Tracheobronchial Injury
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Tracheobronchial injury: tracheobronchial injury is uncommon but immediately life threatening. The
immediate sequelae can include death from asphyxiation, whereas lack of recognition or incorrect
management may result in life-threatening or disabling airway stricture
Incidence:
Only 0.5% of all patients with multiple injuries managed in modern trauma centers suffer from
tracheobronchial injury
Mechanism/ cause of injury:
Penetrating trauma:
- Stab injury (cervical trachea)
- Gunshot injury (cervical and thoracic trachea)
Blunt trauma:
- Blunt injuries of the cervical trachea most commonly result from direct trauma or from
sudden hyperextension
- Direct cervical trauma produces a crush injury of the trachea because it may be impinged on
by the rigid vertebral bodies → dashboard injury
- Unrestrained motor vehicle passengers may hyperextend the neck during head-on collisions
→ striking the neck on the steering wheel or dashboard → a crush injury of cervical trachea
Rare causes – strangulation, burns, caustic injury, iatrogenic injuries
Associated injuries:
Because of the adjacent cervical and intrathoracic structures, penetrating airway trauma
frequently is associated with other major injuries
Cervical trauma of the airway may involve – the esophagus, the recurrent laryngeal nerves, the
cervical spine and spinal cord, the larynx, and the carotid arteries and jugular veins etc.
Intrathoracic penetrating trauma may involve – the esophagus, left recurrent laryngeal nerve,
and spinal cord, great vessels (ascending or descending aorta, pulmonary arteries), heart
chambers, lung parenchyma etc.
Clinical features: accurate diagnosis of tracheobronchial injury requires an understanding of the
mechanism of injury and a high index of suspicion when these mechanisms or common associated
injuries are present.
History of trauma to neck or chest
Initial assessment according to the ATLS protocol
Frequent symptoms:
- Dyspnea and respiratory distress
- Hoarseness or dysphonia
- Hemoptysis
Common signs of airway injury:
- Subcutaneous emphysema
- Pneumothorax
- Persistent large air leak despite a well-placed chest tube
- An air leak from a penetrating neck wound that disappears after intubation is diagnostic
(and identifies the injury site as proximal to the cuff)
Investigations:
Chest x-ray:
- Subcutaneous emphysema
- Pneumothorax
- Pneumomediastinum
- Persistent pneumothorax despite a well-placed chest tube
- Disruption of tracheal or bronchial air column
- Overdistended endotracheal balloon cuff and migration of the balloon toward the
endotracheal tube tip
- Falling lung/ fallen lung sign of Kumpe: complete transection of a main stem bronchus may
result in the classic signs of atelectasis, absent hilum, and a collapsing of the lung away from
the hilum toward the diaphragm (in pneumothorax → collapsed lung towards the hilum/
medially, but in tracheobronchial injury → collapsed lung away from hilum/ inferiorly and
laterally)
Cervical spine x-ray:
- Deep cervical emphysema
- Disruption of tracheal air column
CT scan of chest with virtual bronchoscopy:
- Disruption of the tracheobronchial air column
- Subcutaneous emphysema
- Pneumothorax
- Pneumomediastinum
- Fallen lung sign
- Virtual bronchoscopy will give a clear view of the definitive site of injury
- Associated chest injuries
Bronchoscopy:
- Rigid or fiberoptic bronchoscopy → definitive diagnostic study of choice
- Identify specific site of injury
- Can be used for toileting of the airway
Management:
A. Immediate management: the patient is managed according to the primary survey of ATLS
protocol –
A: secure the airway with cervical spine protection –
Clear the airway and remove any foreign body
If patient is unable to maintain oxygen saturation despite face mask oxygenation
and jaw thrust and chin lift technique → endotracheal intubation (bypass the
lesion by intubating distal to the lesion)
If experienced anesthesiologist is available → double lumen endotracheal tube
(selective ventilation of the uninjured lung)
If endotracheal intubation is failed or difficult → surgical airway by a
tracheostomy
B: breathing –
Look for features of pneumothorax, subcutaneous emphysema and flail
segment
Immediate insertion of chest tube on the affected side under local anesthesia
C: circulation –
Assessment of hemodynamic status
Volume resuscitation according to standard protocol
Urinary catheterization to monitor output
D: deformity –
Look for any neuromuscular disability
If any suspected spinal cord injury → appropriate caution during movement or
transfer of the patient
E: exposure –
Proper exposure for detailed examination
Other:
Adequate analgesic
Broad spectrum antibiotics
Reassurance and counselling of the patient about his/ her condition
B. Subsequent management: secondary survey –
Detailed history
Proper clinical examination
Relevant investigation
C. Definitive treatment:
Conservative treatment: small injury may heal spontaneously. Criteria for conservative
treatment are –
No expanding surgical emphysema
No persistent collapsed lung after chest drain tube insertion
No progressive pneumomediastinum
No esophageal injury
No open tracheal injury
No mediastinitis
Surgical management:
Approach:
o Injury of trachea, carina and right principal bronchus → right
posterolateral thoracotomy
o Injury of left principal bronchus → left posterolateral thoracotomy
o Injury to proximal trachea → low cervical collar incision
Surgical options:
o Simple clean laceration without much devitalized tissue → primary
repair with absorbable or non-absorbable suture, either interrupted or
continuously
o Resection of traumatic segment with primary anastomosis without any
tension
o Injury to lobar bronchus → standard or sleeve lobectomy
Post-operative care:
Aggressive pulmonary toileting
Wean from positive pressure ventilation as soon as possible
Aggressive bronchoscopy to clear the airway of any secretion or granulation
tissue
Early ambulation
Complications if left untreated:
Bronchial stenosis
Recurrent pneumonia
Bronchiectasis
