Major Airways Trauma, Management and Long Term Results

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.

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.

Primary repair of a completely ruptured intermediate bronchus after blunt chest trauma. Case report

BACKGROUND

Tracheobronchial injury is rare and often has a fatal course. The incidence is estimated from 0.8% to 5% in the scenario of blunt or penetrating chest trauma.

CASE PRESENTATION

A 54-year-old male was brought to the emergency department after falling off his bicycle, with impact on head and right shoulder. At pre-hospital assessment, the patient had a free airway, gasping respiration (oxygen saturation 92%) with reduced vesicular breathing. Multiple rib fractures are palpable bilaterally, with subcutaneous emphysema. Computed tomography (CT) showed a large right-sided pneumothorax and consolidated lung lobes. After insertion of two chest tubes on the right, a refractory pneumothorax with large air leakage remained present. Subsequently, a bronchoscopy was performed, confirming a complete rupture of the right intermediate bronchus. Urgent surgical debridement and primary repair with an end-to-end running suture was performed. Rib osteosynthesis was additionally performed bilaterally, because of a flail chest on the right side and penetrating bone fragment on the left side. Respiratory function recovered uneventfully.

CONCLUSION

Airway injuries are uncommon but must always be suspected by the clinician during the early management of chest trauma. To prevent delayed diagnosis and potentially fatal outcome, low-threshold bronchoscopy is the diagnostic modality of choice to accurately confirm the lesion. Primary surgical repair remains the mainstay of the therapeutic management.

Urgent surgical repair is pivotal in the management of major airway injury due to blunt trauma

Background

Blunt traumatic airway injury is a life-threatening injury in which urgent management is pivotal and this would come through improving our clinical management and diagnostic tools. Our objective was to emphasize the importance of early referral and urgent surgical repair of major airway injury.

Results

Records of 42 patients with major airway injury out of 17,520 registered thoracic trauma cases were reviewed over the past 15 years. Twenty-eight cases documented to have major tracheobronchial injuries due to blunt trauma underwent surgical repair either urgent (21 cases) or late (7 cases). The age ranged from 8 to 43 years old with a mean age of 22.3 ± 0.8. The most common presenting symptom was shortness of breath in 22 (78.6%) cases and the most frequent sign was subcutaneous emphysema which was seen in 22 (78.6%) cases. The postoperative morbidity and mortality rates were significantly higher in the delayed repair group (p value < 0.001).

Conclusion

The urgent surgical repair is the treatment of choice for major airway injury which is facilitated by early recognition and referral. It is pivotal to avoid respiratory and systemic complications and related mortality.

Blunt trauma related chest wall and pulmonary injuries: An overview

Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the third most common cause of death in all age groups, one out of four trauma patients die due to thoracic injury or its complications. Blunt injuries constitute the majority of chest trauma. This indicates the importance of chest trauma among all traumas. Blunt chest trauma is usually caused by motor vehicle accident, falling from height, blunt instrument injury and physical assault. As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries. Following these injuries, patients may present with a simple dyspnea or even respiratory arrest. For such patient, it is important to understand the treatment logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries. This is because only 10% of thoracic trauma patients require surgical operation and the remaining 90% can be treated with simple methods such as appropriate airway, oxygen support, maneuvers, volume support and tube thoracostomy. Adequate pain control in chest trauma is sometimes the most basic and best treatment. With definite diagnosis, the morbidity and mortality can be significantly reduced by simple treatment methods.

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.

Surgical treatment of bronchial rupture in blunt chest trauma: a review of literature

Bronchial rupture by blunt chest trauma is rare. We present a case of bronchial injury after blunt chest trauma that was repaired surgically by primary reconstruction. We performed a review of literature to verify if primary reconstruction is suitable for the treatment of adult patients with blunt bronchial injury. A systematic search was conducted to identify cohort studies of bronchial rupture after blunt chest trauma in adult patients between 1985 and 2016 (n=215 articles). Studies were included concerning four or more patients and in case patient data could be extracted. This resulted in 19 articles for final review, consisting of 155 patients. Mean age of 155 patients was 28 (range, 18-60) years. The main bronchus was mostly injured (81%), in 5% including an injury of the trachea and in 14% lobar bronchi injury. Surgical repair was performed in 95% of patients: primary anastomosis in 72%, pneumonectomy in 15%, lobectomy or sleeve resection in 12% and other in 1%. Perioperative mortality rate was 10%. Other complications occurred in 17% (empyema, rebleeding, stenosis and fistula, among others). Data concerning the occurrence of long-term complications or long-term follow-up was not found. Statistical evaluation could not be performed due to lack of consistent patient data. No strong recommendations regarding type and timing of surgery can be made based on the available literature. Based on our multidisciplinary opinion we would advocate primary anastomosis in case of stable vital signs with the goal to preserve healthy lung parenchyma. Moreover, it may be considered transferring these rare cases to an experienced thoracic and trauma surgery center.

[Organ injuries due to thoracic trauma : Diagnostics, clinical importance and treatment principles]

Thoracic trauma can be a life-threatening condition due to the involvement of vital organs, such as the heart, lungs, tracheobronchial tree and the great vessels. A coordinated interdisciplinary management is vital for the survival of the injured person. Modern diagnostic procedures provide an essential basis for the surgical treatment of patients. Surgical treatment principles include insertion of chest drainage, emergency thoracotomy, complex bronchoplastic and vascular reconstructive techniques and cardiac surgical maneuvers. For this reason highly complex surgical procedures are available, which can be effectively and specifically integrated into an interdisciplinary concept. In this review, the most frequent and prognostically relevant conditions, the indicated diagnostics and their significance as well as the surgical treatment principles, are comprehensively presented under consideration of the clinical situation.

Delayed diagnosis of bronchial transection following blunt chest trauma

Diagnosis of blunt tracheobronchial injuries can be challenging. These injuries may appear within months or years following the initial trauma. In general, diagnosis and treatment of delayed presentation of tracheobronchial injuries are uncommon. Herein, we present the case of a 48-year-old woman with complete transection of the right bronchus that was diagnosed 50 days after the initial trauma. Reconstructive surgery of the bronchus was performed successfully without any need for pulmonary resection.

Traumatic bronchial injury

INTRODUCTION

Tracheobronchial injury is a recognized, yet uncommon, result of blunt trauma to the thorax. Often the diagnosis and treatment are delayed, resulting in attempted surgical repair months or even years after the injury.

PRESENTATION OF THE CASE

We present a case report of a 31-year old female who suffered a left main bronchus transection after a motor vehicle accident. The diagnostic, management issues, and clinical findings surrounding this injury are reviewed.

DISCUSSION

Tracheobronchial disruption is a rare, life-threatening injury. Suspicion should be high when pneumomediastinum and pneumothorax are refractory to adequate pleural drainage. Flexible bronchoscopy with intubation distal to the injury may be necessary to prevent loss of the airway. Advance preparation should include setups for bronchoscopy, thoracotomy, and cardiopulmonary bypass. Patient survival depends on preparation and prompt surgical intervention.

CONCLUSION

A high level of suspicion and the liberal use of bronchoscopy are important in the diagnosis of tracheobronchial injury. A tailored surgical approach is often necessary for definitive repair.

Incidence Rate of Post-Intubation Tracheal Stenosis in Patients Admitted to Five Intensive Care Units in Iran

Background

Tracheal stenosis is one of the worst complications associated with endotracheal intubation and it is the most common reason for reconstructive airway surgeries. Due to various local risk factors, the incidence rate of tracheal stenosis may vary in different countries. In order to estimate the incidence rate of post-intubation tracheal stenosis (PITS) in patients admitted to an intensive care unit (ICU), a follow-up study was planned. As there was no similar methodological model in the literature, a feasibility step was also designed to examine the whole project and to enhance the follow-up rate.

Objectives

To estimate the PITS incidence rate in patients admitted to ICUs, as well as to evaluate the feasibility of the study.

Methods

This prospective cohort study was conducted in five hospitals in two provinces (Tehran and Arak) of Iran from November 2011 to March 2013. All patients admitted to ICUs who underwent more than 24 hours of endotracheal intubation were included. Upon their discharge from the ICUs, the patients received oral and written educational materials intended to ensure a more successful follow-up. The patients were asked to come back for follow-up three months after their extubation, or sooner in case of any symptoms developing. Those with dyspnea or stridor underwent a bronchoscopy. The asymptomatic patients were given a spirometry and then they underwent a bronchoscopy if the flow-volume loop suggested airway stenosis.

Results

Some seventy-three patients (70% men) were included in the study. Multiple trauma secondary to motor vehicle accidents (52%) was the most common cause of intubation. Follow-ups were completed in only 14 (19.2%, CI = 0.109 - 0.300) patients. One patient (7%, CI = 0.007 - 0.288) developed symptomatic tracheal stenosis that was confirmed by bronchoscopy. The barriers to a successful follow-up were assessed on three levels: ineffective oral education upon discharge, improper usage of educational materials, and difficulties to attending follow-up visits. There were also some important obstacles in terms of human, time, material, and cost resources, as well as data management.

Conclusions

To enhance the follow-up rate, three strategies were proposed: patient-focused strategies such as emphasizing patient education upon discharge and providing rewards; structural-focused strategies such as scheduling home visits and uploading questionnaires onto the research center’s website; and provider-focused strategies such as selecting coordinators with good communication skills. All necessary resources should also be re-arranged for a multicenter national study.

Repair of tracheobronchial injuries

Tracheobronchial injuries (TBIs) are caused by blunt, penetrating injury or by iatrogenic damage. Most injuries are life threatening and need early and skillful airway management. Bronchoscopy remains the gold standard of diagnosis. Penetrating TBI always needs blunt trauma, and iatrogenic TBI sometimes needs surgical exploration and reconstruction, which is performed after sparing debridement with primary repair and wound closure. Prognosis mainly depends on associated injuries and comorbidities in terms of tracheal membrane laceration.

The role of T-tubes in the management of airway stenosis

OBJECTIVES

When the T-tube is inserted as a temporary stent, it is unclear whether keeping it longer in place has any benefit on the outcome.

METHODS

Among 1738 patients with airway stenosis (1996-2011), 134 underwent T-tube placement (mean duration = 14.3 months); temporarily while waiting for an appropriate time for surgery in 53 (Group 1), as an adjunct after a complex laryngotracheal resection in 27 (Group 2), after surgical failure in 43 (Group 3) and permanently in 11 unresectable strictures (Group 4). A logistic regression model was used for statistical analysis.

RESULTS

Seventy percent of patients were males (age = 33.6 ± 17 years). The main cause was postintubation/post-tracheostomy stenosis in 87% of patients. The stenosis (29.6 ± 14 mm, 5-80 mm) was located in the subglottis in 33%, trachea in 47% and both in 20% of cases. To assess the effect of T-tubes on stabilizing the airway after decannulation, 50 patients who still had a T-tube at the end of follow-up or for <1.5 months were excluded. Of the remaining 84, 31.5, 91.5 and 32.5% of patients in Groups 1, 2 and 3 were stable at least 3 months after decannulation. Moreover, 70% of those who were decannulated at or before 6 months and 53.7% of those who were decannulated after 6 months underwent another intervention (P = 0.17). The age, sex, cause, site of stenosis and even duration of T-tube insertion (P = 0.07) showed no significant effect on the decannulation outcome.

CONCLUSIONS

Although it seems that keeping the T-tube in place for >6 months may increase the chance of successful decannulation, it was not confirmed in our study.