Elsevier

Thoracic Surgery Clinics

Volume 28, Issue 3, August 2018, Pages 429-434
Thoracic Surgery Clinics

Blunt Tracheobronchial Trauma

https://doi.org/10.1016/j.thorsurg.2018.04.008Get rights and content

Section snippets

Key points

  • Most blunt tracheobronchial injuries occur within 2.5 cm of the main carina. The blunt traumatic forces resulting in such damage often result in lethal associated injuries.

  • Fiberoptic bronchoscopy allows for the definite evaluation of such injuries, often suspected clinically or on imaging.

  • Operative management is carried out on stable patients in either early or delayed fashions. Planning such repairs demands strong communication and cooperation with anesthesia. Also, the access incision should

History

Blunt chest trauma has been described as early as during the time of Hippocrates, as presence of hemothorax due to rib fractures. In the 19th century, Webb and Winslow shared the rare survival of tracheobronchial injuries being repaired in that era: the immense forces needed for blunt thoracic injuries make this a lethal injury, making premodern times reporting limited to autopsy reports.1 Nissen, in 1930, described a successful pneumonectomy in the management of a posttraumatic bronchial

Epidemiology

Autopsy reports have provided immense information on this subset of thoracic trauma, because most of these patients do not survive; 80% die on the scene. In a large trauma autopsy series, Bertelsen and Howitz reported 2.8% rate of tracheobronchial injury in their 1178 autopsies, most of which are thoracic rather than cervical.5 Even at busy regional trauma centers only 3 or 4 cases may be managed annually.6 Mortality was reportedly close to 30% for those who arrive alive to the trauma bay. More

Anatomy

Salassa and colleagues11 describes the intricate anatomy of the blood supply to the trachea. By radiolabeled evaluation of 21 cadaveric human tracheae, we have a deeper understanding of the vasculature outlined by Grillo’s earlier work. The cervical trachea has a more constant blood supply than the thoracic. The major source to the cervical trachea is the inferior thyroid artery. The most distal portion of the trachea consistently receives its blood supply from the bronchial arteries. The rest

Diagnosis

Most patients with blunt tracheobronchial trauma will present with dyspnea and respiratory distress. Nearly half of them will also harbor hoarseness, subcutaneous emphysema, pneumothorax, or hemoptysis at presentation. On physical examination, several signs can hint at the presence of a tracheobronchial injury. Absent breath sounds and desaturation can lead to chest tube placement for pneumothorax evaluation. If a large air leak persists after tube thoracostomy, one may suspect an intrathoracic

Management

Securing an adequate airway is the priority when patients are in distress. In suspected cases of major airway injuries, intubation over a fiberoptic bronchoscope has significant advantages. When significant cervical spinal trauma is suspected or has been documented, orotracheal intubation over a bronchoscope may save the day in avoiding or minimizing neck motion and allowing the awake establishment of an airway before sedation. In addition, bronchoscopy allows assessment of the airway

Some reported series

Balci and colleagues15 reviewed their 14-year trauma experience and identified 13 patients who had blunt tracheobronchial injuries out of a total of 8600 trauma patients. Six cases involved the right mainstem and 3 had left mainstem injury. Most frequent associated injuries involved the lung parenchyma and esophagus. All patients underwent primary repair. The most common surgical exposure performed was thoracotomy in 59% of the cases, followed by sternotomy and 1 case had clamshell exposure.

Nonsurgical management

Nonoperative modalities have been recently introduced into the algorithm for tracheobronchial injury management (Fig. 2). Although repair may be inevitable, stabilizing the patient may avert the need for immediate major surgical repair.24, 25 The role of extracorporeal membrane oxygenation may evolve in this arena, although the need for continuous anticoagulation may be problematic with closed head injuries and potential for hemorrhage from associated injuries.26, 27

Future directions

With the advancement in endoscopic technique, some injuries may be managed with stenting and endobronchial repair. The morbidity and mortality still rests in the severity of the associated injuries and their recovery.

Isolated injuries to the membranous trachea, although rare, may be approached as we have learned from the management of iatrogenic intubation injuries. Cardillo stratified these lacerations by severity of injury and clinical effects.28 Level I and II are superficial without

Summary

Blunt tracheobronchial injuries are a rarely survivable injury as a consequence of associated injuries. Clinical presentation commonly includes dyspnea, subcutaneous emphysema, hoarseness, and pneumothorax. Diagnostic modalities include imaging and bronchoscopy. With isolated airway injuries or in patients who are otherwise stable from their associated injuries, early surgical repair is indicated. Communication with anesthesia in establishing initial airway control and in planning the approach

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References (30)

Cited by (16)

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    2024, Surgical Clinics of North America
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    For intrathoracic tension-free anastomosis, an opening on the pericardium or division of the inferior pulmonary ligaments can be performed. These techniques allow a 1–2 cm mobilization of the airway [1,2,11,12]. In case of a severe airway disruption protective tissue flap (pleura, pericardium, mediastinal fat, muscle flap) can be used to cover the anastomosis or separate the oesophagus [1,5,13].

  • Bronchial Disruption Repair in a Child: Suggestions for Opting for One-Lung Ventilation or Extracorporeal Circulatory Support

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    The force required to cause tracheobronchial disruption in this situation carries an extremely high mortality rate, with 30% to 80% of the patients dying before reaching the hospital33; autopsy reports provide much of the information on this subset of patients from which Bertelsen et al documented a 2.8% rate of tracheobronchial injury in 1,178 autopsies.34 Most blunt tracheal injuries are intrathoracic, 80% occurring within 2.5 cm of the carina and the mainstem bronchus.35 As mentioned, such an injury requires a tremendous amount of force given the otherwise pliable chest wall of this age group.

  • Blunt trauma related chest wall and pulmonary injuries: An overview

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    But also the number of patients with tracheobronchial injury who reach the hospital alive increases with improved ambulance services.208 Tracheobronchial injury occurs through three mechanisms209: (1) a sudden anterior to posterior force above the carina level, (2) severe compression injury with the glottis closed, and (3) tear of cricoid and carina adhesions of the trachea in a rapid deceleration. Diagnosis of tracheobronchial injury is very difficult.

  • Injury to the esophagus, trachea, and bronchus

    2023, Acute Care Surgery and Trauma: Evidence-Based Practice: Third Edition
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Disclosure Statement: The authors have nothing to declare.

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