To the Editor: Bronchial rupture due to blunt chest injury in children is very rare and can go undiagnosed for over 48 h. Despite surgical repair following definitive diagnosis by three-dimensional computed tomography (3D-CT) and bronchoscopy, complications from anastomotic stricture can arise, particularly in very young patients. This study aimed to present an algorithm for improved early diagnosis and report learnings from treatment of bronchial rupture after blunt chest trauma in nine children.
A review of the database at Children's Hospital of Chongqing Medical University between January 2014 and July 2018 identified nine consecutive patients who were admitted for bronchial rupture. Inclusive criteria were all patients under age of 16 years who underwent surgical repair for bronchial rupture as the result of blunt force trauma. Two patients were admitted to our hospital directly after injury. Of the seven patients who were transferred to our hospital from local hospitals, one presented with shortness of breath 12 days after chest tube insertion, and six had persistent air leakage or atelectasis despite chest tube insertion. All of the nine patients underwent chest X-rays, 3D-CT and bronchoscopy to establish diagnosis of bronchial rupture. Delay in diagnosis was defined as an interval greater than 48 h from time of injury which is common for patients transferring from peripheral hospitals.
Once bronchial rupture was confirmed, surgical repair was performed as soon as possible. A single-lumen endotracheal tube, guided by bronchoscopy, was inserted into the non-injured bronchus. Posterolateral thoracotomy through the fourth or fifth intercostal space using interrupted stitches with non-absorbable suture in cartilaginous sections and running stitches with absorbable suture in membranous sections of the bronchus was conducted in all patients. The surgery performed included debridement of the injured area, trimming of the edges, and end-to-end (mucosa to mucosa) anastomosis. Dissecting and mobilizing the hilum and incising the inferior pulmonary ligament were used to decrease tension in patients who required large amounts of tissue debridement. Lobectomy should be considered in cases with associated severe pulmonary parenchymal destruction or rupture in the small bronchus.
All patients were followed up using 3D-CT and bronchoscopy, with pulmonary function tests conducted as necessary. Balloon dilation and cryotherapy were performed to relieve bronchial stenosis.
The nine patients consisted of six males and three females, with an average age of 5.4 ± 2.8 years (range 2.5–9.7 years). In three patients, the diagnosis was established within the first 48 h after injury [Table 1]. The mean interval from injury to diagnosis was 15.0 ± 11.8 days (range from 1 to 34 days). Associated injuries include rib fracture (most common), long bone fracture, head trauma, and abdominal trauma [Table 1]. Surgical findings suggested complete transection of main bronchus in all patients [Supplementary Figure 1, http://links.lww.com/CM9/A24] and bronchial rupture was successfully reconstructed by end-to-end anastomosis in all patients. Two patients underwent additional lobectomy. Complications were identified in six patients [Supplementary Table 1, http://links.lww.com/CM9/A24]. No mortality was observed during hospitalization.
The median follow-up time was 24 months (range from 8 to 34 months). Mild bronchial stenosis was identified in six patients without significant complaints. Significant stenosis and granulation formation were found in all patients aged 3 or younger with delayed diagnosis. Significant stenosis and granulation formation were still identified after over 10 treatments with balloon dilation and cryotherapy. In Patient 6 and Patient 8, both improved following bronchial stent placement. Patient 2 declined further treatment, thus follow-up data are unavailable. The pulmonary function tests of Patient 6 and Patient 8 in their last follow-up showed mixed ventilation disturbances with impaired major and small airway ventilation. They are still receiving close follow-up.
Bronchial injuries are not diagnosed within 48 h in 25% to 68% of patients.[1,2] Delay in diagnosis results in scar tissue and obstruction of the bronchus by granulation tissue.[3,4] To improve rapid diagnosis and initiate treatment for bronchial rupture as early as possible, we have developed an algorithm for management of bronchial rupture [Supplementary Figure 2, http://links.lww.com/CM9/A24].
Three patients suffered refractory bronchial stenosis in the follow-up. All of these children had been transferred from peripheral hospitals which delayed diagnosis of bronchial rupture. Compared with other patients who were also delayed in diagnosis but with an uneventful recovery, it is noteworthy that these three patients were all younger than 3 years old. Therefore, a delayed diagnosis and surgery at a young age may contribute to poorer outcomes for children with bronchial rupture. The diameters of the bronchus in very young children are narrow and surgical repair is much more difficult in such cases. However, the correlation between delayed diagnosis for young children and bronchial stenosis following surgery could not be statistically established due to our very limited sample size.
To reduce granulation formation after surgical repair, we recommend the use of mucosa-to-mucosa anastomosis. In our group, the anterior wall of bronchus was repaired using interrupted stitches with non-absorbable suture to reduce the tension of the anastomotic line especially in patients with a long-time delay before diagnosis of bronchial rupture.
Outcomes of Patient 6 and Patient 8 were not satisfactory until stent placement was performed but this also makes necessary a re-intervention to later extract the stent. Pneumonectomy was reported to be effective in pediatric patients with bronchial stenosis; however, in our opinion, pneumonectomy should be avoided in children for improved long term outcomes. A resection of the stenotic segment and end-to-end anastomosis may be potentially useful for patients who develop bronchial stenosis after surgical repair although none of our patients in this study underwent such a procedure.
In conclusion, bronchial rupture is a rare but potentially serious complication of blunt chest trauma. Delay in diagnosis is common, especially in rural areas, and leads to poor clinical outcomes in very young children. Persistent air leak, atelectasis despite chest tube insertion, and pneumomediastinum are indicators of potential bronchial injury. Bronchoscopy and 3D-CT are essential to definitively diagnose bronchial rupture. Surgical repair should be performed as soon as the diagnosis is established. Although balloon dilation and cryotherapy are the standard treatment for bronchial stenosis, we observed that in very young patients, stent placement is more effective to relieve bronchial stenosis after surgical repair.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients or their legal guardians have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of Interest
1. Kiser AC, O’Brien SM, Detterbeck FC. Blunt tracheobronchial injuries: treatment and outcomes. Ann Thorac Surg
2001; 71:2059–2065. doi: 10.1016/S0003-4975(00)02453-X.
2. Demir A, Olcmen A, Kara HV, Dincer SI. Delayed diagnosis of a complete bronchial rupture after blunt thoracic trauma. Thorac Cardiovasc Surg
2006; 54:560–562. doi: 10.1055/s-2006-924480.
3. Bagheri R, Afghani R, Haghi SZ, Fattahi Masoum SH, Sadrizadeh A. Outcome of repair of bronchial injury in 10 patients with blunt chest trauma. Asian Cardiovasc Thorac Ann
2015; 23:180–184. doi: 10.1177/0218492314545621.
4. Wu MH, Tseng YL, Lin MY, Lai WW. Surgical results of 23 patients with tracheobronchial injuries. Respirology
2010; 2:127–130. doi: 10.1111/j.1440-1843.1997.tb00065.x.
5. Gwely NN. Blunt traumatic bronchial rupture in patients younger than 18 years. Asian Cardiovasc Thorac Ann
2009; 17:598–603. doi: 10.1177/0218492309349067.