Tracheal and Main Bronchial Disruptions After Blunt Chest Trauma: Presentation and Management Fritz Baumgartner, MD, Barry Sheppard, MD, Christian de Virgilio, MD, Barry Esrig, MD, Dale Harrier, MD, Ronald J. Nelson, MD, and John M. Robertson, MD Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
Tracheobronchial disruption is one of the less common injuries associated with blunt thoracic trauma. This injury can be life threatening, however, and failure to diagnose it early can lead to disastrous acute or delayed complications. Nine cases of tracheobronchial disruption in the setting of nonpenetrating thoracic trauma were seen at four Los Angeles trauma centers between 1980 and 1987.Mechanism of injury, presentation, diagnosis, and management of these patients were reviewed. Disruptions involved the trachea in 3 patients, the right bronchus in 5 patients, and the left bronchus in 2 patients. Tracheobronchial disruptions occurred in set-
tings of high-energy impact-type injuries and were more likely to have associated injuries than they were to occur alone. Common presenting signs included subcutaneous emphysema, dyspnea, sternal tenderness, and hemoptysis. Radiographic findings were most commonly pneumothorax, pneumomediastinum, and clavicle or rib fractures. Rigid bronchoscopy and fiberoptic bronchoscopy were both highly accurate methods for diagnosis but only in the hands of trained cardiothoracic surgeons. Delay in diagnosis increased the likelihood of postoperative complications. (Ann Thorac Surg 1990;50:569-74)
T
Emphasis was placed on mechanism of injury, initial symptoms and examination, and diagnostic procedures.
he true incidence of tracheobronchial injuries in blunt trauma is difficult to establish because many patients sustaining trauma severe enough to cause such injuries die before reaching the hospital [l].Ecker and colleagues [2] reviewed tracheobronchial injuries over a 10-year period in Dallas County: of 27 patients with blunt tracheobronchial injuries (14 vehicular, 11 air crash, and 2 crush or fall related) only 9 (all of vehicular origin) were alive on reaching the emergency room. Bertelsen and Howitz [3], reviewing 1,178 postmortem reports of persons dying of trauma, reported that only 33 (0.03%) had tracheobronchial disruptions; 27 of them died almost immediately. Although rare, tracheobronchial injuries appear to be on the increase, associated with the increasing use of highspeed transportation [l]. For editorial comment, see page 523. The clinical presentation of tracheobronchial injuries in blunt trauma is varied, and the initial diagnostic evaluation is often misleading. Because the emphasis in management of these injuries is on early diagnosis and intervention [l,2, 4-71, and the acute mortality is high, timely diagnosis of these injuries is essential. We reviewed 9 patients with tracheobronchial disruption from nonpenetrating thoracic trauma. These cases were gleaned from four Los Angeles trauma centers over an 8-year period. Accepted for publication April 30, 1990 Presented at the Southern California Chapter of the American College of Surgeons Meeting, Palm Springs, CA, Jan 27-29, 1989. Address reprint requests to Dr Robertson, Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA 90509.
0 1990 by The Society of Thoracic Surgeons
Material and Methods Records from four trauma centers in the Los Angeles area were reviewed for the period of 1980 to 1987 for patients arriving alive at the emergency room with tracheobronchial injuries from blunt trauma. The institutions included were Harbor-UCLA Medical Center, Torrance; St Mary’s Medical Center, Long Beach; Memorial Medical Center, Long Beach; and Garfield Medical Center, Monterey Park, CA. Tracheal and main bronchial injuries from blunt trauma were included; no segmental bronchial injuries were found. Subsegmental bronchial injuries were excluded.
Case Reports Patient 1 A 21-year-old female unrestrained driver arrived at the emergency room with sternal tenderness. Initial examination documented no subcutaneous emphysema, and chest roentgenogram was normal. In the ensuing hours, subcutaneous emphysema developed over the neck, with tenderness and stridor. Repeat chest roentgenogram showed pneumomediastinum. Flexible bronchoscopy showed hemorrhage into the tracheal mucosa and an abnormal tracheal ring. Results of rigid bronchoscopy performed in the operating room by the surgical resident who had performed the flexible bronchoscopy were then reported as normal, but surgical exploration performed for clinical suspicion showed complete tracheal disruption between the first and second rings. The trachea was 0003-4975/90/$3.50
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Fig 1. Chest roentgenogram of patient 3 showing a right-sided pneumothorax (large open arrowhead), pneumopericurdium (small open arrowhead), mediastinal air stripes (small solid arrow), and marked subcutaneous emphysema that outlines the pectoralis muscle fibers.
repaired with interrupted 5-0 stainless steel sutures. The patient was discharged on the fourteenth day postoperatively with a left vocal cord paralysis.
Patient 2 A 16-year-old female unrestrained automobile passenger arrived in the emergency room obtunded, with no subcutaneous emphysema and equal breath sounds bilaterally. Chest roentgenogram showed fractures of the right second, third, and fourth ribs, a left clavicle fracture, and a widened mediastinum, but no pneumothorax or pneumomediastinum. A right thoracostomy tube was placed prophylactically, and aortography showed a right subclavian pseudoaneurysm. Subcutaneous emphysema developed shortly thereafter. Urgent repair of the pseudoaneurysm was performed through a median sternotomy. Results of postoperative flexible bronchoscopy performed by a surgical resident were reported as normal. Rigid bronchoscopy performed by the cardiothoracic surgeon, however, showed a complete right main bronchial transection, which was repaired through a right posterolateral thoracotomy using interrupted 4-0 Prolene sutures. The patient was discharged home on the sixteenth day postoperatively without complication.
Patient 3 A 20-year-old female unrestrained driver had massive subcutaneous emphysema of the face, neck, chest, and abdomen. She demonstrated hemoptysis, sternal tenderness, and diminished breath sounds on the right. Chest roentgenogram showed a right pneumothorax and massive subcutaneous and mediastinal air (Fig 1). A right thoracostomy tube was then placed, and rigid bronchoscopy showed a right main bronchial transection. This injury was repaired with interrupted 4-0 Prolene sutures through a right posterolateral thoracotomy. A transected thoracic duct was also noted. A postoperative chylothorax
resolved without intervention, and the patient was discharged 3 weeks after operation.
Patient 4 A 15-year-old girl who had been ejected from her car was brought to the emergency room with complaints of chest pain and dyspnea. She demonstrated subcutaneous emphysema across the entire chest, and bilateral thoracostomy tubes were placed empirically. Chest roentgenogram showed pneumopericardium, pneumomediastinum, and bilateral pulmonary contusions. Exploratory laparotomy performed for abdominal tenderness showed a liver hematoma, right adrenal hemorrhage, and perinephric hematoma. Postoperative flexible bronchoscopy showed only main bronchial edema. A persistent thoracostomy tube air leak prompted a repeat flexible bronchoscopy 3 days after the injury, and a small left bronchial tear was noted. Bronchogram then showed a left lower lobe bronchial obstruction without extravasation. A third flexible bronchoscopy on the eighth day after injury showed a left main bronchial laceration spiraling down to obstruct the left lower lobe bronchus. This was repaired with interrupted 3-0 Vicryl sutures through a left posterolateral thoracotomy approach. Postoperative bronchoscopy 5 days after operation showed almost complete obstruction of the repaired bronchus by hypertrophic granulation tissue, which was removed initially with forceps and then again with yttrium-aluminum-garnet laser on the eleventh postoperative day. The patient was discharged home in good condition.
Patient 5 An 18-year-old unrestrained male driver reportedly crushed the steering wheel with his chest and had shortness of breath and hemoptysis. Extensive subcutaneous emphysema, Hamman’s sign, and sternal hematoina were present on examination. Chest roentgenogram
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showed a left pneumothorax and pulmonary contusion requiring placement of a left thoracostomy tube. Flexible bronchoscopy by a cardiothoracic surgeon showed blood in the posterior carina and blood filling the left main bronchus. A bronchogram was normal. A diagnostic peritoneal lavage was positive for blood, and exploratory laparotomy disclosed splenic rupture. The patient had acute respiratory distress syndrome symptoms postoperatively, and flexible bronchoscopy by the same surgeon on the fourth postoperative day showed complete separation of the membranous trachea and main bronchi from the cartilaginous anterior structures. This was repaired with a running 3-0 Prolene suture technique through a right posterolateral thoracotomy with the patient on cardiopulmonary bypass. Bronchoscopy performed on the third postoperative day showed good repair. Sepsis and multiple-system organ failure developed, however, and the patient died 15 days postoperatively.
Patient 6 A 15-year-old boy on a bicycle was struck by a truck and arrived in the emergency room in respiratory distress. Examination showed subcutaneous emphysema over the chest and neck, Hamman’s sign, and diminished breath sounds bilaterally. Chest roentgenogram showed a right first rib fracture, a left clavicle fracture, and bilateral pneumothoraces. Bilateral thoracostomy tubes were placed. The patient was extubated on the second day after injury, but the left lung remained atelectatic and an air leak persisted through the left thoracostomy tube. Flexible bronchoscopy performed on the fifth day after injury showed left main bronchial obstruction without any bronchial tears. A computed tomographic scan of the chest on the seventh day after injury suggested a bronchial transection by the great distance between the carina and atelectatic left lung. Repeat flexible bronchoscopy and rigid bronchoscopy showed a left main bronchial transection. Repair was performed through a left posterolateral thoracotomy, disclosing an abscess around the hilar stump with complete left main bronchial transection. The lingula and left upper lobe were separate from the left lower lobe and were resected; the left main bronchus was anastomosed to the left lower lobe bronchus with interrupted 5-0 Ticron sutures. The patient was discharged on the eighth day after operation.
Patient 7 A 30-year-old man was involved as the driver of an automobile struck by a train. The patient was unconscious on arrival at an outlying hospital, where assessment showed a right hemopneumothorax, basilar skull fracture, second cervical ”hangman’s” fracture, and a right parietal skull fracture. The patient was intubated, and a right thoracostomy tube was placed before the patient was transferred to a trauma center. At the trauma center, the patient was noted to have subcutaneous emphysema over his chest. Halo neck support and ventriculostomy were placed. Flexible bronchoscopy was performed on the third day of admission owing to marked worsening of the subcutaneous emphysema; this suggested a complete
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transection of the right main bronchus. A right posterolateral thoracotomy confirmed the right main bronchial transection, which was repaired with interrupted 3-0 Vicryl sutures. The postoperative course was complicated by a right-sided Enterobacter empyema, which was successfully treated with parenteral aminoglycosides and serial pleural taps. The patient was transferred to a rehabilitation facility 5 weeks postoperatively.
Patient 8 A 37-year-old woman thrown from her car was complaining of hip and back pain. In the emergency room, progressive dyspnea developed, associated with subcutaneous emphysema over the chest and neck, and she had respiratory arrest requiring emergent intubation. Chest roentgenogram showed a left clavicle fracture and bilateral pneumothoraces, which were treated with bilateral thoracostomy tubes. Flexible bronchoscopy showed a transected right main bronchus, which was repaired through a right posterolateral thoracotomy with 4-0 Vicryl sutures and reinforced with a pleural flap. The patient was discharged 3 weeks postoperatively.
Patient 9 A 22-year-old male unrestrained automobile passenger arrived at the emergency room with sternal tenderness, hemoptysis, extensive subcutaneous emphysema, Hamman’s sign, and stridor. Chest roentgenogram showed right pneumothorax and pneumomediastinum. Flexible bronchoscopy showed a small posterior tear of the tracheal mucosa. The right lung, however, remained refractory to reexpansion after placement of two thoracostomy tubes. Rigid bronchoscopy showed a posterior tracheal tear as well as a large right main bronchial tear, which was revealed to be a complete transection of the right main bronchus at operation. The severity of the injury necessitated a right pneumonectomy, and bronchotracheoplasty was performed with 5-0 stainless steel wire reinforced with a pleural flap. The patient died 36 hours postoperatively of refractory right ventricular failure and progressive hypoxia with symptoms of acute respiratory distress syndrome.
Comment The first successful primary repair of a bronchial rupture caused by blunt trauma was reported in 1947 by Kinsella and Johnsrud [8]. In 1959, Hood and Sloan [9] reported significantly improved results with prompt primary repair of these injuries. Since then, several series have demonstrated that early diagnosis and primary repair of these injuries leads to the fewest complications and best longterm results [l, 2, 4-71. Traditionally, subcutaneous emphysema and dyspnea have been the most common initial signs. This was upheld in a recent series of 13 patients sustaining blunt tracheobronchial disruptions in which 85% had subcutaneous emphysema and 77% had dyspnea [5]. Another recent study reported subcutaneous emphysema in 4 of 5 patients and dyspnea in all 5 [6]. We found similar results
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Table 1. lnitial Signs and Symptoms in 9 Patients
Table 3. Injuries Associated With Blunt Tracheobronchial Disruptions
Patient No. Symptom
1
2
Subcutaneous X(D) emphysema Sternal tenderness X Dyspnea X Hemoptysis Hamman’s sign
3 4 5 6 7 8 9
Total
X(D) X X X X X X X
9(2D)
x x x x
X X X x x
X X X
x
x x x x
6 6 4 3
Patient No. Patient 1 Patient 2 Patient 3 Patient 4
D = delayed.
(Table 1). All 9 patients had subcutaneous emphysema, although it was delayed up to 4 hours in 2. Dyspnea was an initial or early symptom in 6 patients. Also common were sternal tenderness in 6 of 9, hemoptysis in 4 of 9, and Hamman’s sign in 3 of 9. Initial chest roentgenograms (Table 2) most commonly showed pneumothorax (6 of 9); 3 patients had bilateral pneumothoraces. One patient had thoracostomy tubes placed for presumed pneumothoraces before chest roentgenogram, which would give a rate of 7 of 9 patients with pneumothoraces. Three of 9 patients had pneumomediastinum. Jones and co-workers [5] reported similar findings, with pneumothorax present in 5 of 13 patients and pneumomediastinum in 6 of 13. Grover and associates [6], however, reported pneumothorax in 4 of 5 patients and pneumomediastinum in 4 of 5 patients. Other radiographic findings in our series were rib fractures, clavicle fractures, pneumopericardium, and widened mediastinum. Only 1 patient had a completely normal chest roentgenogram. The pathogenesis of tracheobronchial rupture in blunt trauma can be divided into three mechanisms. First, a decrease in the anteroposterior diameter of the thorax occurs, with widening of the transverse diameter. The lungs remain in contact with the chest wall and thus are pulled apart, creating traction at the carina. If this force
Table 2. lnitial Thoracic Radiographic Findings in 9 Patients Patient No. Finding
1
Pneumothorax Pneumomediastinum Clavicle fracture Rib fracture(s) Pulmonary contusion Pneumopericardium Widened mediastinum Hemothorax Normal X
2
3
4
5
6
7
8
9Total
X ? X X X X X x x x
X X
x
x x
x
X
X X
6 3 3 2 2 1 1
X
1 1
Question mark indicates patient in whom thoracostomy tubes were placed empirically.
Patient 5 Patient 6 Patient 7 Patient 8
Patient 9
Associated Injuries
None Rib fractures, clavicle fracture, subclavian aneurysm, and closed head trauma Thoracic duct transection Liver hematoma, right adrenal hemorrhage, right perinephric hematoma, and bilateral pulmonary contusions Splenic rupture, myocardial contusion with right bundle-branch block Rib fractures, clavicle fracture Basilar skull fracture, parietal skull fracture, and second cervical vertebral fracture Left clavicle fracture, left superior and inferior pubic ramus fractures None -
exceeds the elasticity of the tracheobronchial tree, rupture occurs. Second, when the trachea and major bronchi are crushed between the sternum and vertebral column with the glottis closed, the sudden increase in intrabronchial pressure produced is greatest in the larger bronchi and rupture may occur. Third, rapid deceleration may result in shearing forces at the areas of fixation, namely the carina and cricoid cartilage [l]. These forces may act alone or in concert. Because of these mechanisms, one would expect tracheobronchial injuries to occur in situations in which a large amount of kinetic energy is transferred to the body, eg, high-speed motor vehicle accidents. Our series illustrates that this is so; all injuries occurred as the result of automotive-associated trauma. All patients were unrestrained, and 3 were thrown from the site of initial impact. The magnitude of energy involved is evident in the following cases: 1 patient’s car was struck by a train, another victim was flung from his bicycle by collision with a truck, and in two cases the patients crushed the vehicle’s steering wheel with their chests. These high-energy transfer situations would also be expected to yield a high incidence of associated injuries. Although the older literature shows associated injuries in only 50% of cases of tracheobronchial disruption from blunt trauma [l], a recent series reported 48 associated injuries in 13 patients [5]. We also found that tracheobronchial disruption in the setting of blunt trauma rarely occurs as an isolated injury (ie, in only 2 of 9 patients). Table 3 summarizes the associated injuries in our series. Review of the older literature shows bronchial injuries equally divided between right and left [9]. We, however,
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Table 4. Results of Fiberoptic Bvonchoscopy Performed in 9 Patients Endoscopist
Finding
Operative Finding
1
Surgical resident
Hemorrhage of tracheal mucosa, abnormal tracheal ring
2 3
Surgical resident CT surgeon
Normal Right main bronchial transection
Complete tracheal disruption Right bronchial transection
i ii“
Trauma surgeon
Main bronchial edema Small left bronchial tear (nonsurgical)
... ...
iiib
Pulmonologist
Left main bronchial laceration spiraling down to obstruct left lower lobe bronchus
Same
i
CT surgeon
...
ii“
CT surgeon
Blood in posterior carina, blood filling left main bronchus Complete separation of the membranous trachea and bronchi from the anterior cartilaginous structures
i
7
Pediatric intensivist CT surgeon CT surgeon
8
CT surgeon
Patient No.
Same
4 Trauma surgeon
5
Same
6
ii”
Left main bronchial obstruction without brortchial tear Left main bronchial transection Ruptured right upper lobe bronchus takeoff and right main bronchial tear Transected right main bronchus
... Same Same Same
9
a
i
ER physician
ii”
CT surgeon
Second bronchoscopy.
CT = cardiothoracic;
Small posterior tear of the tracheal mucosa Posterior tracheal tear and right main tear
... Same, except that right main bronchial tear was a complete transection
Third bronchoscopy.
ER = emergency room.
found right bronchial injuries in 5 of 9 patients and left bronchial injuries in only 2 of 9 patients; although this represents a fairly small sample, the right-sided preponderance agrees with the findings of another recent series in which 7 of 13 tracheobronchial injuries involved the right bronchus and none involved the left [ 5 ] . Table 4 summarizes our experience with flexible bronchoscopy. Although only 3 of 9 of the initial fiberoptic bronchoscopies were correct in their diagnosis, 5 of the 6 incorrect endoscopies were performed by other than cardiothoracic surgeons. Of 14 total flexible bronchoscopies performed on nine lesions, seven were correct in diagnosis and seven missed the lesion. Six of the seven correct endoscopies were performed by cardiothoracic surgeons, and the seventh was performed by a pulmonologist. Of the seven flexible bronchoscopies performed by cardiothoracic surgeons, six correctly identified the lesion. The one lesion missed by a cardiothoracic surgeon was later identified by the same surgeon, suggesting that it changed to a more easily identifiable form. This concept
that lesions could evolve may speak to the issue of the higher accuracy of the cardiothoracic surgeons in their endoscopies, as the cardiothoracic surgeons performed the later endoscopies in some cases. The high accuracy of all bronchoscopies performed by the cardiothoracic surgeons, whether initial or delayed, however, remains impressive. Rigid bronchoscopy was performed in 5 of the 9 cases (Table 5) and showed a lesion requiring operation in 4 of these. The one endoscopy that missed the lesion was performed by a surgical resident. Thus, rigid endoscopy in the hands of a cardiothoracic surgeon provides a 100% sensitivity, specificity, and accuracy. Bronchography did not assist the diagnosis in either of the cases in which it was used. These results clearly indicate that the most experienced individuals are the ones most likely to make the diagnosis of tracheobronchial disruption using rigid or flexible bronchoscopy. When the patient’s clinical condition suggests tracheobronchial disruption, bronchoscopy should be
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Table 5. Results of Rigid Bronchoscopy Performed in 5 of 9 Patients Patient No.
Endoscopist
Finding
Operative Finding
1 2
Surgical resident CT surgeon
Complete tracheal disruption Same
3 6
CT surgeon CT surgeon
9
CT surgeon
Normal Complete right main bronchial transection Right main bronchial tear Left main bronchial transection Posterior tracheal tear and right main bronchial tear
Same Same Same, except that right main bronchial tear was a complete transection
CT = cardiothoracic.
performed by persons well acquainted with the appearance of these potentially life-threatening lesions. A negative bronchoscopy by an inexperienced endoscopist, ie, surgical resident, medical or pediatric intensivist, trauma surgeon, or emergency room physician does not rule out the diagnosis. Of the 9 patients in our series, 5 were diagnosed promptly and 4 had a delayed diagnosis. Of the 5 patients diagnosed promptly, 4 had excellent surgical outcomes. The only complication was that of a unilateral vocal cord paralysis, which may have been present before operation. The fifth patient died as a direct result of the severity of his injury, which dictated pneumonectomy in a trauma setting with its attendant high mortality [lo, 111. Delay in diagnosis was detrimental in all 4 patients. In 2 of the patients, empyema or hilar abscess complicated the postoperative course. The third patient had complications with hypertrophic granulation tissue obstructing the repaired bronchus. The fourth patient had a delay in diagnosis of 4 days, which contributed substantially to his pneumonia, mediastinitis, sepsis, and subsequent multiple-system organ failure. We conclude that in individuals treating victims of high-energy blunt thoracic trauma a high index of suspicion for tracheobronchial disruptions must be maintained to detect these rare lesions. Clinical presentation including subcutaneous emphysema, dyspnea, sternal tenderness, pneumothorax, pneumomediastinum, hemoptysis, and rib or clavicle fractures should increase suspicion. Once the diagnosis of tracheobronchial disruption is entertained, rigid or flexible bronchoscopy should be per-
formed by an individual trained and experienced in the appearance of these injuries. Early recognition and repair of these injuries clearly decreases morbidity and mortality.
References 1. Kirsh MM, Orringer MB, Behrendt DM, et al. Management of tracheobronchial disruption secondary to nonpenetrating trauma. Ann Thorac Surg 1976;22:9>101. 2. Ecker RR, Libertini RV, Rea WJ, et al. Injuries of the trachea and bronchi. Ann Thorac Surg 1971;11:289-98. 3. Bertelsen S, Howitz P. Injuries of the trachea and bronchi. Thorax 1972;27:188-94. 4. Mills SA, Johnston FR, Hudspeth AS, et al. Clinical spectrum of blunt tracheobronchial disruption illustrated by seven cases. J Thorac Cardiovasc Surg 1982;84:49-58. 5. Jones WS, Mavroudis C, Richardson JD, et al. Management of tracheobronchial disruption resulting from blunt trauma. Surgery 1984;95:319-22. 6. Grover FL, Ellestad C, Arom KV, et al. Diagnosis and management of major tracheobronchial injuries. Ann Thorac Surg 1978;28:384-92. 7. Burke JF. Early diagnosis of traumatic rupture of the bronchus. JAMA 1962;181:682-6. 8. Kinsella TJ, Johnsrud LW. Traumatic rupture of the bronchus. J Thorac Surg 1947;16571-83. 9. Hood RM, Sloan HE. Injuries of the trachea and major bronchi. J Thorac Cardiovasc Surg 1959;38:458. 10. Thompson DA, Rowlands BJ, Walker WE, et al. Urgent thoracotomy for pulmonary or tracheobronchial injury. J Trauma 1988;28:276-80. 11. Bowling R, Mavroudis C, Richardson JD, et al. Emergency pneumonectomy for penetrating and blunt trauma. Am Surg 1985;51:13&9.
Tracheobronchial disruption is one of the less common injuries associated with blunt thoracic trauma. This injury can be life threatening, however, and failure to diagnose it early can lead to disastrous acute or delayed complications. Nine cases of tracheobronchial disruption in the setting of nonpenetrating thoracic trauma were seen at four Los Angeles trauma centers between 1980 and 1987.Mechanism of injury, presentation, diagnosis, and management of these patients were reviewed. Disruptions involved the trachea in 3 patients, the right bronchus in 5 patients, and the left bronchus in 2 patients. Tracheobronchial disruptions occurred in set-
tings of high-energy impact-type injuries and were more likely to have associated injuries than they were to occur alone. Common presenting signs included subcutaneous emphysema, dyspnea, sternal tenderness, and hemoptysis. Radiographic findings were most commonly pneumothorax, pneumomediastinum, and clavicle or rib fractures. Rigid bronchoscopy and fiberoptic bronchoscopy were both highly accurate methods for diagnosis but only in the hands of trained cardiothoracic surgeons. Delay in diagnosis increased the likelihood of postoperative complications. (Ann Thorac Surg 1990;50:569-74)
T
Emphasis was placed on mechanism of injury, initial symptoms and examination, and diagnostic procedures.
he true incidence of tracheobronchial injuries in blunt trauma is difficult to establish because many patients sustaining trauma severe enough to cause such injuries die before reaching the hospital [l].Ecker and colleagues [2] reviewed tracheobronchial injuries over a 10-year period in Dallas County: of 27 patients with blunt tracheobronchial injuries (14 vehicular, 11 air crash, and 2 crush or fall related) only 9 (all of vehicular origin) were alive on reaching the emergency room. Bertelsen and Howitz [3], reviewing 1,178 postmortem reports of persons dying of trauma, reported that only 33 (0.03%) had tracheobronchial disruptions; 27 of them died almost immediately. Although rare, tracheobronchial injuries appear to be on the increase, associated with the increasing use of highspeed transportation [l]. For editorial comment, see page 523. The clinical presentation of tracheobronchial injuries in blunt trauma is varied, and the initial diagnostic evaluation is often misleading. Because the emphasis in management of these injuries is on early diagnosis and intervention [l,2, 4-71, and the acute mortality is high, timely diagnosis of these injuries is essential. We reviewed 9 patients with tracheobronchial disruption from nonpenetrating thoracic trauma. These cases were gleaned from four Los Angeles trauma centers over an 8-year period. Accepted for publication April 30, 1990 Presented at the Southern California Chapter of the American College of Surgeons Meeting, Palm Springs, CA, Jan 27-29, 1989. Address reprint requests to Dr Robertson, Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA 90509.
0 1990 by The Society of Thoracic Surgeons
Material and Methods Records from four trauma centers in the Los Angeles area were reviewed for the period of 1980 to 1987 for patients arriving alive at the emergency room with tracheobronchial injuries from blunt trauma. The institutions included were Harbor-UCLA Medical Center, Torrance; St Mary’s Medical Center, Long Beach; Memorial Medical Center, Long Beach; and Garfield Medical Center, Monterey Park, CA. Tracheal and main bronchial injuries from blunt trauma were included; no segmental bronchial injuries were found. Subsegmental bronchial injuries were excluded.
Case Reports Patient 1 A 21-year-old female unrestrained driver arrived at the emergency room with sternal tenderness. Initial examination documented no subcutaneous emphysema, and chest roentgenogram was normal. In the ensuing hours, subcutaneous emphysema developed over the neck, with tenderness and stridor. Repeat chest roentgenogram showed pneumomediastinum. Flexible bronchoscopy showed hemorrhage into the tracheal mucosa and an abnormal tracheal ring. Results of rigid bronchoscopy performed in the operating room by the surgical resident who had performed the flexible bronchoscopy were then reported as normal, but surgical exploration performed for clinical suspicion showed complete tracheal disruption between the first and second rings. The trachea was 0003-4975/90/$3.50
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Fig 1. Chest roentgenogram of patient 3 showing a right-sided pneumothorax (large open arrowhead), pneumopericurdium (small open arrowhead), mediastinal air stripes (small solid arrow), and marked subcutaneous emphysema that outlines the pectoralis muscle fibers.
repaired with interrupted 5-0 stainless steel sutures. The patient was discharged on the fourteenth day postoperatively with a left vocal cord paralysis.
Patient 2 A 16-year-old female unrestrained automobile passenger arrived in the emergency room obtunded, with no subcutaneous emphysema and equal breath sounds bilaterally. Chest roentgenogram showed fractures of the right second, third, and fourth ribs, a left clavicle fracture, and a widened mediastinum, but no pneumothorax or pneumomediastinum. A right thoracostomy tube was placed prophylactically, and aortography showed a right subclavian pseudoaneurysm. Subcutaneous emphysema developed shortly thereafter. Urgent repair of the pseudoaneurysm was performed through a median sternotomy. Results of postoperative flexible bronchoscopy performed by a surgical resident were reported as normal. Rigid bronchoscopy performed by the cardiothoracic surgeon, however, showed a complete right main bronchial transection, which was repaired through a right posterolateral thoracotomy using interrupted 4-0 Prolene sutures. The patient was discharged home on the sixteenth day postoperatively without complication.
Patient 3 A 20-year-old female unrestrained driver had massive subcutaneous emphysema of the face, neck, chest, and abdomen. She demonstrated hemoptysis, sternal tenderness, and diminished breath sounds on the right. Chest roentgenogram showed a right pneumothorax and massive subcutaneous and mediastinal air (Fig 1). A right thoracostomy tube was then placed, and rigid bronchoscopy showed a right main bronchial transection. This injury was repaired with interrupted 4-0 Prolene sutures through a right posterolateral thoracotomy. A transected thoracic duct was also noted. A postoperative chylothorax
resolved without intervention, and the patient was discharged 3 weeks after operation.
Patient 4 A 15-year-old girl who had been ejected from her car was brought to the emergency room with complaints of chest pain and dyspnea. She demonstrated subcutaneous emphysema across the entire chest, and bilateral thoracostomy tubes were placed empirically. Chest roentgenogram showed pneumopericardium, pneumomediastinum, and bilateral pulmonary contusions. Exploratory laparotomy performed for abdominal tenderness showed a liver hematoma, right adrenal hemorrhage, and perinephric hematoma. Postoperative flexible bronchoscopy showed only main bronchial edema. A persistent thoracostomy tube air leak prompted a repeat flexible bronchoscopy 3 days after the injury, and a small left bronchial tear was noted. Bronchogram then showed a left lower lobe bronchial obstruction without extravasation. A third flexible bronchoscopy on the eighth day after injury showed a left main bronchial laceration spiraling down to obstruct the left lower lobe bronchus. This was repaired with interrupted 3-0 Vicryl sutures through a left posterolateral thoracotomy approach. Postoperative bronchoscopy 5 days after operation showed almost complete obstruction of the repaired bronchus by hypertrophic granulation tissue, which was removed initially with forceps and then again with yttrium-aluminum-garnet laser on the eleventh postoperative day. The patient was discharged home in good condition.
Patient 5 An 18-year-old unrestrained male driver reportedly crushed the steering wheel with his chest and had shortness of breath and hemoptysis. Extensive subcutaneous emphysema, Hamman’s sign, and sternal hematoina were present on examination. Chest roentgenogram
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showed a left pneumothorax and pulmonary contusion requiring placement of a left thoracostomy tube. Flexible bronchoscopy by a cardiothoracic surgeon showed blood in the posterior carina and blood filling the left main bronchus. A bronchogram was normal. A diagnostic peritoneal lavage was positive for blood, and exploratory laparotomy disclosed splenic rupture. The patient had acute respiratory distress syndrome symptoms postoperatively, and flexible bronchoscopy by the same surgeon on the fourth postoperative day showed complete separation of the membranous trachea and main bronchi from the cartilaginous anterior structures. This was repaired with a running 3-0 Prolene suture technique through a right posterolateral thoracotomy with the patient on cardiopulmonary bypass. Bronchoscopy performed on the third postoperative day showed good repair. Sepsis and multiple-system organ failure developed, however, and the patient died 15 days postoperatively.
Patient 6 A 15-year-old boy on a bicycle was struck by a truck and arrived in the emergency room in respiratory distress. Examination showed subcutaneous emphysema over the chest and neck, Hamman’s sign, and diminished breath sounds bilaterally. Chest roentgenogram showed a right first rib fracture, a left clavicle fracture, and bilateral pneumothoraces. Bilateral thoracostomy tubes were placed. The patient was extubated on the second day after injury, but the left lung remained atelectatic and an air leak persisted through the left thoracostomy tube. Flexible bronchoscopy performed on the fifth day after injury showed left main bronchial obstruction without any bronchial tears. A computed tomographic scan of the chest on the seventh day after injury suggested a bronchial transection by the great distance between the carina and atelectatic left lung. Repeat flexible bronchoscopy and rigid bronchoscopy showed a left main bronchial transection. Repair was performed through a left posterolateral thoracotomy, disclosing an abscess around the hilar stump with complete left main bronchial transection. The lingula and left upper lobe were separate from the left lower lobe and were resected; the left main bronchus was anastomosed to the left lower lobe bronchus with interrupted 5-0 Ticron sutures. The patient was discharged on the eighth day after operation.
Patient 7 A 30-year-old man was involved as the driver of an automobile struck by a train. The patient was unconscious on arrival at an outlying hospital, where assessment showed a right hemopneumothorax, basilar skull fracture, second cervical ”hangman’s” fracture, and a right parietal skull fracture. The patient was intubated, and a right thoracostomy tube was placed before the patient was transferred to a trauma center. At the trauma center, the patient was noted to have subcutaneous emphysema over his chest. Halo neck support and ventriculostomy were placed. Flexible bronchoscopy was performed on the third day of admission owing to marked worsening of the subcutaneous emphysema; this suggested a complete
571
transection of the right main bronchus. A right posterolateral thoracotomy confirmed the right main bronchial transection, which was repaired with interrupted 3-0 Vicryl sutures. The postoperative course was complicated by a right-sided Enterobacter empyema, which was successfully treated with parenteral aminoglycosides and serial pleural taps. The patient was transferred to a rehabilitation facility 5 weeks postoperatively.
Patient 8 A 37-year-old woman thrown from her car was complaining of hip and back pain. In the emergency room, progressive dyspnea developed, associated with subcutaneous emphysema over the chest and neck, and she had respiratory arrest requiring emergent intubation. Chest roentgenogram showed a left clavicle fracture and bilateral pneumothoraces, which were treated with bilateral thoracostomy tubes. Flexible bronchoscopy showed a transected right main bronchus, which was repaired through a right posterolateral thoracotomy with 4-0 Vicryl sutures and reinforced with a pleural flap. The patient was discharged 3 weeks postoperatively.
Patient 9 A 22-year-old male unrestrained automobile passenger arrived at the emergency room with sternal tenderness, hemoptysis, extensive subcutaneous emphysema, Hamman’s sign, and stridor. Chest roentgenogram showed right pneumothorax and pneumomediastinum. Flexible bronchoscopy showed a small posterior tear of the tracheal mucosa. The right lung, however, remained refractory to reexpansion after placement of two thoracostomy tubes. Rigid bronchoscopy showed a posterior tracheal tear as well as a large right main bronchial tear, which was revealed to be a complete transection of the right main bronchus at operation. The severity of the injury necessitated a right pneumonectomy, and bronchotracheoplasty was performed with 5-0 stainless steel wire reinforced with a pleural flap. The patient died 36 hours postoperatively of refractory right ventricular failure and progressive hypoxia with symptoms of acute respiratory distress syndrome.
Comment The first successful primary repair of a bronchial rupture caused by blunt trauma was reported in 1947 by Kinsella and Johnsrud [8]. In 1959, Hood and Sloan [9] reported significantly improved results with prompt primary repair of these injuries. Since then, several series have demonstrated that early diagnosis and primary repair of these injuries leads to the fewest complications and best longterm results [l, 2, 4-71. Traditionally, subcutaneous emphysema and dyspnea have been the most common initial signs. This was upheld in a recent series of 13 patients sustaining blunt tracheobronchial disruptions in which 85% had subcutaneous emphysema and 77% had dyspnea [5]. Another recent study reported subcutaneous emphysema in 4 of 5 patients and dyspnea in all 5 [6]. We found similar results
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Table 1. lnitial Signs and Symptoms in 9 Patients
Table 3. Injuries Associated With Blunt Tracheobronchial Disruptions
Patient No. Symptom
1
2
Subcutaneous X(D) emphysema Sternal tenderness X Dyspnea X Hemoptysis Hamman’s sign
3 4 5 6 7 8 9
Total
X(D) X X X X X X X
9(2D)
x x x x
X X X x x
X X X
x
x x x x
6 6 4 3
Patient No. Patient 1 Patient 2 Patient 3 Patient 4
D = delayed.
(Table 1). All 9 patients had subcutaneous emphysema, although it was delayed up to 4 hours in 2. Dyspnea was an initial or early symptom in 6 patients. Also common were sternal tenderness in 6 of 9, hemoptysis in 4 of 9, and Hamman’s sign in 3 of 9. Initial chest roentgenograms (Table 2) most commonly showed pneumothorax (6 of 9); 3 patients had bilateral pneumothoraces. One patient had thoracostomy tubes placed for presumed pneumothoraces before chest roentgenogram, which would give a rate of 7 of 9 patients with pneumothoraces. Three of 9 patients had pneumomediastinum. Jones and co-workers [5] reported similar findings, with pneumothorax present in 5 of 13 patients and pneumomediastinum in 6 of 13. Grover and associates [6], however, reported pneumothorax in 4 of 5 patients and pneumomediastinum in 4 of 5 patients. Other radiographic findings in our series were rib fractures, clavicle fractures, pneumopericardium, and widened mediastinum. Only 1 patient had a completely normal chest roentgenogram. The pathogenesis of tracheobronchial rupture in blunt trauma can be divided into three mechanisms. First, a decrease in the anteroposterior diameter of the thorax occurs, with widening of the transverse diameter. The lungs remain in contact with the chest wall and thus are pulled apart, creating traction at the carina. If this force
Table 2. lnitial Thoracic Radiographic Findings in 9 Patients Patient No. Finding
1
Pneumothorax Pneumomediastinum Clavicle fracture Rib fracture(s) Pulmonary contusion Pneumopericardium Widened mediastinum Hemothorax Normal X
2
3
4
5
6
7
8
9Total
X ? X X X X X x x x
X X
x
x x
x
X
X X
6 3 3 2 2 1 1
X
1 1
Question mark indicates patient in whom thoracostomy tubes were placed empirically.
Patient 5 Patient 6 Patient 7 Patient 8
Patient 9
Associated Injuries
None Rib fractures, clavicle fracture, subclavian aneurysm, and closed head trauma Thoracic duct transection Liver hematoma, right adrenal hemorrhage, right perinephric hematoma, and bilateral pulmonary contusions Splenic rupture, myocardial contusion with right bundle-branch block Rib fractures, clavicle fracture Basilar skull fracture, parietal skull fracture, and second cervical vertebral fracture Left clavicle fracture, left superior and inferior pubic ramus fractures None -
exceeds the elasticity of the tracheobronchial tree, rupture occurs. Second, when the trachea and major bronchi are crushed between the sternum and vertebral column with the glottis closed, the sudden increase in intrabronchial pressure produced is greatest in the larger bronchi and rupture may occur. Third, rapid deceleration may result in shearing forces at the areas of fixation, namely the carina and cricoid cartilage [l]. These forces may act alone or in concert. Because of these mechanisms, one would expect tracheobronchial injuries to occur in situations in which a large amount of kinetic energy is transferred to the body, eg, high-speed motor vehicle accidents. Our series illustrates that this is so; all injuries occurred as the result of automotive-associated trauma. All patients were unrestrained, and 3 were thrown from the site of initial impact. The magnitude of energy involved is evident in the following cases: 1 patient’s car was struck by a train, another victim was flung from his bicycle by collision with a truck, and in two cases the patients crushed the vehicle’s steering wheel with their chests. These high-energy transfer situations would also be expected to yield a high incidence of associated injuries. Although the older literature shows associated injuries in only 50% of cases of tracheobronchial disruption from blunt trauma [l], a recent series reported 48 associated injuries in 13 patients [5]. We also found that tracheobronchial disruption in the setting of blunt trauma rarely occurs as an isolated injury (ie, in only 2 of 9 patients). Table 3 summarizes the associated injuries in our series. Review of the older literature shows bronchial injuries equally divided between right and left [9]. We, however,
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573
Table 4. Results of Fiberoptic Bvonchoscopy Performed in 9 Patients Endoscopist
Finding
Operative Finding
1
Surgical resident
Hemorrhage of tracheal mucosa, abnormal tracheal ring
2 3
Surgical resident CT surgeon
Normal Right main bronchial transection
Complete tracheal disruption Right bronchial transection
i ii“
Trauma surgeon
Main bronchial edema Small left bronchial tear (nonsurgical)
... ...
iiib
Pulmonologist
Left main bronchial laceration spiraling down to obstruct left lower lobe bronchus
Same
i
CT surgeon
...
ii“
CT surgeon
Blood in posterior carina, blood filling left main bronchus Complete separation of the membranous trachea and bronchi from the anterior cartilaginous structures
i
7
Pediatric intensivist CT surgeon CT surgeon
8
CT surgeon
Patient No.
Same
4 Trauma surgeon
5
Same
6
ii”
Left main bronchial obstruction without brortchial tear Left main bronchial transection Ruptured right upper lobe bronchus takeoff and right main bronchial tear Transected right main bronchus
... Same Same Same
9
a
i
ER physician
ii”
CT surgeon
Second bronchoscopy.
CT = cardiothoracic;
Small posterior tear of the tracheal mucosa Posterior tracheal tear and right main tear
... Same, except that right main bronchial tear was a complete transection
Third bronchoscopy.
ER = emergency room.
found right bronchial injuries in 5 of 9 patients and left bronchial injuries in only 2 of 9 patients; although this represents a fairly small sample, the right-sided preponderance agrees with the findings of another recent series in which 7 of 13 tracheobronchial injuries involved the right bronchus and none involved the left [ 5 ] . Table 4 summarizes our experience with flexible bronchoscopy. Although only 3 of 9 of the initial fiberoptic bronchoscopies were correct in their diagnosis, 5 of the 6 incorrect endoscopies were performed by other than cardiothoracic surgeons. Of 14 total flexible bronchoscopies performed on nine lesions, seven were correct in diagnosis and seven missed the lesion. Six of the seven correct endoscopies were performed by cardiothoracic surgeons, and the seventh was performed by a pulmonologist. Of the seven flexible bronchoscopies performed by cardiothoracic surgeons, six correctly identified the lesion. The one lesion missed by a cardiothoracic surgeon was later identified by the same surgeon, suggesting that it changed to a more easily identifiable form. This concept
that lesions could evolve may speak to the issue of the higher accuracy of the cardiothoracic surgeons in their endoscopies, as the cardiothoracic surgeons performed the later endoscopies in some cases. The high accuracy of all bronchoscopies performed by the cardiothoracic surgeons, whether initial or delayed, however, remains impressive. Rigid bronchoscopy was performed in 5 of the 9 cases (Table 5) and showed a lesion requiring operation in 4 of these. The one endoscopy that missed the lesion was performed by a surgical resident. Thus, rigid endoscopy in the hands of a cardiothoracic surgeon provides a 100% sensitivity, specificity, and accuracy. Bronchography did not assist the diagnosis in either of the cases in which it was used. These results clearly indicate that the most experienced individuals are the ones most likely to make the diagnosis of tracheobronchial disruption using rigid or flexible bronchoscopy. When the patient’s clinical condition suggests tracheobronchial disruption, bronchoscopy should be
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Table 5. Results of Rigid Bronchoscopy Performed in 5 of 9 Patients Patient No.
Endoscopist
Finding
Operative Finding
1 2
Surgical resident CT surgeon
Complete tracheal disruption Same
3 6
CT surgeon CT surgeon
9
CT surgeon
Normal Complete right main bronchial transection Right main bronchial tear Left main bronchial transection Posterior tracheal tear and right main bronchial tear
Same Same Same, except that right main bronchial tear was a complete transection
CT = cardiothoracic.
performed by persons well acquainted with the appearance of these potentially life-threatening lesions. A negative bronchoscopy by an inexperienced endoscopist, ie, surgical resident, medical or pediatric intensivist, trauma surgeon, or emergency room physician does not rule out the diagnosis. Of the 9 patients in our series, 5 were diagnosed promptly and 4 had a delayed diagnosis. Of the 5 patients diagnosed promptly, 4 had excellent surgical outcomes. The only complication was that of a unilateral vocal cord paralysis, which may have been present before operation. The fifth patient died as a direct result of the severity of his injury, which dictated pneumonectomy in a trauma setting with its attendant high mortality [lo, 111. Delay in diagnosis was detrimental in all 4 patients. In 2 of the patients, empyema or hilar abscess complicated the postoperative course. The third patient had complications with hypertrophic granulation tissue obstructing the repaired bronchus. The fourth patient had a delay in diagnosis of 4 days, which contributed substantially to his pneumonia, mediastinitis, sepsis, and subsequent multiple-system organ failure. We conclude that in individuals treating victims of high-energy blunt thoracic trauma a high index of suspicion for tracheobronchial disruptions must be maintained to detect these rare lesions. Clinical presentation including subcutaneous emphysema, dyspnea, sternal tenderness, pneumothorax, pneumomediastinum, hemoptysis, and rib or clavicle fractures should increase suspicion. Once the diagnosis of tracheobronchial disruption is entertained, rigid or flexible bronchoscopy should be per-
formed by an individual trained and experienced in the appearance of these injuries. Early recognition and repair of these injuries clearly decreases morbidity and mortality.
References 1. Kirsh MM, Orringer MB, Behrendt DM, et al. Management of tracheobronchial disruption secondary to nonpenetrating trauma. Ann Thorac Surg 1976;22:9>101. 2. Ecker RR, Libertini RV, Rea WJ, et al. Injuries of the trachea and bronchi. Ann Thorac Surg 1971;11:289-98. 3. Bertelsen S, Howitz P. Injuries of the trachea and bronchi. Thorax 1972;27:188-94. 4. Mills SA, Johnston FR, Hudspeth AS, et al. Clinical spectrum of blunt tracheobronchial disruption illustrated by seven cases. J Thorac Cardiovasc Surg 1982;84:49-58. 5. Jones WS, Mavroudis C, Richardson JD, et al. Management of tracheobronchial disruption resulting from blunt trauma. Surgery 1984;95:319-22. 6. Grover FL, Ellestad C, Arom KV, et al. Diagnosis and management of major tracheobronchial injuries. Ann Thorac Surg 1978;28:384-92. 7. Burke JF. Early diagnosis of traumatic rupture of the bronchus. JAMA 1962;181:682-6. 8. Kinsella TJ, Johnsrud LW. Traumatic rupture of the bronchus. J Thorac Surg 1947;16571-83. 9. Hood RM, Sloan HE. Injuries of the trachea and major bronchi. J Thorac Cardiovasc Surg 1959;38:458. 10. Thompson DA, Rowlands BJ, Walker WE, et al. Urgent thoracotomy for pulmonary or tracheobronchial injury. J Trauma 1988;28:276-80. 11. Bowling R, Mavroudis C, Richardson JD, et al. Emergency pneumonectomy for penetrating and blunt trauma. Am Surg 1985;51:13&9.
