Management of Airway Trauma I:

Transcription

1 Management of Airway Trauma I: Tracheobronchial Injuries James P. Kelly, M.D., Watts R. Webb, M.D., Peter V. Moulder, M.D., Charles Everson, M.D., Buford H. Burch, M.D., and Edward S. Lindsey, M.D. ABSTRACT One hundred six consecutive patients with injuries to the tracheobronchial tree who were admitted to the emergency room of the Tulane Medical Center Hospital or the Charity Hospital of Louisiana at New Orleans over a period of almost 2 years were analyzed retrospectively. Penetrating trauma of the neck or chest was reported in 1 of the patients, and only 6 had blunt trauma to the neck or thorax as the cause of injury. There were 18 deaths among the 16 patients (16.98%), including 11 (1.75%) of 8 with injuries of the cervical trachea. Seven (5.8%) of 1 with principal injuries of the thoracic trachea died; all 1 patients with major bronchial injuries survived. On admission to the emergency room, all patients had signs of airway compromise such as tachypnea, dyspnea, cyanosis, subcutaneous emphysema, or an abnormal respiratory pattern. Severe airway compromise was evident in 46 patients; 24 (2%) were treated with oral or nasal intubation, 19 (18%) with emergency tracheostomy, and (2%) with intubation of a tracheal injury. Hemoptysis was an unreliable signal of serious injury, being present in only 28 of the patients. Patients who had major vascular injuries combined with trachea involvement were generally not salvageable. In regard to morbidity and mortality, the most common preventable errors were delay in diagnosis and treatment of tracheobronchial injuries, missed esophageal injuries, massive aspiration of blood, and abdominal vascular injuries. Since major airway trauma should be suspected in all cases of blunt or penetrating trauma to the neck or chest, emphasis should be placed on control of the airway and on performing diagnostic bronchoscopy and esophagoscopy in all patients with complex tracheobronchial injuries. Without aggressive and appropriate surgical management, tracheobronchial injuries are usually lethal. At one major medical center, 78% of patients with tracheal or bronchial injuries were dead on arrival [l]. Other re- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA. Presented in part at the Twenty-eighth Annual Meeting of the Southern Thoracic Surgical Association, Palm Beach, FL, Nov 5-7, Accepted for publication Feb 15, 1985 Address reprint requests to Dr. Kelly, Assistant Professor, Department of Surgery, 14 Tulane Ave, Tulane University School of Medicine, New Orleans, LA ports [2, 1 confirm the very high prehospital mortality in patients with this type of injury. In one series, 21% of the patients who reached the hospital died within the first 12 minutes, emphasizing the necessity for immediate recognition and treatment of the injury [4]. Excellent salvage can be achieved only if the condition is diagnosed early and treated with appropriate operative intervention [5-71. A problem of early recognition of such injuries (41, particularly those with tracheal involvement, is the the relative lack of exposure of individual physicians to patients having tracheobronchial injuries; more common pulmonary parenchymal injuries can produce similar findings and thereby divert diagnostic attention from a less common injury, and severe associated injuries may take priority. In some patients, early symptoms are minimal and the lesion is discovered months later because of continued pulmonary problems. For example, among 7 patients with major cervical trauma seen at the Ben Taub Hospital over a period of 27 years, only 65 had tracheal involvement [6]. Thus, major trauma centers may see only a few patients each year with this diagnosis [2, 8, 91. If the survival rate is to be improved, an organized plan of management for recognition and treatment of tracheobronchial injuries must be formulated. This article reviews a large series of injuries to the tracheobronchial tree and focuses on the principles of managing patients with such injuries. Clinical Material Patient Population From July 1,1964, to December 1,198,16 consecutive patients ranging in age from 1 to 47 years (mean, 2.4 years), with injuries to the trachea or bronchus or both, were admitted to the emergency department of the Charity Hospital of Louisiana at New Orleans or to the Tulane Medical Center Hospital. All patients in whom any therapy was initiated were included; thus, in patients in the study, life signs were minimal but an attempt at resuscitation was made. The anatomical location of the injuries was as follows: 8 in the cervical trachea; 1, thoracic trachea; and 1, the major bronchi. One hundred patients had penetrating injuries, and 6 had blunt injuries, 2 of which were in the cervical trachea and 4 in the thoracic trachea or major bronchi. Three of the blunt injuries to the major bronchi resulted in complete separation of the bronchus. Symptoms Clinical features of associated injuries often tended to obscure those of tracheobronchial injuries (Table 1). The 55 1

2 552 The Annals of Thoracic Surgery Vol 4 No 6 December 1985 Table 1. lnjuries and Conditions Associated with Tracheobronchial lnjuries Associated Injury or Condition Site of Primary Injury Thoracic Cervical Trachea Trachea Bronchi Esophageal injury 4 2 Hemopneumothorax Major vessel injury 7 9 Cardiac injury 2 1 Paraplegia Pulmonary injury 2 Recurrent laryngeal nerve injury 1 6 Thyroid gland injury 9 Mandibular fracture 2 Spinal cord injury 2 Homer's syndrome 1 Intraabdominal injury 7 4 Total most common symptom produced by tracheobronchial injury was dyspnea, which was noted in all 9 conscious patients. Ten of the 1 unconscious patients were observed to have difficulty breathing. Hemoptysis was a relatively infrequent sign, being present in only 28 patients. Four patients with both tracheal and carotid artery injuries had massive hemoptysis on admission. Overall, associated major vascular injuries were present in 2 patients (Table 2). Clinical features of the tracheobronchial injuries included subcutaneous emphysema in 9 patients, pneumothorax or pneumohemothorax in 22, and shock or coma in 14. Overall mortality was 16.98% (18 deaths) and was highest in patients with intrathoracic tracheal injuries (7/1; 5.8%), compared with injuries of the cervical trachea (1118; 1.75%). This was primarily a reflection of the severity of the injuries associated with the intrathoracic tracheal injuries. The causes of death in our series are separated into two categories, preventable and nonpreventable (Table ). Six patients in whom the cause of death was nonpreventable had concomitant vascular injuries that were the primary cause of death; blood pressure could not be obtained in patients, in whom emergency room thoracotomies were performed because of massive hemothoraces. The other patients had massive injuries to the carotid vessels along with injuries to the cervical trachea. We classified the preventable deaths into several categories. Two patients were seen with gunshot wounds of the neck and abdomen, and death was due to late recognition of the intraabdominal aortic injury. Three of the 18 patients had massive aspiration of blood and pulmonary failure after a combined injury of the trachea and a vascular structure. Earlier airway control in these pa- Table 2. Major Vascular lnjuries Associated with Tracheobronchial lnjuries No. of No. of Vessel Injured Patients Deaths Carotid artery 6 (5%) Innominate artery 1 1(1%) Thoracic aorta 2 2 (1%) Abdominal aorta 4 2 (5%) Subclavian artery 1 Internal jugular vein Innominate vein 1 Pulmonary artery 2 Table. Causes of Death Cause PREVENTABLE INJURIES Delay in diagnosis and treatment Massive aspiration of blood Missed esophageal injury Abdominal aortic injury NONPREVENTABLE INJURIES Associated carotid injuries Irreversible shock No. tients before angiography might have decreased the mortality associated with aspiration. In 2 of the patients who died and whose deaths were classified as preventable, esophageal injuries had been missed. Twenty-four patients had combined injuries of the trachea and esophagus.* In 18 patients, esophagoscopy was performed with no false-negative results. Two patients with missed esophageal lesions had normal radiopaque (Hypaque) studies in the emergency room. Esophagoscopy was not performed in either patient, and both died of later complications. Twelve Hypaque esophagrams were performed with two missed lesions, for a false-negative rate of 16.7%. Five of the deaths were categorized as preventable because of delay in diagnosis and treatment. Three of these patients had combined laryngeal and cervical tracheal trauma with delays in controlling the airway that led to early death in the emergency room or arrest in the operating room; 1 patient had blunt trauma and the other 2 had penetrating injuries. One patient had a gunshot wound to the neck and chest, and underwent an emergency stemotomy and neck exploration for wounds 'Kelly JP; et al: Management of airway trauma 11: combined injuries of trachea and esophagus. Presented at the annual meeting of the Southern Thoracic Surgical Association, Boca Raton, FL, November 7-9, 1985.

3 55 Kelly et al: Management of Tracheobronchial Injuries of the heart and thoracic trachea. Inability to control the thoracic tracheal injury resulted in intraoperative death. In the fifth patient, a diagnosis of tracheal laceration was made only at autopsy after an emergency laparotomy and a neck exploration for multiple gunshot wounds. Diagnosis Major airway trauma should be suspected in all cases of blunt or penetrating trauma of the neck or chest. Respiratory distress, subcutaneous or mediastinal emphysema, pneumothorax, cyanosis, and hemoptysis should provide clues to major airway trauma. The site of injury to the tracheobronchial tree, leakage of air, and associated injuries with their attendant blood loss determine the early symptoms. The injuries may range from a small laceration accompanied by a persistent cough or emphysema or both to a massive injury with a large air leak and progressive cyanosis. Rupture of the cervical trachea is almost always accompanied by subcutaneous emphysema and mild to moderate airway compromise. Palpation of the neck may reveal the presence of crepitation or absence of the trachea in those in whom a complete separation has taken place. Vascular and esophageal injuries are common with penetrating injuries, and damage to the cervical spine must always be considered. Mediastinal or subcutaneous emphysema is an early sign of injury to the mediastinal trachea or major bronchi. If the mediastinal pleura is violated and the airways communicate with the pleural space, pneumothorax may be quickly associated with dyspnea and progressive respiratory distress as tension pneumothorax follows. A pneumothorax that does not resolve with closed-tube thoracostomy is the sine qua non of mediastinal tracheal or major bronchial injury (Fig 1). Occasionally a bronchial tear may be accompanied by a hemopneumothorax or massive pleural hemorrhage due to associated vascular injuries. Two patients in our series had massive intrapleural hemorrhage with their bronchial injury, 1 from a pulmonary arterial injury and the other from a cardiac injury with tamponade. In our experience, massive hemoptysis heralds an associated vascular injury and not an isolated bronchial or tracheal injury. Occasionally, a patient will survive a partial or complete tear of the bronchus and then experience late symptoms of respiratory distress as stenosis develops. Frequently, granulation tissue and resolving hematoma can be found which, in the process of healing, cause bronchial narrowing, atelectasis, and consolidation (Fig 2). There are many reports of complete bronchial rupture, among them that of Burford and Webb [lo]. The atelectatic lung is capable of reexpansion and essentially normal function if the airway is reconstituted. Immediate repair is preferable for early restoration of lung function. Essentially, normal pulmonary function has been observed when reconstruction was performed two months after the initial injury, whereas repair 1 to 15 years later B Fig 1. Chest roentgenogramsfrom a 26-year-old man involved in a head-on motor vehicle accident. (A) Study made after insertion of a second chest tube. Note nonexpunding pneumothorax, which led to bronchoscopy and primary repair of a ruptured right mainstem bronchus. (B) Study made immediately after repair of the bronchial injury. (C) Study made after removal of chest tubes and before discharge from the hospital.

4 554 The Annals of Thoracic Surgery Vol 4 No 6 December 1985 [ll-141 allows return of function, but not to normal levels. Obviously, a patient should not be committed to single-lung function if both lungs can be made to function normally. A B C Fig 2. Radiographic studiesfiom a 28-year-old man in whom diagnosis of a total bronchial rupture secondary to an automobile accident was delayed. (A) Chest roentgenogram made fourteen days after tracheosfomy showing left lower lobe atelectasis. (B) Chest roentgenogram made eighteen days after the accident demonstrating marked consolidation. (C) Bronchogram showing torn left mainstem bronchus 2 cm beyond the carina. The diagnosis was made by bronchoscopy and bronchography, and the stenosis was successfully repaired by direct anastomosis. The discharge chest roentgenogram was normal. Treat men t In all cases of severe trauma, the airway should be controlled. In approximately half of our patients, immediate oral or nasal intubation or tracheostomy was performed. Control of associated vascular injuries and treatment of a hemothorax, tension pneumothorax, or sucking chest wounds should assume high priority. Immediate treatment of tension pneumothorax by needle and then closed-tube thoracostomy should be performed. Inability to expand the lung after suction has been started should alert the surgeon to the possibility of a major airway injury and the need for bronchoscopy. Treatment is based on the location and extent of the injury. Tracheostomy for minor lacerations of the membranous or cartilaginous portions of the trachea may be performed, as was done in patients early in our series. More recently, early oral or nasal intubation of the trachea followed by suture repair has become our method of approach; tracheostomy is avoided if possible. While tracheostomy may be performed for small tracheal injuries, we have taken an aggressive surgical approach, as many of our patients have additional injuries to other organ systems. Control of the airway by either endotracheal intubation or tracheostomy helps to decrease intratracheal positive pressure and thereby decreases leakage in these defects. Large defects of the cervical trachea, which were the most frequently observed lesion in our series, often require urgent control of the airway. Endotracheal intubation is our method of choice, but tracheostomy or percutaneous intubation of the tracheal defect can be performed. Two patients with complete or nearly complete separation of the cervical trachea due to blunt trauma underwent intubation of the distal trachea over a fiberoptic bronchoscope. Several patients had concomitant injuries of the larynx and cervical trachea in which emergent control of the airway was required. We attempt to evaluate all injuries as thoroughly as possible, and we add laryngoscopy to our standard diagnostic procedures of bronchoscopy and esophagoscopy, if the magnitude of the associated injuries warrants it. For cervical trauma, we use a transverse cervical incision that might be extended up either border of the sternocleidomastoid muscle for exposure of vascular structures or the esophagus. The thyroid is divided at the isthmus for adequate evaluation of the cervical trachea. This incision also allows the possibility of a limited or extended sternotomy for more proximal control of vascular structures and mobilization of the distal trachea. Large defects of the thoracic trachea or major bronchi are usually approached through a lateral thoracotomy by means of an incision in the fifth interspace on the side of the trauma. Three patients in our series had transections of the bronchi from blunt trauma; two of these injuries

5 555 Kelly et al: Management of Tracheobronchial Injuries were discovered early and one late. The injuries were located in the right or left mainstem bronchus and the bronchus intermedius. Occasionally, proximal thoracic tracheal lesions are approached through a sternotomy but only in patients in whom a stemotomy is required for immediate control of a vascular lesion. The surgical approach to chronic sequelae of blunt or penetrating trauma should depend on the site of injury. Because of the possible need for extended resection of a stenotic or completely separated segment of the trachea or a major bronchus, appropriate techniques-including bronchoplasty, laryngeal release, or pulmonary resection-must be considered. Although our initial surgical techniques varied somewhat, we now routinely use monofilament suture in an interrupted fashion to close all defects. An attempt is made to reinforce all sutured defects with pleural or pericardial flaps or with flaps from the intercostal or strap muscles. Tissue reinforcement between the trachea and esophagus is also performed in combined injuries. All patients undergo postoperative fiberoptic bronchoscopy, especially those with circumferential suture lines in the trachea or bronchus. We attempt to extubate patients as soon as possible to minimize the local trauma of intubation. Severely contaminated wounds of the cervical trachea are drained routinely. Closed-tube thoracostomy is used after all intrapleural procedures. Comment The fact that tracheobronchial injuries are uncommon and, thus, often unrecognized and that survival with such injuries is limited contributes to the high mortality associated with them. Patients with untreated injuries, particularly transection of the cervical trachea, may survive for only minutes. In many institutions with active trauma centers, tracheobronchial injuries are seen only a few times each year. In Charity Hospital of Louisiana at New Orleans, one of the most active trauma centers in the United States, an average of only 5 such injuries has been seen per year. Many of the patients in our series had multiple associated injuries, even in remote regions of the body, which contributed to their immediate death or excessive morbidity. These findings emphasize the need for a watchful attitude and an aggressive treatment plan. The early diagnosis of tracheobronchial injury is important to successful management. Early signs may include a subtle cough, subcutaneous emphysema, or a nonexpanding pneumothorax. In managing the severely injured patient with a tracheobronchial injury, priorities must be assigned for appropriate therapy. Control of the airway with intubation or tracheostomy is of paramount importance. A chest roentgenogram after closed-tube thoracotomy can confirm the presence of a nonexpand- ing pneumothorax. Bronchoscopy with esophagoscopy and early surgical treatment are recommended for all lesions. The definitive treatment for tracheal and bronchial injuries is immediate primary suture of the wound. Tracheostomy alone is not recommended except in patients with fractures of the larynx, trachea, or cricoid cartilages with airway compromise. Tracheostomy is not necessary to protect the suture lines after repair of the thoracic trachea or major bronchus. Drainage is recommended only for heavily contaminated combined injuries. Associated injuries are numerous and determine the prognosis after severe tracheobronchial injuries. Since concomitant esophogeal injuries were frequently seen in our series and often were not appreciated because of lack of early symptoms, esophagoscopy is strongly recommended for all patients with tracheobronchial injuries. Esophagoscopy proved to be much more accurate than a contrast esophagram in diagnosing injuries to the esophagus. References 1. Ecker RR, Libertini RV, Rea WJ, et al: Injuries of the trachea and bronchi. Ann Thorac Surg 11:289, Blass DC, James EC, Reed RJ 111, et al: Penetrating wounds of the neck and upper thorax. J Trauma 182, Chavez CM, Anas P, Conn JH: Surgical approach to injuries of the cervical trachea. South Med J Eijgelaar A, Homan van der Heide JN: A reliable early symptom of bronchial or tracheal rupture. Thorax 25:116, Meinke AH, Bivins BA, Sachatello CR Selective management of gunshot wounds to the neck. Am J Surg 1814, Sheely CH, Mattox KL, Beall AC Jr: Management of acute cervical tracheal trauma. Am J Surg 128:85, Symbas PN, Hatcher CR Jr, Boehm GAW: Acute penetrating tracheal trauma. Ann Thorac Surg 22:47, Greene R, Stak l? Trauma of the larynx and trachea. Radio1 Clin North Am 16:9, Urschel HC Jr, Razzuk MA: Management of acute traumatic injuries of tracheobronchial tree. Surg Gynecol Obstet 16:11, Webb WR, Burford TH: Studies of the reexpanded lung after prolonged atelectasis. AMA Arch Surg 66:81-89, Burch BH: Tracheobronchial injuries. In Sheft R (ed): Sheft s Initial Management of Thoracic and Thoraco- Abdominal Trauma. Second edition. Springfield, IL, Thomas, 1968, pp Webb WR: Initial management of the patient with a chest injury. J La State Med SOC 1161, Carter R, Wareham EE, Brewer LA I11 Rupture of the bronchus following closed chest trauma. Am J Surg 14:177, Mahaffney DE, Creech, Boren HG, Sprint WH Traumatic rupture of the bronchus: clinical and experimental study. Ann Surg 148:871, 1958