Abstract
A tracheobronchial avulsion is a very rare and serious condition that occurs mostly due to blunt trauma chest caused by high-speed traffic accidents. In this article, we present a challenging case of a 20-year-old male who had a right tracheobronchial transection with carinal tear which was repaired on cardiopulmonary bypass (CPB) through right thoracotomy. Challenges faced and a review of literature will be discussed.
How to cite this article
Kaur A, Singh VP, Gautam PL, Singla MK, Krishna MR. Tracheobronchial Injury: Role of Virtual Bronchoscopy. Indian J Crit Care Med 2022;26(7):879–880.
Keywords: Bronchopleural fistula, Cardiopulmonary bypass, Tracheobronchial injury
Highlights
This is a rare case of life-threatening tracheobronchial injury (TBI). This case increases the awareness about the difficulties encountered during the induction and handling of such cases and the value of advanced preparation. Virtual bronchoscopy is another tool giving additional information for aiding in early diagnosis and management plan.
Introduction
Tracheobronchial injury is a potentially life-threatening condition. Blunt trauma to the chest and iatrogenic airway injury is the most common causes of tracheobronchial injuries, and this constitutes 1–2% of chest injuries.1,2 In these patients, it is important to recognize clinical signs and symptoms of TBI as conventional airway control may result in a catastrophic situation with failure to ventilate due to tension pneumothorax.3 In 60% of polytrauma patients, there is associated chest trauma and has a mortality of 20–25%.4 In this report, we will discuss a very rare case of tracheobronchial avulsion injury and its management.
Case Description
In this report, we present a case of a 20-year-old man who was bought to the emergency room after being crushed between the car and a tractor. Following the initial examination, there was extensive surgical emphysema over the entire chest. Chest radiograph showed bilateral pneumothorax with bilateral multiple rib fractures (Fig. 1), following which bilateral chest tubes were inserted immediately, and chest X-ray after intercostal drains showed non-expansion of the right lung. The patient underwent urgent CT chest imaging, which showed bilateral pneumothorax with bilateral intercostal drains in situ and suspicion of right bronchial tear (Fig. 2). The patient was taken emergently to the operating room and planned for surgery under high-risk consent. Preoperative vitals showed SpO2 of 88% on the reservoir bag mask with a pulse rate of 138/minutes and respiratory rate of 36/minutes. Because of suspected bronchial injury, we planned to do bronchoscope-guided awake intubation with standby CPB, but the patient was not co-operative. During induction, the patient had severe hypoxia and required rescue airway control with endotracheal intubation. He continued to deteriorate due to a large bronchopleural fistula, and his condition worsened quickly to catastrophic hypotension. The patient was taken on CPB, and a right posterolateral thoracotomy was performed. Surgical findings showed right mainstem bronchus transection from trachea with carinal tear extending to right bronchus. An end-to-end anastomosis was done between the right main bronchus and the trachea. The postoperative course was uneventful, and the patient was discharged after a week. Postoperatively we reconstructed CT images for virtual bronchoscopy, which revealed the right bronchial injury.
Fig. 1.
Chest X-ray before insertion of intercostal drains
Fig. 2.
CT chest at the level of carina before insertion of intercostal drains, arrow showing site of tracheal laceration
Discussion
Tracheobronchial injury is a rare clinical situation in which a missed diagnosis and conventional airway management can result in catastrophic ventilation failure. We report a very rare case of tracheobronchial avulsion due to blunt chest trauma caused by a road traffic accident. Motor vehicle accidents are the most common mechanism of these kinds of injuries.5 Few such cases of tracheobronchial avulsion due to blunt chest trauma have been reported.6
In this case report, the patient had a complete right tracheobronchial tear with carinal extension. Other mechanisms of TBI due to blunt trauma have been suggested by Kiser et al., who have classified them into three types–rupture of tissues due to reflex glottis closure, due to shearing forces at the cricoid cartilage and carina, and due to chest compression anteroposteriorly leading to the laceration at the level of the carina.7 Clinical presentation of tracheobronchial injuries can be nonspecific and include subcutaneous emphysema, pneumomediastinum, and pneumothorax. Our patient also presented with similar findings. Computed tomography has 85% sensitivity to detecting airway lesions.8 It may show mediastinal emphysema, fallen lung sign, separation in the tracheobronchial air column, or the exact location of the injury. Flexible bronchoscopy is the key to diagnosis in suspected patients and remains the gold standard.9 These major tracheobronchial injuries pose a challenging situation to the anesthesiologist. There was little discrepancy between virtual bronchoscopy and operative findings. In such cases, surgical repair should be performed as early as possible.
Our patient respiratory distress, despite the insertion of bilateral intercostal drains, rendered a high index of suspicion of TBI. Early recognition of clinical signs, prompt diagnosis, appropriate airway management, and early surgical repair led to an improved outcome. If feasible, virtual bronchoscopy may give additional information to do better planning for anesthesia and surgery.
To conclude, TBI caused by blunt trauma is an uncommon life-threatening scenario. As Benjamin Franklin’s quote, “If you Fail to Plan, You Are Planning to Fail”. This case increases awareness about the difficulties encountered during the handling of such cases and the value of advanced preparation. Virtual bronchoscopy is another tool giving additional information for aiding in early diagnosis and helping in the management plan.
Orcid
Amandeep Kaur https://orcid.org/0000-0002-9093-3132
Vikram Pal Singh https://orcid.org/0000-0001-8215-6508
Parshotam Lal Gautam https://orcid.org/0000-0002-7615-4781
Manender Kumar Singla https://orcid.org/0000-0002-2448-3057
M Ravi Krishna https://orcid.org/0000-0002-5360-3847
Footnotes
Source of support: Nil
Conflict of interest: None
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