Complete transection of the right main bronchus: case report

Abstract

Tracheobronchial injuries (TBIs) have a high mortality rate unless aggressive treatment is used. The clinical presentation is variable depending on the presence of associated injuries and on whether the peribronchial tissues remain intact. High index of clinical suspicion and accurate interpretation of radiological findings are necessary to diagnose the injury at presentation and allow prompt surgical intervention with primary repair of the airway. Herein, we describe a case of complete right main bronchus rupture in a 10-year-old boy diagnosed by chest computed tomography.

Introduction

TBIs have a high mortality rate unless aggressive treatment is used. In 76% of patients, the injury occurs within 2 cm of the carina and in 43% within the first 2 cm of the right main bronchus [1].

The clinical presentation is variable depending on the presence of associated injuries and on whether the peribronchial tissues remain intact [2].

High index of clinical suspicion and accurate interpretation of radiological findings are necessary to diagnose the injury at presentation and allow prompt surgical intervention with primary repair of the airway. Delays in treatment increase the risk of mortality and of delayed partial or complete bronchial stenosis [3].

The management of bronchial rupture is surgery, like end-to-end anastomosis, and rarely pulmonary resections. Herein, we describe a case of complete right main bronchus rupture in a 10-year-old boy diagnosed by chest computed tomography.

Case report

A 10-year-old child brought to casualty with his history of blunt trauma chest with machine. History of pain in chest and difficulty in breathing.

On examination, child was tachypneic, pulse 130/min, BP 90/60 mm of Hg, and Spo₂ 76%.

Child had massive subcutaneous emphysema extending up to the face cranially and trunk caudally.

Chest X-ray showed bilateral pneumothorax for which bilateral intercostal drain was put.

In view of worsening Spo₂ stats and extensive subcutaneous emphysema, child was intubated and planned for computed tomography chest. Computed tomography chest showed complete transection of the right main bronchus with right lung collapse (Fig. 1).

Fig. 1.

CT chest S/O complete transection of the right main bronchus

Child was taken up for emergency surgery for repair of bronchus. Patient was planned for right thoracotomy but due to worsening hemodynamics at the time of induction, midline sternotomy was performed and cardio pulmonary bypass (CPB) assisted primary repair of the bronchus was done using vicryl 4–0 suture (Fig. 2).

Fig. 2.

Primary repair of the bronchus

Post-operative period was uneventful. X-ray showed full expansion of the right lung. Child was extubated after 12 h, managed with intravenous antibiotics, analgesics, and intravenous fluids. Chest physiotherapy was started from post-operative day 1.

Child was discharged on post-operative day 7 after doing CT chest which showed full expansion of the right lung (Fig. 3).

Fig. 3.

Post-operative CT chest showing complete expansion of the right lung

Discussion

Tracheobronchial rupture is a very rare injury in children. Proposed mechanisms of injury are a rapid decrease in the anteroposterior diameter of the thorax with a compression of the airway between the sternum and vertebrae, a sudden increase in intrabronchial pressure against a narrow glottis and rapid deceleration [4].

It has been reported that 80% of these injuries occurring after blunt trauma take place within 2–3 cm of the carina [5]. In our case, the rupture was a complete avulsion of the right main bronchus.

The first reported case of traumatic ruptured bronchus is attributed to Webb in 1848 [6]. Primary surgical repair was first successfully performed by Scannell in 1951 [7].

The initial clinical presentations [8] are subcutaneous emphysema (85%) and dyspnea (77%). Other clinical manifestations include persistent large air leaks, pneumothorax, massive atelectasis, and failure to expand the lung with thoracostomy tube drainage. Decreased upper lung margin below the level of bifurcation (fallen lung sign) on CT scan is regarded as a typical sign for a complete disruption of the main bronchus [8].

Flexible fiber optic bronchoscopy is the gold standard in establishing diagnosis and also can be used to guide endotracheal tube into the main bronchus to isolate the affected main bronchus.

Successful treatment of a tracheobronchial disruption includes prompt diagnosis, early airway repair under appropriate surgical approach, good anesthesia techniques, and the best operative techniques.

Rupprecht et al. reported that reconstruction of the tracheobronchial tree within the first 24 h showed no degree of later pulmonary dysfunction. On the other hand, late reconstruction was associated with a decrease between 30 and 50% of vital and 80% of diffuse capacity [8].

The best surgical approach for tracheobronchial disruption is postero-lateral thoracotomy [9].

The optimal surgical procedure for tracheobronchial disruption is debridement of injured tissue, end-to-end anastomosis [10] and preservation of tracheal and bronchial blood supply and the limitation of tension while repairing tracheobronchial disruption.

Conclusion

Tracheobronchial injuries are usually rare and transection of the tracheobronchial tree due to blunt trauma of the chest is even rarer. It is rare to find total transection of the right bronchus, in the case of blunt trauma to the chest without any other associated injury. Sign and symptoms are non-specific. So, a high degree of suspicion is required to diagnose tracheobronchial injuries. Transected trachea or bronchus may successfully undergo end to end anastomosis.

Compliance with the ethical standards

No ethical approval and consent required.

Conflict of interest

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The authors declare that they have no conflict of interest.

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