Using CT to diagnose tracheal rupture

Tracheal bifurcation repair for blunt thoracic trauma in a patient with COVID-19

BACKGROUND

Tracheobronchial injury (TBI) is a rare but potentially life-threatening trauma that requires prompt diagnosis and treatment. We present a case in which a patient with COVID-19 infection was successfully treated for a TBI through surgical repair and intensive care with extracorporeal membrane oxygenation (ECMO) support.

CASE PRESENTATION

This is the case of a 31-year-old man transported to a peripheral hospital following a car crash. Tracheal intubation was performed for severe hypoxia and subcutaneous emphysema. Chest computed tomography showed bilateral lung contusion, hemopneumothorax, and penetration of the endotracheal tube beyond the tracheal bifurcation. A TBI was suspected; moreover, his COVID-19 polymerase chain reaction screening test was positive. Requiring emergency surgery, the patient was transferred to a private negative pressure room in our intensive care unit. Due to persistent hypoxia and in preparation for repair, the patient was started on veno-venous ECMO. With ECMO support, tracheobronchial injury repair was performed without intraoperative ventilation. In accordance with the surgery manual for COVID-19 patients in our hospital, all medical staff who treated this patient used personal protective equipment. Partial transection of the tracheal bifurcation membranous wall was detected and repaired using 4-0 monofilament absorbable sutures. The patient was discharged on the 29th postoperative day without postoperative complications.

CONCLUSIONS

ECMO support for traumatic TBI in this patient with COVID-19 reduced mortality risk while preventing aerosol exposure to the virus.

Post-intubation iatrogenic tracheobronchial injuries: The state of art

Iatrogenic tracheobronchial injury (ITI) is an infrequent but potentially life-threatening disease, with significant morbidity and mortality rates. Its incidence is presumably underestimated since several cases are underrecognized and underreported. Causes of ITI include endotracheal intubation (EI) or percutaneous tracheostomy (PT). Most frequent clinical manifestations are subcutaneous emphysema, pneumomediastinum and unilateral or bilateral pneumothorax, even if occasionally ITI can occur without significant symptoms. Diagnosis mainly relies on clinical suspicion and CT scan, although flexible bronchoscopy remains the gold standard, allowing to identify location and size of the injury. EI and PT related ITIs more commonly consist of longitudinal tear involving the pars membranacea. Based on the depth of tracheal wall injury, Cardillo and colleagues proposed a morphologic classification of ITIs, attempting to standardize their management. Nevertheless, in literature there are no unambiguous guidelines on the best therapeutic modality: management and its timing remain controversial. Historically, surgical repair was considered the gold standard, mainly in high-grade lesions (IIIa-IIIb), carrying high morbi-mortality rates, but currently the development of promising endoscopic techniques through rigid bronchoscopy and stenting could allow for bridge treatment, delaying surgical approach after improving general conditions of the patient, or even for definitive repair, ensuring lower morbi-mortality rates especially in high-risk surgical candidates. Our perspective review will cover all the above issues, aiming at providing an updated and clear diagnostic-therapeutic pathway protocol, which could be applied in case of unexpected ITI.

Imaging in the Intensive Care Unit

Radiology plays an important role in the management of the most seriously ill patients in the hospital. Over the years, continued advances in imaging technology have contributed to an improvement in patient care. However, even with such advances, the portable chest radiograph (CXR) remains one of the most commonly requested radiographic examinations. While they provide valuable information, CXRs remain relatively insensitive at revealing abnormalities and are often nonspecific. Chest computed tomography (CT) can display findings that are occult on CXR and is particularly useful at identifying and characterizing pleural effusions, detecting barotrauma including small pneumothoraces, distinguishing pneumonia from atelectasis, and revealing unsuspected or additional abnormalities which could result in increased morbidity and mortality if left untreated. CT pulmonary angiography is the modality of choice in the evaluation of pulmonary emboli which can complicate the hospital course of the ICU patient. This article will provide guidance for interpretation of CXR and thoracic CT images, discuss some of the invasive devices routinely used, and review the radiologic manifestations of common pathologic disease states encountered in ICU patients. In addition, imaging findings and complications of more specific clinical scenarios in which the incidence has increased in the ICU setting, such as patients who are immunocompromised, have interstitial lung disease, or COVID-19, will also be discussed. Communication between the radiologist and intensivist, particularly on complicated cases, is important to help increase diagnostic accuracy and leads to an improvement in the management of the most critically ill patients.

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.

Repairing the injured bronchus in blunt chest trauma – A case series

Introduction

Traumatic bronchial injury (TBI) is uncommon, difficult to diagnose and often missed. The incidence of TBI among blunt trauma patients is estimated to be around 0.5–2%. Bronchoplastic surgery is indicated in most cases to repair the tracheobronchial airway and preserve lung capacity. There is limited existing literature addressing the management of this condition in view of its rarity. The comprehensive management and outcomes of these patients are discussed.

Methods

The case notes of all patients who presented with persistent lung collapse due to trauma since July 2017 were reviewed retrospectively. Those patients requiring surgical intervention were included in the review. The mode of injury, clinical, radiological and bronchoscopy findings, concurrent injuries, type of surgery, length of stay (LOS) and operative outcomes were reviewed.

Results

Out of 11 patients who presented with persistent lung collapse post-blunt trauma, four (36%) were found to have structural bronchial disruption. All of them underwent successful repair of the injured bronchus, without the need of a pneumonectomy. The other seven patients were successfully treated conservatively.

Conclusion

The repair of the injured bronchus is essential in improving respiratory function and to prevent a pneumonectomy. Routine bronchoscopic evaluation should be performed for all suspected airway injuries as recommended in our management algorithm. Delayed presentations should not hinder urgent referral to thoracic centers for tracheobronchial reconstruction.

Spontaneous rupture of trachea treated conservatively: A case report

Introduction and importance

Spontaneous rupture of the trachea is a rare, life-threatening condition. Spontaneous rupture associated with corticosteroid use has been rarely reported in the literature.

Case presentation

We report a case of a 17-year-old male, a known case of nephrotic syndrome managed by corticosteroid treatment, who presented with diffuse neck and chest swelling after forceful coughing resulting in a spontaneous rupture of the trachea. The diagnosis was established using radiological imaging. The patient was managed conservatively with significant improvement and was discharged shortly.

Clinical discussion

Prolonged use of corticosteroids may lead to spontaneous rupture of the trachea due to tracheal wall weakness. Radiological imaging followed by bronchoscopy can be used to confirm the diagnosis. Management can either be conservative or surgical, depending on the case.

Conclusion

Conservative treatment by pain relief, intravenous fluids, and antibiotics should be considered an alternative to surgery in selected patients.

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Spontaneous rupture of the trachea is a rare and life-threatening condition.

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Spontaneous rupture of the trachea can be predisposed by prolonged corticosteroid use.

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The prompt diagnosis and appropriate management of patients with tracheal rupture are crucial.

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Diagnostic measures for spontaneous tracheal rupture include radiological imaging with the possible need for bronchoscopy.

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Tracheal rupture should be suspected in the presence of pneumomediastinum and cervical emphysema without pneumothorax.

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Tracheal rupture can be managed either conservatively or surgically depending on the patient’s whole clinical picture.

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.

Spontaneous pneumomediastinum in accidental chlorine gas inhalational injury: case report and review of literature

A young man presented in emergency department with shortness of breath and cough after accidental inhalation of chlorine gas. Initial presentation was unremarkable; therefore, he was kept under observation for 8 hours and was later discharged. After 5 hours, the patient presented again in emergency department with sudden-onset shortness of breath and chest discomfort. On examination, subcutaneous crepitation around the neck and chest was found. Chest and neck X-ray revealed subcutaneous emphysema and pneumomediastinum. CT neck and chest was done, which revealed subcutaneous emphysema and pneumomediastinum and a linear air density in close approximation to right posterolateral wall of trachea at the level of superior margin of sternum was reported. These findings raised the possibility of tracheal injury which was later confirmed by fiberoptic laryngoscopy. The patient was intubated due to hypercapnic respiratory failure resulting from hypoventilation and respiratory distress. Bilateral chest tube insertion was done due to worsening subcutaneous emphysema, high ventilator parameters and prevention of progression to pneumothorax. He was extubated after 5 days; bilateral chest tubes were removed before discharge and underwent uneventful recovery.

Imaging Manifestations of Chest Trauma

Trauma is the leading cause of death among individuals under 40 years of age, and pulmonary trauma is common in high-impact injuries. Unlike most other organs, the lung is elastic and distensible, with a physiologic capacity to withstand significant changes in contour and volume. The most common types of lung parenchymal injury are contusions, lacerations, and hematomas, each having characteristic imaging appearances. A less common type of lung injury is herniation. Chest radiography is often the first-line imaging modality performed in the assessment of the acutely injured patient, although there are inherent limitations in the use of this modality in trauma. CT images are more accurate for the assessment of the nature and extent of pulmonary injury than the single-view anteroposterior chest radiograph that is typically obtained in the trauma bay. However, the primary limitations of CT concern the need to transport the patient to the CT scanner and a longer processing time. The American Association for the Surgery of Trauma has established the most widely used grading scale to describe lung injury, which serves to communicate severity, guide management, and provide useful prognostic factors in a systematic fashion. The authors provide an in-depth exploration of the most common types of pulmonary parenchymal, pleural, and airway injuries. Injury grading, patient management, and potential complications of pulmonary injury are also discussed. ^©RSNA, 2021.

Finding the bubble: atypical and unusual extrapulmonary air in the chest

OBJECTIVE

To describe the radiologic findings of extrapulmonary air in the chest and to review atypical and unusual causes of extrapulmonary air, emphasizing the importance of the diagnosis in managing these patients.

CONCLUSION

In this article, we review a series of cases collected at our center that manifest with extrapulmonary air in the thorax, paying special attention to atypical and uncommon causes. We discuss the causes of extrapulmonary according to its location: mediastinum (spontaneous pneumomediastinum with pneumorrhachis, tracheal rupture, dehiscence of the bronchial anastomosis after lung transplantation, intramucosal esophageal dissection, Boerhaave syndrome, tracheoesophageal fistula in patients with esophageal tumors, bronchial perforation and esophagorespiratory fistula due to lymph-node rupture, and acute mediastinitis), pericardium (pneumopericardium in patients with lung tumors), cardiovascular (venous air embolism), pleura (bronchopleural fistulas, spontaneous pneumothorax in patients with malignant pleural mesotheliomas and primary lung tumors, and bilateral pneumothorax after unilateral lung biopsy), and thoracic wall (infections, transdiaphragmatic intercostal hernia, and subcutaneous emphysema after lung biopsy).

Management of tracheobronchial injuries

Tracheobronchial injuries (TBI) are a heterogenous group of sometimes life-threatening traumas with different management approaches. Symptoms are mediastinal and subcutaneous emphysema, bloody secretions from the airway or haemoptysis in alert patients, and high air leakage along the cuff or increased ventilatory resistance may be signs for TBI in intubated patients. The necessity of immediate clinical evaluation, CT-scan and bronchoscopic evaluation are essential for prompt diagnosis and classification as well as experienced air way management and treatment, these patients are best managed from interdisciplinary teams including thoracic surgeons. While iatrogenic tracheal membrane laceration from intubation can be treated by lesion bridging with ventilation tube, stent application, open operative repair or endoluminal repair, intraoperative accidental cuts should be repaired by direct suture or with vital tissue coverage in case of local ischemia. The management of blunt or penetrating injury is sequential and needs immediate establishment and maintenance of a secure patent airway to provide adequate oxygenation. The next step is the treatment of life-threatening collateral injuries like major hemorrhage, cranial trauma or major organ damage arranged in the trauma team. The treatment of penetrating injuries to the airway need operative exploration in almost every case with minimal local dissection and debridement followed by direct repair. Muscle flap coverage is useful in case of combined esophageal injury. Damage of the tracheobronchial tree after blunt trauma must be repaired by direct suture or local tissue sparing resection and anastomosis. These lesions can be missed in the initial phase and may become prominent with scar tissue formation, stenosis and atelectasis in the later phases.

Successful tracheoscopy-assisted reconstruction of traumatic tracheal avulsion in a cat

OBJECTIVE

To outline the clinical findings, surgical management, complications, and outcomes in a case of intrathoracic, traumatic, tracheal avulsion.

CASE SUMMARY

A 2-year-old domestic shorthair cat presented with respiratory distress 18 days after a motor vehicle accident. A tracheal avulsion was diagnosed and treated by surgical anastomosis. The initial anastomosis failed. The subsequent tracheoscopic-assisted tracheal anastomosis was successful. The cat had no further episodes of respiratory distress following the second surgery in a 9-month follow-up period.

UNIQUE INFORMATION PROVIDED

This communication describes a complication of intrathoracic, traumatic, tracheal avulsion repair that has not previously been described and the use of tracheoscopy during the subsequent surgical procedure to ensure accurate suture placement.

Detection and Management of Intraoperative Pneumothorax during Laparoscopic Cholecystectomy

Intraoperative pneumothorax is a rare but potentially lethal complication during general anesthesia. History of lung disease, barotrauma, and laparoscopic surgery increase the risk of developing intraoperative pneumothorax. The diagnosis during surgery could be difficult because the signs are often nonspecific. We report a case of a middle-aged gentleman who developed right pneumothorax during an elective laparoscopic cholecystectomy. The patient had no risk factors for adverse events during the preoperative assessment (ASA1). The patient underwent general anesthesia and was put on mechanical ventilation. The first signs of abnormality immediately after surgical port insertion were tachycardia and low oxygen saturation in addition to sings of airway obstruction. The diagnosis of pneumothorax was made clinically by chest auscultation and later confirmed by intraoperative chest radiograph. Supportive treatment was started immediately through halting the surgery and manually ventilating the patient using 100% oxygen. Definitive treatment was then done by inserting an intercostal tube. After stabilizing the patient, the surgery was completed; then, the patient was extubated and shifted to the surgical ward. Postoperative computed tomography (CT) scan was done and showed only minimal liver laceration. The patient was discharged after removing the intercostal tube and was stable at the follow-up visit. Therefore, it is important to have a high index of suspicion to early detect and treat such complication. In addition, good communication with the surgeon and use of available diagnostic tools will aid in the proper management of such cases.

Imaging of Neck Visceral Trauma

The neck visceral space is a complex region housing several vital structures. Diagnostic imaging plays an important role in the evaluation of neck visceral injuries. Many injuries are initially missed by both clinicians and radiologists because of their infrequency and the high likelihood of other more obvious injuries. Understanding which diagnostic modality to apply at given point in the work-up; recognizing relevant clinical signs, symptoms, and injury mechanisms; and knowing pertinent direct and indirect imaging findings of injury allow radiologists to either directly render the correct diagnosis or choose the most appropriate tool for doing so.

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.

Massive Subcutaneous Emphysema After Multiple Tracheal Intubation

Early confi rmation of tracheal injury is crucial while encountering massive subcutaneous emphysema in emergency department to prevent patients from serious morbidity or mortality. Clinicians often underestimate the difficulty of tracheal intubation, especially for inexperienced physician. We highlight that the use of video laryngoscopy-assisted tracheal intubation or ultrasound for diffi cult airway management. An 80-yearold woman presented to emergency department because of diffuse subcutaneous emphysema in her chest and neck after multiple attempts of intubation. Subcutaneous crepitus was palpated in the chest and neck. The chest X-ray showed diffuse subcutaneous emphysema in chest wall and neck. The computed tomography revealed paratracheal air, focal defect at right posterior aspect of lower trachea and subcutaneous emphysema, pneumomediastinum and pneumoretroperitoneum. Bronchoscopy demonstrated the presence of 2 cm in length longitudinal laceration wound above the carina. She refused surgical intervention and was treated conservatively. Most patients with tracheal injury may present with subcutaneous emphysema and respiratory distress. Diagnosis could be made based on the findings of computed tomography and bronchoscopy examination. Early recognition could prompt surgical intervention and empirical antibiotics administration to preclude immediate acute respiratory distress.

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.

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.

Penetrating Neck Injuries: from ER to OR

Neck contains several vital structures, in a small close space, in complex relationship to each other, and unprotected by any bony framework. Any injury to this crucial region, hence mostly becomes an acute emergency. Appropriately managing the same has always been a point of constant discussion amongst head and neck surgeons. The basic aim of the study was to discuss the management, comorbidities, prognosis and associated complications encountered in a series of patients with penetrating neck trauma (piercing platysma), presenting to the emergency over a period of 1 year. Combat injuries and patients declared as brought dead at the time of first examination were excluded. This was a retrospective study of patients with cut throat injury, managed at a tertiary center of northern India from June 2014 to September 2015. Following management in the ER as per ATLS guidelines, all patients were then operated for specific injuries. Graph pad software was used for statistical analysis. Of the 15 patients studied in total, 11 (73.3%) were males. The mean patient age was 33.67 years. Mean duration of presentation was 20.85 h. 60% patients had homicidal injuries. Tracheostomy and Ryle's tube insertion was done in 8 (53.3%) patients. Exploration and surgical repair was done in all patients without any mortality. 4 patients developed post-operative complications. Mean duration of hospital stay was 9.2 days. Immediate resuscitation followed by exploration and primary repair is a must in all patients of penetrating neck injury.

Computed tomographic findings in a Bluetick Coonhound with a longitudinal thoracic tracheal tear

A 9-year-old intact male Bluetick Coonhound presented for progressive subcutaneous emphysema of 5 days' duration due to a suspected tracheal tear. Cervical computed tomography (CT) and thoracic CT were performed after failure to identify the tracheal tear with tracheoscopy. A longitudinal tracheal tear was identified starting 4.3 cm cranial to the tracheal bifurcation and extending caudally over a distance of 3.6 cm. Severe pneumomediastinum, subcutaneous emphysema, and retroperitoneal gas were also present. A follow-up CT 7 days postoperatively confirmed the successful repair of the tear with partial resolution of the presurgical secondary pathology and the patient recovered uneventfully.

Endoscopic treatment with fibrin glue of post-intubation tracheal laceration

Post-intubation tracheal laceration (PITL) is a rare and potential life-threatening condition requiring prompt diagnosis and treatment. A conservative treatment is indicated in patients with laceration <2 cm in length while surgery is the treatment of choice for laceration >4 cm. For laceration between 2-4 cm, the best treatment is debate; some authors recommend surgery while others do not definitely exclude endoscopic treatment. Herein, we reported the endoscopic treatment with fibrin glue of PITL. The procedure is performed using a standard video-bronchoscopy in operating room; the patient is in spontaneous breathing and deep sedation. After identification of tracheal laceration, the fibrin glue is injected through a dedicated double lumen catheter into the lesion. After mixing both components of fibrin glue, polymerization of fibrin occurs resulting in an elastic and opaque clot that closes the lesion. The key success of the procedure is based on accurate patient selection. Patients are eligible if (I) they are clinically stable and in spontaneous respiration; (II) with a small and superficial tracheal laceration (≤4 cm in length and without oesophageal injury); (III) localized at level of the upper or middle trachea; and (IV) without clinical and/or radiological signs of mediastinal collection, of emphysema or pneumomediastinum progression, and of infection.

Tracheal tear from blunt neck trauma in children: Diagnosis and management

We describe the management of posterior trachea tears after blunt neck trauma in two children. The first, a 5 year-old boy who fell off his scooter, causing a 1.0cm tear in the membranous cervical trachea, was managed conservatively with 5 days of intubation. The second, a 12 year-old girl who fell on her bicycle, causing a 4.0cm tear in the membranous thoracic trachea, was repaired with thoracoscopic techniques. The presumed mechanism may be expansion of the U-shaped cartilage with tear of the membranous trachea. The size, location, and severity of symptoms dictate the decision about primary repair versus conservative management.

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.

Successful Conservative Management of Tracheal Injury After Forceful Coughing During Extubation: A Case Report

A-56-year-old woman underwent carpal tunnel release surgery under general anesthesia. Thirty minutes after extubation, the patient complained of chest discomfort with dyspnea. Swelling of the neck and upper anterior chest was observed. Computed tomography of the chest showed tracheal rupture at the brachiocephalic trunk level, and bronchoscopy demonstrated a 5 cm linear tracheal defect in the posterior membranous wall, 6 cm proximal to the carina. Surgical repair of the tracheal injury was impossible due to its location. The patient was managed with intubation, mechanical ventilator care, and antibiotics. She made a full and uncomplicated recovery and was discharged 18 days after the original injury. When suspicious symptoms appear in patients receiving mechanical ventilation support, an immediate and accurate diagnostic process should be undertaken to rule out endotracheal tube-related tracheal injuries and to avoid potentially lethal complications.

Airway stenting in the management of iatrogenic tracheal injuries: 10-Year experience

BACKGROUND AND OBJECTIVE

Iatrogenic tracheal injury (ITI) is a rare yet severe complication of endotracheal tube (ETT) placement or tracheostomy. ITI is suspected in patients with clinical and/or radiographic signs or inefficient mechanical ventilation (MV) following these procedures. Bronchoscopy is used to establish a definitive diagnosis.

METHODS

We conducted a retrospective, single-centre chart review of 35 patients between 2004 and 2014. Depending on the nature and location of ITI and need for MV, patients were triaged to surgical repair, endoscopic management with airway stents or conservative treatment consisting of ETT or tracheotomy cannula (TC) placement distal to the wound and bronchoscopic surveillance.

RESULTS

Three of the four patients (11.43%) presenting with tracheoesophageal fistula (TEF) underwent surgery. Seven patients (20%) who did not require MV underwent endoscopic surveillance. Of the 24 ventilated patients (68.57%), 7 with ITI in the lower trachea were treated with silicone Y-stent (ETT or TC was placed inside the stent) and 17 patients with ITI in the upper trachea were managed by placing ETT or TC cuff distal to the injury. Overall management success, defined as complete healing of the ITI, was seen in 88.57% of patients. Four patients (11.43%) died of non-ITI-related comorbidities.

CONCLUSION

Conservative management should be considered in non-ventilated patients with ITI and when ITI is located in the upper trachea of ventilated patients where ETT or TC bypasses the injury. Airway stenting should be considered in ventilated patients with ITI located in the lower trachea. Surgery should be reserved for TEF and conservative and endoscopic management failure.

Tracheobronchial Injury caused by Blunt Trauma: Case Report and Review of Literature

Tracheobronchial injuries are rare cases requiring skillful airway management. We report a challenging case of tracheobronchial injury in a young adult who was run over by a tractor and was referred to us from a peripheral hospital with endotracheal tube in situ. He was severely hypoxaemic on initial presentation. Diagnostic work up showed high suspicion for right bronchial transection along with left lung upper lobe contusion. Due to deteriorating clinical condition of the patient and despite immediate unavailability of fibreoptic bronchoscope, patient was immediately taken up for right posterolateral thoracotomy and double lumen tube was inserted. The position of the tube was confirmed clinically. As soon as the fibreoptic bronchoscope arrived, it was again used to confirm the position of double lumen tube. Patient's clinical condition improved after repair of the injured right bronchus and he was later extubated the next day.

COMPARISON OF FLUOROSCOPY AND COMPUTED TOMOGRAPHY FOR TRACHEAL LUMEN DIAMETER MEASUREMENT AND DETERMINATION OF INTRALUMINAL STENT SIZE IN HEALTHY DOGS

Tracheal collapse is a progressive airway disease that can ultimately result in complete airway obstruction. Intraluminal tracheal stents are a minimally invasive and viable treatment for tracheal collapse once the disease becomes refractory to medical management. Intraluminal stent size is chosen based on the maximum measured tracheal diameter during maximum inflation. The purpose of this prospective, cross-sectional study was to compare tracheal lumen diameter measurements and subsequent selected stent size using both fluoroscopy and CT and to evaluate inter- and intraobserver variability of the measurements. Seventeen healthy Beagles were anesthetized and imaged with fluoroscopy and CT with positive pressure ventilation to 20 cm H2 O. Fluoroscopic and CT maximum tracheal diameters were measured by three readers. Three individual measurements were made at eight predetermined tracheal sites for dorsoventral (height) and laterolateral (width) dimensions. Tracheal diameters and stent sizes (based on the maximum tracheal diameter + 10%) were analyzed using a linear mixed model. CT tracheal lumen diameters were larger compared to fluoroscopy at all locations (P-value < 0.0001). When comparing modalities, fluoroscopic and CT stent sizes were statistically different. Greater overall variation in tracheal diameter measurement (height or width) existed for fluoroscopy compared to CT, both within and among observers. The greater tracheal diameter measured with CT and lower measurement variability has clinical significance, as this may be the imaging modality of choice for appropriate stent selection to minimize complications in veterinary patients.

Emergent repair of bronchial transection: both right and left main bronchial lung ventilation at surgery makes it easy for all

Maintaining adequate gas exchange is crucial during surgical repair of tracheobronchial injuries in children and reflects the skills of the anaesthetist and the surgeon. We present a 7-year-old girl who underwent urgent repair of the bronchial transection and novel use of ventilation of the transected lung helped accomplish the repair successfully.

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.

Spontaneous Tracheal Rupture in a Case of Interstitial Lung Disease (ILD): A Case Report

Spontaneous tracheal rupture is one of the rare life threatening conditions. Tracheal lacerations are generally secondary to cervical or chest trauma or occurring as a complication of endotracheal intubation. Only two cases of spontaneous tracheal rupture are reported, in adults, one due to acquired tracheobronchomalacia and other due to long term steroid use. We hereby report a very rare case of spontaneous tracheal rupture in young male patient of interstitial lung disease (ILD) who was on steroids for two months and developed spontaneous subcutaneous emphysema and pneumomediastinum. Tracheal rupture was diagnosed on unenhanced computed tomography (CT) and reconstructed virtual bronchoscopic images. Patient subsequently died due to cardiac arrest.

Penetrating Thoracic Injury

This article discusses the role of radiology in evaluating patients with penetrating injuries to the chest. Penetrating injuries to the chest encompass ballistic and nonballistic injuries and can involve superficial soft tissues of the chest wall, lungs and pleura, diaphragm, and mediastinum. The mechanism of injury in ballistic and nonballistic trauma and the impact the injury trajectory has on imaging evaluation of penetrating injuries to the chest are discussed. The article presents the broad spectrum of imaging findings a radiologist encounters with penetrating injuries to the chest, with emphasis on injuries to the lungs and pleura, diaphragm, and mediastinum.

Unusual case of acute tracheal injury complicated by application of positive end expiratory pressure (PEEP)

Blunt neck trauma can be caused by a variety of injuries such as deceleration, road traffic accidents and crush injuries. The worst scenario is airway rupture. We report an unusual case of acute tracheal injury in a 34-year-old Irish man who presented with a history of strangulation while working with a tractor. On arrival, he had one episode of mild haemoptysis and reported pain around the base of the neck and voice hoarseness. His chest X-ray revealed pneumopericardium and CT of thorax showed airway oedema. After elective intubation, positive end-expiratory pressure (PEEP) of 5 cm H2O caused deterioration in his clinical condition with increasing surgical emphysema and rise of carbon dioxide partial pressure (PaCO2), which was completely reversed after stopping PEEP. This case shows how PEEP and intermittent positive pressure ventilation can worsen air leak and compromise stability in patients with acute tracheal injury.

To breathe or not to breathe: a review of artificial airway placement and related complications

Artificial airway devices are commonly used to provide adequate ventilation and/or oxygenation in multiple clinical settings, both emergent and nonemergent. These frequently used devices include laryngeal mask airway, esophageal-tracheal combitube, endotracheal tube, and tracheostomy tube and are associated with various acute and late complications. Clinically, this may vary from mild discomfort to a potentially life-threatening situation. Radiologically, these devices and their acute and late complications have characteristic imaging findings which can be detected primarily on radiographs and computed tomography. We review appropriate positioning of these artificial airway devices and illustrate associated complications including inadequate positioning of the endotracheal tube, pulmonary aspiration, tracheal laceration or perforation, paranasal sinusitis, vocal cord paralysis, post-intubation tracheal stenosis, cuff overinflation with vascular compression, and others. Radiologists must recognize and understand the potential complications of intubation to promptly guide management and avoid long-term or even deadly consequences.

Multidetector computer tomography: evaluation of blunt chest trauma in adults

Imaging plays an essential part of chest trauma care. By definition, the employed imaging technique in the emergency setting should reach the correct diagnosis as fast as possible. In severe chest blunt trauma, multidetector computer tomography (MDCT) has become part of the initial workup, mainly due to its high sensitivity and diagnostic accuracy of the technique for the detection and characterization of thoracic injuries and also due to its wide availability in tertiary care centers. The aim of this paper is to review and illustrate a spectrum of characteristic MDCT findings of blunt traumatic injuries of the chest including the lungs, mediastinum, pleural space, and chest wall.

Conservative management of post-intubation tracheal tears-report of three cases

Iatrogenic tracheal rupture is a rare complication after intubation. We present three patients with tracheal tears. In all of these patients, a common finding was a lesion of the posterior tracheal wall with postoperative subcutaneous and emphysema as the first clinical sign of the rupture. Diagnosis and follow-up were based on clinical and endoscopic findings and chest computed tomography (CT) scans. In our cases with progressive subcutaneous and mediastinal emphysema or dyspnea, we performed a tracheotomy and bypassed the lesion with a tracheostomy tube to avoid an increase in air leakage into the mediastinum. Under broad-spectrum antibiotic therapy, no mediastinitis occurred and all patients survived without sequelae. Closure of tracheostomy was scheduled for 1-2 months after tracheal injury. Analysis of surgical and anesthesiological procedures revealed no abnormalities and the accumulation of tracheal injuries was considered as accidental. We found that in clinically stable patients with spontaneous breathing and with no mediastinitis, a conservative management of tracheal tears is a safe procedure.

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.

Imaging of penetrating injuries of the head and neck:current practice at a level I trauma center in the United States

Penetrating neck injuries are commonly related to stab wounds and gunshot wounds in the United States. The injuries are classified by penetration site in terms of the three anatomical zones of the neck. Based on this zonal classification system, penetrating injuries to the head and neck have traditionally been evaluated by conventional angiography and/or surgical exploration. In recent years, multidetector-row computed tomography (CT) angiography has significantly improved detectability of vascular injuries and extravascular injuries in the setting of penetrating injuries. CT angiography is a fast and minimally invasive imaging modality to evaluate penetrating injuries of the head and neck for stable patients. The spectrum of penetrating neck injuries includes vascular injury (extravasation, pseudoaneurysm, dissection, occlusion, and arteriovenous fistula), aerodigestive injury (esophageal and tracheal injuries), salivary gland injury, neurologic injury (spinal canal and cerebral injuries), and osseous injury, all of which can be evaluated using CT angiography. Familiarity with the complications and imaging characteristics of penetrating injuries of the head and neck is essential for accurate diagnosis and optimal treatment.