Rupture bronchique bilatérale: problèmes de prise en charge ventilatoire

The authon report the case of bilateral bronchial rupture in a 39-year-old multiple trauma patient. During the thoracotomy for right main bronchus repair, a partial left bronchial rupture was recognized because of severe hypoxaemia after left selective intubation.     

Successful re-reconstruction for complete disruption of the right main bronchus by blunt chest trauma

A 22 year-old man was brought to our hospital about twenty-three minutes following a high-speed motorbicycle accident in which he had blunt chest trauma. He was in severe respiratory distress with marked dyspnea and restless with extensive subcutaneous emphysema involving anterior chest wall, cervical and bilateral inguinal regions. A chest X-ray revealed bilateral pneumothorax involving mediastinal emphysema and also fracture of right submandibular and clavicula. In spite of orotracheal intubation and insertion of bilateral chest tube, continuous air leak and pneumothorax did not improve. Bronchoscopy revealed the disruption of mucosa of the right main bronchus at the bifurcation. Emergency right thoracotomy was performed and there was the complete disruption of the right main bronchus. Anastomosis of the right main bronchus with circumferential resection was undertaken on May 30, 1987 about two hours after trauma. About three months after reconstruction, bronchoscopic examination revealed stomal stenosis with deformation of tracheobronchial cartilage and granulation. The stenosis showed severe irregularity by deformed cartilage and thickened scar, so widening by Nd-YAG laser vaporization was inadequate in effect. Seven months after first reconstruction, we performed re-reconstructive operation, right upper sleeve lobectomy with partial resection of carcina and right wall of trachea for scar with severe deformation of cartilage. Following the operation, the patient suffered from sepsis with pneumonitis accompanied by lung edema. This complication was treated successfully. We considered that acute pneumonitis was caused by reventilation with increase of perfusion after tracheobronchial reconstruction. Consequently, we thought it important to treat such patients with long term IPPB postoperatively with adequate medication for respiratory system.     

Bronchial and cardiac ruptures due to blunt trauma

Tracheobronchial and cardiac injuries following blunt thoracic trauma are uncommon but can be life-threatening. We report a case in which the patient with bronchial and right atrial ruptures due to blunt trauma survived after emergent repairs. An 18-year-old female driver was transported to our hospital after a traffic accident and was hemodynamically stable on arrival. Chest computed tomography revealed cervicomediastinal emphysema and hemopericardium, and fiberoptic bronchoscopy showed a tear in the right main bronchus. She was intubated with a double-lumen endotracheal tube guided by bronchoscopy. A median sternotomy was undertaken, and a laceration of the right atrium was oversewn without the use of cardiopulmonary bypass. After that, right-sided thoracotomy was performed. The tear in the membranous portion of the right main bronchus was repaired with interrupted sutures, and the suture lines were wrapped with a pedicled flap of intercostal muscle.     

Tracheobronchial rupture due to blunt chest trauma: a follow-up study

From 1970 to 1988, 9 patients were treated for tracheobronchial rupture arising from nonpenetrating thoracic trauma. All patients had dyspnea and pneumothorax. Four patients had rupture of the right main bronchus, 3 had rupture of the left main bronchus, 1 had rupture of the right intermediate bronchus, and 1 had rupture of the trachea. Four patients were operated on within 24 hours. Three of them had a massive air leak into the suction drainage and underwent thoracotomy. The fourth patient presented difficulties with endotracheal intubation and required a collar incision. Primary reconstruction was performed in all 4 patients. Five patients had a delay of nine to 89 days before operation. All of them had good primary healing but later developed dyspnea. Bronchoscopy revealed scar obstruction in all 5. The stenosed segment was resected in 4 patients at thoracotomy. The fifth patient, who had an intermediate bronchus rupture, underwent lobectomy. Seven patients were followed from 6 months to 18 years. One of them, who had a nine-day delay in treatment, needed further operation 6 months after the accident because of scar obstruction. The other 6 patients were interviewed, examined, and studied with spirometry, body plethysmography, bronchoscopy, and bronchography. In these 6 patients no stricture was seen, and there was no reduced pulmonary function due to the rupture even when operation was delayed.     

A case report of compression of right pulmonary artery and bronchus by aneurysmal dilated ascending aorta in tetralogy of Fallot--suspension of ascending aorta

The patient was a 63-days-old boy who was admitted to our hospital because of moderate cyanosis and tachypnea. After admission, severe respiratory distress and emphysematous change of the right lung on the chest X-ray developed progressively. Echocardiogram and angiocardiogram demonstrated that a tetralogy of Fallot associated with right aortic arch and absence of pulmonary valve, and revealed remarkably dilated ascending aorta which compressed the right pulmonary artery and bronchus. Therefore, the emergency operation in that the ascending aorta was suspended to the 2nd rib was performed through a right thoracotomy. After surgery, his respiratory distress and emphysema of the right lung completely disappeared. To our knowledge, this is the 2nd reported case in which suspension of ascending aorta was successfully performed for pulmonary complication in congenital cardiovascular anomalies as this patient.     

Anesthetic management of a patient with bronchopleural fistula following blunt trauma chest: A brief report

Blunt trauma to the chest resulting in rupture of a major bronchus is rare. These injuries are often fatal because of respiratory distress; difficulties in establishing an airway, and the high frequency of associated multiple organ injuries. We report the anesthetic and intensive care management of a patient with bronchopleural fistula following blunt chest injury and post-thoracotomy stump leak. This case was unique because of shearing of right main bronchus close to carina, such injuries are not only difficult to repair but also, double lumen tube was kept for more than 48 h to prevent reopening of the suture. Successful management of the case is described with brief review of the literature.     

Bronchial injury due to double-lumen endobronchial tube

A 68-years-old and 148 cm tall female with lung cancer was operated on a left lower lobectomy via posterolateral thoracotomy. A 35 Fr double-lumen endobronchial tube was smoothly inserted and the tip was placed in the left main bronchus whose position was confirmed by fiberoptic bronchoscope. After lobectomy and lymph node dissection were completed, 1-lung ventilation was terminated, the left chest cavity was filled with saline, and an air-leak test was performed. Immediately after the initiation of bilateral lung ventilation, massive air-leak was observed in the left hilar region and the saline in the chest regurgitated into the airway, and she fell into critical ventilatory insufficiency. After sucking the saline in the chest, thorough observation revealed a 3 cm-long rupture of the membranous portion of the left main bronchus. The rupture was manually occluded and ventilatory insufficiency was avoided, then the tip of the endobronchial tube was re-inserted into the right main bronchus and right single lung ventilation was initiated. The rupture was closed by a 4-0 polydioxanone (PDS) running suture with no coverage. The patient was extubated immediately after the operation. Ten days later, she had a tiny bronchial fistula, and it was cured by chest drainage only, and she discharged home on the 48th postoperative day.     

Right pneumonectomy syndrome in infancy treated with an expandable prosthesis

Severe respiratory distress developed in a 5-month-old infant approximately ten days after pneumonectomy for complete sequestration of the right lung. Right pneumonectomy syndrome was diagnosed by bronchography, which revealed thinning and obstruction of the left main bronchus during expiration. A right thoracotomy was then performed, and an inflatable tissue expander with a subcutaneous injection port was inserted into the right chest cavity to prevent recurrence of the mediastinal shift and to allow for future growth. The patient has done well, requiring reinjection of the prosthesis with additional volume on one occasion in a 20-month period of follow-up.     

Embolie gazeuse peropératoire chez un traumatisé hépatique. Intérêt de l’oxygénothérapie hyperbare

A young man was admitted for a polytraumatism associating head trauma and blunt abdominal trauma with hepatic injury. He was managed with a damage control surgery with a perihepatic packing. During the second look surgery, he developed a paradoxal gazous embolism by air aspiration in the sus-hepatic vein. This has never been described before in such traumatism. The patient presented a respiratory distress, a circulatory shock due to right infarction and an intracranial hypertension with bilateral mydriasis. He was immediately treated by hyperbaric oxygenotherapy. The evolution was good and he recovered without sequelae.     

Successful treatment of severe asthma-associated plastic bronchitis with extracorporeal membrane oxygenation

We describe a case of near-fatal asthma requiring extracorporeal membrane oxygenation (ECMO). The patient presented with severe respiratory distress, which was not responsive to conventional pharmacological therapy. The patient also failed to respond to mechanical ventilation and thus was placed on venovenous ECMO for temporary pulmonary support. A fiberoptic bronchoscopy revealed that large amounts of thick bronchial secretions had occluded the main bronchus, which suggested plastic bronchitis secondary to asthma. Aggressive airway hygiene with frequent bronchoscopies and application of biphasic cuirass ventilation for facilitation of secretion clearance were performed to improve the patient's respiratory status. The patient achieved a full recovery and suffered no neurological sequelae. This case illustrates that aggressive pulmonary hygiene with ECMO is a useful therapy for patients with asthma-associated plastic bronchitis.     

Iatrogenic rupture of the left mainstem bronchus in tracheobronchial intubation

A 74-year-old woman underwent right thoracotomy to remove a lung neoplasm. After general anesthesia had been induced, a no. 37 Bronchocath (Mallinkrodt) left endobronchial tube (TDL) was inserted. The TDL was initially positioned in the right mainstem bronchus and then had to be removed and repositioned in the left mainstem bronchus. It was not deemed necessary to use a fibrobronchoscope at this stage. During surgery the reduced minute expiratory volume and signs of pneumomediastinum made it necessary to perform tracheobronchoscopy. This led to the diagnosis of a rectilinear rupture of the left mainstem bronchus starting immediately below the carina, at the level of the pars membranacea and extending as far as the origin of the superior lobar bronchus. The left TDL was replaced by a similar right TDL and emergency left thoracotomy was performed following surgical repair of the damage. No problems of note occurred during the postoperative period. The patient did not present any of the predisposing risk factors for rupture of the tracheo-bronchial tree, except for slight fragility of tracheal respiratory mucosa. The anesthetist did not use fibrobronchoscopy or any devices to control the pressure level of TDL sleevs during the intubation and selection of the bronchus. These aids might have prevented the occurrence of a potentially fatal complication.     

Surgical rescue for life-threatening hypoxemia caused by a mediastinal tumor

We recently encountered a patient with a large anterior mediastinal tumor who developed severe hypoxemia during general anesthesia. This life-threatening hypoxemia was treated by extracorporeal membrane oxygenation using emergent percutaneous cardiopulmonary support followed by extirpation of the tumor. We found that total arteriovenous shunt resulting from compression by the mediastinal tumor caused this severe hypoxemia (total obstruction of left main bronchus and of the right pulmonary artery).     

Management of bilateral congenital bronchial stenosis in an infant

Congenital bronchial stenosis is a very uncommon condition in children. A full-term neonate showed severe respiratory distress soon after birth. Bronchoscopy and spiral computed tomography with multiplanar reconstruction disclosed a short stenosis of the left main bronchus, next to the carina, and another stenosis in the intermediate bronchus with air trapping in the right middle and lower lobes. The child underwent resection and reconstruction of the left main bronchus, and right middle and lower lobectomies after a failed attempt of bronchoscopic dilatation of the intermediate bronchus. A temporary silicon tracheal stent was necessary to achieve permanent extubation. The patient was discharged in good condition without any oxygen dependency and remains asymptomatic 1 year after surgery. Management of children with airway stenosis is complex, and surgeons involved in it should be familiar with multiple surgical and endoscopic techniques. A team approach in a referral center is the best option to achieve an optimal result.     

A case of a chronic traumatic thoracic aneurysm with compression of left main bronchus at the isthmus

A case of successfully treated chronic traumatic thoracic aneurysm is reported. A 43-year-old man was admitted suffering from severe respiratory distress. He had a history of a blunt chest trauma in a traffic accident twenty-three years ago. A plain chest film, bronchofiberscopy, chest CT, MRI and angiography revealed a calcified aneurysm with compression of left main bronchus at the isthmus. He was successfully treated by replacement with woven Dacron graft under partial left heart bypass by means of a centrifugal pump. His postoperative course was uneventful. The literature states operative cases demonstrate a significantly higher survival rate compared to the nonoperative cases. Surgical treatment should be strongly considered for potential aortic rupture.     

Traumatic laceration of the right middle lobar bronchus; report of a case

We described the rare case of 26-year-old woman with a traumatic laceration of the right middle lobar bronchus. The patient suffered blunt chest trauma in a traffic accident. Chest roentgenography showed bilateral pneumothorax, right multiple rib and clavicle fractures and emphysema in the subcutaneous and mediastinal lesions. Bilateral thoracic drainages were performed under controlled mechanical ventilation. Massive air leakage from the right chest tube was observed. Bronchofiberscopy 2 days after the accident revealed laceration of the right middle lobar bronchus. A right middle lobectomy was performed via thoracotomy. The patient was discharged on hospital day 51. In terms of the rare bronchial laceration is discussed.     

Kommerell's diverticulum and right-sided aortic arch: a cohort study and review of the literature

We report four consecutive cases of Kommerell's aneurysm of an aberrant left subclavian artery in patients with a right-sided aortic arch and the results of a systematic review of the literature. In our cohort of patients, three had an aneurysm limited to the origin of the aberrant subclavian artery, causing dysphagia and cough, and one had an aneurysm involving also the distal arch and the entire descending thoracic aorta, causing compression of the right main-stem bronchus. A left subclavian-to-carotid transposition was performed in association with the intrathoracic procedure, and a right thoracotomy was used in all patients. One of the patients underwent surgery with deep hypothermia and circulatory arrest, and the others with the adjunct of a left-heart bypass. The repair was accomplished with an interposition graft in two patients and with endoaneurysmorrhaphy in the others. The postoperative course was complicated by respiratory failure and prolonged ventilation in one patient, and one patient died because of severe pulmonary emboli. The survivors are alive and well at a follow-up of 1 to 3 years. Only 32 cases of right-sided aortic arch with an aneurysm of the aberrant subclavian artery have been reported: 12 were associated with aortic dissection, and 2 presented with rupture. Surgical repair was accomplished in 29 patients. A number of operative strategies were described: right thoracotomy, bilateral thoracotomy, left thoracotomy with sternotomy, sternotomy with right thoracotomy, and left thoracotomy. In only 12 cases was the subclavian artery reconstructed. We believe that a right thoracotomy provides good exposure and avoids the morbidity associated with bilateral thoracotomy or sternotomy and thoracotomy. We feel that a left subclavian-to-carotid transposition completed before the thoracic approach revascularizes the subclavian distribution without increasing the complexity of the intrathoracic procedure.     

Polytrauma with tension pneumothorax with inserted chest tube

The authors report a case of a 25-year-old woman with a polytrauma, caused by a free fall of 12 metres in suicidal intention. Following endotracheal intubation and mechanical ventilation by an emergency physician at the scene, the patient was delivered to the emergency room of an university hospital. An ultrasonic check of the abdomen revealed free fluid in the abdominal cavity, and a rupture of liver and spleen was suspected. Since breath sounds over the right lung were diminished, a chest tube was inserted immediately in the fifth intercostal space in the anterior axillary line. About 300 millilitres of blood were drained by the tube. Shortly thereafter, a laparotomy was performed, where spleen and liver rupture were confirmed and treated. After 60 minutes, the patient developed severe hypotension coupled with ventricular tachycardia and fibrillation, and resuscitation measures had to be initiated. Since breath sounds over the right lung were missing, a tension pneumothorax was suspected and a thoracotomy performed immediately. While huge amounts of air and blood were emerging from the thoracic cavity, a rupture of the right mainstem bronchus as well as of the right pulmonary artery and vena subclavia was identified. The chest tube was found dislocated into the subcutaneous tissue. Despite of open heart compression, application of adrenaline and noradrenaline and substitution of packed red blood cells and of crystalloid and colloid solutions, all resuscitation measures failed so that the patient died shortly after on the operation table. This case illustrates first the difficulties of an adequate thoracic trauma management, particularly, when clinical symptoms are discrete, second the problems of the insertion and control of a chest tube, and third risks associated with wrong position or secondary dislocation which may include - as in our case - "masking" of severe injury patterns and delay of life-saving measures such as an immediate thoracotomy. In order to improve prognosis of patients with poly-/thoracic trauma, establishment of spiral-CT in emergency centres, routine bronchoscopy and safe handling of chest tubes may be helpful.     

Blunt diaphragmatic rupture: four year’s experience

Background Blunt diaphragmatic rupture (DR) is a rare condition usually masked by multiple associated injuries, which are the main cause of morbidity and mortality. The overall incidence of diaphragmatic injury is 0.8–5.8% in blunt trauma—2.5–5% in blunt abdominal trauma and 1.5% in blunt thoracic trauma. A correct diagnosis remains difficult and is usually made late. Methods Over four years 12 patients with blunt DR were treated in our hospital. Their charts and X-rays were analyzed. All the surgeons involved were interviewed. Diagnostic and treatment modalities were analyzed and discussed. Results Acute diaphragmatic rupture (ADR) was diagnosed in nine patients within seven days. Three patients presented with bowel obstruction and post-traumatic diaphragmatic hernia was diagnosed intraoperatively. Nine patients had rupture of the left hemidiaphragm, two had rupture of the right hemidiaphragm, and one had bilateral DR. Diagnosis of DR was made in all patients in the ADR group before surgery. The correct diagnosis was made within 12 h by junior medical officers in 66.6% of cases. Two patients were diagnosed on a second chest X-ray in response to progressive respiratory distress. The diaphragmatic defect was repaired in all patients via laparotomy; only one patient required additional thoracotomy. Mortality was 25%. Conclusions Single or serial plain chest radiographs with a high index of suspicion are diagnostic in most cases of DR. Respiratory distress should be treated with intubation as intercostal drainage (ICD) may not improve the situation and is associated with a high risk of iatrogenic injuries. Surgical repair is mandatory and laparotomy should be the preferred approach in unstable patients. To avoid missed injury thorough inspection of both hemidiaphragms should be done routinely on every trauma patient undergoing laparotomy. It is widely recommended to use non-absorbable suturing for diaphragm repair but slowly absorbable material seems reliable also.     

Rupture of a thoracic aneurysm in the left bronchus

Aortobronchic fistula is a very unusual complication of thoracic aneurysm. We report the case of a 71-year old man with rupture of a thoracic aortic aneurysm in the left main bronchus. The patient had suffered a car crash fifteen years ago, without any evidence of aortic rupture at the time. Thereafter, he developed an aortic isthmic dilation (36 mm in diameter). The patient suffered from long standing pulmonary insufficiency and emphysema and was admitted several times on an urgent basis for acute dyspnea. During an hospitalization for respiratory distress, he presented haemoptysis and left lung hyperinflation secondary to partial fistulization and extrinsic compression of the main left bronchus. Isthmic aortic resection and prosthetic grafting was performed and the left main bronchus was closed by an autologous pericardial patch. Ten days later, following an air-leak from the bronchial closure, a transposed latissimus dorsi flap was used by the plastic surgeon to repair the defect. Nevertheless, the patient died from multisystemic failure six weeks later.     

Tracheoplasty for congenital stenosis of the entire trachea

Congenital stenosis involving the entire length of the trachea has generally been regarded as a fatal disease. Tracheoplasty using costal cartilage grafts to enlarge the lumen was successfully employed in such a case, and the technique is described. A 12-mo-old female was referred with recurrent severe respiratory distress since birth. By tracheoscopy and bronchography, the entire trachea was seen to be stenotic. The left bronchus was of normal caliber by bronchogram and the left lung was over inflated, while the right lung was aplastic. Through a midsternal thoracotomy, the left bronchus was incised and cannulated for ventilation. Longitudinal incision of the entire length of the anterior wall of the trachea permitted the advance of a nasotracheal tube along the inner surface of the divided trachea to the carina. Two pieces of costal cartilage were used to fill the defect in the anterior wall of the trachea. The grafts were attached to the tracheal edges by interrupted 5-0 Dexon sutures. The endotracheal tube was successfully removed two months later. The subsequent course of the patient has been satisfactory.