Published online Jun 6, 2022. doi: 10.12998/wjcc.v10.i16.5185
Peer-review started: August 14, 2021
First decision: November 17, 2021
Revised: November 21, 2021
Accepted: April 2, 2022
Article in press: April 2, 2022
Published online: June 6, 2022
Processing time: 291 Days and 17.3 Hours
The number of patients with bronchial trauma (BT) who survived to hospital admission has increased with the improvement of prehospital care; early diagnosis and treatment should be considered, especially among blunt trauma patients, whose diagnosis is frequently delayed.
To describe the early recognition and surgical management considerations of blunt and penetrating BTs, and to elaborate the differences between them.
All patients with BTs during the past 15 years were reviewed, and data were retrospectively analyzed regarding the mechanism of injury, diagnostic and therapeutic procedures, and outcomes. According to the injury mechanisms, the patients were divided into two groups: Blunt BT (BBT) group and penetrating BT (PBT) group. The injury severity, treatment procedures, and prognoses of the two groups were compared.
A total of 73 patients with BT were admitted during the study period. The proportion of BTs among the entire cohort with chest trauma was 2.4% (73/3018), and all 73 underwent thoracotomy. Polytrauma patients accounted for 81.6% in the BBT group and 22.9% in the PBT group, and the mean Injury Severity Score was 38.22 ± 8.13 and 21.33 ± 6.12, respectively. Preoperative three-dimensional spiral computed tomography (CT) and/or fiberoptic bronchoscopy (FB) were performed in 92.1% of cases in the BBT group (n = 38) and 34.3% in the PBT group (n = 35). In the BBT group, a delay in diagnosis for over 48 h occurred in 55.3% of patients. In the PBT group, 31 patients underwent emergency thoracotomy due to massive hemothorax, and BT was confirmed during the operation. Among them, 22 underwent pulmo-tractotomy for hemostasis, avoiding partial pneumonectomy. In this series, the overall mortality rate was 6.9% (5/73), and it was 7.9% (3/38) and 5.7% (2/35) in the BBT group and PBT group, respectively (P > 0.05). All 68 survivors were followed for 6 to 42 (23 ± 6.4) mo, and CT, FB, and pulmonary function examinations were performed as planned. All patients exhibited normal lung function and healthy conditions except three who required reoperations.
The difference between blunt and penetrating BTs is obvious. In BBT, patients generally have no vessel injury, and the diagnosis is easily missed, leading to delayed treatment. The main cause of death is ventilation disturbance due to tension pneumothorax early and refractory atelectasis with pneumonia late. However, in PBT, most patients require emergency thoracotomy because of simultaneous vessel trauma and massive hemothorax, and delays in diagnosis are infrequent. The leading cause of death is hemorrhagic shock.
Core Tip: There are significant differences between blunt and penetrating bronchial traumas (BTs), particularly the severity of the injury, the site of the injury, the incidence of shock, the time before surgery, and the surgical procedure. From our experiences, single lumen intubation should be performed immediately after BT injury to reach the contralateral main bronchus to ensure ventilation of the healthy lung. We also summarize the four functions of temporary clamping of the pulmonary hilus during thoracotomy. In addition, pneumonectomy should be avoided, especially in penetrating BT patients, due to the limited lung tissue damage.