Asian Cardiovasc Thorac Ann 2008;16:65-67
© 2008 Asia Publishing EXchange Ltd
Clear-Cut Complete Rupture of Origin of Right Main Bronchus
Petros T Mihos, PhD,
Konstantinos Potaris, PhD,
Ioannis Gakidis, MD,
Pavlos M Myrianthefs, PhD1,
George J Baltopoulos, PhD1
Department of General Thoracic Surgery
1 Athens University School of Nursing ICU, General Hospital of Attica "KAT", Athens, Greece
For reprint information contact: Petros T Mihos, PhD Tel: 30 210 628 0133 Fax: 30 210 628 0133 Email: pmichos{at}yahoo.gr, 107A Thermopilon Street, 15235, Vrilissia, Athens, Greece.
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ABSTRACT
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Complete rupture of the main bronchus after blunt thoracic trauma is rare. Most patients with blunt traumatic injury to the trachea or bronchus die before arriving at hospital. A 26-year-old man with complete right main bronchus rupture was successfully treated by urgent surgical intervention and postoperative fiberoptic bronchoscopy for bronchial toilet.
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INTRODUCTION
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Traumatic tracheobronchial rupture is an uncommon complication of blunt thoracic trauma, with an incidence ranging from < 1% to 2.8% of trauma cases.1 Previous reports emphasize the importance of early diagnosis and surgical intervention to improve the prognosis.2,3 In a recent review of the literature since 1870, Kiser and colleagues3 identified 256 patients with blunt tracheobronchial injury. Right-sided bronchial injury was most frequently reported (47%), and rupture occurred within 2 cm of the carina in 76% of patients. The diagnosis is not easy despite increased awareness of this type of injury, and it is not uncommon to be made weeks or months after the rupture occurred, as it can be missed in patients with multiple injuries. We describe a rare case of traumatic complete right main bronchus rupture.
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CASE REPORT
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A 26-year-old previously healthy man was admitted to our hospital following a motorcycle accident. He presented with dyspnea. Radiography showed no rib, long bone, spine, or pelvic fractures. A right tension pneumothorax was confirmed on a chest radiograph and immediately drained (Figure 1A
). Ultrasonography was negative for abdominal injuries. The patient was intubated because of his altered mental status (Glasgow coma score 6) due to a brain injury. However, the lung was not expanded on a subsequent chest radiograph and there was a continuous air leak from the chest tube (Figure 1B). He was hemodynamically stable; blood gas analysis showed PaO2 of 50 mm Hg, PaCO2 of 44 mm Hg, and a pH of 7.36. A large right bronchial rupture was suspected. Fiberoptic bronchoscopy (FOB) in the operating room showed complete rupture of the right main bronchus 7 mm to 1 cm from its origin at the carina. The patient was intubated with a left double-lumen tracheal tube guided by FOB. On successful isolation of the left lung with expansion of both the tracheal and bronchial cuffs, the air leak from the chest tube stopped, and oxygen saturation improved significantly. After a right posterolateral thoracotomy, complete right main bronchus rupture within 7 mm of the carina was confirmed, without any other injury to the lung or great vessels of the mediastinum (Figure 2A).
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Figure 1. (A) Right tension pneumothorax; (B) No lung expansion and persistent pneumothorax; the arrows show the margins of the pneumothorax.
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Figure 2. (A) Complete rupture of the origin of the right main bronchus. The white arrow indicates the trachea, the black arrow indicates the bronchus. (B) Tracheal re-implantation of the bronchus (arrowed).
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Tracheal re-implantation of the bronchus was successfully performed after minimal debridement, using 4/0 Prolene sutures in an interrupted fashion, with extraluminal knots (Figure 2B
). The anastomosis was covered with an intercostal muscle flap. Postoperative computed tomography showed the known brain contusion with brain edema, right lung contusion, and the reconstructed right main bronchus. In the intensive care unit, the patient was kept under deep sedation and analgesia because of his brain injury, and he underwent fiberoptic bronchoscopy daily until the 10th postoperative day, for bronchial toilet and to monitor healing of the anastomosis. He was not extubated early because of the brain contusion, as medically indicated. He was ventilated by assist-control mode ventilation with a tidal volume of 6 mL·kg–1 and the respiratory rate was adjusted according to the PaCO2 and pH, without positive end-expiratory pressure. Peak inspiratory pressure, compliance, plateau pressure, and airway resistance were monitored. The patient was extubated on the 14th postoperative day with a Glasgow coma score of 14/15 and excellent gas exchange function (PaO2/FiO2 ratio > 300). After extubation, he underwent another computed tomography scan of the thorax, which showed significant improvement in the right lung contusion and the reconstructed right main bronchus. At follow-up after 3, 6 and 12 months, the patient reported no complication.
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DISCUSSION
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Right main bronchial rupture is a very rare clinical entity as most patients die at the scene. From 1873 to 1996, 31 cases were reported, and there have been 2 further case reports since then.2,4,5 Three other series of patients with tracheobronchial injuries have referred to several cases of right main bronchus rupture.6–8 Three possible underlying mechanisms for the development of injury to the trachea and bronchus have been described. The first is forceful compression of the chest, decreasing the anteroposterior diameter while widening the transverse diameter. This is the usual mechanism involved in crush injuries. The second mechanism is compression of the chest and the tracheobronchial tree while the glottis is closed, which produces a rapid increase in airway pressures, especially in the trachea and larger bronchi. The third mechanism relates to the rapid deceleration observed in motor vehicle accidents. As the lungs are fixed at the carina but are mobile within the pleural space, rapid deceleration creates a shearing force, causing rupture of the tracheobronchial tree. This was probably the case in our patient. The higher incidence of right main bronchus rupture among tracheobronchial injuries may be due to the shorter length of the right main bronchus which is also less protected than the trachea or the left main bronchus, and to the heavier right lung that may cause more traction on the right bronchus.3
Tracheobronchial injuries are not diagnosed immediately in 25% – 68% of patients as they frequently present as an indolent process involving retained secretions, poor lung expansion, recurrent pneumothoraces, and eventually high-grade bronchial obstruction; thus the diagnosis is often delayed.3 The persistence of a collapsed lung with massive air leak from the chest tube despite successful drainage may be the initial sign of tracheobronchial rupture. A patient with suspected airway injury should undergo FOB for diagnosis and localization of the rupture. The essential issues in the management are early recognition and surgical repair. In our case, the lack of expansion of the lung with a continuous air leak was the key to clinical suspicion. The diagnosis was confirmed during FOB and on opening the thoracic cavity. Surgical debridement must be performed in acute or chronic injury to create healthy edges for primary repair. Although the standard sutures are absorbable, some surgeons prefer nonabsorbable sutures in an interrupted fashion with extraluminal knots.3 During his intensive care unit stay, our patient underwent careful tracheobronchial toilet and observation of the reconstructed right main bronchus by FOB. Fiberoptic bronchoscopy permits direct visualization to monitor the healing process, and also has the advantage of allowing bronchial toilet without danger to the repaired area. A high level of suspicion and the use of bronchoscopy are necessary for a successful outcome.
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REFERENCES
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ABSTRACT
INTRODUCTION
