Management of tracheobronchial injuries

Abstract

Tracheobronchial injuries (TBI) are a heterogenous group of sometimes life-threatening traumas with different management approaches. Symptoms are mediastinal and subcutaneous emphysema, bloody secretions from the airway or haemoptysis in alert patients, and high air leakage along the cuff or increased ventilatory resistance may be signs for TBI in intubated patients. The necessity of immediate clinical evaluation, CT-scan and bronchoscopic evaluation are essential for prompt diagnosis and classification as well as experienced air way management and treatment, these patients are best managed from interdisciplinary teams including thoracic surgeons. While iatrogenic tracheal membrane laceration from intubation can be treated by lesion bridging with ventilation tube, stent application, open operative repair or endoluminal repair, intraoperative accidental cuts should be repaired by direct suture or with vital tissue coverage in case of local ischemia. The management of blunt or penetrating injury is sequential and needs immediate establishment and maintenance of a secure patent airway to provide adequate oxygenation. The next step is the treatment of life-threatening collateral injuries like major hemorrhage, cranial trauma or major organ damage arranged in the trauma team. The treatment of penetrating injuries to the airway need operative exploration in almost every case with minimal local dissection and debridement followed by direct repair. Muscle flap coverage is useful in case of combined esophageal injury. Damage of the tracheobronchial tree after blunt trauma must be repaired by direct suture or local tissue sparing resection and anastomosis. These lesions can be missed in the initial phase and may become prominent with scar tissue formation, stenosis and atelectasis in the later phases.

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

“…One patient in this group suffered such an outcome (Table 1 ). Debridement should be performed before anastomosis; otherwise, the rate of failure or complications, such as leakage and stenosis due to granulation, will increase[ 2 , 3 , 14 , 17 ]. If the lung can be expanded, anastomosis can be performed.…”

A narrative review of traumatic mediastinal injuries and their management: the thoracic surgeon perspective

“…Other important considerations for non-operative management include absence of esophageal injury, minimal mediastinal air and non-progressive pneumomediastinum or subcutaneous emphysema ( 40 ). These minor injuries can be treated with close monitoring of clinical status (stability of subcutaneous emphysema and respiratory status) with recommendations for follow up bronchoscopy and course of antibiotics ( 36 , 39 , 41 ).…”

“…Once the injury is identified and exposed, de-vitalized tissue is debrided to ensure the closure of healthy membranous tissue ( 35 - 37 , 41 ). For simple, clean lacerations repair can be carried out primarily with simple interrupted absorbable sutures such as a 4-0 vicryl with consideration of buttressing the repair with an intercostal muscle flap ( 35 - 37 , 41 ). All surgical knots should be tied to the outside in hopes of decreasing granulation tissue formation.…”

Cervical Repair of Iatrogenic Tracheobronchial Injury by Tracheal T-Incision

“…Symptomatic patients with fullthickness tracheobronchial injury require a surgical repair to avoid the development of mediastinitis and other sequela. 3,4 Despite some reports on endoscopic techniques, the open-surgical repair of tracheobronchial injuries remains the standard treatment. [5][6][7] Traditionally, tracheobronchial injuries in the upper and middle third of the trachea are approached through a cervical incision, whereas the lower third and the main bronchi are usually approached by a right-sided posterolateral thoracotomy.…”