Tracheobronchial injuries are rare but potentially lethal injuries that are associated with thoracic trauma, iatrogenic damage, or inhalation injuries. They most commonly occur within 2.5 cm of the main carina or in the right middle lobe bronchus and superior segmental bronchi bilaterally. Flexible bronchoscopy is the definitive diagnostic study to document the site and extent of injury. Treatment involves either non-operative management with endotracheal intubation for small lacerations, or surgical repair for larger tears or those involving the full thickness of the tracheobronchial wall. Surgical approaches depend on the location of the tear.

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