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J Thorac Cardiovasc Surg 1997;113:415-417
© 1997 Mosby, Inc.
BRIEF COMMUNICATIONS |
Nieuwegein, The Netherlands
Received for publication August 12, 1996 accepted for publication August 26, 1996. Address for reprints: Filip Muysoms, MD, Emiel Clauslaan 133, 9800 Astene-Deinze, Belgium.
A 16-year-old boy was transferred from another hospital to our department because of clinical suspicion of a bronchial rupture after blunt chest trauma. He had been in a traffic accident as the driver of a small motorcycle. On admission he was intubated, nonsedated, and anxious. He had hypotension, tachycardia, and massive subcutaneous emphysema over the chest, the upper part of the abdomen, and in the neck. A small thoracic catheter was in place. A roentgenogram of the chest made in the referring hospital showed a complete pneumothorax on the right side with extensive subcutaneous and mediastinal emphysema. He had a stable pelvic fracture, confirmed by radiography.
The patient was sedated. An arterial pressure line, a jugular catheter, and a larger thoracic drain were placed. A major air leak was detected. A flexible bronchoscope, inserted in the emergency department, revealed a large defect of the right main bronchus just distal to the carina. The patient was then taken to the operating room for urgent thoracotomy. After placement of a single-lumen endotracheal tube into the left main bronchus, the patient was positioned on his left side and a right posterolateral thoracotomy above the fifth rib was performed. The right lung had collapsed and the right upper lobe contained a large intrapulmonary hematoma. A complex, double bronchial rupture was present—a complete transection of the right main bronchus and an incomplete rupture of the right lower lobe bronchus. The cartilaginous portion of the main bronchus was transected transversely about 1 cm distal to the carina. The membranous portion had ruptured transversely more proximally at the level of the carina. The two transection planes were connected by a double longitudinal tear at the junction between the cartilaginous and membranous parts of the right main bronchus (Fig. 1). The right lower lobar bronchus had an incomplete transverse rupture about half the circumference of the bronchus and 0.5 cm distal to the ostium of the bronchus for the right middle lobe. Both ruptures wereprimarily repaired. Interrupted resorbable Vicryl 3-0 sutures were used for the cartilaginous part. The membranous part of the main bronchial rupture was repaired with three continuous 5-0 polypropylene sutures. Care was taken to minimize peribronchial dissection so as to avoid compromising bronchial vascularization. After the repair, a minor air leak from the main bronchial suture was accepted. The sutures were covered with parietal pleura and fibrin glue. After the operation, the patient was supported with a ventilator for 6 days; the thoracic drain was removed after 5 days. Further recovery was uneventful, and after rehabilitation for the pelvic fracture the patient was discharged 30 days after admission. A roentgenogram of the chest showed good expansion of the right lung and a resorbing hematoma of the right upper lobe (Fig. 2). A follow-up bronchoscopic study after 5 months showed good patency of the main and lobar bronchi. On radioscopy the hematoma of the right upper lobe had disappeared.
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1,2 Symptoms of bronchial rupture include dyspnea, subcutaneous emphysema, and pneumothorax. Associated injuries are very frequent in these patients.
For diagnosis, bronchoscopy is the method of first choice. Bronchoscopy should be used liberally in injured patients in whom bronchial rupture is suspected. 2
Roentgenographic signs of rupture of a major airway are subcutaneous emphysema, pneumothorax, and pneumomediastinum. 3 Isolated tracheal injury or main bronchial rupture limited to the mediastinum results in massive mediastinal and deep cervical emphysema, without pneumothorax (type 2 injury). Extramediastinal bronchial rupture with communication to the pleural space causes ipsilateral pneumothorax and most often associated pneumomediastinum (type 1 injury). 2
Immediate primary repair of the bronchial rupture is advocated to preserve functional lung tissue and to provide the best long-term results. 1,2,4 Resection of lung tissue, however, cannot always be avoided.
Symbas, Justicz, and Ricketts 5 have divided tracheobronchial ruptures into three types: transverse, longitudinal, and complex, complex injuries being either combined transverse and longitudinal ruptures or multiple ruptures. In their review of 189 cases, complex ruptures represented only 8% of the total. In the two patients with involvement of a lobar bronchus, a lobe resection was performed. In our patient, full functional preservation of the right lower lobe was obtained by primary repair of the ruptured lobar bronchus.
Most intrathoracic airway ruptures caused by blunt trauma are situated at the distal trachea or the main bronchi within 2.5 cm of the carina. 2,4 This was true of the right main bronchus and carinal injury in our patient.
Cardiopulmonary bypass has been used for the repair of complex bilateral ruptures. 5 An important disadvantage is the risk of generalized heparinization, with possible bleeding at other sites of injury such as fractures or cerebral lesions.
Anesthetic management of the ruptured airway can be difficult and hazardous. Care should be taken to prevent further disruption of the airway during endotracheal intubation. Bronchoscopic guidance must be used. The tube should be passed distal to the rupture in the case of tracheal rupture, and it should be passed into the main bronchus of the unaffected lung in the case of bronchial rupture. 2,5
The prognosis of tracheobronchial ruptures is often related to the severity of associated injuries in these multiply injured patients. Over the long term, bronchial stenosis by granulation tissue after primary repair of a bronchial rupture is to be feared. 3 Regular bronchoscopic checks should be performed. Stenosis can be managed either with endoscopic laser therapy or, if endoscopic treatment is unsuccessful, by reoperation.
In conclusion, in this patient with a complex tracheobronchial rupture, primary repair of the bronchus was possible even at the level of a lobar bronchus, with complete functional preservation of lung tissue.
References
This article has been cited by other articles:
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  H. Sirbu, B. Herse, T. Busch, and H. Dalichau Complex reconstruction of the right bronchial system J. Thorac. Cardiovasc. Surg., November 1, 1997; 114(5): 870 - 870. [Full Text]
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