Delayed repair of bronchial avulsion in a child through median sternotomy

Complete transection of the bilateral main bronchus in a 5-year-old patient: a case report

BACKGROUND

Tracheobronchial injuries caused by blunt chest trauma are rare in children, and such injuries usually involve multiple organs. Most cases involve respiratory failure on the way to the hospital, and the mortality rate is high. Herein, we describe the case of a 5-year-old patient who fell from an electric vehicle, causing complete rupture of the bilateral main bronchus.

CASE PRESENTATION

We treated a 5-year-old patient with complete bilateral main bronchus rupture. Chest computed tomography (CT) failed to detect bronchial rupture. Continuous closed thoracic drainage resulted in a large amount of bubble overflow. Tracheal rupture was suspected. Fibreoptic bronchoscopy revealed complete rupture of the right main bronchus and rupture of the left main bronchus. Emergency tracheoplasty was performed under cardiopulmonary bypass (CPB). During the operation, we found that the bilateral main bronchi were completely ruptured. Postoperative recovery was smooth. The traditional surgical method for treating these injuries is lateral thoracotomy. However, a median sternotomy provides a better opportunity for selective repair. Extracorporeal circulation-assisted surgery is required for patients with unstable breathing.

CONCLUSION

Complete fractures of the bilateral main bronchi are rare. Bronchial rupture should be suspected in the presence of expansion defect-dropped lungs and massive air leakage despite tube thoracostomy in haemopneumothorax developing after thoracic trauma. Extracorporeal circulation-assisted tracheoplasty is a relatively safe option for children whose respiratory system is difficult to maintain, thus ensuring oxygenation ventilation and a clear surgical field.

Use of a modified tracheal tube in a child with traumatic bronchial rupture: A case report and review of literature

BACKGROUND

Trauma is one of the leading causes of death in the pediatric population. Bronchial rupture is rare, but there are potentially severe complications. Establishing and maintaining a patent airway is the key issue in patients with bronchial rupture. Here we describe an innovative method for maintaining a patent airway.

CASE SUMMARY

A 3-year-old boy fell from the seventh floor. Oxygenation worsened rapidly with pulse oxygen saturation decreasing below 60%, as his heart rate dropped. Persistent pneumothorax was observed with insertion of the chest tube. Fiberoptic bronchoscopy was performed, which confirmed the diagnosis of bronchial rupture. A modified tracheal tube was inserted under the guidance of a fiberoptic bronchoscope. Pulse oxygen saturation improved from 60% to 90%. Twelve days after admission, right upper lobectomy was performed using bronchial stump suture by video-assisted thoracic surgery without complications. A follow-up chest radiograph showed good recovery. The child was discharged from hospital three months after admission.

CONCLUSION

A modified tracheal tube could be selected to ensure a patent airway and adequate ventilation in patients with bronchial rupture.

Preserving lung after traumatic transection of left lower lobe bronchus from bullet injury

A 22-year-old soldier was shot in the left chest by a bullet from close range. He was found to have a left haemothorax and remained shocked despite aggressive resuscitation. Due to difficult terrain and night time movement restrictions, there were limitations to the transfer of patient. So he was attended at a peripheral hospital. At emergency thoracotomy, three segmental arteries to left upper lobe were ligated and haemostasis was secured. The level of transection of left lower lobe bronchus was identified to be below the origin of the apical segmental bronchus. The lower lobe bronchus was successfully re-attached and followed up with a daily bronchoscopic clearance of distal airway. The patient made a full recovery. Anastomosis of left lower lobe bronchus after traumatic transection is a viable option for preserving an amputated lobe, in trauma settings, provided haemostatic control has been adequately achieved.

Delayed repair of posttraumatic bronchial transection

Tracheobronchial injuries (TBI) are uncommon but potentially fatal injuries that can occur following blunt trauma to the thoracic region. Occasionally the diagnosis is not made at initial presentation, and patients present late with various sequelae. A 3 year old boy sustained blunt thoracic injury and developed respiratory distress, pneumothorax, and subcutaneous emphysema, which were managed conservatively with intercostal tube. Bronchoscopy performed to assess the cause of persistent collapse of the right lung and continued respiratory distress showed complete block of right main bronchus one cm away from the carina. Thoracotomy was performed and the transected ends of the bronchus were anastomosed. Postoperatively the right lung expanded with relief in respiratory distress. This report highlights the success of delayed repair of TBIs as an alternative to pneumonectomy.

Pneumomediastinum in blunt trauma: A review

Pneumomediastinum (PM) is an uncommon finding after blunt trauma to the neck or chest. Motor vehicle collisions are the most common cause in adults, while falls are the most common in children. The majority of traumatic PM results from medial tracking of air from a concomitant pneumothorax. The Macklin effect, of air tracking medially along peribronchial sheaths from alveolar rupture, is responsible for most other cases. Chest pain is the most common symptom, and crepitus the most common sign. The majority of PM will resolve spontaneously, and requires no specific intervention. Only 1—6% of cases result from rupture of the larynx, trachea, bronchi or oesophagus. Hoarseness, dyspnea, persistent lung collapse or air leak should increase suspicion for aerodigestive injury. Computed tomography (CT) can help differentiate benign etiology from those that require surgical correction. High suspicion for aerodigestive injury based on clinical and/or CT findings should prompt diagnostic bronchoscopy and/or oesophagram.

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.