Abstract

      Tracheo-bronchial disruption is an uncommon injury usually associated with severe, blunt thoracic trauma and rarely occurs in isolation. Due to the natural anatomic protection of the thoracic bronchial tree, severe trauma is required to disrupt it and is usually associated with multiple injuries. We report on a patient who suffered antero-posterior compression trauma to the chest and developed severe right bronchial injury.

Key words: Trauma, Bronchus, Injuries.

Introduction

        The incidence of tracheo-bronchial disruption following blunt chest trauma is less than 1% and most patients with this type of injury do not survive to reach hospital care (1- 5). The commonest mechanism of injury, in about 50% of patients, is compression of the chest causing rupture of the right main bronchus. The clinical presentation depends to a large extent on the presence of associated injuries and on the extent of rupture of the bronchial tree (2-4). A high index of clinical suspicion and accurate interpretation of radiological findings are necessary to diagnose the injury at presentation, and allow prompt surgical interventions with primary repair of the airway. Delay in treatment increases the risk of mortality, and of delayed partial, or complete, bronchial stenosis (6-8)..


Case Report


         A 24-year old male presented to the Accident and Emergency (A&E) Department of Hamad General Hospital, with a history of compressive blunt chest trauma due to a heavy object falling from a height. The patient was complaining of right sided chest and back pain associated with breathlessness and haemoptysis. Physical examination revealed a stable patient with a normal hemodynamic status. He had no neurological problems (Glasgow Coma Scale 15/15). There was tenderness, subcutaneous emphysema with absence of air entry on the right side of the chest. He also had injury to the right ankle which did not necessitate urgent treatment. The chest X-ray (CXR) performed in A& E showed a right pneumothorax, collapsed right lung and shifting of the mediastinum to the left side. There was also fracture of the right scapula and fractures of the 2nd, 3rd, and 4th right ribs (Figure 1).

A right chest drain inserted in the A&E department revealed a continuous massive air leak. Subsequent CT scan of the chest, showed a right pneumothorax, a mediastinal shift to the left, right lung collapse, right branch main bronchus injury, and a chest tube in place on the right side. The patient was admitted to the trauma Intensive Care Unit. Flexible bronchoscopy was done and this revealed a complete rupture of the right main bronchus just below the carina. Following the bronchoscopy, the patient developed acute respiratory distress and required emergency intubation and ventilation with a double lumen tube to ventilate the left lung and isolation of the right lung. He was transferred to theatre and underwent a right thoracotomy which confirmed complete separation of the right main bronchus just below the carina (Figures 2 and 3). A direct repair was performed with interrupted proline sutures, reinforced with a pleural patch. The patient made an uncomplicated initial recovery..
 

Figure 2

 

Figure 3

Discussion


       The first reported case of traumatic ruptured bronchus is attributed to Webb (9) in 1848 following a post- mortem examination on a man run over by a cart. Primary surgical repair was first successfully performed by Scannell in 1951(10). The mechanism of injury is thought to be a combination of antero-posterior compression of the chest resulting in traction on the carina as the lungs remain in contact with the lateral chest wall, and sudden increase in intrabdominal pressure due to reflex closure of the glottis (3,11). Over 80% of injuries occur within 2cm of the carina and most are young patients with relatively elastic chest walls. It’s not surprising that the forces required are severe, therefore associated injuries are common.
Mortality and morbidity: Death occurs in approximately 30% of patients with tracheo-bronchial tears, with 50% of fatalities occurring within the first hour. Mortality may be related to inadequate airway, tension pneumothorax, occlusion of the airway by protrusion of the esophagus into the tear, or accompanying injuries. In two thirds of survivors the diagnosis is delayed, occasionally for many years, resulting in complications such as airway stenosis, pneumonia, mediastinitis, sepsis and decreased pulmonary capacity.

Clinical Presentation: Two clinical presentations have been documented, depending on whether the peribronchial tissues remain intact or not. If the leak ruptures into the pleural cavity a large pneumothorax results in dyspnoea which fails to resolve, and may become worse with placement of a chest tube. The diagnosis in this case is usually obvious and intervention is generally required (3,4). If the peri-bronchial tissues remain intact, symptoms may be minimal as no significant air leak or pneumothorax develops and small amounts of mediastinal air may not be visualized on plain chest radiography. In such a situation, a high index of clinical suspicion is required, particularly in young patients, where the mechanism of injury suggests a possible airway injury. A controlled search for mediastinal or cervical emphysema must be made. CXR is the standard initial scanning examination for evaluation of most chest conditions, including possible tracheo-bronchial injury. Computerized tomorography can be used to diagnose complete avulsion of a bronchus but incomplete tears will be missed, making bronchoscopy mandatory. Due to the risk of disruption of peri-bronchial tissues, the bronchoscopy should be performed in an operating theatre with full anesthetic back-up, so that an endotracheal tube can be passed distal to the rupture or the lung isolated immediately, with a double lumen endotracheal tube, if a rupture is identified. Once a bronchial rupture is confirmed, immediate primary surgical repair gives the best long term results (2,4,7,11). This should be performed with absorbable sutures to avoid the problem of granulation with non-absorbable sutures. If the diagnosis is missed, granulation tissues at the site of rupture lead to progressive bronchial obstruction, which may be complicated by distal infection, leading to permanent parenchymal damage (3,4,7). In this situation, resection of the stenosed segment with reimplantation is the treatment of choice and may restore some lung function, even after several months.
In conclusion, trachea-bronchial rupture is an unusual complication of blunt chest trauma. The diagnosis may be delayed unless the treating medical staff has a high index of clinical suspicion in addition to the correct interpretation of clinical and radiological findings. Where the diagnosis is suspected, immediate bronchoscopy with proper management is mandatory to achieve satisfactory results. .

 

References

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