Traumatic Injury to the Trachea and Bronchus
Section snippets
Incidence
It is estimated that only 0.5% of all patients with multiple injuries managed in modern trauma centers suffer from tracheobronchial injury [1]. Because virtually all studies of airway trauma combine penetrating and blunt causes and do not publish a denominator of cervical and thoracic injuries with which to calculate the true incidence of airway involvement, however, this is at best a crude estimation.
Penetrating neck injuries have a 3% to 6% incidence of cervical tracheal injury [2]. Less than
Mechanism of injury
Most tracheobronchial injuries result from blunt or penetrating trauma, although iatrogenic injuries and less common causes, such as strangulation, burns, or caustic injury, occasionally result in airway injury. Most penetrating trauma is caused by stab wounds or gunshot wounds and only uncommonly may occur from impalement or slash injuries. Nearly all stab injuries of the trachea are cervical in origin, because of the deep location of the intrathoracic trachea. Knife injuries produce a tearing
Associated injuries
Because of the adjacent cervical and intrathoracic structures, penetrating airway trauma frequently is associated with significant associated injuries that often are major determinants of outcome. Blunt trauma is often associated with multiple injuries involving not only chest, but abdomen, head, and orthopedic structures [15]. Cervical trauma of the airway frequently involves the esophagus, the recurrent laryngeal nerves, the cervical spine and spinal cord, the larynx, and the carotid arteries
Diagnosis
Airway injuries become the first priority in trauma, and because of their acuity and critical importance in stabilizing the patient, initial steps in management may proceed simultaneously with the diagnosis of airway pathology and associated injuries. Dyspnea and respiratory distress are frequent symptoms, occurring in 76% to 100% of patients [16], [18], [19]. The other common symptom is hoarseness or dysphonia, which occurred in 46% of the patients in a series published by Reece and Shatney
Initial airway management
The initial and most important priority in acute tracheobronchial injury is to secure a satisfactory airway. Patients with respiratory distress and the clinical suspicion of an airway injury should be intubated immediately, preferably with the guidance of a flexible bronchoscope, as described previously. If the patient is unstable either hemodynamically or in terms of respiratory status, however, the optimal first method still remains oral entubation with in-line cervical stabilization.
In a
Anesthetic management
Close cooperation between the anesthesiologist and surgeon is critical to the successful management of a tracheobronchial injury. In most cases a long, single-lumen tube is not only sufficient, but safe. In selected circumstances, use of an endobronchial blocker or carefully passed double lumen tube may be required.
In hemodynamically stable patients, high-frequency jet ventilation provides an effective option for ventilation with relatively low airway pressures. Its main advantage is during
Surgical management
Minor injuries may not be initially apparent or recognized, because of a lack of clinical suspicion or concealment by prompt distal intubation for stabilization of a patient with multiple injuries. These minor injuries may heal without direct surgical repair without negative sequelae if they involve less than one third of the circumference of the airway. Mucosal defects, not associated with ongoing air leak, may also heal and do not require immediate intervention. The most reliable short- and
Postoperative management
Careful airway observation is maintained in the early postoperative period. Aggressive pulmonary toilet, including the liberal use of bedside bronchoscopy, is important because these patients may have difficulty clearing secretions past their anastomosis or area of airway repair. Patients who have an associated vocal cord paralysis may have even more difficulty with pulmonary toilet because of their inability to produce an effective cough. These patients may benefit from a commercially
Complications
The complications of tracheobronchial repair are similar to those of airway resection and reconstruction and consist mostly of anastomotic problems. Anastomotic dehiscence or restenosis occurs in 5% to 6% of patients after tracheal reconstruction [33]. Initial management involves securing the airway, usually with an endoluminal or tracheal T tube until healing is complete and the perioperative inflammation has subsided. Most of these patients can be managed with subsequent airway resection and
Late presentation
Patients may incur delayed treatment after tracheobronchial trauma for three reasons. First, the initial injury may have been subtle and initially missed in the early or intermediate trauma management. Second, severe associated injuries may have prevented early definitive management of recognized airway injury. Third, initial attempts at repair may fail, resulting in dehiscence or late stenosis.
In any of these scenarios, the sequelae are similar. Although the airway may be partially or
Results
Injury to the trachea and proximal bronchi is a lethal injury, with more than 75% of patients with blunt tracheobronchial trauma dying before arrival to the emergency department [7]. There are no known series of autopsy studies of penetrating tracheobronchial trauma to give a similar prehospital mortality denominator. In both instances, however, death is most likely caused by associated injuries rather than by the tracheobronchial injury itself.
In patients operated on for penetrating injuries,
Summary
Tracheobronchial injuries are relatively uncommon, often require a degree of clinical suspicion to make the diagnosis, and usually require immediate management. The primary initial goals are twofold: stabilize the airway and define the extent and location of injury. These are often facilitated by flexible bronchoscopy, in the hands of a surgeon capable of managing these injuries. Most penetrating injuries occur in the cervical area. Most blunt injuries occur in the distal trachea or right
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