an injury which may easily missed

1. Tracheobronchial Injuries
Dr. K Khaing Saw Lwin
MBBS, MRCSEd, MMedSc(Thoracic Surgery)

2. • Rare
• potentially lethal injuries
• associated with -
(1) thoracic trauma,
(2) iatrogenic damage, and
(3) inhalation injuries.

3. Traumatic tracheobronchial
injuries

4. Common sites
1. Within 2.5 cm of the main carina (fixed position
shear develops between restrained and
unrestrained airways  disruption of the
bronchus
2. Right middle lobe bronchus and the superior
segmental bronchi bilaterally
(airwaysrelatively long  susceptible to
differential deceleration forces)
3. spiral tears of the right mainstem and bronchus
intermedius (rotational and compressive forces)

5. Presenting symptoms
• Typical - respiratory distress, dyspnea,
• TB injuries with communication to pleural
space air leak in ICD tube
• Others – Horseness or dysphonia
• tenderness or focal rib pain
• Symptoms + a high-energy impact  chest
CT scan and bronchoscopic examination

6. • common diagnostic signs
1.subcutaneous emphysema(35%-85%)
2.pneumothorax (20%-50%)
3.hemoptysis (14%-25%)

7. A.E. Balci et al. / European Journal of
Cardio-thoracic Surgery 22 (2002) 984–989
ROSSBACH ET AL 183
1998;65:182–6 MANAGEMENT OF TRACHEOBRONCHIAL
INJURIES

8. definitive diagnostic study of choice
• Flexible bronchoscopy (under GA)
- an inspection of the tracheobronchial tree
documenting the site and extent of injury,
- in an intubated patient withdrawal of the
endotracheal tube to diagnose proximal
tracheal tears
• A high level of suspicion important for
diagnosis (occasionally exhibit normal clinical
appearance and negative endoscopic findings)

9. Airway management
• Tracheostomy
• Needle cricothyroidectomy
• ET tube insertion

10. Management

11. Non-operative treatment
• small laceration is either small (less than
approximately 2 cm) and amenable to
adequate cuff positioning
• Not involving the whole thickness of the
tracheobronchial wall,
• for patients in a poor general condition with a
very high operative risk

12. `Non-operative' management
• intubation with the cuff inflated distal to the
tear
• a chest tube drainage if necessary
• adequate antibiotic management
• High ventilatory pressures should be avoided
• observed carefully for airway obstruction and
pulmonary and mediastinal sepsis

13. Note
• Emergency bronchoscopy was done under
general anaesthesia using a flexible endoscope
inserted through an uncuffed endotracheal tube
that was repositioned in such a way as to ensure
inspection of both the upper and lower rims of
the rupture
• After the investigation the tube was either fixed
in its definitive position for conservative
treatment or brought into a position that was
adequate for immediate surgical repair

14. Absolute indication for surgery
• free rupture of a proximal bronchus into the
pleural space

15. Indications for surgical repair
• tension pneumothorax with
tracheobronchopleural fistula developing after
drainage
• rapidly increasing pneumomediastinum and
increasing subcutaneous emphysema in spite of
conservative treatment attempts
• transmural tear with free vision beyond the
tracheobronchial wall longer than 2 cm
• prolapse of the esophageal wall into the tracheal
lumen
• mediastinitis

16. • approach for surgical repair  the location and
the length of the tear
• Collar incision Injuries of the cervical trachea
and larynx
• Right posterolateral thoracotomy  distal
trachea, the bifurcation, both mainstem bronchi.
• Left thoracotomy  only for isolated transverse
abruptions of the left mainstem bronchus close
to the lobar orifices

18. ROSSBACH ET AL Ann Thorac Surg
MANAGEMENT OF TRACHEOBRONCHIAL INJURIES 1998;65:182–6

21. Method
• ? simple, interrupted 4-0 Vicryl sutures
• ? Non-absorbale monofilament sutures

22. Issues
• Tracheostomy (+/-)
• No of days intubated

23. When Post op bronchoscopy
• ? 1,2,4d
• ? 1 week

24. A.E. Balci et al. / European Journal of Cardio-thoracic Surgery 22 (2002) 984–989

25. Late complication of TBI
• Formation of granulation tissue at the site of
injury
• Partial airway obstruction
• Secondary respiratory tract infection

26. REFERENCES
• A.E. Balci et al. / European Journal of Cardio-
thoracic Surgery 22 (2002) 984–989
• ROSSBACH ET AL Ann Thorac Surg
MANAGEMENT OF TRACHEOBRONCHIAL
INJURIES 1998;65:182–6
• S. Gabor et al. / European Journal of Cardio-
thoracic Surgery 20 (2001) 399±404

27. THANKS