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Eur J Cardiothorac Surg 2003;23:379-383
© 2003 Elsevier Science NL

A review of 24 patients with bronchial ruptures: is delay in diagnosis more common in children?

^a Department of Thoracic and Cardiovascular Surgery, School of Medicine, Mersin University, Mersin, Turkey
^b Thoracic Surgery Department, Ataturk Center for Chest Disease and Thoracic Surgery, Ankara, Turkey

Received 17 April 2002; received in revised form 23 October 2002; accepted 4 November 2002.

^* Corresponding author. GMK Bulvar Egricam Mah., Kasim Ekenler Sit. Blok B D:14, Mersin, Turkey. Tel.: +90-324-329-31-90; fax: +90-324-327-34-54

	Abstract

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
Objective: Bronchial ruptures due to blunt chest traumas are rarely encountered injuries. Because they occur seldom in pediatric age groups, even total ruptures of bronchi can be overlooked in the absence of accompanying lesions. This condition may result in a delay of diagnosis that consequently leads to irreversible septic changes in the lungs, which make resections unavoidable. The determination of predisposing factor(s) may be valuable in predicting and prevention of such situations. Method: We reviewed the records of 24 patients with bronchial ruptures hospitalized between January 1974 and December 2001 in Atatürk Center for chest disease and chest surgery. We divided the cases as ‘early’ and ‘delayed’ and each group consisted of ‘adult (age>15 years)’ and ‘pediatric (age<15 years)’ patients. Results: On reviewing the records of these patients, we observed that 75% of the delayed cases were under the age of 11 years when they survived the thoracic trauma. Conclusion: The susceptibility of children to delays is emphasized and the possible causes are discussed in the light of world literature. Simple approaches to minimize the number of misdiagnosed pediatric cases are highlighted.

Key Words: Tracheobronchial rupture • Children • Incomplete tears • Complete tears • Bronchiectasis

	1. Introduction

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
Bronchial ruptures due to blunt chest traumas are rare injuries [1]. Although most of the cases present a dramatic life threatening clinic, some cases may run a much more benign course with minimal symptoms [2]. Their rare occurrence combined with vague clinical pictures can lead to delays in diagnosis. Especially in cases with no accompanying lesions, this condition may result in tracheobronchial and pulmonary sequels which can make resections unavoidable. As we reviewed the records of 24 patients with early and delayed diagnosis in a comparative manner, we observed that this event seems to be more common in pediatric age groups. In this paper, we discussed the possible causes of this observation and underlined some simple approaches to minimize the number of the misdiagnosed cases.

	2. Patients and methods

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
Twenty-four patients with bronchial ruptures due to blunt chest traumas underwent surgical intervention in our institution between January 1974 and December 2001. In this retrospective study, the records of these patients were investigated to determine the differences between early and delayed cases and to inquire the possible associations between delays and age groups. Detailed data on patients are given in Tables 1, 2A, 2B and 3A, 3B.

	3. Results

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

Most of the acute cases consisted of males (n=13, 81.2% versus n=3, 18.8%). The lesions occurred following blunt chest traumas such as traffic accidents (n=11, 69%), compressions (n=3, 19%) or falls from heights (n=2, 12%). All but four patients had accompanying lesions. These were musculoskeletal injuries (n=15), head trauma (n=2) and upper abdominal trauma (n=2). Among the patients with accompanying lesions (n=12), a considerable number had more than one traumatic lesion (58%).

In this group, the most frequent physical findings involving the respiratory system were shortness of breath, subcutaneous emphysema, cyanosis and abnormal breath sounds on the affected side. All of the patients presented with at least one of these symptoms. Hemoptysis occurred less frequently and was seen in three patients only. Since the history and clinical picture in these patients strongly suggested an airway disruption, radiological examinations were undertaken as soon as the emergency restoration of the respiratory balance and control of the associated lesions were achieved. Cervicomediastinal emphysema (n=12, 75%), pneumothorax and persistent air leak through chest tubes (n=9, 56%) and atelectasis (n=5, 31%) in varying degrees were the most frequently encountered symptoms at this step. Hemothorax was seen in three patients. Following radiological examination and clinical observation, the definitive diagnosis was established within the first 3 days by either rigid or flexible bronchoscopy in all of the cases.

In this group, the results of the bronchoscopic examinations revealed that most of the lesions were located on the right (n=8) and left main bronchus (n=4). The other four lesions were on the right intermediary bronchus (n=2), right upper lobe bronchus (n=1) and left upper lobe bronchus (n=1). While in ten cases the lesions were complete disruptions, six lesions were in form of incomplete tears. All but three lesions were located within a distance of 2.5 cm from the tracheal bifurcation (Table 2A, B).

On the other hand, the delayed eight patients in whom bronchial ruptures had been initially overlooked in some other hospitals, applied 20 days–20 years after the trauma with complaints associated mainly with recurrent pulmonary infections. Six of the eight patients in this group were younger than 15 years of age. According to their histories, they had had no accompanying lesions except mild thoracic soft tissue lacerations. We also found out that a bronchoscopic examination had not been performed in any of them. No clear data could be obtained whether a radiological examination was performed or not.

The symptoms in these cases suggested rather recurrent pulmonary infections than a bronchial rupture. As a matter of fact, their radiological examination revealed findings such as atelectatic lung fields or bronchlectasis. Despite the history of a thoracic trauma, we performed rigid bronchoscopy under general anesthesia primarily to exclude any aspirated object, because we observe such clinical pictures usually in association with aspirated foreign bodies in this age group. In patients with tracheobronchial ruptures, we found strictures due to organized granulation tissue. In these cases, the tears were located on the right main bronchus (n=4), left main bronchus (n=3) and left lower lobe bronchus (n=1). The underlying lesions leading to this process were incomplete tears in six cases. In two patients, the type of the rupture could not be identified (Table 3A, B).

All patients underwent posterolateral thoracotomies. In the group consisting of early cases (n=16), we had to perform four resections due to extensive parenchymal or bronchial damage (one right upper, one left upper, two right inferior+middle lobectomies). In the remaining 12 patients, bronchial stump revision and end-to-end anastomosis were performed. In all of them, bronchial suture lines were covered either with pleura or with intercostal muscle flaps. Eleven of these 12 patients had uneventful postoperative periods. Bronchoscopic surveillance was carried out on the postoperative first, seventh, 30th and 90th days, respectively. Any finding suggesting secretions or atelectasis led to additional bronchoscopic aspirations. In one patient, empyema developed but we could discharge the patient without further complications.

The only mortality in this series occurred in the patient who underwent right upper lobectomy in the first 24 h following the trauma. This patient died on the 15th postoperative day because of empyema and multiple system insufficiency (Table 2A).

In the ‘delayed group’, six of the eight patients had to undergo resective surgery because of either bronchiectasis or dense parenchyma fibrosis (three right pneumonectomies, two left pneumonectomies and one left lower lobectomy) (Fig. 1 ). In the remaining two patients, we preferred to perform end-to-end anastomosis instead of resection because the delay time was short. In only one of them, a 11-year-old boy, who had applied on the 20th day after the trauma, the postoperative period run without complications. In the other patient who had applied 1 month after trauma, empyema developed due to re-expansion failure and we had to perform partial thoracoplasty later (Table 2A, B).

View larger version (128K): [in this window] [in a new window]   Fig. 1. Bronchographic demonstration of a right main bronchial stricture and consequent bronchiectasis in a 12-year-old girl due to an incomplete rupture after a motor vehicle accident.

	4. Discussion

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
The transfer of large amounts of kinetic energy to the human body during deceleretion often causes many lethal accompanying injuries so that most of the victims die before they can receive medical help [1–3].Together with the quite unique nature of the injuring mechanism, the fatality of accompanying lesions are meant to be a reason for their rare presentation [4–6]. During this period of 27 years, we hospitalized nearly 3500 patients with blunt chest traumas but only 24 cases had tracheobronchial ruptures. Our incidence of 0.7% is in concordance with previous studies [7].

In acute cases, with respect to presentations, accompanying lesions, diagnostic techniques, operations undertaken and the outcomes, there were no significant differences from the literature published yet [1–7].

The symptoms in our delayed cases were also not different from other series either in form or incidence. As in previously reported cases, our patients presented mainly with signs and symptoms associated with recurrent pulmonary infections [6]. Intermittent cough, fever and expectoration were present in all of the patients (100%). Shortness of breath on exertion was a rare finding in our series which may be due to the low mean age in this subgroup [6]. Physical findings and the results of radiological examinations also correlated with the literature.

But two observations made in the group of delayed cases are worth discussing, In our delayed patients, a remarkable finding was that 75% of the patients were younger than 15 years when they survived the trauma. This observation arouses the suspicion whether an association is present between pediatric age groups and delay of the diagnosis. Tracheobronchial ruptures are rarely encountered injuries occurring in less than 1% of blunt chest traumas [8,9]. They occur seldom in pediatric age groups [10]. But on the other hand, it is also well known that children are more susceptible to thoracic visceral injuries because of the elasticity of their thoracic cage. The soft thoracic cage can readily transfer kinetic energy in amounts large enough to injure the thoracic viscera without being affected by itself [11,12]. In the light of these two facts, it can be concluded that an incomplete tear can be overlooked easily when it is the only visceral injury with minimal or no accompanying complaints. Besides it must be kept in mind, that the psychological shock to survive an accident or the loss of a family member can make the children more reluctant to express any complaints which could be alarming for the physicians. Therefore, to minimize the risk of a misdiagnosis in children with seemingly no injuries a simple method may be to inquire the type and severity of the accident [1,13]. When we did this in our limited cases, we observed that there was at least one heavily injured victim in all of the accidents in which our young patients were involved.

In the light of this observation, we think that radiological examinations should be performed even in children with no complaints if they survived an accident in which one or more heavily injured casualties were present. In case of negative findings, radiological examinations must be repeated after a certain period of time since complications due to bronchial ruptures generally arise in 5–7 days [6]. When findings suggest mediastinal emphysema, atelectasis or pneumothorax, a bronchoscopic study must be undertaken by an experienced thoracic surgeon to rule out any bronchial injury.

In the delayed patients subgroup, our high resection rate is another topic worth discussing. Although a recent review stated that no association was detected between delay in treatment and successful repair of the injury and 90% of the injuries could be repaired successfully even 1 year after trauma [14], we had to perform resections in six of eight patients (75%). It is a common finding that following a complete rupture, the distal bronchus becomes completely obliterated so that distal lung tissue may be preserved from airborne infections thus enabling a successful repair even years later [5–7,11,14]. But, in incomplete tears, hematoma and granulation tissue forming on the location of the injury can progress to scar tissues narrowing the bronchial lumen. This process leaves the airway patent eventually. The impaired bronchial clearance inevitably leads to recurrent infections of the retained secretions which destroys the lung and precludes the possibility of restoring function [5–7,11,15].

On the other hand, the absence of infection does not always indicate the possibility of re-anastomosis. Sometimes, fibrosis following atelectasis may prevent re-expansion [13]. Insufflation of the bronchus during operation permits assessment of the possibility of re-expansion [11].

The indications for resective surgery in our six patients were either preoperatively documented bronchiectasis or our intraoperative observation of a fibrotic and unexpandable lung tissue. In six of these patients, the tracheobronchial injuries were in form of incomplete tears, in the remaining two, the injuries were so old that their types could not be identified exactly.

In conclusion, although performed on a limited number of patients, the results of this retrospective study suggest that:

1. the probability that incomplete tears cause minimal or no symptoms may be higher in children so that they may be overlooked more often;
   
2. incomplete tears are more apt than complete tears to cause irreversible pulmonary sequel by narrowing the affected bronchus and impairing the bronchial clearance;
   
3. an inquiry about the severity of the accident may be alarming for the physicians to associate minimal thoracic soft tissue complaints of the children with much more serious airway disruptions;
   
4. the importance of doctors' education employed in peripheral hospitals on tracheobronchial injuries and to insist on performing close follow-ups by repetitive radiological and bronchoscopic examinations even in the presence of least suspicion especially in children;
   
5. and that the patients must be addressed to specialized centers upon establishing the diagnosis of bronchial rupture.
   

	Footnotes

 
This study was carried out in Thoracic Surgery Department, Atatürk Center for Chest Disease and Thoracic Surgery, Ankara, Turkey between 1974 and 1998 when the authors worked together in the same institution.

	References

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 

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