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Table of Contents
CASE REPORT  
Year : 2013  |  Volume : 16  |  Issue : 2  |  Page : 140-143
Perioperative management of tracheobronchial injury following blunt trauma


1 Department of Cardiac Anesthesia, Deenanath Mangeshkar Hospital and Research Centre, Pune, Maharashtra, India
2 Department of Cardiac Surgery, Deenanath Mangeshkar Hospital and Research Centre, Pune, Maharashtra, India
3 Department of Surgery, Deenanath Mangeshkar Hospital and Research Centre, Pune, Maharashtra, India

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Date of Submission22-Oct-2012
Date of Acceptance03-Jan-2013
Date of Web Publication29-Mar-2013
 

   Abstract 

We describe tracheobronchial injury (TBI) in a 17-year-old teenager following blunt trauma resulting from a road traffic accident. The patient presented to a peripheral hospital with swelling over the neck and face associated with bilateral pneumothorax for which bilateral intercostal drains were inserted and the patient was transferred to our institute. Fiber-optic videobronchoscopy (FOB) was performed, the trachea and bronchi were visualized, and the site and extent of injury was assessed. Spontaneous respiration was maintained till assessment of the airway. Then the patient was anesthetized with propofol and paralyzed using succinylcholine and a double-lumen endobronchial tube was inserted; thereafter, the adequacy of controlled manual ventilation and air-leak through intercostal drains was assessed and the patient was transferred to operating room (OR) for repair of the airway injury. The OR was kept ready during FOB to manage any catastrophe. This case describes the need for proper preparation and communication between health care team members to manage all possible scenarios of traumatic TBI.

Keywords: Blunt trauma, One-lung ventilation, Tracheobronchial injury

How to cite this article:
Juvekar NM, Deshpande SS, Nadkarni A, Kanitkar S. Perioperative management of tracheobronchial injury following blunt trauma. Ann Card Anaesth 2013;16:140-3

How to cite this URL:
Juvekar NM, Deshpande SS, Nadkarni A, Kanitkar S. Perioperative management of tracheobronchial injury following blunt trauma. Ann Card Anaesth [serial online] 2013 [cited 2018 Jan 24];16:140-3. Available from: http://www.annals.in/text.asp?2013/16/2/140/109772



   Introduction Top


Tracheobronchial injury (TBI) can result from non-penetrating or penetrating trauma to the neck or chest, [1] inhalation of harmful fumes, [2] or aspiration of liquids or objects. [3] Non-penetrating injuries are usually caused by blunt trauma or deceleration injury. Deceleration injuries are either caused due to impact or momentum. TBI due to blunt trauma is considered to be caused by any combination of three possible mechanisms: an increase in pressure within the airways, shearing, and pulling apart. [4] Tracheal disruption is a rare occurrence and is seen in 14% of the penetrating neck and chest trauma cases and 0.34-1.5% of all blunt trauma cases including adults and children. [5] Lesions can be transverse occurring between the rings of the trachea, longitudinal, or spiral. In 8% of the injuries, the lesions are complex occurring in more than one location, with more than one type of lesion or on both of the main bronchi and trachea. [6] Transverse tears are more common than longitudinal or complex ones. [2] Posterior tracheal tears are more common than anterior tears as cartilaginous rings become deformed and create stress on the membranous portion of posterior trachea. [7] The most common tracheal injury is a tear near the carina or in the membranous wall of the trachea. [8] TBI is a serious condition and may cause life-threatening respiratory insufficiency. Of the patients who die of TBI, most of them do so before receiving emergency care either due to airway obstruction, exsanguination, or from injuries to other vital organs. Mortality among survivors who reach the hospital may be as high as 30%. [9] The signs and symptoms among patients of TBI vary based on the location and severity of injury and include dyspnea (76-100%), hemoptysis (25%) [10] dysphonia, coughing, and abnormal breath sounds. We report management of a case of TBI due to blunt injury following road traffic accident (RTA).


   Case Report Top


A 17-year-old male epileptic patient was admitted to a peripheral hospital following RTA. Bilateral emphysema was noted over the neck and face. The chest X-ray revealed bilateral pneumothorax for which bilateral intercostal drains were inserted and the patient was shifted to our institute for further management. On arrival, the patient was hemodynamically stable and maintained oxygen saturation (SpO 2 ) of 94-95% with 4 liters per minute O 2 delivered nasally. There was no evidence of any external injury. The high-resolution computerized tomography (HRCT) of thorax revealed a linear tear in the trachea and right main stem bronchus with pneumomediastinum and lung contusions. A nasogastric tube (NGT) was carefully inserted keeping in mind the possibility of associated esophageal injury and the patient was kept nil by mouth. Fiber-optic videobronchoscopy (FOB) was planned under sedation followed by endobronchial intubation under vision. High-frequency jet ventilator (Acutronics medical equipments) was kept standby with preparation to conduct FOB and resultant surgery under high frequency jet ventilation, if required. The operating room (OR) and the perfusion technology team was kept ready to deal with any catastrophe during FOB. The patient was prepared for FOB with xylocaine viscous gargles and 4% xylocaine nebulization. The patient was sedated with intravenous (IV) midazolam 2 mg and butorphanol 1 mg. FOB revealed a semi-lunar tear on the trachea just at the origin of the right main-stem bronchus. Further part of the right bronchus was not visualized and the left bronchus was found to be normal [Figure 1] and [Figure 2]. Vital signs remained stable and SpO 2 remained at 100% throughout the diagnostic examination. After visualizing the trachea and bronchus, a left-sided 39F double-lumen tube (DLT) was inserted after anesthetizing the patient with propofol 150 mg and paralyzing with succinyl choline 100 mg. The position of DLT was confirmed by auscultation and FOB; thereafter, on gentle manual ventilation, the air-leak through both the intercostal tubes was assessed and adequacy of ventilation was confirmed. Then, after paralyzing with vecuronium 6 mg, the patient was shifted to OR for repair of the TBI. The controlled mechanical ventilation was continued using 400 ml tidal volume and 10 breathing rate. The anesthesia was maintained with air, oxygen, sevoflurane; fentanyl and vecuronium. The patient was monitored using ECG, SpO 2 , EtCO 2 , temperature and intra-arterial blood pressure and central venous pressure. A right posterolateral thoracotomy was performed through the 4 th intercostal space; the 4 th rib was excised extra-periostially and intercostals based pedicle was harvested. One-lung ventilation (OLV) was instituted and mediastinal pleural flap was raised. The azygous vein was divided to expose the area of the carina. The right main bronchus was found totally avulsed from the origin with a thrombus between the two avulsed edges. During OLV, FiO 2 1, PEEP 5 mmHg and insufflation of the right lung with oxygen was initiated to maintain a saturation of 92-93%. The edges of the trachea were minimally refreshed, sutured with interrupted sutures, and buttressed with intercostal based flap. The suture line was tested for leaks and the chest was closed after inserting an intercostal drain. After chest closure, epidural catheter was inserted in the left lateral position at T10-11 by midline approach with loss of resistance to air and catheter was placed 6 cm in the epidural space. 6 ml 0.125% bupivacaine with 100 mcg fentanyl was given as a bolus after a test dose of 2 ml 2% xylocaine-adrenaline through the epidural catheter and an infusion of 0.1% bupivacaine was started for postoperative analgesia. The DLT was changed to 9 mm cuffed oral endotracheal tube and the patient was shifted to intensive care unit for elective ventilation under sedation and paralysis taking utmost care not to allow the patient to cough. Analgesia was ensured with epidural bupivacaine and intravenous paracetamol and diclofenac. The patient was extubated uneventfully after 24h. In the postoperative period, there was no significant air-leak from the ICDs and they were removed on the 8 th postoperative day after performing a check fiber-optic bronchoscopy which revealed an intact suture line with no stenosis [Figure 3]. The patient was discharged on postoperative day 11. The patient has been advised follow-up at 6 months to look for any evidence of airway stenosis.
Figure 1: Preoperative bronchoscopy showing the semilunar tear in the trachea at the origin of right main bronchus

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Figure 2: Preoperative bronchoscopy showing the avulsed right main bronchus from the trachea

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Figure 3: Postoperative bronchoscopy

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   Discussion Top


TBI should be suspected with penetrating or blunt injury to neck or chest. The chest X-ray is the initial imaging technique which can be misleading and normal in one in five cases of blunt trauma and TBI. [11] Subcutaneous or mediastinal emphysema, [6] hemoptysis, [10] pneumothorax, bronchopleural fistula, or persistent air-leak after ICD insertion are definite signs of TBI. Computed tomography (CT) scan detects over 90% of TBI resulting from blunt trauma, but neither CT scan nor chest X-ray are replacements to bronchoscopy. [9] Bronchoscopy is the most effective method to diagnose, locate, and determine the severity of TBI, [10] and is the only method that allows definite diagnosis. [11] Flexible bronchoscopy is the fastest and most reliable technique. [12] Majority of the tracheobronchial disruptions need surgical repair. Minimal air leak or main bronchus injury involving less than one-third of the circumference and in apposition can be treated non-surgically. In the present patient, the right main stem bronchus could not be visualized beyond the origin; therefore, we decided to explore and surgically repair the injury.

Esophageal injury can also be associated because of its crushing between the trachea and vertebral bodies or due to sudden rise in the intraluminal pressure by the blunt forces. In our case, the intensivists had inserted a NGT very carefully on admission. Esophagoscopy during FOB to rule out esophageal injury prior to inserting NGT would have been ideal. Although the case proceeded uneventfully, it is important to be prepared for every possible scenario that could take place. The American Society of Anesthesiologists modified trauma algorithm for airway disruptions emphasizes: Maintenance of spontaneous ventilation even with modified rapid sequence induction; Awake fiber-optic intubation for all major tears; Use of DLT, Two small single-lumen tubes or single-lumen tube with bronchial blocker; Placement of endotracheal tube below the level of tear to avoid pressurization above the level of tear; Establishment of surgical airway, if the above interventions are not working and consideration of establishment of CPB via femoral vessels for major tears; and, Avoidance of transtracheal jet ventilation or positive pressure ventilation through laryngeal mask airway. [13]

Removable stents to manage large acute tracheal tears is a new approach being used. It was first described and documented by Creagh-Brown et al. [14] The use of removable stents avoids problems of overgrowth of granulation tissue [3] which may need surgery to maintain airway.

In this case, spontaneous ventilation was maintained till the extent of injury was determined. The patient was then paralyzed with a short-acting depolarizing muscle relaxant and positive pressure ventilation was used after placement of DLT. The presence of bilateral ICDs made positive pressure ventilation relatively safe. Any increase in the air leak was carefully observed and jet ventilation was kept ready in case the air leak increased substantially; additionally we had an option to switch over to OLV, if ventilation were inadequate. As there was no increase in the air-leak, intermediate acting non-depolarizing muscle relaxant was used for paralysis during surgery. Although guidelines suggest maintaining spontaneous ventilation as far as possible, we deemed it safer to paralyze the patient while shifting the patient from the bronchoscopy suite to avoid patient coughing on the tube endangering further increase in the air-leak. Performing FOB in the OR is ideal, should a need for urgent cardiopulmonary bypass (CPB) arise. In our case, it could not be arranged due to lack of portable equipment needed for FOB. The perfusion technologist team was kept on standby in the OR. [13],[15] In the eventuality of inadequate ventilation, percutaneous cannulation of the femoral vessels for the conduct of CPB is a choice, alternatively, preparations for the cannulation of femoral vessels is made before initiating anesthesia.

Tracheal tears and severe airway injury may eventually lead to stenosis, stricture, and scarring. This phenomenon is more common in the pediatric population as compared to adults. [16] So check bronchoscopy and documentation should be done which will serve as a reference guide for further management if required. [16] In our case, we did a check FOB at 1 week and have advised the patient to come for follow-up at 6 months.

To summarize, this case report emphasizes the key points in the management of airway trauma with special emphasis on maintenance of spontaneous ventilation till the level of airway injury is determined. It also stresses on preparation of the operation theatre to manage any catastrophe that may arise and the coordination between different specialties.

 
   References Top

1.Johnson SB. Tracheobronchial injury. Semin Thorac Cardiovasc Surg 2008;20:52-7.  Back to cited text no. 1
    
2.Euathrongchit J, Thoongsuwan N, Stern EJ. Nonvascular mediastinal trauma. Radiol Clin North Am 2006;44:251-8.  Back to cited text no. 2
    
3.Stark P. Imaging of tracheobronchial injuries. J Thorac Imaging 1995;10:206-19.  Back to cited text no. 3
    
4.Hwang JC, Hanowell LH, Grande CM. Perioperative concerns in thoracic trauma. Baillieres Clin Anaesthesiol 1996;10:123-53.  Back to cited text no. 4
    
5.Mukherjee K, Isbell JM, Yang E. Blunt posterior tracheal laceration and esophageal injury in a child. J Pediatr Surg 2009;44:1292-4.  Back to cited text no. 5
    
6.Chu CP, Chen PP. Tracheobronchial injury secondary to blunt chest trauma: Diagnosis and management. Anaesth Intensive Care 2002;30:145-52.  Back to cited text no. 6
    
7.Mezhir JJ, Glynn L, Liu DC, Statter MB. Handlebar injuries in children: Should we raise the bar of suspicion? Am Surg 2007;73:807-10.  Back to cited text no. 7
    
8.Smith M, Ball V. Thoracic trauma. Cardiovascular/Respiratory Physiotherapy. St Louis: Mosby; 1998. p. 217.  Back to cited text no. 8
    
9.Rieley RD, Miller PR, Meridith JW. "Injury to esophagus, trachea and bronchus".In Moore EJ, Feliciano DV, Mattox KL. Trauma. New York: Mc Graw-Hill, Medical Pub Division; 2004. p. 544-7.  Back to cited text no. 9
    
10.Karmy-Jones R, Wood DE. Traumatic injury to the trachea and bronchus. Thorac Surg Clin 2007;17:35-46.  Back to cited text no. 10
    
11.Wintermark M, Schnyder P, Wicky S. Blunt traumatic rupture of a mainstem bronchus: Spiral CT demonstration of the "fallen lung" sign. Eur Radiol 2001;11:409-11.  Back to cited text no. 11
    
12.Rico FR, Cheng JD, Gestring ML, Piotrowski ES. Mechanical ventilation strategies in massive chest trauma. Crit Care Clin 2007;23:299-315.  Back to cited text no. 12
    
13.American Society of Anesthesiologists. ASA difficult airway algorithm modified for trauma. ASA Newsllet 2005;69:14.  Back to cited text no. 13
    
14.Creagh-Brown B, Sheth A, Crerar-Gilbert A, Madden BP. A novel approach to the management of acute tracheal tear. J Laryngol Otol 2008;122:1392-3.  Back to cited text no. 14
    
15.Jaffe R, Samuels S. Anesthesiologist's Manual of Surgical Procedures. 4 th ed. Philadelphia, PA: Lippincott, Williams and Wilkins; 2009. p. 737-1.  Back to cited text no. 15
    
16.Holzki J, Laschat M, Puder C. Iatrogenic damage to the pediatric airway: Mechanisms and scar development. Paediatr Anaesth 2009;19:131-46.  Back to cited text no. 16
    

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Nilesh M Juvekar
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.109772

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