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

Chest computed tomography with multiplanar reformatted images for diagnosing traumatic bronchial rupture: a case report

INTRODUCTION

Unnoticed bronchial injury during the early stage of resuscitation of multiple trauma is not rare and increases mortality and morbidity.

METHODS

Three-dimensional reconstruction of the airways using a workstation connected to a multidetector chest computed tomography (CT) scanner may change the diagnostic strategy in patients with blunt chest trauma with clinical signs evocative of bronchial rupture.

RESULTS

In this case report of a young motor biker, a complete disruption of the intermediary trunk was first misdiagnosed using standard chest helical CT and bronchoscopy. Postprocessing procedures including three-dimensional extraction of the tracheobronchial tree were determinants for establishing the diagnosis, and emergent surgical repair was successfully performed. Follow-up using CT with three-dimensional reconstructions evidenced a bronchial stenosis located at the site of the rupture.

CONCLUSION

The present study demonstrates the potential interest of performing three-dimensional reconstructions by extraction of the tracheal-bronchial tree in patients with severe blunt chest trauma suspected of bronchial rupture.

Clear-cut complete rupture of origin of right main bronchus

Complete rupture of the main bronchus after blunt thoracic trauma is rare. Most patients with blunt traumatic injury to the trachea or bronchus die before arriving at hospital. A 26-year-old man with complete right main bronchus rupture was successfully treated by urgent surgical intervention and postoperative fiberoptic bronchoscopy for bronchial toilet.

Multiplanar reconstruction: a new method for the diagnosis of tracheobronchial rupture?

OBJECTIVE

To compare multiplanar reconstruction with operative techniques (bronchoscopy, surgery and/or autopsy) for the diagnosis of tracheobronchial rupture.

DESIGN

Prospective, observational study.

SETTING

Surgical intensive care unit.

PATIENTS AND PARTICIPANTS

Tracheobronchial rupture was suspected on clinical grounds and from radiological findings.

INTERVENTIONS

An initial helical computed tomography scan was performed on all patients meeting the inclusion criteria, and operative techniques were then performed. Multiplanar reconstructions were reformatted and reviewed by two independent radiologists.

MEASUREMENTS AND RESULTS

Twenty-four consecutive patients met the inclusion criteria. Tracheobronchial rupture was diagnosed in 13 patients by at least one operative technique. Multiplanar reconstructions were positive in 15 patients. The diagnostic sensitivity and specificity of multiplanar reconstructions were 100% (95%CI, 85-100) and 82% (95%CI, 64-82), respectively. The positive and negative predictive values were 87% (95%CI, 74-87) and 100% (95%CI, 78-100), respectively. For tracheobronchial rupture, the positive and negative likelihood ratios were 5.5 (95%CI, 2.35-5.5) and 0 (95%CI, 0-0.24), respectively. The Kappa coefficients were 0.83 (95%CI, 0.6-1.06) for agreement between operative techniques and multiplanar reconstruction, and 0.91 (95%CI, 0.59-0.91) for agreement between the two radiologists.

CONCLUSIONS

Multiplanar reconstruction appears to be a sensitive technique for the identification of tracheobronchial rupture because of its excellent negative likelihood ratio. In clinical practice, negative multiplanar reconstruction can exclude a diagnosis of tracheobronchial rupture, making bronchoscopy unnecessary. When multiplanar reconstruction is positive, tracheobronchial rupture should be confirmed by bronchoscopy.

DESCRIPTOR

Trauma.

Triage and Outcome of Patients with Mediastinal Penetrating Trauma

BACKGROUND

A retrospective study was conducted detailing an experience with echocardiography and contrast-enhanced helical computed tomographic angiographic (CTA) scans in the evaluation of stable patients with mediastinal penetrating trauma (MPT).

METHODS

Unstable patients underwent emergent operative intervention, and stable patients underwent chest roentgenogram, transthoracic echocardiography (TTE), and CTA. Further testing (angiogram, bronchoscopy, esophagoscopy, esophagogram) was done only if one of these studies revealed evidence of a trajectory in the vicinity of major vasculature or viscera.

RESULTS

Between 1997 and 2003, 207 patients had MPT. Seventy-two (35%) were unstable (45 gun shot wounds, 27 stab wounds) and 19 died in the emergency department. Fifty-three had emergent intervention and 32 survived. Work-up was done on 135 stable patients (65%) consisting of 46 gunshot wounds and 89 stab wounds, of which 5 had a positive TTE result and underwent a repair of a cardiac injury. CTA evaluation was normal in almost 80% of patients, who subsequently did not require further evaluation or treatment. In the stable patients, endoscopy or esophagography confirmed one tracheal injury and no esophageal injury. In the entire group, 10 patients (7%) had occult injury, and there were no deaths or missed injuries.

CONCLUSIONS

In cases of MPT, unstable patients require surgery, and in stable patients, TTE and chest CTA are effective screening tools. Patients with a negative TTE and CTA results can be observed and may not require further testing or endoscopy, whereas patients with positive TTE or CTA results require further assessment to exclude occult injury.

Role of Conservative Medical Management of Tracheobronchial Injuries

BACKGROUND

The purpose of this study is to describe and assess the effectiveness of conservative treatment as the chosen treatment for tracheobronchial injury (TBI) management. This is a retrospective and descriptive study, which took place at a single center.

METHODS

From January 1993 to July 2004, 33 TBIs were treated in our hospital. Eighteen (54.5%) were iatrogenic injuries and 15 (45.5%) were traumatic noniatrogenic injuries. Eighteen (55%) of the TBI patients were women and 15 (45.5%) were men, with a mean age of 46.7 +/- 23.4 years (range, 14-88 years). Eighteen (54.5%) of the injuries were caused by orotracheal intubation or tracheostomy, 13 (39.4%) by blunt trauma, and 2 (6.1%) by penetrating tracheal injuries. The average diagnostic delay was 18.29 +/- 19.8 hours. The mean injury size was 2.6 +/- 1.3 cm (range, 1-7 cm). Fourteen (42.4%) injuries were located in the cervical trachea, 8 (24.2%) in the thoracic trachea, 10 (30.3%) in the bronchi, and 1 (3%) involved both trachea and the main bronchi. Conservative treatment was applied in 20 (60.6%) of the 33 cases. Surgery should be performed in cases of esophageal-associated injuries, progressive subcutaneous or mediastinal emphysema, severe dyspnea requiring intubation, difficulty with mechanical ventilation, pneumothorax with an air leak through the chest drains, or mediastinitis.

RESULTS

Conservative medical or surgical treatments achieved good outcomes in 28 (84.8%) cases. Five patients (15.2%) died while in the hospital; 4 of these were medically treated and 1 was surgically treated. Mortality was related to older patients and patients that had been diagnosed during mechanical ventilation. Major symptoms (progressive subcutaneous emphysema, dyspnea, sepsis) were detected more often in cartilaginous injuries (p < 0.05). Conservative treatment was considered more effective in membranous injuries (p < 0.05), and these sorts of injuries were not related to a high mortality rate (p > 0.05). Mortality was not related to conservative treatment, sex, diagnostic delay, injury mechanism, location, or length of the TBI (p < 0.05).

CONCLUSIONS

Conservative treatment for TBI is effective regardless of the mechanism of production, length, or site of the injury. Conservative treatment should be carefully assessed in patients who meet strict selection criteria. Membranous injuries can be treated more often with a conservative approach, however, cartilaginous injuries should be treated surgically if major symptoms are detected.

Tracheobronchial injuries from blunt trauma

Tracheobronchial injuries from trauma can be life threatening. We present a case report of a 23-year-old man who suffered a left main bronchus transection after a motorbike accident. The diagnostic and management issues surrounding tracheobronchial injuries are reviewed. Early diagnosis and treatment lead to the best outcome, with almost complete return of pulmonary function.

Acute tracheobronchial injuries: Impact of imaging on diagnosis and management implications

PURPOSE

To evaluate the role of chest radiography, single-slice CT and 16-row MDCT in the direct evidence of tracheobronchial injuries.

METHODS

Patients with acute tracheobronchial injury were identified from the registry of our level 1 trauma center during a 5-year period ending July 2005. Findings at chest radiograph and CT were compared to those shown at bronchoscopy.

RESULTS

Eighteen patients with tracheobronchial injury - three patients with cervical trachea injury, eight with thoracic trachea injury and seven with bronchial injury - were identified. Twelve patients had a blunt trauma (67%), six patients had a penetrating (iatrogenic) injury (33%). Chest radiograph directly identified the site of tracheal injury in four cases, showing overdistension of the endotracheal cuff in three cases and displacement of the endotracheal tube in one case. At the level of the bronchi, chest radiograph demonstrated only one injury. CT directly identified the site of tracheal injury in all the cases showing the overdistension of the endotracheal cuff at the level of the thoracic trachea (three cases), posterior herniation of the endotracheal cuff at the thoracic trachea (three cases), lateral endotracheal cuff herniation at the thoracic trachea (one case), tracheal wall discontinuity at the cervical (one case) and at the thoracic trachea (one case) and displacement of endotracheal tube at the cervical trachea (two cases). At the level of the bronchi, CT correctly showed the site of injury in six case including: discontinuity of the left main bronchial wall (two cases), the "fallen lung" sign (one case), right main bronchial wall enlargement (one case), discontinuity of the right middle bronchial wall (two cases). In one case, CT showed just direct "air leak" at the level of the carina suggesting main bronchus injury. This finding was confirmed by bronchoscopy.

CONCLUSION

Chest radiograph was helpful for the assessment of iatrogenic tracheal injuries. CT detected the site of blunt tracheobronchial injuries in 94% of the cases. Multiplanar 16-row MDCT reconstructions, were essential for the optimal surgical approach.

[Tracheal injury from cervical stabbing]

We report a case of isolated tracheal injury after a cervical stab without any other cervical damage. Diagnosis was performed by bronchoscopic and clinical examination. Plastic suture was performed with end-to-end anastomosis. The patient was discharged with good health status on the eleventh postoperative day.

[Medical and surgical management of noniatrogenic traumatic tracheobronchial injuries]

OBJECTIVE

To describe the medical and surgical management of noniatrogenic traumatic tracheobronchial injuries.

PATIENTS AND METHOD

From January 1993 to July 2004, 15 cases of traumatic tracheobronchial injury were treated in our department. The diagnosis was established by bronchoscopy and a computed tomography chest scan was performed on all patients. Surgical treatment was selected for patients with unstable vital signs, an open tracheal wound, associated esophageal lesions, progression of subcutaneous or mediastinal emphysema, mediastinitis or suspicious mediastinal secretions on imaging tests, or difficulties with mechanical ventilation due to the traumatic tracheobronchial injury.

RESULTS

The mean (SD) age of the patients was 35.5 (18.9) years and 12 (80%) were male. Of the 15 cases, 13 (86.7%) had penetrating trauma and 2 (13.3%) blunt trauma. The most common location of the injury was in the bronchi (9 cases; 60%), followed by the cervical trachea (4 cases; 26.6%), followed by both the thoracic trachea and bronchi (2 cases; 13.4%). The most common initial symptom was subcutaneous emphysema, which presented in 11 (73.3%) patients. Chest (12 cases; 86.7%) and orthopedic injuries (9 cases; 60%) were the most common associated injuries. Surgery was the treatment of choice in 11 (73.3%) cases and conservative medical treatment in 4 (26.7%). An irreversible brain injury caused the death of 1 patient receiving conservative treatment.

CONCLUSIONS

Tracheobronchial injuries may be treated conservatively if they meet strict selection criteria. Size and location should not be used as selection criteria for surgical treatment.

Nonoperative Management of Tracheobronchial Injuries in Severely Injured Patients

PURPOSE

A rupture of the airway due to blunt chest trauma is rare, and treatment can prove challenging. Many surgeons suggest operative management for these kinds of injuries. Nonoperative therapy is reported only in exceptional cases. But there is still a lack of evidence from which to recommend surgical repair of these injuries as the first choice procedure.

METHODS

We retrospectively analyzed the records of 92 multiple injured patients admitted to our trauma department between July 2002 and July 2003 for the incidence and management of tracheobronchial rupture (TBR).

RESULTS

Five (5.4%) of 92 patients suffered from tracheobronchial injuries. The mean injury severity score was 38. There were three male and two female patients, with a mean age of 23 years. All patients had lesions <2 cm in size and were treated nonoperatively. One patient died from multiorgan failure, but the others recovered from TBR uneventfully. One patient developed acute pneumonia as a result of respirator therapy, but none of the patients had mediastinitis or tracheal stenosis within 3 months after injury.

CONCLUSION

We believe that surgical treatment is not mandatory in patients with small to moderate ruptures, and such aggressive treatment may even have adverse effects, especially in patients with multiple injuries.

Successful Conservative Management in Iatrogenic Tracheobronchial Injury

BACKGROUND

The aim of this study was to describe and to assess the effectiveness of conservative treatment as the chosen treatment for managing iatrogenic tracheobronchial injuries (ITBI).

METHODS

Between January 1993 and December 2003, 33 tracheobronchial injuries were treated in our hospital. Eighteen (54.5%) were ITBI and 15 (45.5%) were traumatic noniatrogenic injuries. Of the ITBI patients, sex distribution was 15 (83%) females and 3 (17%) males with a mean age of 57.7 +/- 20.7 years (range, 17 to 88 years). Fifteen (83.3%) of the injuries were caused by orotracheal intubation and 3 (15.7%) by tracheotomy. The average diagnostic delay was 25.7 +/- 22.9 hours. The mean injury size was 2.83 +/- 1.02 cm (range, 1 to 4 cm). Nine (50%) injuries were located in the cervical trachea, 6 (33.3%) in the thoracic trachea, and 3 (16%) involved both trachea and main bronchi. Conservative treatment was chosen for 17 (94.4%) of the 18 cases. We performed surgical repair in only 1 case owing to progressive subcutaneous emphysema and increasing difficulty with mechanical ventilation.

RESULTS

No complications arose from the use of conservative treatment. Four patients (22%) died in our hospital, 3 of these of non-ITBI-related causes. Mortality was not related to four variables: sex, diagnostic delay, location, or size of the ITBI. Fourteen of the 18 patients (77.7%) were discharged uneventfully, and the endoscopic and clinical follow-up examinations were satisfactory in all patients.

CONCLUSIONS

Conservative treatment for ITBI is effective regardless of production, size, or site of the injuries. Surgical treatment is advisable in specific cases: rapid progression of subcutaneous and mediastinal emphysema, mediastinitis, and difficulty with mechanical ventilation.

Posterior tracheal wall laceration after blunt neck trauma in children: a case report and review of the literature

Adults seem to be more vulnerable than children to tracheal lacerations. Tracheal lacerations have been described particularly after surgical procedures and penetrating trauma, but they may also result from minor blunt trauma. We report the case of a 7-year-old boy who sustained a posterior tracheal wall laceration after a direct frontal fall on a wooden strut. We also review the literature on posterior wall tracheal laceration as an isolated feature after blunt cervical trauma in children, the diagnostic features and management options.

Isolated tracheal rupture caused by blunt trauma and the importance of early diagnosis: a case report

Tracheal rupture usually occurs after blunt traumas. Isolated tracheal rupture is an extremely rare condition. The diagnosis of isolated tracheal rupture is very important for treatment and prognosis. Physical examination and imaging techniques should be used to make the diagnosis. Lateral neck and chest X-rays are very important for early diagnosis. Other techniques are thorax, neck tomography and bronchoscopy. In this paper we present a case of isolated tracheal rupture and discuss the early diagnostic techniques used.

Diagnosis and treatment of traumatic intrathoracic major bronchial disruption

The purpose of this study was to review our experience with intrathoracic major bronchial disruptions due to trauma and to describe the diagnosis and treatment.

METHODS

A retrospective review was performed of major bronchial injuries managed in Kuwait (1995-2001), n=12. Clinical presentation, diagnostic evaluation, surgical management, and outcome were reviewed.

RESULTS

The mechanism of injury involved blunt trauma in seven patients and penetrating trauma in five. Tachypnea and subcutaneous emphysema (occurring in 10, 9 of the patients, respectively) are common. Nine patients had pneumothorax and air leak after tube thoracostomy. The diagnosis was confirmed by bronchoscopy in all patients. The majority of the injuries were repaired primarily. Lung resection was necessary in two patients. Four patients sustained complications including death (two patients), atelectasis (one patient), and pneumonia (one patient). Follow-up bronchoscopy revealed no evidence of granulation tissue or stenosis at the site of repair.

CONCLUSION

The diagnosis of intrathoracic major bronchial disruptions required a high index of suspicion and liberal use of bronchoscopy. The majority were repaired primarily with good outcome.

Pulmonary trauma emergency department evaluation and management

Pulmonary trauma is a significant cause of morbidity and mortality in the United States. It is imperative for the emergency physician to identify promptly patients who require immediate therapy. In patients who have limited injuries, literature shows that often conservative management provides improved outcome. As the exposure to automobiles and firearms continues to increase in the setting of improved prehospital management, the emergency physician will encounter an increasing amount of pulmonary trauma. This rise in respiratory injuries will require a more aggressive approach of patients with minimal morbidity and mortality. A systematic approach to respiratory injuries is crucial to improving patient outcomes.

Tracheal trauma

The etiology, presentation, and management of blunt and penetrating injuries of the trachea has been reviewed. The approach to and outcome following management of more unusual situations such as iatrogenic injuries has also been briefly reviewed. Early recognition of these problems and careful attention to the details of acute management can convert a life-threatening situation into one that can usually be successfully managed by the techniques of tracheal surgery developed and popularized by Dr. Grillo.

Successful surgical management of complete tracheal disruption due to penetrating injury

Successful management of penetrating injury to the trachea is rare, especially in Japan. A 32-year-old female attempted suicide by stabbing herself in the throat with a knife, and at operation the trachea was found to be completely disrupted. A median sternotomy made possible end-to-end anastomosis of the trachea. All other important organs including the great vessels, esophagus, and lungs were intact, but the pleura was open on the right side. The patient was managed under heavy sedation and with controlled ventilation for more than a week postoperatively, because of her suspected mental condition. She was extubated on postoperative day 13 and transferred to a mental hospital on day 16. We concluded that early diagnosis and surgical repair were important for the successful management of this patient with tracheal disruption.

Tracheobronchial injury secondary to blunt chest trauma: diagnosis and management

Tracheobronchial injury is an uncommon complication in blunt chest trauma. The typical clinical features include haemoptysis, dyspneoa, and air leak. Tracheobronchial injury occurs after high energy impact and is commonly associated with injuries of other vital organs. If tracheobronchial injury is undetected and left untreated, it may cause persistent air leak which can render ventilation difficult and inefficient. Diagnosis of tracheobronchial injury should be made and confirmed by flexible bronchoscopy. The essence of airway management is to bypass the lesion by means of endobronchial intubation to the healthy bronchus with a single-lumen or double-lumen endotracheal tube. Such manoeuvres can also facilitate surgical access if thoracotomy is indicated. Taking into account the size of the lesion and the resulting respiratory status, surgical reconstruction of the injured airway is often necessary. More severe injury may even require lobectomy or pneumonectomy. Late complications of untreated tracheobronchial injury include bronchial stenosis, recurrent pneumonia and bronchiectasis. Prompt diagnosis and treatment generally lead to good functional recovery.

Membranous tracheal rupture in children following minor blunt cervical trauma

Injuries to the tracheobronchial tree are well-recognized sequelae of massive blunt or penetrating injuries of the neck or chest. They may also occur as a rare complication of endotracheal intubation. We present 2 cases of a less well-recognized clinical entity, rupture of the membranous trachea following minimal blunt trauma to the neck in children. The case histories and management of this disorder are discussed. Recognition and treatment of this problem requires a high index of suspicion for the lesion and timely investigations. Open repair of the trachea to secure a stable airway is recommended for this injury, unless the wound is small and the wound edges are well approximated.

Decelerational thoracic injury

BACKGROUND

Among the five major decelerational thoracic injuries [myocardial contusion (MC), traumatic aortic disruption (TAD), sternal fracture (SF), flail chest (FC), and tracheobronchial disruption (TBD)], coexisting injuries are seemingly rare.

METHODS

To test this hypothesis, we reviewed the records of all patients, with final diagnosis (FDX) codes of these injuries, treated at our Level I trauma center for the 10 years preceding 1997.

RESULTS

Among 142 patients, all victims of motor vehicle crashes, there were 38 MC, 36 TAD, 33 FC, 28 SF, and 7 TBD. There were six coexisting injuries (3.5%). Three patients with coexisting injury died in the operating room. All three had TAD; one of these three had TBD plus MC; one had additionally FC and MC and the third had FC in addition to the TAD. One patient with SF and probable MC died in the emergency room. Two patients with FC and a coexisting injury survived. One had MC, the other SF.

CONCLUSION

We conclude that these decelerational thoracic injuries, with the exception of sternal fracture, are sufficiently life threatening by themselves to cause fatality. When combined, the threat to life is potentiated. Death occurs at the scene or shortly after arrival in the ER. The diagnosis of one may help exclude the diagnosis of each of the other four. The role of sternal fracture in this paradigm remains an enigma.

Blunt thoraco-abdominal injury

Recent advances in blunt thoraco-abdominal trauma management include improvements in imaging, particularly in trauma bay ultrasound. Indications for non-operative management have expanded for solid organ and aortic injury. The physiology of abdominal compartment syndrome continues to be defined, with resulting improvements in care.