Tracheobronchial injuries (TBIs) are encountered with

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1 Acute Injuries of the Trachea and Major Bronchi: Importance of Early Diagnosis David C. Cassada, MD, Mudiwa P. Munyikwa, MD, Mark P. Moniz, MD, Raymond A. Dieter, Jr, MD, George F. Schuchmann, MD, and Blaine L. Enderson, MD Department of Surgery, The University of Tennessee Medical Center at Knoxville, Knoxville, Tennessee Background. Tracheobronchial injuries are encountered with increasing frequency because of improvements in prehospital care and early initiation of the Advanced Trauma Life Support protocol. We review our experience with these injuries with the hypothesis that the leading determinant of patient outcome is the time interval to diagnosis. Methods. Patients with tracheobronchial injury were identified from the registry of our level 1 trauma center during a 10-year period ending December Clinical presentation, diagnostic evaluation, surgical management, and outcome were reviewed. Results. Twenty patients with ten cervical tracheal injuries and ten intrathoracic tracheobronchial injuries were treated. The mechanism of injury involved blunt trauma in 11 and penetrating trauma in 9. All patients underwent surgical debridement and primary repair. Patients with isolated airway injuries were discharged home after a mean hospital stay of 6 days and had no early complications. Three patients had delayed diagnosis (> 24 hours), and all sustained complications including death (1 patient) and multiorgan system failure (2 patients). The overall mortality rate was 15%. Conclusions. Operative management of tracheobronchial injuries can be achieved with acceptable mortality. Independent of mechanism or anatomic location of injury, delay in diagnosis is the single most important factor influencing outcome. Early recognition of tracheobronchial injury and expedient institution of appropriate surgical intervention are essential in these potentially lethal injuries. (Ann Thorac Surg 2000;69:1563 7) 2000 by The Society of Thoracic Surgeons Tracheobronchial injuries (TBIs) are encountered with increasing frequency because of improvements in prehospital care and early initiation of the Advanced Trauma Life Support protocol. Many patients still die before reaching the hospital. In 1971, Ecker and associates [1] reported their study of blunt TBIs in Dallas County, TX and found that of 27 patients seen over a 10-year period, only 9 were alive on reaching the emergency room. Reviewing 1,178 postmortem reports of persons dying of trauma, Bertelsen and Howitz [2] found that only 33 (0.03%) had TBI and of them, 27 (82%) died almost immediately. Earlier reports [3, 4] emphasized the importance of early diagnosis and treatment. More recently, Rossbach and associates [5], in their review of 32 patients with TBI over a 28-year period, found that a high index of suspicion and the liberal use of bronchoscopy were essential in the diagnosis of the occult injury. We reviewed our experience with these injuries with the hypothesis that the key determinant of patient outcome was the time interval to diagnosis. Accepted for publication Nov 27, Address reprint requests to Dr Cassada, Department of Surgery, The University of Tennessee Medical Center, Box U-11, 1924 Alcoa Hwy, Knoxville, TN Material and Methods Patients with TBI treated from January 1988 through December 1997 at The University of Tennessee Medical Center at Knoxville, a level 1 trauma center, were identified through the trauma registry. The prehospital, hospital, and autopsy records were reviewed for mechanism of injury, clinical presentation, associated injuries, radiographic and bronchoscopic findings, surgical management, and outcome. Outcome was evaluated in relation to potential risk factors including mechanism of injury, associated injuries, anatomic location of injury, and time interval between injury and diagnosis. Univariate analysis was performed by 2 test and Fisher s exact test for categoric variables and Student s t test for continuous variables. Multiple logistic regression was then performed to determine the independent factors related to outcome. A p value of less than 0.05 was considered significant. Results All injuries involved the upper airway between the cricoid cartilage and the secondary bronchial bifurcations. Of the 20 patients treated, 10 had cervical tracheal injuries, 9 had major bronchial lacerations, and 1 had intrathoracic tracheal injury. The mean age was 27 years (range, 8 to 45 years), and there were 14 male and 6 female patients (Table 1). Nineteen patients arrived from 2000 by The Society of Thoracic Surgeons /00/$20.00 Published by Elsevier Science Inc PII S (00)

2 1564 CASSADA ET AL Ann Thorac Surg ACUTE TRACHEOBRONCHIAL INJURIES 2000;69: Table 1. Summary of Patient Data Patient No. Sex Age (y) Mechanism of Injury Airway Injury Surgical Management ICU Course (d) Length of Hospitalization (d) Complication 1 F 30 Motor vehicle Right bronchial laceration with interrupted 3-0 Prolene 2 F 23 Knife stab wound Right bronchial Right lower lobe pulmonary laceration vein ligation, repair of with interruped 4-0 Vicryl 3 M 32 Motor vehicle Open trachea Death 4 M 22 Motor vehicle Open trachea Anterior neck dissection, two-layer lateral laceration repair with 3-0 chromic and 3-0 Vicryl, tracheostomy 5 M 40 Motor vehicle Right bronchial Death injury 6 M 20 Knife stab wound Puncture wound to anterior trachea Left anterior neck dissection, closure with 5-0 Prolene M 44 All-terrain vehicle 8 M 30 Gunshot wound 9 F 15 Motor vehicle 10 M 14 Pedestrian struck by car 11 F 27 Knife stab wound 12 F 25 Gunshot wound 13 M 37 All-terrain vehicle 14 M 45 Knife stab wound 15 M 41 Motor vehicle 16 M 8 Gunshot wound 17 F 16 Pedestrian struck by car 18 M 22 Gunshot wound 19 M 22 Shotgun wound to chest 20 M 20 Motor vehicle Laceration of right Tracheal transection 3-cm posterior tracheal laceration Transection of right Anterior tracheal laceration 8-cm distal posterior tracheal tear Tracheal laceration Laceration at tenth tracheal ring Right bronchial tear right bronchial injury Right disruption Tracheal laceration Avulsion of left Complex right tracheal laceration Right thoracotomy, bronchial repair with interrupted 3-0 Vicryl Debridement and tracheostomy Necklace incision, transtracheal repair of posterior laceration with interrupted 3-0 chromic, anterior repair with 3-0 Prolene with interrupted 3-0 Vicryl Median sternotomy for vascular control, right neck exploration, repair with interrupted 3-0 Vicryl, stented with endotracheal tube with interrupted Prolene suture Neck exploration with debridement, tracheostomy Transverse necklace incision, interrupted 3-0 Vicryl repair, tracheostomy with pledgetted 4-0 Prolene, pedicle of fascia oversewn Primary repair with 3-0 Ticron, sternothyroid muscle flap, esophageal repair with interrupted 4-0 Prolene Closure of posterior wound with 3-0 interruped Prolene, debridement with tracheostomy placement Left thoracotomy, left pneumonectomy, resection of ribs, muscle flap reconstruction Right thoracotomy, right lobectomy, exploratory laparotomy, gastrostomy months Sepsis Many 1 year Sepsis Death NA 21 Bronchopleural fistula ICU intensive care unit; NA not available.

3 Ann Thorac Surg CASSADA ET AL 2000;69: ACUTE TRACHEOBRONCHIAL INJURIES 1565 Table 2. Primary Survey Findings Finding Mean Glasgow Coma 7 11 Score a Mean trauma score a 7 10 Endotracheal intubation 3 4 Patent airway 7 4 Dead on arrival 2 0 a Average scores. the scene of the incident, and 1 was transferred from another facility. Ten were transported to the trauma center by helicopter, 9 by ambulance, and 1 by automobile. The mechanism of injury involved motor vehicle collision in 11 and penetrating injury in 9. The patients with blunt trauma overall had a lower Glasgow Coma Score and revised trauma score and more associated injuries than the group with penetrating injury (Tables 2, 3). Four patients (25%) were endotracheally intubated in the field, but the two prehospital deaths resulted from failure to secure an airway. Forty-five percent of the TBIs were diagnosed by physical examination and confirmed intraoperatively; the rest required bronchoscopy for definitive diagnosis (Table 4). When indicated, further evaluation including esophagoscopy and angiography was done to rule out associated injuries. Because more than half of the patients had a patent airway on arrival in the trauma center, the first indications of TBI were often clinical and radiographic findings of cervical subcutaneous emphysema, pneumomediastinum, and persistent pneumothorax with brisk air leak despite tube thoracostomy. Intrathoracic TBI often was seen as a persistent pneumothorax, and cervical injuries tended to result in pneumomediastinum or normal chest radiograph (Table 5). Tracheobronchial injury was found in 3 patients 24 hours or more after presentation, and they are considered as having a late diagnosis. All patients underwent surgical debridement and primary repair. Operative approaches included nine posterolateral thoracotomies, eight anterior neck explorations (five sternocleidomastoid incisions, three necklace incisions), and one median sternotomy. The definitive Table 3. Associated Injuries Injury Intracranial 7 3 Spinal central nervous system 1 3 Orthopedic 4 1 Solid organ 1 0 Bony thorax 10 7 Esophageal 1 2 Table 4. Mechanism of Injury Versus Method of Confirming Diagnosis Method of Confirmation treatment consisted of local debridement followed by repair with interrupted 3-0 or 4-0 polyglactin (Vicryl) or polypropylene (Prolene) suture. Two patients required pulmonary lobe resections for irreparable pulmonary vascular injuries. The rate of technical success, defined as establishment of airway continuity and control of bleeding, was 100%. The postoperative courses, including sepsis and death, were similar between the penetrating and blunt trauma groups, except that 2 patients with penetrating spinal cord injuries required prolonged ventilation (Table 6). Two early deaths en route to the trauma center were due to failure to establish an airway. In 1 patient, attempts at endotracheal intubation resulted in completion of a tracheal laceration, and extraluminal inflation of the cuff caused the death of the patient as the two ends of the trachea became widely separated. The other patient was found on postmortem examination to have a complete right disruption as the cause of hypoxemiarelated death. Three patients had delayed diagnosis ( 24 hours) and progressed to multisystem organ failure with one death. One patient with a persistent pneumothorax after pulmonary resection required pleurodesis. The overall morbidity was 20% (4 patients) with a mortality rate of 15% (3 patients). Closed head injuries, mechanism or anatomic location of injury, and time interval to diagnosis were all evaluated as possible risk factors for sepsis and death (Table 7). Logistic regression analysis showed that delay in diagnosis was the only independent prognostic factor for postoperative morbidity. Comment Mechanism of Injury Blunt Physical examination 3 4 Bronchoscopy 7 3 Intraoperative examination 1 1 Postmortem examination 1 0 Tracheobronchial injuries were thought to be universally fatal before Krinitzki [6] presented the case of a human Table 5. Anatomic Location of Injury Versus Chest Radiographic Findings a Radiographic Finding Cervical (n 10) Anatomic Location Intrathoracic (n 10) Pneumothorax after 1 9 chest tube Pneumomediastinum 5 7 Normal chest radiograph 4 0 a All chest radiographs demonstrated subcutaneous emphysema.

4 1566 CASSADA ET AL Ann Thorac Surg ACUTE TRACHEOBRONCHIAL INJURIES 2000;69: Table 6. Postoperative Course Versus Mechanism of Injury Course ICU LOS (d) Total LOS (d) Rehabilitation center 2 1 Sepsis 1 2 Death 2 1 ICU intensive care unit; LOS length of stay. long-term survivor in Twenty years later, Kinsella and Johnsrud [7] reported the first successful primary repair of a bronchial rupture caused by blunt trauma. Since then, several series [8 10] have demonstrated that early diagnosis and primary repair of these injuries lead to the least complications and the best long-term results. The usual principles of trauma care apply to the treatment of major airway injuries. Rapid physical assessment and management of bleeding and shock should be undertaken, with primary attention given to managing the airway [1, 2, 5, 8]. For a patient in respiratory distress, an endotracheal tube should be passed, if possible, over a flexible bronchoscope. In our series, 55% of the patients were seen with a secure airway and were breathing comfortably on supplemental oxygen. Elective blind intubation secondary to inability to stent over a potential cervical tracheal injury is therefore discouraged [8]. Complete disruption of a compensated upper-airway laceration by intubation can be a fatal error by the clinician who is inclined to immediately intubate the patient for airway injury. Baumgartner and associates [11] delivered this warning in 1997 in the case of a patient with complete tracheal transection with false intubation. Although their patient survived, the outcome is usually fatal. The diagnosis of major airway injury depends first on a thorough history and physical examination with careful inspection of the site of injury, particularly in the case of penetrating trauma, for evidence of leaking air in the cervical region [5, 12]. A chest radiograph suggestive of TBI in a patient in stable condition necessitates prompt bronchoscopy in either the emergency department or the operating room in anticipation of surgical exploration. Bronchoscopy was used in 10 patients in our series (7 in Table 7. Risk Factors for Sepsis and Death After Tracheobronchial Injury Risk Factor Sepsis p Value Death Anatomic location: cervical versus intrathoracic Mechanism of injury: penetrating versus blunt trauma Delay in diagnosis Intracranial injury the blunt injury group, 3 in the penetrating injury group) and confirmed the location and extent of injury in all. Accurate interpretation of the chest radiograph is essential in the early diagnosis of occult upper-airway injury. In 1989, Unger and co-workers [3] found that the preponderant findings on chest radiograph included subcutaneous emphysema, pneumomediastinum, pneumothorax, and air surrounding the bronchi. Mediastinal and subcutaneous emphysema can be massive if pleural rupture occurs. All our patients had subcutaneous emphysema on presentation. In their series of 9 patients, Baumgartner and associates [4] found subcutaneous emphysema and dyspnea were the most consistent presenting features of TBI. Once a diagnosis of major airway injury is made, the surgical management includes open debridement and repair to establish airway continuity [9, 13 15]. Most groups prefer nonabsorbable sutures, such as polypropylene, although some surgeons choose to use braided polyglactin sutures. In our series, both types of suture were used in interrupted through-and-through fashion with extraluminal knots (See Table 1). Clinical follow-up was inconsistent, and little data are available on subsequent development of hypertrophic granulation tissue. If there is irreparable damage to a major or massive pulmonary vascular injury, lobectomy or pneumonectomy may be the only surgical option to repair the airway, as was the case in 2 of our patients. Kirsh and associates [3] postulated three specific patterns of TBI based on the mechanism of injury in blunt trauma. The first involves rapid compression of the chest and the anteroposterior diameter of the thorax with a simultaneous widening of the transverse diameter. This produces lateral motion resulting in traction on the trachea at the carina. The second mechanism involves an increase in the intratracheal pressure that occurs against a closed glottis. The intraluminal pressure then exceeds the tracheal elastic strength, which results in rupture at the membranous and cartilaginous junctions. In the third mechanism, rapid deceleration results in shearing forces at fixed points along the trachea, including the cricoid cartilage and the carina, leading to disruption. In our review, blunt upper-airway injuries occurred most frequently at the takeoff of the right (84%). Three patients had delay in diagnosis, and all had septic complications with one resultant death. The delay in diagnosis was due to failure to consider the possibility of airway injury in a timely fashion. A prolonged period of hypoxia adversely affects all organ systems and can be only partially reversed by eventual restoration of the airway. A high level of suspicion with ready use of diagnostic techniques such as bronchoscopy is required to identify the occult injury. In conclusion, operative management of TBIs can be achieved with acceptable mortality. Independent of mechanism or anatomic location of injury, delay in diagnosis is the single most important factor influencing outcome. Early recognition of TBI and expedient institu-

5 Ann Thorac Surg CASSADA ET AL 2000;69: ACUTE TRACHEOBRONCHIAL INJURIES 1567 tion of appropriate surgical intervention are essential in these potentially lethal injuries. References 1. Ecker RR, Libertini RV, Rea WJ, Sugg WL, Webb WR. Injuries of the trachea and bronchi. Ann Thorac Surg 1971; 11: Bertelsen S, Howitz P. Injuries of the trachea and bronchi. Thorax 1972;27: Unger JM, Schuchmann GS, Grossman JE, Pellett JR. Tears of the trachea and main bronchi caused by trauma. AJR 1989; 153: Baumgartner F, Sheppard B, de Virgilio C, et al. Tracheal and main bronchial disruptions after blunt chest trauma: presentation and management. Ann Thorac Surg 1990;50: Rossbach MM, Johnson SB, Gomez MA, Sako EY, Miller OLW, Calhoon JH. Management of major tracheobronchial injuries: a 28-year experience. Ann Thorac Surg 1998;65: Krinitzki SI. Zur Kasuistik einer vollständigen Zerreissung des rechten Luftrohrenastes. Virchows Arch 1928;266: Kinsella TJ, Johnsrud LW. Traumatic rupture of the. J Thorac Surg 1947;16: Kirsh MM, Orringer MB, Behrendt DM, Sloan H. Management of tracheobronchial disruption secondary to nonpenetrating trauma. Ann Thorac Surg 1976;22: Symbas PN, Hatcher CR Jr, Boehm GAW. Acute penetrating tracheal trauma. Ann Thorac Surg 1976;22: Hood RM, Sloan HE. Injuries of the trachea and major bronchi. J Thorac Cardiovasc Surg 1959;38: Baumgartner FJ, Ayres B, Theuer C. Danger of false intubation after traumatic tracheal transection. Ann Thorac Surg 1997;63: Best BG, Stevenson HM. Complete transection of the main. Injury 1983;14: Martinez MJ, Hotzman RS, Salcedo VM, Garcia-Rinaldi R. Successful repair of a transected intrathoracic trachea after chest trauma. J Thorac Cardiovasc Surg 1986;91: Grover FL, Ellestad C, Arom KV, Root HD, Cruz AB, Trinkle JK. Diagnosis and management of major tracheobronchial injuries. Ann Thorac Surg 1979;28: Hasegawa T, Endo S, Sohara Y, et al. Successful surgical treatment of a complete traumatic tracheal disruption. Ann Thorac Surg 1997;63: Notice From the Southern Thoracic Surgical Association The Forty-seventh Annual Meeting of the Southern Thoracic Surgical Association will be held November 9 11, 2000, Marco Island, Florida. The Postgraduate Course will be held the morning of Thursday, November 9, 2000, and will provide in-depth coverage of thoracic surgical topics selected primarily as a means to enhance and broaden the knowledge of practicing thoracic and cardiac surgeons. Members wishing to participate in the Scientific Program should submit an original and one copy of their abstract to Peter K. Smith, MD, Chairman, Program Committee, the Southern Thoracic Surgical Association, 401 N Michigan Ave, Chicago, IL Manuscripts accepted for the Resident Competition need to be submitted to the STSA headquarters office no later than October 1, The Resident Award will be based on abstract, presentation, and manuscript. Applications for membership should be completed by September 1, 2000, and forwarded to Duke E. Cameron, MD, Membership Committee Chairman, Southern Thoracic Surgical Association, 401 N Michigan Ave, Chicago, IL Carolyn E. Reed, MD Secretary/Treasurer Southern Thoracic Surgical Association 401 North Michigan Ave Chicago, IL (800) 685-STSA or (312) fax: (312) stsa@sba.com; by The Society of Thoracic Surgeons Ann Thorac Surg 2000;69: /00/$20.00 Published by Elsevier Science Inc