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

Multidisciplinary management of tracheobronchial injury

Tracheobronchial injury is a heterogeneous entity comprising multiple rare and potentially life-threatening scenarios. We performed a systematic literature review focusing on post-intubation tracheal injuries (PiTIs) and post-traumatic tracheobronchial injuries (PTTBIs).PiTIs are often longitudinal lacerations of the middle third of the membranous trachea. Subcutaneous emphysema of the face and trunk following tracheal intubation should immediately trigger the diagnosis. Diagnosis may be suspected on the chest computed tomography (CT) and should be confirmed by bronchoscopic examination. Conservative management is encouraged for a spontaneously breathing or stable patient on noninvasive ventilation. Surgical repair is mandatory when mechanical ventilation is required and if bridging of the injury is impossible.PTTBIs are often associated with other severe injuries. Patients often present with massive subcutaneous emphysema and intractable pneumothorax. Diagnosis may be suspected on the chest CT and should be confirmed by bronchoscopic examination. Early surgical repair is indicated. In selected patients, conservative management can be considered.

Tracheobronchial injuries in chest trauma: a 17-year experience

Objective

to discuss the clinical and therapeutic aspects of tracheobronchial lesions in victims of thoracic trauma.

Methods

we analyzed the medical records of patients with tracheobronchial lesions treated at the São Paulo Holy Home from April 1991 to June 2008. We established patients' severity through physiological (RTS) and anatomical trauma indices (ISS, PTTI). We used TRISS (Trauma Revised Injury Severity Score) to evaluate the probability of survival.

Results

nine patients had tracheobronchial lesions, all males, aged between 17 and 38 years. The mean values ​​of the trauma indices were: RTS - 6.8; ISS - 38; PTTI - 20.0; and TRISS - 0.78. Regarding the clinical picture, six patients displayed only emphysema of the thoracic wall or the mediastinum and three presented with hemodynamic or respiratory instability. The time interval from patient admission to diagnosis ranged from one hour to three days. Cervicotomy was performed in two patients and thoracotomy, in seven (77.7%), being bilateral in one case. Length of hospitalization ranged from nine to 60 days, mean of 21. Complications appeared in four patients (44%) and mortality was nil.

Conclusion

tracheobronchial tree trauma is rare, it can evolve with few symptoms, which makes immediate diagnosis difficult, and presents a high rate of complications, although with low mortality.

Airway trauma: a review on epidemiology, mechanisms of injury, diagnosis and treatment

Airway injuries are life threatening conditions. A very little number of patients suffering air injuries are transferred live at the hospital. The diagnosis requires a high index of suspicion based on the presence of non-specific for these injuries symptoms and signs and a thorough knowledge of the mechanisms of injury. Bronchoscopy and chest computed tomography with MPR and 3D reconstruction of the airway represent the procedures of choice for the definitive diagnosis. Endotracheal intubation under bronchoscopic guidance is the key point to gain airway control and appropriate ventilation. Primary repair with direct suture or resection and an end to end anastomosis is the treatment of choice for patients suffering from tracheobronchial injuries (TBI). The surgical approach to the injured airway depends on its location. Selected patients, mainly with iatrogenic injuries, can be treated conservatively as long as the injury is small (<2 cm), a secure and patent airway and adequate ventilation are achieved, and there are no signs of sepsis. Patients with delayed presentation airway injuries should be referred for surgical treatment. Intraoperative evaluation of the viability of the lung parenchyma beyond the site of stenosis/obstruction is mandatory to avoid unnecessary lung resection.

Management of post-intubation tracheal membrane ruptures: A practical approach

Tracheal rupture is an infrequent, severe complication of endotracheal intubation, which can be difficult to diagnose. Post-intubation tracheal rupture (PiTR) is distinct from non-iatrogenic causes of tracheobronchial trauma and often requires different treatment. The increasing adoption of pre-hospital emergency services increases the likelihood of such complications from emergency intubations. Effective management strategies for PiTR outside specialist cardiothoracic units are possible. Two cases of severe PiTR, successfully managed non-operatively on a general medical-surgical intensive care unit, illustrate a modified approach to current standards. The evidence base for PiTR is reviewed and a pragmatic management algorithm presented.

Clinical features and management of closed injury of the cervical trachea due to blunt trauma

Background

We retrospectively reviewed the presentation, diagnosis, treatment, and outcomes of patients with closed injury of the cervical trachea. We evaluated factors that improve diagnosis and treatment, reduce mortality, and avoid tracheal stenosis.

Methods

We reviewed the clinical data of 17 patients with closed injury of the cervical trachea. All patients underwent CT scanning or endoscopy, tracheal exploration, low tracheotomy, and tracheal repair.

Results

In 12 patients, breathing, phonation, and swallowing functions had returned to normal at 2 weeks. In three patients, breathing and swallowing functions had recovered at 2 weeks, but hoarseness continued. In two patients, tracheal stenosis prevented extubation and required further surgery; in these patients breathing and swallowing functions had recovered at 6 months.

Conclusions

Closed injury of the cervical trachea may cause airway obstruction and is potentially life-threatening. Early diagnosis and repair to restore structure and function are important to ensure survival and avoid tracheal stenosis.

[Management of tracheobronchial ruptures]

We report the case of a 25-year-old man who suffered a severe trauma with a complete rupture and separation of the right main bronchus. The patient presented on the scene with respiratory distress and severe hypoxemia. At the admission in the trauma resuscitation unit, the CT scan and fiberoptic examination confirmed the diagnosis of right main bronchus rupture. Selective fiberoptic intubation of the left main bronchus was done and the patient was sent to the operating theater for urgent thoracotomy. During thoracotomy, profound arterial oxygen desaturation requested the right main bronchus being intubated by the surgeon under the control of view and separate lung ventilation, until the end of the bronchus suture. Surgery allowed the patient to survive. He was then discharged alive from the hospital at day 36. Severe tracheobronchial rupture may be rapidly associated with major respiratory distress and severe hypoxemia that necessitate specialised care in referring centre. Initial orientation of these patients appears to be as important that airway and hypoxemia management.

Assessing fluid responsiveness in critically ill patients: False-positive pulse pressure variation is detected by Doppler echocardiographic evaluation of the right ventricle

OBJECTIVES

To determine whether peak systolic velocity of tricuspid annular motion assessed by tissue Doppler echocardiography (Sta), a right ventricular function parameter, can discriminate patients with true- and false-positive pulse pressure variation. Pulse pressure variation is used to predict fluid responsiveness in mechanically ventilated patients. However, this parameter has been reported to be falsely positive, especially in patients with right ventricular dysfunction.

DESIGN

A prospective study.

SETTING

Medical and surgical intensive care unit of a university hospital.

PATIENTS

Thirty- five mechanically ventilated patients hospitalized for >24 hrs with a pulse pressure variation of >12%.

INTERVENTIONS

Doppler echocardiography (including measurement of Sta and stroke volume) was performed before and after infusion of 500 mL of colloid solution. Patients were classified into two groups according to their response to fluid infusion: responders (at least 15% increase in stroke volume) and nonresponders.

MEASUREMENTS AND MAIN RESULTS

Twenty-three patients (66%) were responders (true-positive group) and 12 (34%) were nonresponders (false-positive group). Before volume expansion, Sta was statistically lower in the nonresponder group (0.13 [0.04] vs. 0.20 [0.05], p = .0004). The area under the curve of the receiver operating characteristic curve was 0.87 (95% confidence interval, 0.74-1). In patients with pulse pressure variation of >12%, a Sta cutoff value of 0.15 m/s discriminated between responders and nonresponders with a sensitivity of 91% (80-100) and a specificity of 83% (62-100).

CONCLUSIONS

A Sta value of <0.15 m/s seems to be an accurate parameter to detect false-positive pulse pressure variation. Echocardiography should therefore be performed before fluid infusion in patients with pulse pressure variation of >12%.