Injuries to the major airway after blunt thoracic trauma in children: review of 2 cases

Complex bronchial ruptures in blunt thoracic trauma: management and outcome

Complex bronchial ruptures are rare. Primary surgical repair is the preferred procedure. The aim of this retrospective case series was to study the clinical presentation of these complex bronchial injuries and their management and outcomes. Patients with injuries to the trachea or those who had simple single bronchial rupture and isolated lobar and segmental injuries were excluded. Twenty-one patients were operated for bronchial rupture due to blunt chest trauma. Seven patients had complex bronchial injuries and had right bronchial tree injury (n = 3), left bronchial tree injury (n = 3), and rupture of both right and left main bronchi (n = 1). Fibreoptic bronchoscopy established the diagnosis in all patients. Postoperative complications included atelectasis in four patients (57%) and left recurrent laryngeal nerve paralysis (n = 1; 14.3%), and one patient required tracheostomy (14.3%). All patients had follow-up bronchoscopy 2 months later, which showed no stenosis or scar formation in any of the patients. We concluded that primary repair of complex bronchial injuries, with preservation of the normal functioning lung, is the preferred option as it carries favorable immediate- and long-term results.

Management of chest trauma in children

Chest trauma in children is caused by high-energy blows, due in general to traffic accidents, that involve several other body regions. They occur mainly in the first decade of life and can be penetrating but are more often non-penetrating. Rib fractures and lung contusions, sometimes associated with pneumothorax or haemothorax, are the more usual injuries, but tracheobronchial rupture, cardiac, oesophageal or diaphragmatic injuries may also occur. These injuries are treated with supportive respiratory and haemodynamic measures, drainage of air or blood from the pleural space and, at times, surgical repair of the injured organ(s). Ruptures of the airway may be difficult to treat and occasionally require suture, anastomosis or resection. Oesophageal injuries can be treated conservatively with antibiotics, drainage and parenteral nutrition. Diaphragmatic tears should be repaired operatively. Overall mortality ranges from 6 to 20%. Mortality is high but this is mainly due to the associated presence of extra-thoracic trauma, and particularly to head injuries.

[Tracheobronchial rupture in childhood]

Tracheobronchial rupture after blunt trauma is rare, especially in a pediatric population. In this paper, we report the case of a 3-year-old child who presented with a rupture of the tracheobronchial tree as a result of multiple injuries (thoracic and cerebral) sustained from a traffic accident. The surgical repair consisted of a sleeve resection (right upper lobectomy with reanastomosis of the bronchus intermedius to the right stem bronchus). As tracheobronchial rupture is a rare condition, particularly in children, physicians must have a high index of suspicion. The diagnosis and treatment of this condition are discussed.

Delayed presentation and treatment of tracheobronchial injuries due to blunt trauma

BACKGROUND

Blunt thoracic trauma that results in tracheobronchial injury is difficult to diagnose. Many injuries are catastrophic and result in early mortality. Others are not immediately life threatening and are missed at initial presentation. Some of those injuries will later become symptomatic and will require medical attention. Ideal treatment in that situation is not yet clearly defined.

OBJECTIVES

The objective is to review the current literature of delayed diagnoses of traumatic tracheobronchial injuries, their management, and the results of the most common repair methods. An interesting case report from this institution is presented as well.

DESIGN

A Medline search of the English literature of delayed presentation of tracheobronchial injuries over the past 10 years was performed. Delayed diagnosis was defined as injuries not identified during the initial hospitalization.

RESULTS

The median time from initial presentation to diagnosis was 6 months. Dyspnea (56%) and pneumonia (39%) were the most common complaints. No difference in complications was observed between parenchymal sparing procedures and resections.

CONCLUSIONS

Despite delays in presentation and the radiographic appearance of destroyed distal lung, proximal injuries can often be repaired without sacrifice of distal lung parenchyma. Bronchial sleeve resections or end-to-end anastomosis can be performed safely in most situations.