Tracheobronchial rupture caused by blunt chest trauma: acute respiratory management

Management of traumatic tracheobronchial separation in a teenager using a fabricated extra-long endotracheal tube

Tracheobronchial separation (TBS) due to blunt chest trauma in children is extremely rare. We report the case of a 14-year-old boy who fell 20 feet and developed respiratory distress, bilateral pneumothoraces, pneumomediastinum, and subcutaneous emphysema. Computed tomography imaging at the initial institution failed to detect tracheobronchial disruption, and the patient was managed conservatively. The patient's worsening condition prompted bronchoscopic examination which revealed complete separation of the right main bronchus from the trachea. Single-lung ventilation was instituted using a fabricated extra-long nasotracheal tube due to the patient's large size and mandibular fracture, and the airway was primarily anastamosed with an open thoracotomy approach. The clinical features of tracheobronchial separation as well as anesthetic, clinical and surgical management of this rare but life-threatening injury are described.

The lung and pediatric trauma

Thoracic trauma is relatively frequent in children and causes considerable mortality. This is mainly due to the multiorganic nature of the trauma. The lung is more often affected even in the absence of rib fractures because of the considerable pliability of the chest wall that allows direct transfer of energy to this organ. Injuries to the heart, the aorta, the esophagus, and the diaphragm are rare. Lung contusion and laceration cause parenchymal hemorrhage and consolidation sometimes accompanied by pneumothorax and/or hemothorax. Tracheobronchial disruption is rare but life-threatening. Most traumatic lung injuries may be treated with rest, respiratory support, and eventually intercostal drainage. Large hemorrhage may require thoracotomy, and persistent pneumothorax (indicative of tracheobronchial disruption) may require intubation with fiberoptic bronchoscopic assistance and eventually reparative or ablative surgery. Adult respiratory distress syndrome is very rarely seen in children with thoracic trauma, but it remains highly lethal.

High-frequency percussive ventilation during surgical bronchial repair in a patient with one lung

We report the case of a patient that had undergone a left pneumonectomy during which a double-lumen tube was used and an undetected right bronchial laceration occurred. After diagnosis the patient underwent a second operation to repair the tear. The role of high-frequency percussive ventilation in enabling adequate gas exchange during the bronchial repair is described and discussed.

Anaesthetic management of tracheobronchial rupture following blunt chest trauma

Injuries to the tracheobronchial tree are a well-recognized sequel of massive blunt trauma to the chest, and although unusual, are life threatening. We report a 16-year-old-boy who developed complete disruption of both bronchi after a motor vehicle accident. After induction of general anaesthesia and oral intubation, ventilation could not be maintained, and oxygenation worsened abruptly with peripheral oxygen saturation values less than 60%. Jet ventilation through two intrabronchial catheters, inserted via emergency thoracotomy, raised the saturation from 60% to 100%, and surgery thereafter was straightforward. The anaesthetic management of tracheobronchial repair is discussed.

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.

Tracheal rupture following blunt chest trauma presenting as endotracheal tube obstruction

In this report, we describe a patient in whom a tracheal tear followed blunt thoracic trauma. The diagnosis was made late resulting in problems with ventilation, endotracheal tube obstruction and cardiac arrest. Difficulties with early recognition of tracheobronchial injuries may be caused by non-specific findings as well as the lack of exposure of physicians to patients with these injuries. The signs and symptoms of tracheobronchial injuries are described, as well as their differential diagnoses. A review of airway management has been made as it requires combined anaesthetic and surgical expertise. Injuries of the trachea may have severe, life-threatening consequences and early diagnosis and management reduce morbidity and mortality.

Tracheobronchial Injuries Caused by Blunt Trauma

Tracheobronchial injuries, once rare complications of blunt trauma to the anterior neck and chest, are becoming more common. Traffic accidents account for most of these injuries. There are several possible mechanisms for airway rupture, the site of which is dictated by the location of the trauma and the points of airway fixation. The vast majority of cervical tracheal injuries occur above the fourth tracheal ring, whereas thoracic tracheal and bronchial lesions tend to occur in the vicinity of the carina. The presence of respiratory distress and signs of air leak, such as subcutaneous emphysema and persistent pneumothorax despite thoracostomy tube drainage, characterize many of these injuries. In some patients, however, the paucity of clinical findings leads to a delay in diagnosis until a late complication, such as lung collapse or suppuration; occurs. Flexible bronchoscopy remains the most valuable tool for diagnosis. Early surgical repair is recommended except for some minor injuries, which can be managed expectantly and with close follow-up. Patients who reach the hospital alive have a good prognosis.

Tracheobronchial injuries in children

Five patients with tracheobronchial injuries secondary to blunt thoracic trauma were reviewed over a 9-year period. Bronchial disruption occurred in four cases and tracheal disruption in one. Of the four patients with bronchial disruption, a major airway injury was suspected early because of a large air leak or persistent pulmonary atelectasis. However, definitive diagnosis by bronchoscopy was delayed from 4 to 16 days due to initial response to conservative management. Bronchial repair was achieved in every case: additional lobectomy was required in only one instance. Postoperative bronchial stenosis occurred in one patient and responded well to dilatation. The child with a blowout perforation of the trachea was diagnosed early by bronchoscopy and was successfully managed without surgery. Tracheobronchial injury is one of the most severe injuries caused by blunt trauma and requires a high index of suspicion for early diagnosis and surgery. Bronchial repair is successful in most instances.