Management of thoracic trauma
Tracheobronchial Injury

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Tracheobronchial injuries (TBI) can be challenging to diagnose, manage, and definitively treat. They encompass a heterogeneous group of injuries that are often associated with other injuries. Although relatively rare, diagnosis and treatment of TBI often requires skillful and creative airway management, careful diagnostic evaluation, and operative repairs that are often resourceful and necessarily unique to the given injury. An experienced surgeon with a high level of suspicion and the liberal use of bronchoscopy constitute the major tools necessary for diagnosing and treating these injuries. Most TBI can be repaired primarily using a tailored surgical approach and techniques specific to the injury. Associated injuries are common, and surgeons must be knowledgeable in treating a wide variety of physiologic abnormalities, especially those involving the chest wall and lung parenchyma, if a successful outcome is to be achieved in the management of these often challenging patients.

Section snippets

Anatomy

The anatomy of the tracheobronchial tree traverses two areas of the body: the neck and the thorax. While in the neck, the trachea is in close association to the carotid sheath and recurrent nerves laterally, to the esophagus posteriorly, and to the skin anteriorly, which makes it relatively prone to external injury. It continues through the thoracic inlet into the chest, where it is in close association to the great vessels and heart anteriorly, the pleura and lungs laterally, and to the

Incidence and Presentation

The true incidence of TBI is difficult to establish, as a large proportion (30% to 80%) of these patients will die before reaching the hospital.2 However, it is estimated on the basis of autopsy reports that 2.5% to 3.2% of patients who die as a result of trauma may have associated TBI.3, 4 More than 80% of TBI due to blunt trauma is located within 2.5 cm of the carina.4 Resuscitation of a patient with TBI can be difficult, as obtaining adequate ventilation may require novel approaches to

Associated Injuries

Pneumothorax is the presence of free air in the pleural space resulting in partial or total lung collapse. Pneumothorax may or may not be seen on plain radiograph. The parietal and visceral pleurae lie next to each other, forming a potential pleural space in which the lung normally lies in apposition to the chest wall. Expansion of the intrathoracic space causes a negative pressure, which in turn is transmitted to the pleural space, which then behaves like a bellows pulling air into the lungs

Diagnosis

The diagnosis of TBI is often times difficult, and a high index of suspicion is necessary. It is a relatively rare injury diagnosed in patients presenting to the emergency department that have sustained blunt chest trauma, with a reported incidence of 0.3% to 2%.56, 57 Physical examination is important in screening, and findings may include hoarseness, subcutaneous emphysema, diminished breath sounds, hemoptysis, and tachypnea. Although plain chest radiograph is helpful for the assessment of

Surgical Treatment

Depending on the severity of associated injuries and on airway compromise directly due to TBI, surgical treatment can be either immediate or delayed. Delayed repair of TBI can be successful, even if performed months out from the original injury.59 This is a common scenario seen in patients who present later with collapsed lung on radiograph, dyspnea, and a history of blunt force trauma where diagnosis of their TBI was missed at the time of injury. However, late complications of untreated TBI

Summary

In summary, tracheobronchial injuries, although relatively rare, encompass a heterogeneous group of injuries that often require skillful and creative airway management, careful diagnostic evaluation, and operative repairs that are often resourceful and necessarily unique to the given injury. An experienced surgeon with a high level of suspicion and the liberal use of bronchoscopy constitute the major tools necessary for diagnosing and treating these injuries. Most TBI can be repaired primarily

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