Management and outcome of bronchial trauma due to blunt versus penetrating injuries

Abstract

BACKGROUND The number of patients with bronchial trauma (BT) who survived to hospital admission has increased with the improvement of prehospital care; early diagnosis and treatment should be considered, especially among blunt trauma patients, whose diagnosis is frequently delayed. AIM To describe the early recognition and surgical management considerations of blunt and penetrating BTs, and to elaborate the differences between them. METHODS All patients with BTs during the past 15 years were reviewed, and data were retrospectively analyzed regarding the mechanism of injury, diagnostic and therapeutic procedures, and outcomes. According to the injury mechanisms, the patients were divided into two groups: Blunt BT (BBT) group and penetrating BT (PBT) group. The injury severity, treatment procedures, and prognoses of the two groups were compared. RESULTS A total of 73 patients with BT were admitted during the study period. The proportion of BTs among the entire cohort with chest trauma was 2.4% (73/3018), and all 73 underwent thoracotomy. Polytrauma patients accounted for 81.6% in the BBT group and 22.9% in the PBT group, and the mean Injury Severity Score was 38.22 ± 8.13 and 21.33 ± 6.12, respectively. Preoperative three-dimensional spiral computed tomography (CT) and/or fiberoptic bronchoscopy (FB) were performed in 92.1% of cases in the BBT group ( n = 38) and 34.3% in the PBT group ( n = 35). In the BBT group, a delay in diagnosis for over 48 h occurred in 55.3% of patients. In the PBT group, 31 patients underwent emergency thoracotomy due to massive hemothorax, and BT was confirmed during the operation. Among them, 22 underwent pulmo-tractotomy for hemostasis, avoiding partial pneumonectomy. In this series, the overall mortality rate was 6.9% (5/73), and it was 7.9% (3/38) and 5.7% (2/35) in the BBT group and PBT group, respectively ( P > 0.05). All 68 survivors were followed for 6 to 42 (23 ± 6.4) mo, and CT, FB, and pulmonary function examinations were performed as planned. All patients exhibited normal lung function and healthy conditions except three who required reoperations. CONCLUSION The difference between blunt and penetrating BTs is obvious. In BBT, patients generally have no vessel injury, and the diagnosis is easily missed, leading to delayed treatment. The main cause of death is ventilation disturbance due to tension pneumothorax early and refractory atelectasis with pneumonia late. However, in PBT, most patients require emergency thoracotomy because of simultaneous vessel trauma and massive hemothorax, and delays in diagnosis are infrequent. The leading cause of death is hemorrhagic shock.

Mechanism matters: mortality and endothelial cell damage marker differences between blunt and penetrating traumatic injuries across three prehospital clinical trials

“…The incidence of blunt versus penetrating mechanisms www.nature.com/scientificreports/ of injury differ based upon the environment of injury (combat versus civilian setting) and the country where injury occurs 34,35 . Previous work has demonstrated that mechanism of injury may influence the compensatory response, impact the benefit of resuscitation, and generate an effect modification on risk factors for mortality following traumatic injury [13][14][15][16][17][18][19][20][21][22][23] . Of this body of work, several studies have demonstrated that mechanism of injury impacts the efficacy and safety of hydroxyethyl starch resuscitation, such that the use of hydroxyethyl starch is beneficial and safe in the resuscitation of penetrating injured patients, but not blunt injured patients 13,18,22 .…”

“…Blunt relative to penetrating mechanism of injury is also associated with many underlying differences that may contribute to heterogeneity of an enrolled study cohort 16 . Characteristics such as urban versus rural injury location 36 , air medical versus ground transport 37 , transfer origin 38 , prehospital transport time 11 and socioeconomic factors 39 are known to differ across mechanism of injury and represent inherent confounders when comparing blunt versus penetrating injury in any cohort of injured patients.…”

“…Blunt and penetrating mechanisms of injury contribute to this heterogeneity. Several studies have demonstrated that mechanism of injury may influence the compensatory response, impact the benefit of resuscitation and generate an effect modification on risk factors for mortality following traumatic injury [13][14][15][16][17][18][19][20][21][22][23] . However, less is known regarding the respective morbidity, mortality time course and resultant immune response which follows blunt and penetrating injury.…”

Traumatic main airway rupture successfully rescued by extracorporeal membrane oxygenation: A case report

“…This high-energy trauma is combined with fractures of the ribs and sternum, which alter the intrathoracic pressure state through paradoxical breathing, thereby affecting the stability of the thorax. The combination of massive pneumothorax and extensive lung contusion can potentially result in death from respiratory failure (3). In order to alleviate airway obstruction and restore thoracic stability, such patients often require active surgical procedures (4).…”