Traumatic injury to the trachea and bronchus

Traumatic cervical tracheal trunk complete rupture combined with cardiac arrest: A case report

Traumatic main bronchus rupture is a relatively rare injury in thoracic trauma, which is extremely critical, with a mortality rate as high as 70% - 80%. The complete rupture and displacement of the traumatic cervical trachea can lead to asphyxia, hypoxia, and cardiac arrest, even death of the patient in a short time. We performed emergency surgery with the support of extracorporeal membrane oxygenation for a case of traumatic cervical tracheal trunk complete rupture and displacement combined with cardiac arrest and achieved a successful rescue. We summarized our experience and found that timely surgical reconstruction of the airway is the key to increasing the traumatic main bronchus rupture survival of patients.

Anesthetic Management of Iatrogenic Tracheal Injury: A Case Report

Tracheal perforation following oesophagectomy is a very rare and occasionally life-threatening condition that requires a high degree of suspicion and early intervention for optimal patient outcomes. This article presents a case report of a 46-year-old male who presented with respiratory failure secondary to tracheal perforation at the level of carina following a two-stage oesophagectomy. He underwent a second emergency procedure; the airway was secured with a left-sided double-lumen tube, and tracheal perforation was successfully repaired. This case report will briefly cover the challenges and difficulties faced by anesthetists in the airway management, ventilation, and hemodynamic instability of such patients.

Secretome Analysis of Human Nasal Fibroblast Identifies Proteins That Promote Wound Healing

Conditioned medium from cultured fibroblast cells is recognized to promote wound healing and growth through the secretion of enzymes, extracellular matrix proteins, and various growth factors and cytokines. The objective of this study was to profile the secreted proteins present in nasal fibroblast conditioned medium (NFCM). Nasal fibroblasts isolated from human nasal turbinates were cultured for 72 h in Defined Keratinocytes Serum Free Medium (DKSFM) or serum-free F12: Dulbecco's Modified Eagle's Medium (DMEM) to collect conditioned medium, denoted as NFCM_DKSFM and NFCM_FD, respectively. SDS-PAGE was performed to detect the presence of protein bands, followed by MALDI-TOF and mass spectrometry analysis. SignalP, SecretomeP, and TMHMM were used to identify the secreted proteins in conditioned media. PANTHER Classification System was performed to categorize the protein according to protein class, whereas STRING 10 was carried out to evaluate the predicted proteins interactions. SDS-PAGE results showed the presence of various protein with molecular weight ranging from ~10 kDa to ~260 kDa. Four protein bands were identified using MALDI-TOF. The analyses identified 104, 83, and 7 secreted proteins in NFCM_FD, NFCM_DKSFM, and DKSFM, respectively. Four protein classes involved in wound healing were identified, namely calcium-binding proteins, cell adhesion molecules, extracellular matrix proteins, and signaling molecules. STRING10 protein prediction successfully identified various pathways regulated by secretory proteins in NFCM. In conclusion, this study successfully profiled the secreted proteins of nasal fibroblasts and these proteins are predicted to play important roles in RECs wound healing through various pathways.

A rare and unique experience of a blunt intrathoracic traumatic injury of the trachea and its management in South Africa: a case report

Blunt intrathoracic tracheal injuries are rare, even among blunt chest trauma patients. An early diagnosis based on a high index of suspicion allows for timely surgical management of potentially fatal airway trauma, thereby improving overall outcomes. Diagnosing these injuries can be difficult due to their nonspecific clinical features and the occasional difficulty in radiologic diagnosis. If a patient exhibits respiratory compromise with difficult ventilation and poor lung expansion, despite the insertion and management of an intercostal drain following high-energy blunt trauma, there should be a heightened suspicion of potential airway trauma. The aim of primary repair is to restore airway integrity and to minimize the loss of pulmonary parenchyma function. This case report discusses the rare clinical presentation of a patient with blunt trauma to the intrathoracic airway, the surgical management thereof, and his overall outcome. Although blunt traumatic injuries of the trachea are extremely rare and often fatal, early surgical intervention can potentially reduce the risk of mortality.

[Traumatic Tracheobronchial Injuries - Recommendation of the Interdisciplinary Working Group of the DGT and DGU to Establish a Uniform Classification for Diagnostics and Therapy]

Traumatic tracheobronchial injuries are extremely rare. In comparison, iatrogenic injuries are somewhat more common. A literature search revealed that there is a large number of case reports and small case series for this clinical entity. There are hardly any reviews and they usually have a low level of evidence. One reason for this is the lack of a classification to allow comparison of the individual cases with each other. There is only one classification for iatrogenic injuries of the posterior tracheal wall, which the authors modified and expanded with regard to traumatic tracheobronchial injuries. This classification was extended by the authors to also include traumatic injuries. A three-digit classification is presented here. The grading of the injury covers the entire spectrum of injury patterns, from peribronchial emphysema to wall injuries of different depths to subtotal and complete rupture of the bronchus. In addition, the anatomical location and the cause of the injury were added to the classification. The levels of injury in the tracheobronchial tree are distinguished anatomically. The third digit distinguishes traumatic, iatrogenic and spontaneous injuries. On the basis of the three-digit classification resulting from these parameters, it is possible to group individual cases together and to develop recommendations for diagnostics and therapy.

Successful airway management of traumatic complete tracheal transection

A man in his 20s sustained complete tracheal transection after being injured by a sandbag pile falling on his neck. An oral endotracheal tube (ETT) was inserted by rapid sequence induction in view of respiratory distress. CT revealed that the ETT did not traverse the distal tracheal segment; however, there were rebreathing bag movements, and normal capnograph and oxygen saturation, which were misleading clinical findings. We describe the successful airway management in this challenging case.

Tracheal Rupture After Trauma: A Successful Conservative Management

Tracheobronchial injury (TBI) is a rare life-threatening injury that can result from either penetrating or blunt trauma. Treatment may be surgical or conservative, but the evidence regarding which is the best approach is still very scarce. This case report describes the successful conservative management of a 32-year-old male with a traumatic tracheal laceration. The alarming signs and symptoms, the imaging modalities of choice, the rationale behind the treatment strategy, and the most common complications are detailed here. Through this case, the authors wish to highlight the features that should lead to the suspicion of this potentially fatal traumatic injury, as well as raise awareness on how to adequately manage these patients.

Emergency repair of blunt traumatic bronchus injury presenting with massive air leak

Blunt traumatic tracheobronchial injury is rare, but can be potentially life-threatening. It accounts for only 0.5%-2% of all trauma cases. Patients may present with non-specific signs and symptoms, requiring a high index of suspicion with accurate diagnosis and prompt treatment. A 26-year-old female was brought into the emergency department after sustained a blunt trauma to the chest from a high impact motor vehicle accident. She presented with signs of respiratory distress and extensive subcutaneous emphysema from the chest up to the neck. Her airway was secured and chest drain was inserted for right sided pneumothorax. CT of the neck and thorax revealed a collapsed right middle lung lobe with a massive pneumothorax, raising the suspicion of a right middle lobe bronchus injury. Diagnosis was confirmed by bronchoscopy. In view of the difficulty in maintaining her ventilation and persistent pneumothorax with a massive air leak, immediate right thoracotomy via posterolateral approach was performed. The right middle lobar bronchus tear was repaired. There were no intra- or post-operative complications. She made an uneventful recovery. She was asymptomatic at her first month follow-up. A repeated chest X-ray showed expanded lungs. Details of the case including clinical presentation, imaging and management were discussed with an emphasis on the early uses of bronchoscopy in case of suspected blunt traumatic tracheobronchial injury. A review of the current literature of tracheobronchial injury management was presented.

Robotic repair of traumatic bronchial disruption: A minimally invasive and multi-disciplinary approach to a complex constellation of injuries

Bronchial disruption is a catastrophic consequence of blunt thoracic trauma with high pre-hospital lethality. This injury is classically managed through a large thoracotomy incision to facilitate adequate exposure for open repair. Here, we describe a case of complete bronchus intermedius disruption following a motor vehicle accident that was repaired via robotic thoracoscopy. The patient sustained multi-system trauma, including a grade III liver laceration, an innominate artery pseudoaneurysm, and femoral condyle fracture, all of which required systematic intervention and multi-disciplinary coordination to best facilitate this patient's care. This patient recovered well from his multiple injuries and was discharged after an uneventful post-operative course.

Tracheobronchial Injury: Role of Virtual Bronchoscopy

A tracheobronchial avulsion is a very rare and serious condition that occurs mostly due to blunt trauma chest caused by high-speed traffic accidents. In this article, we present a challenging case of a 20-year-old male who had a right tracheobronchial transection with carinal tear which was repaired on cardiopulmonary bypass (CPB) through right thoracotomy. Challenges faced and a review of literature will be discussed.

How to cite this article

Kaur A, Singh VP, Gautam PL, Singla MK, Krishna MR. Tracheobronchial Injury: Role of Virtual Bronchoscopy. Indian J Crit Care Med 2022;26(7):879-880.

Blunt thoracic trauma: role of chest radiography and comparison with CT - findings and literature review

In the setting of acute trauma where identification of critical injuries is time-sensitive, a portable chest radiograph is broadly accepted as an initial diagnostic test for identifying benign and life-threatening pathologies and guiding further imaging and interventions. This article describes chest radiographic findings associated with various injuries resulting from blunt chest trauma and compares the efficacy of the chest radiograph in these settings with computed tomography (CT). Common chest radiographic findings in blunt thoracic injuries will be reviewed to improve radiologic identification, expedite management, and improve trauma morbidity and mortality. This article discusses demographic information, mechanism of specific injuries, common imaging findings, imaging pearls, and pitfalls and exhibits several classic imaging findings in blunt chest trauma. Thoracic structures commonly injured in blunt trauma that will be discussed in this article include vasculature structures (aortic trauma), the heart (cardiac contusion, pericardial effusion), the esophagus (esophageal perforation), pleural space and airways (pneumothorax, hemothorax, bronchial injury), lungs (pulmonary contusion), the diaphragm (diaphragmatic rupture), and the chest wall (flail chest). Chest radiography plays an important role in the initial evaluation of blunt chest trauma. While CT imaging has a higher sensitivity than chest radiography, it remains a valuable tool due to its ability to provide rapid diagnostic information in time-sensitive trauma situations and is ubiquitously available in the trauma bay. Familiarity with the gamut of injuries that may occur as well as identification of the associated chest radiograph findings can aid in timely diagnoses and prompt management in the setting of acute blunt chest trauma.

Tracheal trauma in rhesus macaques (Macaca mulatta)

Tracheal disruption is a previously unreported complication of nonhuman primate social trauma. Two cases were identified in rhesus macaques with subcutaneous emphysema. These cases resolved with medical management and demonstrate that the combined use of radiography and tracheoscopy allows rapid assessment and diagnosis of tracheal trauma in nonhuman primates.

Diagnosis of a tracheal tear by use of an oxygen analyzer in a dog with cervical trauma

CASE DESCRIPTION

A 7.75-year-old sexually intact male Welsh Terrier was examined because of cervical soft tissue wounds and an inability to maintain hemoglobin oxygen saturation without oxygen supplementation following a dog attack.

CLINICAL FINDINGS

A 2-cm-long penetrating wound that extended into a large open pocket was identified on the left ventral aspect of the dog's neck. The dog was anesthetized and underwent advanced imaging, the findings of which suggested that the trachea was intact. However, when the cuff of the endotracheal tube was deflated during the dog's recovery from anesthesia, sudden oxygen desaturation occurred. Given no radiographic signs of deteriorating lung injury, a tracheal tear was suspected. For rapid confirmation of a tracheal tear, without the need for additional advanced imaging, the oxygen concentration at the skin wound was investigated by use of an oxygen analyzer. When the dog was breathing 100% oxygen, the analyzer identified a higher oxygen concentration at the edge of the penetrating wound, compared with the concentration of oxygen in room air; the leakage of oxygen-rich gases from the airway through the wound confirmed the presence of a tracheal tear, immediately indicating the need for surgical exploration and repair.

TREATMENT AND OUTCOME

Surgical repair of the tracheal tear with a left sternothyroideus muscle flap was successfully performed.

CLINICAL RELEVANCE

For this dog, an oxygen analyzer was used to confirm the presence of a tracheal tear, suggesting that application of an oxygen analyzer may be useful in the emergency management of neck trauma cases.

Pediatric tracheal trauma

Tracheal trauma is an uncommon but potentially serious cause of airway injury in children. Presentation may be acute in cases of blunt or penetrating trauma, or delayed in cases of chronic irritation or indwelling endotracheal tubes. Symptoms include dyspnea, progressive respiratory distress, neck and chest swelling and ecchymosis, and dysphonia. Workup is pursued as allowed by the patient's clinical status and may include plain radiography, computed tomography, and endoscopy. Accuracy and efficiency of diagnosis is paramount for those at risk of rapid decompensation. Treatment may include observation, elective and strategic intubation, or primary surgical repair.

Extracorporeal Membrane Oxygenation Support During Repair of a Non-Iatrogenic Tracheal Injury

Tracheal trauma is uncommon but carries major morbidity and mortality. A 26-year-old male sustained a near-transection of the cervical trachea due to penetrating trauma. Veno-venous extracorporeal membrane oxygenation (ECMO) support allowed for a controlled primary repair with muscular buttress and facilitated airway management. Facial injuries prevented oral intubation and retrograde intubation through the transection established an airway. On the tenth post-operative day, a percutaneous tracheostomy was performed through the surgical site. This case discusses the management, technical details, and adjuncts to successfully repair complex tracheal injuries.

Factors determining surgical outcome after bronchial re-implantation for traumatic main bronchus transection

Objectives:

The diagnosis of traumatic transection of main bronchus is often delayed, resulting in attempts at surgical repair sometimes even months after the injury. Our aim is to analyze the factors affecting surgical outcome in patients undergoing lung preserving bronchial re-implantation for bronchial transection.

Materials and Methods:

This is a retrospective analysis of prospectively maintained data of 10 cases of traumatic transection of main bronchus who underwent bronchial re-implantation at a tertiary thoracic surgery center in India. Patients were divided into two groups based on their total length of hospital stay. Occurrence of postoperative complications and/or hospital stay >7 days were considered poor surgical outcomes.

Results:

Out of 10 patients, 6 were left main bronchus transections and 4 right main bronchus transections. The male-female ratio was 7:3. Right-sided bronchial injury and higher preoperative Injury Severity Score (ISS) were associated with poor surgical outcomes (P < 0.01). These patients also had significantly higher anastomotic complications, chest tube duration, and prolonged postoperative air leak. Age of the patient, preoperative hemoglobin or albumin levels, and time of referral did not influence the surgical outcomes.

Conclusions:

Poorer surgical outcomes were observed in patients who had right-sided main bronchus injury and higher ISSs. Time of referral did not influence the outcome. This study is limited by small sample size and retrospective nature. As no single center will have large numbers of this uncommon injury, multicenter pooled data are needed to re-affirm the findings of this study.

Damage control of laryngotracheal trauma: the golden day

Laryngotracheal trauma is rare but potentially life-threatening as it implies a high risk of compromising airway patency. A consensus on damage control management for laryngotracheal trauma is presented in this article. Tracheal injuries require a primary repair. In the setting of massive destruction, the airway patency must be assured, local hemostasis and control measures should be performed, and definitive management must be deferred. On the other hand, management of laryngeal trauma should be conservative, primary repair should be chosen only if minimal disruption, otherwise, management should be delayed. Definitive management must be carried out, if possible, in the first 24 hours by a multidisciplinary team conformed by trauma and emergency surgery, head and neck surgery, otorhinolaryngology, and chest surgery. Conservative management is proposed as the damage control strategy in laryngotracheal trauma.

Right main bronchus rupture associated with blunt chest trauma: a case report

Background

Tracheobronchial injury is one of the least common injuries in the scenario of blunt chest trauma. However, around 81% of patients with airway injury die immediately or before arriving at the emergency department due to tension pneumothorax. It presents with non-specific signs and symptoms challenging prompt diagnosis.

Case presentation

A 15-year-old adolescent who was riding a bicycle suffered an accident when he fell down a cliff, approximately 5 m deep. Upon admission to the emergency department, he presented with signs of respiratory distress. The airway was secured and a thoracoabdominal angiography was performed. The image reported pneumomediastinum, a small right pneumothorax, areas of pulmonary contusion, and an image of loss of continuity in the anterior superior wall of the right main bronchus highly suggestive of bronchial rupture. The bronchial lesion was then confirmed by fiberoptic bronchoscopy. Taking into account the patient’s characteristics, conservative management was chosen, and the patient was transferred to the intensive care unit (ICU) where protective tracheal intubation was performed.

Conclusions

A delay in diagnosis increases the rate of complications, mainly infectious complications and the formation of granulation tissue that could potentially obstruct the airway, impacting the patient’s outcome. The first step in the management of these patients is securing the airway, which should be done immediately. The gold standard for the diagnosis and characterization of airway injuries is bronchoscopy as it is the most effective tool to assess topography, extent, and depth of the lesion.

Tracheobronchial injuries: tertiary center experience

Background

Tracheobronchial injury is a rare and serious outcome of thoracic trauma. The aim of this study was to describe our experience in the management of tracheobronchial injuries.

Methods

We reviewed the presentation, line of management, and results of all 23 patients (17 males and 6 females) with a mean age of 27.87 years, who presented with traumatic tracheobronchial injuries and were admitted to the level 3 trauma center of our university emergency hospital over an eight-year period.

Results

Blunt trauma was the leading cause (73.9%) of injury. Bronchoscopy was routinely performed. A right thoracotomy was carried out in 73.9% of patients. The right main bronchus was the most common site of injury (30.4%), followed by the trachea in 26.1%. Pulmonary resection was undertaken in 5 cases. Three operative mortalities were recorded.

Conclusion

Tracheobronchial injuries can be treated conservatively or ideally by surgical repair which is the core line of treatment. Surgery has excellent outcomes depending on skillful use of bronchoscopy and the surgeon’s experience of the surgical approach and technique.

Anesthetic management of tracheal laceration from traumatic dislocation of the first rib: a case report and literature of the review

Background

Tracheobronchial lacerations from trauma can be life-threatening and present significant challenges for safe anesthetic management. Early recognition of tracheal injuries and prompt airway control can be lifesaving.

Case presentation

A 56-year-old man with no significant medical history presented with difficulty breathing after a blunt trauma to his chest to the emergency room and was diagnosed with dislocation of the first rib and tracheal laceration after a chest tomography (CT) study. Subcutaneous emphysema in neck area quickly worsened indicating continuous air leak. Emergent surgical repair was scheduled. General anesthesia with maintaining spontaneous ventilation was performed and a 5.5 mm endotracheal tube was placed under the guidance of flexible bronchoscopy. Depth of anesthesia was maintained to achieve a Bispectral Index Score of 40–60. Once the offending first rib was removed, a 7.5 mm endotracheal tube was inserted distal to the laceration site with the guidance of flexible bronchoscopy. Once confirmed location of the endotracheal tube, cisatracurium was administered intravenously and the patient was managed on mechanical ventilation with interval positive pressure ventilation. The operation was successful and he was transferred to the ICU intubated. He then received elective surgical repairs for sternum fracture, multiple rib fractures and hemopneumothorax under general anesthesia on day 5 after the first surgery and was extubated on postoperative day 7. The subsequent course was uneventful. Comprehensive rehabilitation was done for 2 weeks and he was discharged home on postoperative day 41.

Conclusions

Early diagnosis and multidisciplinary collaborations are keys to the successful management of this patient. Flexible bronchoscopy is particularly useful in airway management for urgent trachea tracheal laceration repair.

Bronchial injuries: a tale of differing presentations

Bronchial disruptions are uncommon but nevertheless grievous injuries and are usually secondary to major thoracic trauma. Although many are associated with other catastrophic injuries causing early mortality, their presentations can be late and they are often difficult to diagnose. Their management is frequently challenging and the ideal course of treatment is not yet clearly defined. Here, we describe two cases of main bronchial injuries presenting to us with post-traumatic collapse lung, albeit with a widely differing post-trauma course. Both required thoracotomy followed by a resection and anastomosis of the disrupted/stenotic segment. Operative results were good with both cases showing a well-expanded lung and no postoperative anastomotic site stenosis during the period of follow-up. Our experience highlights that patients with major bronchial injuries can have varying presentations. High degree of suspicion is necessary for early diagnosis and prompt surgical treatment. Resection of the stenosed/fibrosed segment followed by anastomosis yields good results.

Treatment of Tracheobronchial Injuries: A Contemporary Review

Tracheobronchial injury is a rare but a potentially high-impact event with significant morbidity and mortality. Common etiologies include blunt or penetrating trauma and iatrogenic injury that might occur during surgery, endotracheal intubation, or bronchoscopy. Early recognition of clinical signs and symptoms can help risk-stratify patients and guide management. In recent years, there has been a paradigm shift in the management of tracheal injury towards minimally invasive modalities, such as endobronchial stent placement. Although there are still some definitive indications for surgery, selected patients who meet traditional surgical criteria as well as those patients who were deemed to be poor surgical candidates can now be managed successfully using minimally invasive techniques. This paradigm shift from surgical to nonsurgical management is promising and should be considered prior to making final management decisions.

Laryngeal fracture presentation and management in United States emergency rooms

OBJECTIVES/HYPOTHESIS

There are limited data on laryngeal fracture presentation and management in US emergency departments (EDs). We aimed to characterize patients who are diagnosed with laryngeal fractures in the ED and identify management patterns.

STUDY DESIGN

Retrospective review of the Nationwide Emergency Department Sample (NEDS) from 2009 to 2011.

METHODS

The NEDS was queried for patient visits with a primary diagnosis of open or closed laryngeal fracture (International Classification of Diseases, Ninth Revision codes 807.5 and 807.6). Patient demographics, comorbidities, ED management, and hospital characteristics were extracted.

RESULTS

There were 3,102 ED visits with a diagnosis of laryngeal fracture during the study period. Mean patient age was 40.9 years (range, 3-93 years). The majority of patients were male (85.5%) and sustained a closed (vs. open) fracture (91.4%), with an overall mortality rate of 3.8%. The majority of patients were treated for more than one injury during the same visit (76.2%). Most patients were evaluated at a trauma hospital (53.9%), and most patients were admitted to the hospital (71.9%). Emergent intubation or tracheostomy was rarely reported (2.6% and 0.1% of all cases), and a minority of patients underwent fiberoptic flexible laryngoscopy in the ED (1.9%). Laryngeal fractures occurred more frequently during summer months (28.2%). Mean charge for the entirety of the ED stay was $4,957.34.

CONCLUSIONS

Laryngeal fracture is rare and frequently associated with other injuries. The frequency of emergent airway procedure, imaging, and flexible fiberoptic laryngoscopy is lower than expected, raising concerns about appropriate workup and management or recognition of injury in the ED setting.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:2341-2346, 2019.

Successful Stenting for Bronchial Stenosis Resulting from Blunt Airway Trauma

Blunt airway trauma is rare but life threatening. Injuries to other vital organs accompany this type of injury in most cases; therefore, conservative treatment may be considered first. In cases of delayed fibrotic airway stenosis after conservative treatment, surgical treatment or bronchoscopic intervention are therapeutic options. We herein report a case of delayed airway stenosis after a blunt traumatic airway injury that was successfully managed by silicone stenting.

Traumatic Airway Injuries: Role of Imaging

Airway Injuries are rare but often immediately life threatening. Incidence ranges from 0.5-2 % in blunt and 1-6 % in penetrating trauma. Upper airway injuries (UAI) are often clinically apparent and get shunted during the primary survey in the emergency department. Few UAI and majority of lower airway injuries (LAI) are occult on primary survey and need a high suspicion index. Clinically, the diagnosis of tracheobronchial injury is delayed in many patients because the airway column is maintained by the peribronchial tissue. Imaging in the form of MDCT, in conjunction with endoscopy, plays a role in delineating the exact site and extent of injury and ruling out associated vascular and esophageal injuries for definitive management of UAI. Chest radiographs and ultrasonography help raise suspicion of LAI by detection of pneumomediastinum, persistent pneumothorax and/or subcutaneous emphysema and should be followed up with multidetector computed tomography (MDCT) which is the mainstay of diagnosis. However, it requires careful evaluation of the airway tract and a thorough knowledge about the mechanism of trauma for detection of subtle injuries. Reconstructions in multiple planes and use of various post-processing techniques including minimum intensity projection (MinIP) images enhance the detection rate. The specific signs of LAI on CT include discontinuity in the tracheobronchial tree, focal intimal flap projecting in the lumen, focal soft tissue attached to the tracheal/bronchial wall, complete cut off of the bronchus/trachea and the fallen lung sign. We, hereby, illustrate the imaging spectrum of traumatic airway injuries in detail and discuss their management implications.

Imaging and Management of Thoracic Trauma

Thoracic injury results from penetrating and blunt trauma and is a major contributor to overall trauma morbidity and mortality in the United States. Modern imaging algorithms utilize ultrasound, chest radiograph, and computed tomography with intravenous contrast to accurately diagnose and effectively treat patients with acute thoracic trauma. This review focuses on the etiologies, signs and symptoms, imaging, and management of several life-threatening thoracic injuries including tracheobronchial rupture, pulmonary parenchymal injury, hemothorax, pneumothorax, diaphragmatic rupture, and axial skeleton injury.

Successful phased approach to a patient with synchronous traumatic descending aortic pseudoaneurysm and bronchial rupture

A 34-year-old woman was referred to our center because of collapsed left lung and left main bronchial stenosis 1 week after a vehicular accident. Bronchoscopic observation revealed stenosis in the left main and lobar bronchus. Computed tomography (CT) angiography found traumatic descending aortic pseudoaneurysm after admission. Phased intervention strategy was adopted. The aortic rupture was repaired with endovascular stent firstly, followed by sleeve reconstruction of the left main bronchus through posterolateral thoracotomy 11 days later. She recovered uneventfully and resulted in an excellent long-term outcome. The diagnosis and treatment of this case is discussed.

Accuracy of CT chest without oral contrast for ruling out esophageal perforation using fluoroscopic esophagography as reference standard: a retrospective study

PURPOSE

Esophageal perforation has a high mortality rate. Fluoroscopic esophagography (FE) is the procedure of choice for diagnosing esophageal perforation. However, FE can be difficult to perform in seriously ill patients.

METHODS

We retrospectively reviewed charts and scans of all patients who had undergone thoracic CT (TCT) without oral contrast and FE for suspicion of esophageal perforation at our hospital between October, 2010 and December, 2015. Scans were interpreted by a single consultant radiologist having > 5 years of relevant experience. Statistical analysis was performed using SPSS version 20. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of TCT were computed using FE as reference standard.

RESULTS

Of 122 subjects, 106 (83%) were male and their median age was 42 [inter-quartile range (IQR) 29-53] years. Esophageal perforation was evident on FE in 15 (8%) cases. Sensitivity, specificity, PPV and NPV of TCT for detecting esophageal perforation were 100, 54.6, 23.4 and 100%, respectively. When TCT was negative (n = 107), an alternative diagnosis was evident in 65 cases.

CONCLUSION

Thoracic computed tomography (TCT) had 100% sensitivity and negative predictive value for excluding esophageal perforation. FE may be omitted in patients who have no evidence of mediastinal collection, pneumomediastinum or esophageal wall defect on TCT. However, in the presence of any of these features, FE is still necessary to confirm or exclude the presence of an esophageal perforation.

Less is more: lung-sparing direct repair of a traumatic rupture of the bronchus intermedius

Major trauma is one of the most common causes of death in the western world in the young population (15-25 years). Thoracic trauma represents 25% of traumatic deaths, and the incidence of tracheobronchial injuries in literature is lower than 5%. Nevertheless, airway injuries are life-threatening conditions. Here we present a case of a 25-year-old patient who underwent a severe motorcycle crash. The injury severity score (ISS) was 35 at admission to the hospital. A right middle bronchus laceration <2 cm involving the whole thickness of the wall of the bronchus intermedius was identified. An urgent right posterolateral thoracotomy was performed, and the lesion was directly repaired. A conservative intervention was the key to grant our patient a healthy life.

Thoracic Trauma

Management of chest trauma is integral to patient outcomes owing to the vital structures held within the thoracic cavity. Understanding traumatic chest injuries and appropriate management plays a pivotal role in the overall well-being of both blunt and penetrating trauma patients. Whether the injury includes rib fractures, associated pulmonary injuries, or tracheobronchial tree injuries, every facet of management may impact the short- and long-term outcomes, including mortality. This article elucidates the workup and management of the thoracic cage, pulmonary and tracheobronchial injuries.

Complete cricotracheal transection due to blunt neck trauma without significant symptoms

Laryngotracheal injuries are relatively rare but their mortality rate is fairly high. Complete disruption of trachea is extremely rare and a systematic approach is needed for early diagnosis and favourable outcome. The patients symptoms and physical signs do not necessarily correlate with the severity of the injuries and this case report highlights it. This is a case report of 25-year-old man who arrived to the emergency department 8 h after a motor accident in which a rope was wrapped around his neck. Because of the good general and respiratory condition of the patient on admission, the pathognomonic signs of laryngeal injury were not noticed. A computed tomographic scan showed distortion of cricotracheal framework. Flexible bronchoscopy showed cricotracheal transaction. Immediately, the endotracheal tube was advanced distal to the transection site under bronchoscopic guide and then after neck exploration primary end-to-end cricotracheal anastomosis was performed.

Scary gas: a spectrum of soft tissue gas encountered in the axial body (part II)

Ectopic gas in the mediastinum, subperitoneal abdomen, and superficial soft tissues is concerning and can be seen in the setting of trauma, iatrogenic injuries, infection, and inflammation. It can spread along different dissection pathways and may present remotely from the involved organ as described in part one. Recognition of ectopic gas on imaging and differentiating it from other causes of benign gas is very important as these conditions associated with ectopic gas can lead to rapid patient deterioration and usually require urgent surgery. In part two, the different causes of ectopic and benign gas in the torso are reviewed as well as the imaging features that can help to narrow the differential diagnosis.

Clinical analysis of eight patients with blunt main stem bronchial injuries

BACKGROUND

Blunt main stem bronchial injuries are rare but potentially life-threatening injuries in clinical. The aim of this study was to sum up the experience on diagnosis and treatment of blunt main stem bronchial injuries.

METHODS

This report retrospective1y analyzed eight cases of main stem bronchial injuries induced by blunt chest trauma between 2013 and 2016 in Tangdu Hospital, Fourth Military Medical University.

RESULTS

There were eight patients, including four men and four women. The definitive diagnosis was confirmed by fibrobronchoscopy. Mean time between injury and treatment in our hospital was 4.25 days (range, 1-12 days). Mean length of airway tear was 1.04 cm (range, 0.5-2 cm). In four patients there was an injury to the left main stem bronchus, in three patients to the right main stem bronchus and in one patient to the ambilateral main stem bronchus. Emergent operation was performed in two patients and elective operation in six patients. End to end bronchial anastomosis was performed via right thoracotomy in two patients and via left thoracotomy in three patients, and primary repair was performed via right thoracotomy in two patients and via left thoracotomy in the remaining one patient. There was no death in this group. Seven patients had no complications and were able to take part in normal activities. One patient suffered from anastomotic stricture after operation was healed by granulation tissue resection and cryotherapy under fibrobronchoscopy.

CONCLUSIONS

Fibrobronchoscopy is able to define the blunt main stem bronchial injuries precisely and surgical approach is the preferred method for patients with these life-threatening complications.

The anesthesia of trachea and bronchus surgery

The trachea and bronchus surgery is generally performed due to stenosis, traumatic injury, foreign body and tumors. Preoperative evaluation and anesthesia management are very important issues because of higher mortality and morbidity rates. Patients may be asymptomatic, but airway difficulties, hypoxia, stridor, cough, hemoptysis are common conditions in these patient population. The collaboration between the surgeon and the anesthesiologist is very substantial and necessary. Anesthetic techniques include various applications such as one lung ventilation, fiberoptic intubation, jet ventilation, and apneic oxygenation, general anesthesia with or without neuromuscular blockade. In this review, anesthesia management of the trachea and bronchus surgery is evaluated in the light of new knowledge.

Management of blunt pulmonary injury

Thoracic injuries account for 25% of all civilian deaths. Blunt force injuries are a subset of thoracic injuries and include injuries of the tracheobronchial tree, pleural space, and lung parenchyma. Early identification of these injuries during initial assessment and resuscitation is essential to reduce associated morbidity and mortality rates. Management of airway injuries includes definitive airway control with identification and repair of tracheobronchial injuries. Management of pneumothorax and hemothorax includes pleural space drainage and control of ongoing hemorrhage, along with monitoring for complications such as empyema and chylothorax. Injuries of the lung parenchyma, such as pulmonary contusion, may require support of oxygenation and ventilation through both conventional and nonconventional mechanical ventilation strategies. General strategies to improve pulmonary function and gas exchange include balanced fluid resuscitation to targeted volume-based resuscitation end points, positioning therapy, and pain management.

Complete cervical tracheal transection due to blunt trauma

Case

A 31-year-old man was caught up in the rotor of a snow-removing truck. He was diagnosed with tension pneumothorax and managed with tube thoracostomy in the ambulance. But he was left with respiratory discomfort. Computed tomography scan suggested the diagnosis of complete cervical tracheal transection.

Outcome

The endotracheal tube was advanced distal to the transection site under bronchoscopic guidance, which stabilized the patient's cardiopulmonary condition. The tracheal injury healed well after emergent surgical repair.

Conclusion

Complete cervical tracheal transection is rare and requires a high index of suspicion for timely diagnosis. It is important to secure the airway, which can be done by fiberoptic bronchoscopy.

Imaging of Large Airways Disorders

OBJECTIVE

Recent technical advances, including the routine use of CT thin sections and techniques such as 2D minimum-intensity-projection and 3D volume images, have increased our ability to detect large airways diseases. Furthermore, dedicated CT protocols allow the evaluation of dynamic airway dysfunction.

CONCLUSION

With diseases of the large airways more commonly seen in daily practice, it is important that radiologists be familiar with the appearances, differential diagnosis, and clinical implications of these entities.

Tracheobronchial injury due to blunt chest trauma

Tracheobronchial avulsion resulting from blunt trauma is a very rare and serious condition, mostly due to high-speed traffic crashes. In this article, we briefly report the case of an 18-year-old man who was injured in a car accident and because of massive persistent air leakage (despite appropriate chest tube drainage), deemed to have a deep tracheobronchial injury. Due to a rapid drop in the patient's O₂ saturation, he underwent an anterolateral thoracotomy. Endotracheal intubation was performed under direct visualization. The right mainstem bronchus was disrupted from the carina with a 1.5-cm stump remaining on the carina, and the remainder was crushed to the origin of the right superior lobe bronchus. Hence, a right superior lobectomy was performed and the postoperative course was uneventful.

Management of Blunt Pulmonary Injury

Thoracic injuries account for 25% of all civilian deaths. Blunt force injuries are a subset of thoracic injuries and include injuries of the tracheobronchial tree, pleural space, and lung parenchyma. Early identification of these injuries during initial assessment and resuscitation is essential to reduce associated morbidity and mortality rates. Management of airway injuries includes definitive airway control with identification and repair of tracheobronchial injuries. Management of pneumothorax and hemothorax includes pleural space drainage and control of ongoing hemorrhage, along with monitoring for complications such as empyema and chylothorax. Injuries of the lung parenchyma, such as pulmonary contusion, may require support of oxygenation and ventilation through both conventional and nonconventional mechanical ventilation strategies. General strategies to improve pulmonary function and gas exchange include balanced fluid resuscitation to targeted volume-based resuscitation end points, positioning therapy, and pain management.

Management of tracheobronchial injuries

Tracheobronchial injury is one of cases which are relatively uncommon, but must be suspected to make the diagnosis and managed immediately. In such a case, primary initial goals are to stabilize the airway and localize the injury and then determine its extend. These can be possible mostly with flexible bronchoscopy conducted by a surgeon who can repair the injury. Most of the penetrating injuries occur in the cervical region. On the other hand, most of the blunt injuries occur in the distal trachea and right main bronchus and they can be best approached by right posterolateral thoracotomy. The selection of the manner and time of approaching depends on the existence and severity of additional injuries. Most of the injuries can be restored by deploying simple techniques such as individual sutures, while some of them requires complex reconstruction techniques. Apart from paying attention to the pulmonary toilet, follow-up is crucial for determination of anastomotic technique or stenosis. Conservative treatment may be considered an option with a high probability of success in patients meeting the criteria, especially in patients with iatrogenic tracheobronchial injury.

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.