Chest
Volume 155, Issue 3, March 2019, Pages 595-604
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Special Features
Treatment of Tracheobronchial Injuries: A Contemporary Review

https://doi.org/10.1016/j.chest.2018.07.018Get rights and content

Tracheobronchial injury is a rare but a potentially high-impact event with significant morbidity and mortality. Common etiologies include blunt or penetrating trauma and iatrogenic injury that might occur during surgery, endotracheal intubation, or bronchoscopy. Early recognition of clinical signs and symptoms can help risk-stratify patients and guide management. In recent years, there has been a paradigm shift in the management of tracheal injury towards minimally invasive modalities, such as endobronchial stent placement. Although there are still some definitive indications for surgery, selected patients who meet traditional surgical criteria as well as those patients who were deemed to be poor surgical candidates can now be managed successfully using minimally invasive techniques. This paradigm shift from surgical to nonsurgical management is promising and should be considered prior to making final management decisions.

Section snippets

Risk Factors

Risk factors for tracheobronchial injury can be categorized as mechanical and anatomic (Table 2).1, 2, 3, 4, 5, 6, 7, 11, 12, 27, 28, 29, 30, 31 Of these, the most important modifiable risk factors are procedural or instrumentation related. These risk factors can be addressed by appropriate education about airway treatment. In a systematic review involving 182 patients, Miñambres et al1 found that being female, older than 65 years of age, and emergency intubations were the most important

Manifestations of Tracheobronchial Injury

Clinical presentation of iatrogenic or traumatic tracheobronchial injuries can be nonspecific irrespective of the etiology. Typical findings in the setting of tracheobronchial injury can be subcutaneous emphysema, pneumomediastinum, and pneumothorax.7, 32, 33 Acute respiratory failure can also occur, but the diagnosis could be difficult in patients with preexisting respiratory failure. On occasion, hemoptysis,34 pneumoperitoneum (if the air dissects the fascial layers into the abdomen)35 or

Diagnosis of Tracheobronchial Injury

A high degree of clinical suspicion, CT imaging, and bronchoscopy, in that order, can help diagnose tracheal injury. Radiographic imaging may reveal pneumomediastinum, subcutaneous emphysema, pneumothorax, or the tracheal tear itself37, 38 (Fig 1). Bronchoscopy remains the “gold standard” for the diagnosis of tracheal injury. Bronchoscopy not only helps in identifying the exact location and size of the injury but may also help in treatment of the injury.39, 40 In endotracheally intubated

Location and Types of Tracheobronchial Injury

The anterior trachea, including the cartilage, or the ligamentous portions between the tracheal rings, are most commonly injured during penetrating trauma.37 Most traumatic tracheobronchial injuries take place within 2.5 cm of the carina, and mainstem bronchial injuries comprise more than 85% of these injuries.43 The most frequent cause of penetrating tracheobronchial injuries is gunshot wounds. These injuries could occur in any region of the respiratory tract.44 Patients with gunshot wounds to

Treatment of Tracheobronchial Injury

Treatment of tracheobronchial injury in most instances needs to be individualized, based on the patient’s comorbidities, clinical presentation, and anatomy of the tracheobronchial injury. For superficial tracheobronchial injuries (level I) conservative treatment with follow-up bronchoscopy is preferred.7 In tracheobronchial injuries involving the mucosal layer with subcutaneous or mediastinal emphysema (level II injuries), patients are usually treated on a case-by-case basis. The role of

Surgical Treatment

There are no specific guidelines regarding the surgical treatment of tracheobronchial injury. Traditionally, most experts have agreed that patients with tracheal tears longer than 4 cm in length and those who deteriorate clinically should be treated surgically (Table 4).33, 39, 55, 56 In a retrospective study of tracheobronchial injuries, 39 of 50 patients had iatrogenic injury; of these 30 patients were treated by open surgical repair while the rest were treated conservatively. The authors

Nonsurgical Treatment

Patients with airway injuries (levels I and II) and who are clinically stable, that is, breathing spontaneously, or those who require minimal ventilator support and have tracheal tears less than or equal to 2 cm, should be considered for nonsurgical treatment (Table 4).1, 11, 32, 41, 63 Other suggested criteria for conservative treatment include the following: absence of esophageal injury, minimal mediastinal air, and nonprogressive pneumomediastinum or subcutaneous emphysema.41 Previously it

Treatment of Poor Surgical Candidates

Patients who are deemed to be at high surgical risk due to comorbidities or the severity of the underlying disease can now be treated by minimally invasive techniques. Temporary placement of a covered self-expanding metallic stent (SEMS) could offer some advantages under these circumstances (Fig 3). First, the stent will mechanically obstruct the tracheal defect. Second, there may be an exuberant inflammatory response with granulation tissue formation that could potentially augment closure of

Prevention of Tracheobronchial Injury

Injury to the tracheobronchial tree may not be preventable in the setting of blunt or penetrating trauma. However, in cases of iatrogenic injury, prevention is the key. Appropriate training for practitioners who perform endotracheal intubation can help prevent multiple failed attempts. It is well known that the difficulty of intubation increases with each unsuccessful attempt and predicts failure on subsequent attempts.76 Appropriate training and education of support staff, including

Prognosis

The prognosis for the patient with tracheobronchial injury depends on various factors related to the underlying clinical status of the patient, the extent of tracheobronchial injury, and the type of repair. Miñambres et al1 indicated that although tracheobronchial injury is more common among females, males tend to have a higher risk of mortality. In their study, the overall mortality was 22% (n = 40/182), but this was felt to be due to the underlying cause for respiratory failure rather than

Conclusion

Tracheobronchial injury may not be as rare as previously reported. It occurs infrequently but remains a high-impact event with significant morbidity and mortality. Injuries that were historically treated by surgical repair can now be successfully treated via careful multidisciplinary patient selection for interventional pulmonology techniques at centers of excellence. This is a promising treatment strategy and should be considered prior to surgical treatment; especially in patients who do not

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