INTRODUCTION:Tracheobronchial injuries rarely occur as a result of blunt trauma. Bronchial injuries occurring beyond the carina comprise approximately 9.3% of tracheobronchial injuries (1). We present the case of a young patient with a tear near the bronchus intermedius who was managed effectively with a bronchoscopically-placed endobronchial blocker.
CASE PRESENTATION:DT was a 15 year old male involved in an unwitnessed all-terrain vehicle accident. Paramedics found the patient in respiratory distress and he was intubated at the scene. On arrival to the ED, the patient was tachycardic and required a high FIO2. He had diffuse subcutaneous air and bilateral chest tubes were placed for presumed pneumothoraces, with the right having a brisk airleak. A CT scan demonstrated persistent collapse of the right lung despite a well-placed posterior chest tube, so a second, anterior chest tube was placed. Bronchoscopy was performed and revealed blood in the right mainstem bronchus. Distally, a one-half centimeter tear was visualized within the bronchus intermedius, at the junction of the right middle and right lower lobes. No intervention was taken at this time but the airleak continued to worsen. At repeat bronchoscopy, the bronchial tear had worsened, doubling in size. The decision was made to exclude the right lung from positive pressure ventilation. Attempts to place a dual-lumen endotracheal tube were unsuccessful. An endobronchial blocker was then placed with bronchoscopic guidance in the right bronchus intermedius proximal to the injury. Post-placement the patient’s airleak quickly resolved. The patient was maintained with deep sedation and neuromuscular blockade to avoid disruption of the endobronchial blocker. Two days later, the patient’s endotracheal tube was removed along with the blocker and the airleak did not return. His chest tubes were eventually removed and six-month follow up chest x-ray was normal.
DISCUSSIONS:Tracheobronchial injury is a rare and deadly complication of blunt trauma, and its diagnosis is often missed or delayed (1). Patients may complain of respiratory distress or show signs of tension pneumothorax. Subcutaneous air, pneumothorax, and pneumomediastinum are common findings in bronchial injuries. Although bronchoscopy is the diagnostic modality of choice, chest x-ray and CT scan are also helpful, demonstrating the site of injury in 94% of patients in some series. Traumatic tracheobronchial injuries are classified according to their proximity to the mainstem bronchii. Proximal tracheal injuries are frequently observed or, if necessary, repaired primarily. More distal injuries often respond to conservative management with a tube thoracostomy. If this proves ineffective, definitive treatment may include surgical resection, ranging anywhere from wedge resection to pneumonectomy. For patients with injuries at or near the takeoff to the primary lobes, treatment options are limited. Resultant broncho-pleural fistulas may preclude non-operative management, but surgery would frequently involve removing too much lung tissue; in this case, a right middle and lower lobectomy. Alternative management strategies, such as silicone stents or single lung ventilation, have been reported in the literature with variable success. Our medical team felt that the placement of an endobronchial blocker was a precise, low-risk means of excluding an enlarging bronchial tear from positive-pressure ventilation. The prospect of a bi-lobectomy was clearly not ideal in this 15 year old patient. Our management strategy enabled continued contribution of the right upper-lobe to ventilation and avoided surgery.
CONCLUSION:Tracheobronchial injuries are a rare but deadly occurrence in blunt trauma. We feel that the use of an endobronchial blocker should be considered in anyone with a difficult bronchial injury who requires positive-pressure ventilation.
DISCLOSURE:Michael Galle, No Financial Disclosure Information; No Product/Research Disclosure Information