Tracheobronchial Injury

LOWER TRACHEA AND MAJOR BRONCHI Most injuries to major bronchi are due to rapid deceleration and shearing of more mobile bronchi from relatively fixed proximal structures. However, forced expiration against a closed glottis and/or compression against the vertebral column may cause bursting of these structures.

Numerous reports have emphasized that the most common presenting signs and symptoms are dyspnea, hemoptysis, subcutaneous emphysema, Hamman sign, and sternal tenderness. A large pneumothorax, pneumomediastinum, deep cervical emphysema, and an endotracheal tube balloon with a round appearance on chest roentgenograms may suggest tracheobronchial injury; however, approximately 10 percent are almost completely asymptomatic.

Most tracheobronchial injuries occur within 2 cm of the carina or at the origin of lobar bronchi. On bronchoscopy, the usual bronchial injury seen is a transverse tear in a main bronchus or a disruption at the origin of an upper lobe bronchus. The characteristic injury in the trachea is a vertical tear in the membranous portion near its attachment to the tracheal cartilages.

Even if the lung expands and the air leak stops, lacerations of the bronchi involving more than a third of the circumference should be repaired because they tend to eventually cause severe bronchial stenosis with repeated pulmonary infections or complete atelectasis. Untreated tracheal tears may result in severe mediastinitis.

The majority of airway injuries can be corrected using standard techniques. With complex ruptures, cardiopulmonary bypass can provide safety during correction of the lesion and may encourage repair of the involved lung rather than its resection.

Those patients who survive a tracheal transection generally have their injury in the cervical trachea and have no associated injuries. Intrathoracic tracheal transection is usually associated with two or more major injuries and is almost invariably fatal. Concurrent esophageal injuries occur in almost 25 percent of penetrating tracheobronchial injuries and are easily missed unless esophagoscopy or contrast studies are also performed.

CERVICAL TRACHEAL INJURIES Injuries to the cervical trachea from blunt trauma usually occur at the junction of the trachea and cricoid cartilage. This is most frequently caused when the anterior neck strikes the dashboard in an automobile accident. Evidence of trauma to the neck with subcutaneous emphysema should arouse suspicion of this injury. Inspiratory stridor usually indicates a 70 to 80 percent upper airway obstruction. However, cricotracheal separation is often only suspected when an endotracheal tube or bronchoscope cannot be inserted past the cricoid cartilage.

If the patient has a laceration of the trachea that is small and high, it may be managed simply by performing a tracheostomy below the injury. All lacerations of the trachea should be repaired.

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