Introduction
Background
Tracheobronchial tears are rare injuries that are usually related to blunt trauma that involves a partial or complete laceration or puncture of the tracheal or bronchial wall.
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Pathophysiology
Tracheobronchial tears can be caused by the following:
- Shearing forces between the fixed carina or proximal bronchus and the mobile distal bronchi/lungs in a deceleration injury
- Rapid anteroposterior compression of the chest that causes lateral traction on the lungs and tearing of the bronchus from the fixed carina
- Rupture that results from an abrupt increase in pressure against a closed glottis
- Compression of the trachea between the sternum and spinal column
- Blunt trauma to the cervical trachea
- Necrosis that results from compromised mucosal blood flow after overinflation of an endotracheal tube (ETT) cuff
- Perforation by a stylet or ETT
- Other penetrating injuries
Frequency
United States
Tracheobronchial injuries occur in 0.4-1.5% of patients with major blunt trauma and are found in 2.8-5.4% of trauma-related autopsies. Tracheobronchial tears also have been reported in 18% of autopsies after the administration of emergency intubation; however, because minor injuries are often not identified, the actual frequency of this condition may remain unknown.
International
Few data are available regarding the frequency of tracheobronchial tears.
Mortality/Morbidity
Death occurs in approximately 30% of patients with tracheobronchial tears, with 50% of fatalities occurring within the first hour of the injury. Mortality may be related to an inadequate airway, tension pneumothorax, occlusion of the airway by protrusion of the esophagus into the tear, or accompanying injuries. In two thirds of survivors, the diagnosis is delayed, occasionally for many years, resulting in complications such as airway stenosis, atelectasis, pneumonia, mediastinitis, sepsis, and decreased pulmonary capacity.
Race
No specific data are available regarding racial predilection for this condition.
Sex
Blunt trauma accounts for the preponderance of all tracheobronchial injuries. Tracheobronchial injury from blunt trauma is 3 times more common in males, because blunt trauma involves males much more often than females. However, because women's tracheas are smaller, females have a greater chance of iatrogenic injury from ETTs.
Age
A higher incidence of serious chest trauma is seen in patients younger than 40 years; therefore, overall, tracheobronchial tears are seen more often in younger patients. Patients older than 40 years who suffer blunt chest trauma and who have diabetes, or who are generally in poor medical condition, are at higher risk for tracheobronchial tears. As in women, children have smaller tracheas and thus have a greater possible risk of iatrogenic injury from ETTs.
Anatomy
Multiple anatomic variables and common mechanisms of injury account for local susceptibility to tracheobronchial tears. The trachea and proximal bronchi have varying amounts of cartilaginous support, which strengthens them against injury, but the posterior tracheal membrane is unsupported by cartilaginous rings. Occasionally, blunt trauma to the anterior neck results in rupture of the cervical trachea; this is usually a longitudinal tear of the posterior tracheal membrane.
During intubation, ETTs and stylets are naturally directed against the relatively weaker posterior tracheal membrane; therefore, intubation-related injuries are more common in the posterior trachea. Cartilaginous support decreases progressively from the trachea to the distal bronchi, which are more membranous than cartilaginous.
The stronger proximal cartilage framework tends to fix the trachea and proximal bronchi in place, whereas the distal bronchi and lungs are more mobile. Consequently, deceleration injuries from blunt trauma typically occur at the transition zone between the fixed and mobile bronchus, within 2.5 cm of the carina. The left main bronchus is relatively protected by a longer mediastinal course. Although several studies have found right bronchial injury to be more common, several other investigators have reported an equal distribution between left and right bronchial injuries. The larger main bronchi are at higher risk of rupture than the smaller peripheral bronchi during a sudden increase in pressure because, according to Laplace law, in a cylindrical body, wall tension (T) equals internal pressure (P) times internal radius (R), or: T = P X R.
Presentation
Clinical signs of tracheobronchial tears include the following:
- Dyspnea
- Cough
- Hemoptysis
- Cyanosis
- Cervical subcutaneous emphysema
- Tracheal shift
- Persistent pneumothorax following satisfactory placement of a thoracostomy tube
- Signs of airway obstruction
Immediate treatment for this condition depends on the patient's condition and the presence of any associated injuries. At a minimum, emergency bronchoscopic confirmation of the diagnosis and location is important if a tracheobronchial tear is suspected. This procedure may aid in placing the ETT cuff beyond the injury or selectively intubating the unaffected bronchus.
Short lacerations of the upper one third of the trachea are occasionally treated with antibiotics and intubation beyond the level of the injury. In addition, some small or peripheral bronchial tears may be treated conservatively; however, nonoperative treatment can result in scarring and stenosis.
Surgical repair is indicated when a transmural tear that is longer than 1 cm causes a pneumothorax that is unrelieved by tube thoracostomy. Severe trauma may require resection of the damaged tissue.
Although the importance of early diagnosis and primary repair is indisputable, successful repair as long as 11 years after the initial injury has been reported.
Preferred Examination
Chest radiography is the standard initial screening examination for evaluation of most chest conditions, including possible tracheobronchial injury; however, computed tomography (CT) scanning is preferred if a tracheobronchial tear is suspected. In appropriate circumstances, multiplanar or virtual endoscopic reconstructions from the CT scan data can be performed to clarify questionable findings.
Definitive diagnosis of a tracheobronchial tear is made by bronchoscopy or surgical exploration. If clinical or radiographic findings suggest airway injury, diagnostic bronchoscopy is recommended.
Limitations of Techniques
Conventional radiography and CT scanning play important roles in the imaging of tracheobronchial tears. Although imaging findings can be highly suggestive in certain instances, radiography and CT scanning are often nonspecific for evaluating tracheobronchial tears.
Differential Diagnoses
Other Problems to Be Considered
Cervical spine trauma
Chest trauma
Neck trauma
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| References |
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Further Reading
Keywords
tracheal rupture, bronchial rupture, airway rupture, tracheal laceration, bronchial laceration, airway laceration, tracheal fracture, bronchial fracture, airway fracture, tracheal avulsion, bronchial avulsion, airway avulsion, tracheal injury, bronchial injury, airway injury
