INTRODUCTION: Traumatic bronchial disruption is a frequent result of high impact chest injury. Patients are usually not suitable candidates for bronchial repair at the time of their initial presentation, and require aggressive pulmonary hygiene. We describe a case in which a patient with severe distal left mainstem laceration undergoes repair with subsequent restoration of ventilation to the left lower lobe following several weeks of mechanical ventilation.
CASE PRESENTATION: This patient was a 41 year old male who sustained a fall from approximately 40 feet. He presented with multiple injuries, including a fracture of the left first rib and subcutaneous emphysema on his chest radiograph indicating a possible underlying bronchial disruption which was confirmed by bronchoscopy. The laceration was seen extending from the distal left mainstem bronchus at the bifurcation of the upper and lower lobes. An endobronchial blocker was inflated at the laceration site to tamponade bleeding and the patient underwent aggressive resuscitation. He also underwent thoracostomy for a right-sided hemorrhagic effusion. It was uncertain if he would survive his injuries, and a tracheostomy was placed. He made a full neurological recovery. Three weeks following his initial injury, he returned to the operating room for surgical repair of his left mainstem bronchial disruption. He had extensive granulation tissue with complete atelectasis of his left lower lobe. The bronchus was opened with blunt dissection and the use of endobronchial balloons and was closed with interrupted sutures. Post-operatively, his course was complicated by recurrent mucus plugging distal to the repair, and the regrowth of granulation tissue. He was unable to be liberated from mechanical ventilation. An interventional pulmonologist was consulted. The patient subsequently underwent rigid bronchoscopy with electrocautery to remove endobronchial granulation tissue and placement of a silicone-coated stent (Polyflex, Boston Scientific). The patient was then extubated and decannulated. Approximately eight weeks later, he presented with increased cough. His stent had migrated to the trachea. It was removed en bloc with biopsy forceps via fiberoptic bronchoscopy without complication. The patient is now ambulatory and fully recovered.
DISCUSSIONS: Patients with chest trauma and endobronchial disruption are usually managed with pneumonectomy and/or lobectomy at initial presentation. The mortality rate is approximately 43.7%, with the majority of deaths occurring within 72 hours of the initial trauma . This results in a marked decrease in reserve pulmonary function, which leaves these patients at high risk for pulmonary compromise and ventilator dependence in the future. Our patient is unique, as his bronchial repair did not occur at the time of injury, but was delayed. This may lead to increased mortality if there is a lung laceration with significant intrapleural bleeding . Following surgical repair, our patient developed persistent atelectasis and remained ventilator dependent. Finally, the patient was given a coated metallic stent. Most frequently, metallic stents are used which are nonremovable . The benefit of these stents is that they have a lower incidence of migration, better tensile strength and patency. The disadvantage is that they have a higher risk of erosion and perforation. Silicone stents are safer, but more likely to migrate.
CONCLUSION: We conclude that from our experience, endobronchial repair with surgical closure and the use of a silicone-coated stent, may be considered as an alternative to pneumonectomy in patients with severe endobronchial disruption resulting from chest trauma.
DISCLOSURE: Jeffrey Kim, None.