal wall, respectively, was performed. Finally, two 21 Charrière chest tubes were placed (Silicon; Redax Inc, Mirandola, Italy).
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Fig 2. Schematic overview of the pericardial patch to reconstruct the macerated dorsal tracheobronchial wall.
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A tracheotomy was carried out after reintubation due to respiratory failure on day 2 after surgery. Two weeks later a limited insufficiency of patch anastomosis resulting in abscess formation around the right main bronchus forced us to reoperate. After debridement a latissimus dorsi flap was placed over a leakage in the median dorsal wall of the tracheal bifurcation reaching distally 1 cm into the right tracheobronchial passage, suturing being carried out using 5.0 polydioxane sutures.
During the days to follow, weaning was hampered due to a respiratory airway collapse at the site of the muscular flap. Spontaneous respiration ceased and was substituted by continuous positive airway pressure breathing to keep the airway open. Three weeks after admission, weaning was successful and spontaneous respiration without support was well tolerated without any evidence of airway collapse. No evidence of stricture was found endoscopically, and a well-recovered tracheobronchial system had been achieved. The patient was discharged from the hospital on day 42 after admission.
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Comment
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We report here on the management of a traumatic dissection of the right main bronchus and subtotal rupture of the tracheal bifurcation in a child. Tracheobronchial ruptures describe any injury between the cricoid cartilage and the bronchioli. Their cause includes iatrogenic mechanisms, blunt chest trauma, penetrating wounds, avulsion, and explosive injuries. Frequency in children is difficult to assess. In the more recent literature the incidence varies between 0.7% and 2.8%. The male-female ratio is 2:1 or higher, the main cause being blunt chest trauma due to motor vehicle accidents [1, 2, 4]. Differences in anatomy and mechanisms of injury distinguish childhood injuries from those in adults. There is a large discrepancy between extent of intrathoracic injuries compared with visible external damage often presenting without external signs of trauma [1]. Pathophysiologically, the thorax is more compressible in children, allowing transmission of heavy forces to the organs of the thoracic cavity. Children with blunt injuries are more likely to require long periods of hospitalization compared with those who have penetrating trauma [2].
We believe that children who experienced such a severe traumatic blunt tracheobronchial lesion requiring long-term ventilation who had a successful outcome have never been reported. The severity of tracheobronchial lesions is obvious in major trauma, but it is often underestimated in cases with minor symptoms at the beginning. Subcutaneous emphysema and respiratory distress are the most common clinical presentation [1, 4]. A computed tomographic scan of the neck and thorax permits more accurate visualization of the structures involved. On the one hand, a computed tomographic scan must be performed before bronchoscopy [4, 6]. However, on the other hand, a computed tomographic scan was not necessary in a meta-analysis of 31 cases to make the decision for surgery [5]. The role of preoperative bronchoscopy must be discussed separately [3]. Possible diagnostic advantages compared with time-consuming preoperative assessment of the injuries must be weighed up carefully and individually. In the mentioned meta-analysis, the diagnostic algorhythm included obligatory bronchoscopy and led to surgery in all cases [5]. Respiratory distress due to an interrupted airway system is the determining factor. As reported herein, stabilization of tracheobronchial system with continuous positive airway pressure avoids bronchial collapse, thus decreasing the risk of strictures, and facilitates the weaning process. This is especially important for long-term outcome in children with fragile airways [4].
We advocate early surgical treatment for tracheobronchial injuries, ensuring rapid relief from a life-threatening situation with an excellent operative outcome. We suggest a left or right posterolateral thoracotomy in accordance with clinical findings. To ensure adequate ventilation and oxygenation, the endotracheal tube can be placed manually through the open chest by the surgeon, decreasing further damage through blind mechanical manipulation. Technically, 4-0 or 5-0 polydioxane sutures are used to repair the tracheobronchial lesions. In the case of subtotal rupture, the possibility of a volitional surgical transection of the remaining bronchus with subsequent end-to-end anastomosis should be kept in mind. Parenchymal resection can be advisable in large traumatic areas, but was not necessary in our case. In the case of a massive trauma, a bronchoplastic attempt must be performed. A pericardial patch offers appropriate cover due to high-wall stability and adequate breech. To increase compactness, a pericardial fat lobe may be used. However, adequate anatomical reconstruction and width are mandatory for a sufficient long-term outcome.
The indication for surgical repair is based on a synopsis of clinical, radiologic, and endoscopic findings. Respiratory distress in the absence of a pneumothorax, rapidly increasing subcutaneous and mediastinal emphysema or continuous pneumothorax after chest drainage with persisting air leak and no re-expansion of the lung are strong indications for surgery. Transmural ruptures or esophageal wall prolapsed into the trachea must lead to surgery [5]. Our case emphasizes the importance of quick surgical repair to achieve appropriate recovery.
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References
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- Slimane MA, Becmeur F, Aubert D, et al. Tracheobronchial rupture by blunt thoracic trauma in children J Pediatr Surg 1999;34:1847-1850.[Medline]
- Özdülger A, Cetin G, Erkmen Gülhan E, Topcu S, Tastepe I, Kaya S. A review of 24 patients with bronchial ruptures: is delay in diagnosis more common in children? Eur J Cardiothorac Surg 2003;23:379-383.[Abstract/Free Full Text]
- Poli-Merol ML, Belouadah M, Parvy F, Chauvet P, Egreteau L, Daoud S. Tracheobronchial injury by blunt trauma in children: is emergency tracheobronchoscopy always necessary? Eur J Pediatr Surg 2003;13:398-402.[Medline]
- Balci AE, Kazez A, Eren S, Ayan E, Ozalp K, Eren MN. Blunt thoracic trauma in children: review of 137 cases Eur J Cardiothorac Surg 2004;26:387-392.[Abstract/Free Full Text]
- Gabor S, Renner H, Pinter H, et al. Indications for surgery in tracheobronchial ruptures Eur J Cardiothorac Surg 2001;20:399-404.[Abstract/Free Full Text]
- Epelman M, Ofer A, Klein Y, et al. CT diagnosis of traumatic bronchial rupture in children Pediatr Radiol 2002;32:888-891.[Medline]
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Abstract
Introduction
