A case of complete transection of right main bronchus in a child: Role of thoracoscopy and bronchoscopy.

Isolated tracheobronchial injuries are extremely rare in children and challenging due to life threatening complications. Blunt trauma to chest, especially in pediatric age group, is usually associated with multi-organ involvement and high mortality rate. These patients rarely reach a hospital. We have described here a case of complete transection of right main bronchus in a child, without hilar vascular injury, and its successful management, emphasizing the role of bronchoscopy and thoracoscopy.

INTRODUCTION

Blunt chest trauma resulting tracheobronchial (TB) rupture is rare, especially in children. These injuries are potentially life threatening and present with severe respiratory distress. TB rupture is usually the result of high velocity road traffic accidents, and it can also be caused by crushing or twisting injury or by a fall from a height. High index of clinical suspicion with prompt early diagnosis and treatment reduces mortality and morbidity.

CASE REPORT

We received a 5-year-old male child from a peripheral hospital to our emergency room, with a history of run over by a bullock cart. On arrival, the child was in severe respiratory distress with absence of peripheral pulses and air entry on the right side of chest as well as un-recordable blood pressure. The child was resuscitated with crystalloids and vasopressor support.

An immediate bedside chest X-ray showed massive tension pneumothorax on the right side and an intercostal drain (ICD) tube was inserted [Figure 1a]. The child was stabilized for the next 24 h, but ICD showed continuous massive air leak and the child had persistent tachypnoea. A computed tomography (CT) scan image showed a collapse lung and massive pneumothorax with a suspicion of right main bronchus injury.

Figure 1

(a) Preoperative X-ray showing right tension pneumothorax (b) Thoracoscopic view of bronchial transection and air leak (c) Introperative picture of right main bronchial transection

The child was taken to the operating room. After intubation with single lumen endotracheal tube, a fiber optic bronchoscopy showed right mainstem bronchus obliteration by hematoma just 1.5 cm from carina, and the endotracheal tube was guided into left main bronchus. A diagnostic thoracoscopy was done to reveal complete transection of the right main bronchus and no associated mediastinal injuries [Figure 1b].

A right postero-lateral thoracotomy showed bronchial transection about 1.5 cm from the carina [Figure 1c]. The distal end was dissected out from the hilar structures and bronchial continuity was established by an end-to-end anastomosis with 4-0 vicryl interrupted sutures. The child was extubated and was in intensive care unit (ICU) with oxygen support. Early postoperative chest X-ray showed features of pneumonitis, which resolved with intravenous (IV) antibiotics and chest physiotherapy, with complete lung expansion seen on chest X-ray [Figure 2].

Figure 2

Postoperative X-ray showing right lung expansion

DISCUSSION

The incidence of TB injuries is about 0.7–2.8%,[1] and mortality relating to TB injuries is very high. The mechanism of TB injuries[2] are traction at the carina, rapid deceleration, or sudden increase of pressure in the TB tree.

The aorta lies anterior to the right main bronchus and arches posterior to the left main bronchus. Hence, the right main bronchus is more prone to injury as it lies directly over rachis, whereas left bronchus is protected posteriorly by aorta.

The patients with traumatic rupture of TB tree present with breathlessness, mediastinal and subcutaneous emphysema, hemoptysis, pneumothorax, atelectasis, persistent air leak, and failure to expand the lung with thoracostomy tube drainage.[3] Our patient presented with tension pneumothorax and shock following blunt chest trauma. Mortality is very high in these patients, unless it is diagnosed and intervened very early. A successful outcome depends on high index of clinical suspicion.

“Fallen lung sign” featuring a collapsed lung in dependant position, hanging on the hilum by its vascular attachments, is a more direct sign seen on CT scan. Flexible fiber optic bronchoscopy is the gold standard in establishing diagnosis and also can be used to guide endotracheal tube in to the main bronchus to isolate affected main bronchus.[4] Though CT scan in our case did not show the pathognomonic fallen lung sign, suspicious discontinuity of right main bronchus was identified.

With recent advances in pediatric thoracoscopic procedures, video assisted thoracic surgery (VATS) can be utilized for the initial diagnostic evaluation and surgical management of hemodynamically stable patients.[45] In a study conducted by Lobe et al.,[6] it was concluded that minimal access surgery (MAS) is becoming an accepted modality in the management of adults with trauma, but its use in children is rarely reported. MAS were used as a diagnostic and even as a therapeutic modality in repairing diaphragmatic lacerations.

We utilized the availability of VATS for confirmation of bronchial transection and also to rule out other mediastinal and diaphragmatic injuries, as the child was hemodynamically stable.

Primary treatment of TB injuries is thoracotomy and bronchial repair. Interrupted, absorbable sutures are used exclusively to allow growth and to avoid the troublesome granuloma problems associated with non-absorbable sutures.