[Management of Tracheobronchial Injuries due to Brunt Trauma].

BACKGROUND: Tracheobronchial injuries resulting from blunt trauma are relatively rare among chest injuries. However, if these injuries are not managed properly, they can be fatal. The prognosis is intricately linked to the precise diagnosis and treatment. We herein report three cases of tracheobronchial trauma that required surgical intervention. Case 1:A 17-year-old male sustained injuries when his torso became entangled in heavy machinery. The diagnosis revealed a tear in the right main bronchus, which required transportation with left single- lung ventilation. The patient was treated by tracheobronchial reconstruction. Case 2:A 71-year-old male experienced trauma when his car collided with a utility pole. He was transported to the hospital after tracheal intubation due to a laceration of the tracheal membranous area. The site of the injury was closed with sutures. Case 3:A 17-year-old female who had been struck by a train suffered acute respiratory failure and was transported to the hospital after intubation. Veno-venous extracorporeal membrane oxgenation (VV-ECMO) was initiated in response to poor oxygenation. Complete rupture of the right middle bronchial trunk and laceration of the right main bronchial membrane were observed, and bronchoplasty was performed. CONCLUSION: A swift and accurate diagnosis, coupled with timely and judicious therapeutic interventions, play a pivotal role in managing tracheal and bronchial injuries.

Cervical Repair of Iatrogenic Tracheobronchial Injury by Tracheal T-Incision.

BACKGROUND: Tracheobronchial injury is a rare but potentially life-threatening condition. Various surgical treatment options have been described for symptomatic patients with full-thickness injury. However, studies comprising a meaningful number of patients are sparse. METHODS: We retrospectively analyzed all patients who received surgical repair of tracheobronchial injury between January 1999 and May 2021 at the Department of Thoracic Surgery, Medical University of Vienna. Patient characteristics, surgical variables, postoperative morbidity, and mortality were retrieved and analyzed. RESULTS: Fifty patients with a median age of 68 years (range, 17-88) were included in the analysis. The etiologies of the iatrogenic tracheobronchial injuries were emergency intubation (48%), elective percutaneous dilatation tracheostomy (38%), or elective intubation (14%). The most common location of tracheobronchial injuries was distal third (28%) with a median length of 50 mm (range, 20-100 mm). The surgical approach was cervicotomy in 52%, thoracotomy in 38%, sternotomy in 2%, and combined approaches in 8% of cases. Moreover, intraoperative venovenous (n = 4) or venoarterial (n = 2) extracorporeal membrane oxygenation support was required in 12% of cases. Procedure-related mortality was 0%. However, as patients with tracheobronchial injury usually have severe comorbidities, the rate of patients discharged alive from the intensive care unit was only 66%. The median follow-up period of discharged patients was 5.5 months (range, 0.7-209). Airway stenosis or dehiscence was not observed in any patient. CONCLUSIONS: Surgical repair of tracheobronchial injuries can be performed safely with a low procedure-related morbidity. If possible, the less-invasive cervical access should be preferred for patients with tracheobronchial injury, even for injuries extending to the main bronchi.

Video-assisted Thoracic Surgery for Main Bronchial Rupture After Blunt Chest Trauma in Children.

Main bronchial rupture caused by blunt chest trauma is a rare injury, especially in children. Treatment is traditionally performed through an open thoracotomy, which increases the risk of musculoskeletal deformity in growing children. Video-assisted thoracic surgery has emerged as a feasible minimally invasive approach for main bronchial rupture, with lower perioperative mortality. This report demonstrates that video-assisted thoracic surgery can be safely performed for main bronchial rupture in children.

Emergency repair of blunt traumatic bronchus injury presenting with massive air leak.

Blunt traumatic tracheobronchial injury is rare, but can be potentially life-threatening. It accounts for only 0.5%-2% of all trauma cases. Patients may present with non-specific signs and symptoms, requiring a high index of suspicion with accurate diagnosis and prompt treatment. A 26-year-old female was brought into the emergency department after sustained a blunt trauma to the chest from a high impact motor vehicle accident. She presented with signs of respiratory distress and extensive subcutaneous emphysema from the chest up to the neck. Her airway was secured and chest drain was inserted for right sided pneumothorax. CT of the neck and thorax revealed a collapsed right middle lung lobe with a massive pneumothorax, raising the suspicion of a right middle lobe bronchus injury. Diagnosis was confirmed by bronchoscopy. In view of the difficulty in maintaining her ventilation and persistent pneumothorax with a massive air leak, immediate right thoracotomy via posterolateral approach was performed. The right middle lobar bronchus tear was repaired. There were no intra- or post-operative complications. She made an uneventful recovery. She was asymptomatic at her first month follow-up. A repeated chest X-ray showed expanded lungs. Details of the case including clinical presentation, imaging and management were discussed with an emphasis on the early uses of bronchoscopy in case of suspected blunt traumatic tracheobronchial injury. A review of the current literature of tracheobronchial injury management was presented.

Blunt Traumatic Tracheobronchial Injury: a Clinical Pathway.

Background: Motor vehicle collisions (MVC) are a major burden on healthcare systems. Saudi Arabia is one of the countries with a high mortality rate of MVC. Blunt tracheobronchial injuries are rare; however, it is a catastrophic event that requires a high center of care. Lack of experience and advanced faculty prompt early stabilization and transfer of the victim for advanced care. Due to the uncertainty of management of these injuries, we would like to share our experience in dealing with such injuries. Objective: To address the difficulties in initial management and transfer of patient with blunt traumatic tracheobronchial injuries. Methods: This is a single-center retrospective case-series study including patients admitted as cases of trauma including all age groups with blunt acute tracheobronchial injuries confirmed by imaging or bronchoscope. Results: In our study, four patients with tracheobronchial injuries were identified, and a retrospective analysis was performed. Two of the males and one of the females are adults, while the other two are pediatrics. Two of them have a right main bronchial injury and the other two have a left main bronchial injury. Posterolateral thoracotomy and bronchial anastomosis were performed on all four patients and were followed up. Conclusion: In Saudi Arabia, blunt trauma is a prevalent type of injury, although tracheobronchial injuries are uncommon. In the event of trauma, a high index of suspicion of tracheobronchial injuries in a high mechanism injury warrants prompt treatment. Due to a lack of experienced and specialized hands in this field, management may be delayed, and eventually lead to unfavorable outcomes, hence we thought of a guide to facilitate the decision-making.

Primary repair of a completely ruptured intermediate bronchus after blunt chest trauma. Case report.

BACKGROUND: Tracheobronchial injury is rare and often has a fatal course. The incidence is estimated from 0.8% to 5% in the scenario of blunt or penetrating chest trauma. CASE PRESENTATION: A 54-year-old male was brought to the emergency department after falling off his bicycle, with impact on head and right shoulder. At pre-hospital assessment, the patient had a free airway, gasping respiration (oxygen saturation 92%) with reduced vesicular breathing. Multiple rib fractures are palpable bilaterally, with subcutaneous emphysema. Computed tomography (CT) showed a large right-sided pneumothorax and consolidated lung lobes. After insertion of two chest tubes on the right, a refractory pneumothorax with large air leakage remained present. Subsequently, a bronchoscopy was performed, confirming a complete rupture of the right intermediate bronchus. Urgent surgical debridement and primary repair with an end-to-end running suture was performed. Rib osteosynthesis was additionally performed bilaterally, because of a flail chest on the right side and penetrating bone fragment on the left side. Respiratory function recovered uneventfully. CONCLUSION: Airway injuries are uncommon but must always be suspected by the clinician during the early management of chest trauma. To prevent delayed diagnosis and potentially fatal outcome, low-threshold bronchoscopy is the diagnostic modality of choice to accurately confirm the lesion. Primary surgical repair remains the mainstay of the therapeutic management.

Traumatic Avulsion of Right Upper Lobe Bronchus in a Three-Year-Old.

Major bronchial injury during blunt trauma is a life-threatening occurrence in children. We describe a 3-year-old female who presented with a near circumferential tear at the takeoff of the right upper lobe bronchus after an all-terrain vehicle accident. This is an unusual blunt traumatic injury in the pediatric population and highlights the need for evaluation when a large, persistent air leak occurs after chest tube placement.

Bronchial rupture following endobronchial blocker placement: a case report of a rare, unfortunate complication.

BACKGROUND: Lung separation may be achieved through the use of double lumen tubes or endobronchial blockers. The use of lung separation techniques carries the risk of airway injuries which range from minor complications like postoperative hoarseness and sore throat to rare and potentially devastating tracheobronchial mucosal injuries like bronchus perforation or rupture. With few case reports to date, bronchial rupture with the use of endobronchial blockers is indeed an overlooked complication. CASE PRESENTATION: A 78-year-old male patient with a left upper lobe lung adenocarcinoma underwent a left upper lobectomy with a Fuji Uniblocker® as the lung separation device. Despite an atraumatic insertion and endobronchial blocker balloon volume within manufacturer specifications, an intraoperative air leak developed, and the patient was found to have sustained a left mainstem bronchus rupture which was successfully repaired and the patient extubated uneventfully. Unfortunately, the patient passed on in-hospital from sepsis and other complications. CONCLUSION: Bronchial rupture is a serious complication of endobronchial blocker use that can carry significant morbidity, and due care should be exercised in its use and placement. Bronchoscopy should be used during insertion, and the volume and pressure of the balloon kept to the minimum required to prevent air leak. Bronchial injury should be considered as a differential in the presence of an unexplained air leak.

Dynamic Expression of Transient Receptor Potential Vanilloid-3 and Integrated Signaling with Growth Factor Pathways during Lung Epithelial Wound Repair following Wood Smoke Particle and Other Forms of Lung Cell Injury.

Prior studies revealed increased expression of the transient receptor potential vanilloid-3 (TRPV3) ion channel after wood smoke particulate matter (WSPM) treatment of human bronchial epithelial cells (HBECs). TRPV3 attenuated pathologic endoplasmic reticulum stress and cytotoxicity mediated by transient receptor potential ankyrin-1. Here, the basis for how TRPV3 expression is regulated by cell injury and the effects this has on HBEC physiology and WSPM-induced airway remodeling in mice was investigated. TRPV3 mRNA was rapidly increased in HBECs treated with WSPM and after monolayer damage caused by tryptic disruption, scratch wounding, and cell passaging. TRPV3 mRNA abundance varied with time, and stimulated expression occurred independent of new protein synthesis. Overexpression of TRPV3 in HBECs reduced cell migration and wound repair while enhancing cell adhesion. This phenotype correlated with disrupted mRNA expression of ligands of the epidermal growth factor, tumor growth factor-ß, and frizzled receptors. Accordingly, delayed wound repair by TRPV3 overexpressing cells was reversed by growth factor supplementation. In normal HBECs, TRPV3 upregulation was triggered by exogenous growth factor supplementation and was attenuated by inhibitors of growth factor receptor signaling. In mice, subacute oropharyngeal instillation with WSPM also promoted TRPV3 mRNA expression and epithelial remodeling, which was attenuated by TRPV3 antagonist pre- and cotreatment. This latter effect may be the consequence of antagonist-induced TRPV3 expression. These findings provide insights into the roles of TRPV3 in lung epithelial cells under basal and dynamic states, as well as highlight potential roles for TRPV3 ligands in modulating epithelial damage/repair. SIGNIFICANCE STATEMENT: Coordinated epithelial repair is essential for the maintenance of the airways, with deficiencies and exaggerated repair associated with adverse consequences to respiratory health. This study shows that TRPV3, an ion channel, is involved in coordinating repair through integrated repair signaling pathways, wherein TRPV3 expression is upregulated immediately after injury and returns to basal levels as cells complete the repair process. TRPV3 may be a novel target for understanding and/or treating conditions in which airway/lung epithelial repair is not properly orchestrated.

Rupture of contralateral mainstem bronchus during uniportal video-assisted thoracoscopy surgery lobectomy and 3 successful cases of repair.

BACKGROUND: Our goal was to discuss the treatment for rupture of contralateral mainstem bronchus during uniportal video-assisted thoracoscopy surgery (uniportal VATS) lobectomy. CASE PRESENTATION: We analyzed clinical data of 3 cases of rupture of contralateral mainstem bronchus during uniportal VATS. Surgical repair was performed immediately under an uniportal VATS during operation, as a result, 3 cases of bronchial rupture all were repaired successfully, and we continued to complete lobectomy and systemic lymph node dissection. Reexamination was performed after 1 week, and no fistula was found in trachea and bronchi through a fiberoptic bronchoscopy. The time range for indwelling the chest tube is 6-9 days, and the hospital stay is 8-10 days. No abnormality was observed on chest radiography when the 3 patients returned to the hospital 1 month after the operation for the second reexamination. CONCLUSIONS: Instant surgical repair is recommended to the treatment of bronchial rupture in thoracic surgery. It is safe and feasible to repair bronchial tear with uniportal VATS.

Removal of Airway Foreign Body in a Premature Neonate.

OBJECTIVE: Airway foreign bodies are the leading cause of infantile deaths and fourth among preschool children. Airway foreign bodies in extremely premature neonates represent a rare but potentially lethal entity. There are very few reports in the literature describing the treatment of such a condition in premature neonates. The objectives of this report are to describe the safe removal of an airway foreign body in an extremely premature infant using urologic instruments in a trans-endotracheal tube fashion and to review the literature for other techniques that have proven safe and effective, thereby adding technical options for future cases. METHODS: We reviewed the case reported and reviewed pertinent literature. RESULTS: A 2-week old, ex-24 3/7-week, 820-g pre-mature infant was intubated with a 2.5 endotracheal tube. After intubation, a 2-cm foreign body was discovered in the distal trachea by chest x-ray. The child's respiratory status continuously deteriorated with increasing oxygen and positive pressure requirements. While remaining intubated, the child underwent direct suspension laryngoscopy, the ventilator circuitry was disconnected, and the object was successfully removed using a 1.2 mm rigid ureteroscope and 1.1 mm grasping forceps through the 2.5 endotracheal tube. CONCLUSION: This case report demonstrates the effectiveness of using a 1.2 mm ureteroscope and 1.2 mm urologic graspers to extract an airway foreign body from an extremely premature neonate through an endotracheal tube without paralyzing the patient. This method provides a safe and effective means of visualizing and, if necessary, manipulating the airway in a population prone to respiratory complications.

Migration of ingested sharp foreign body into the bronchus: a case report and review of the literature.

BACKGROUND: Foreign body ingestion is a common emergence in gastroenterology. Foreign bodies are most likely to be embedded in the esophagus. The sharp ones may penetrate the esophageal wall and lead to serious complications. CASE PRESENTATION: A 72-year-old Chinese female was admitted to our hospital with a 4-day history of retrosternal pain and a growing cough after eating fish. Chest computed tomography scan indicated that a high-density foreign body (a fish bone) penetrated through the esophageal wall and inserted into the left main bronchus. First, we used a rigid esophagoscope to explore the esophagus under general anesthesia. However, the foreign body was invisible in the side of the esophagus. Then, the fiberoptic bronchoscopy was performed. We divided the fish bone, which traversed the left main bronchus, into two segments under holmium laser and removed the foreign body successfully. The operation time was short and there were no complications. The patient was discharged 1 week postoperatively and was symptom free even under a liquid diet. CONCLUSIONS: There are several challenges in the management of this rare condition. We applied the technique of interventional bronchoscopy to the management of esophageal foreign body flexibly in an emergency. A surgery was avoided, which was more invasive and costly.

Contemporary management strategies of blunt tracheobronchial injuries.

BACKGROUND: Tracheobronchial injuries are rare but feasibly life-threatening conditions. A prompt diagnosis and early management can be lifesaving. Due to the unspecific symptoms and indirect radiological signs the diagnosis often delays. OBJECTIVES: We present a short series of patients suffering from tracheobronchial airway laceration. All the three patients had blunt thoracic or neck trauma and showed early signs of tracheobronchial injury. In the first case a 44-year-old woman was crushed by a bus. Subcutaneous emphysema, pneumothorax on chest computed tomography and hypoxaemia despite of chest tube suggested the presence of an airway injury. During operation a 4-cm-long tear of the trachea and a complete transection of the right main bronchus were found. In the second case a 12-year-old girl was crossed by a truck trailer. Early signs were respiratory failure, extended subcutaneous emphysema, blood clot in the larynx, pneumothorax on both sides. Chest CT showed pneumomediastinum. During the operation a longitudinal laceration was found separating the two main bronchi at the bifurcation. In the third case a 9-year-old boy was injured in a car accident, when the seat-belt crossed his neck. Spreading subcutaneous emphysema, pneumomediastinum and an overinflated endotracheal tube's cuff were found on CT. A completely transected trachea between the first and second tracheal rings was found. All three patients required fast intubation and bronchoscopic examination to confirm the diagnosis, and to identify the site of lacerations. All the patients underwent primary reconstruction and recovered successfully. CONCLUSIONS: In case of suspected tracheobronchial injury, a high index of suspicion is required for early diagnosis. Most commonly respiratory distress, subcutaneous emphysema and pneumothorax are found on physical examination. Prompt intubation below the site of the injury and early laryngo- or bronchoscopic examination have priority, as we did in our cases. A primary anastomosis is required with minimal resection during urgent operation. A better outcome is to be expected when extubation is done early after surgery. We offer ordinal steps that should be taken to lead to a prompt management and good long-term outcome based on the literature and our experiences.

Repair of traumatic avulsion of the right bronchus in children using extracorporeal membrane oxygenation support.

Traumatic avulsion of the right main bronchus in children is usually caused by blunt trauma or traffic accidents. Primary repair by suturing is the preferred treatment. Lesions are life threatening and urgent or emergency surgical repair is indicated. We report our experience with 2 cases of traumatic avulsion of right bronchus in children successfully suture repaired with the use of extracorporeal membrane oxygenation.