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【摘要】 目的 探讨外伤性主支气管断裂的诊断和手术治疗效果。方法 胸片、CT和纤维支气管镜是诊断支气管断裂的主要方法。结果 11例均行支气管断端吻合，术后肺膨胀良好，肺功能基本恢复。结论 主支气管断裂的诊断一旦确立，应尽快手术治疗，能获得良好的疗效。
【关键词】 支气管；破裂；诊断；外科；治疗
Traumatic main bronchial rupture:diagnosis and surgical treatment
ZHAO Yong-xiang,FAN Qin-ming,HU Jing-yun,et al.Department of Cardiothoracic Surgery,The Third Xiangya Hospital,Central South University,Changsha 410013,China
【Abstract】 Objective To study the diagnosis and surgical treatment for traumatic main bronchial rupture.Methods Chest Xrays,CT and fiberoptic bronchoscopy were the main means to confirm the diagnosis.Bronchial endtoend anastomosis were performed in 10 patients and pneumonectomy on one case because of infection.Results All the lungs were well ventilated and lung function recovered.Conclusion Main bronchial rupture occurs relatively rarely.Early diagnosis and operative intervention save lives.
【Key words】 bronchi;rupture;diagnosis;surgery;treatment
Acute injuries of bronchial system are rare and lifethreatening situations,which can cause acute asphyxia［1,2］. Main bronchial rupture,a rare but potentially fatal condition,results from blunt/penetrating chest and has different clinical pictures［3～6］,occurrences of these injuries are only about 0.8% of all chest injuries. Since 1994,we have treated totally 11 cases,the diagnosis and surgical treatment for these cases are reported here.
1 Clinical information
1.1 General information The information was obtained by reviewing the operative records and archive files from 1994 to 2003 at our hospitals. The group consisted of 11 patients (male:7 cases,female: 4 cases) with penetrating or blunt bronchial injuries who were revealed in the emergency department (see Fig.1,2). All injuries involved the main stem bronchi. The right main bronchial rupture consisted of 4 cases,while the left main bronchial 7 cases. The shortest time of trauma was 7 days,the longest time was one year and half. Clinical findings: the most common presenting signs of airway disruption were dyspnea,pneumothorax,mediastinum and subcutaneous emphysema in 8 cases,hemoptysis in 5 cases. In 7 patients the atelectasis were found in 10 days to 3 months after trauma. Radiology: chest Xray showed that complete transaction of a main bronchus might result in the classic signs of atelectasis,“absent hilum” or a collapsing of the lung away from the hilus toward the diaphragm,known as the falling lung sign of kumpe. CT showed the site of stenosis and the secondary consequences of airway narrowing have been useful in the delayed setting and may directly reveal bronchial rupture or stenosis. Fiberoptic brochoscopy: the bronchial cutoff in 4 patients was found,location of bronchial stenosis,edema and the distance between the cutoff and bronchial bifuraction could be seen.
1.2 Surgical treatment Bronchial rupture were reconstructed successfully by “end to end”anastomosis in 10 patients of this group (see Table 1).After operation,the lobes were well ventilated. One right lung resection in a patient with right bronchus rupture was performed due to pulmonary infection. All the patients were discharged after uneventful postoperative and following periods,whose blood gas analysis and vital capacity were also improved obviously.
Table 1 Patients lesion sites and surgical treatment
2 Discussion
2.1 Diagnosis The clinical findings for most patients with traumatic main bronchial rupture are complicated because their clinical symptoms can be lessened through closed drainage so that is for us to timely make an earlier diagnosis for them. Because of this,the onethird of patients can be saved by timely making diagnosis and correct treatment. The diagnosis for the bronchial rupture is based upon clinical,radiological,and endoscopical finding. The clinical presentations for the bronchial rupture in the earlier traumatic stage constitute 2 types. Type Ⅰ: bronchial crack is connected to pleural cavity, whose clinical finding showed dyspnea and traumatic pneumothorax. 6 patients out of this group belonged to this type. Type Ⅱ: bronchial crack is covered with the mediastinal pleural so as not to directly be gotten through the pleural cavity. The clinical finding showed mediastinum and subcutaneous emphysema. 6 patients out of the current group belonged to this type. The surgical treatment could be performed on these patients due to the initial diagnosis of airway injury missed. Granulation tissue and stricture of the bronchus with develop within the first 1 to 4 weeks and will usually lead to symptoms, signs and radiological findings of pneumonia, bronchiectasis, atelectasis, and absent. Wheezing and postobstructive pneumonia are the common presentations of bronchial stenosis so that the atelectasis occurred. The pnenumonia occurred in 8 patients of this group within 10 days to 3 months after injury.
Radiological finding: In the earlier stage of patients, Xray sign are traumatic pneumothorax, mediastinal and subcutaneous emphysema and “fallen lung with absent hilum”(signs of complete bronchial transaction)［7］. In the current group, the phenomenon was not so often. In the late stage of patients, the atelectasis of the whole injured lung occured. CT showed the rupture looked like the blind tube end.
Fiberoptic bronchoscopy is the most effective diagnostic tool in case of suspected airway injury［8～13］. Moreover, fiberoptic bronchoscopy allows a rather clear determination of the extent and depth of the rupture establishing a further important parameter for the choice of treatment. For emergency bronchoscopy, which was done under anesthesia, we chose a flexible endoscope inserted through an endotracheal tube, the latter being uncuffed in order not to increase the damage and to be readily repositioned for inspection of the rims of the rupture. This technique enabled sufficient ventilation, a meticulous inspection, and a clearcut positioning of the endotracheal tube once the investigation was finished, without any need for changing endoscopic divices. In 9 patients of our group the tentative diagnosis was confirmed by fiberoptic bronchoscopy.
If there is a traumatic pneumothorax in patients with sever chest injury, which could completely be well ventilated after closed chest drainage, or the atelectasis occurred one week after chest trauma, the diagnosis of main bronchus rupture should be considered, and the fiberoptic bronchoscopy for a clear diagnosis should be done as early as possible.
2.2 Surgical treatment Choice for surgical treatment time: Once the diagnosis for the bronchus rupture is done, if the patients condition is available, the primary suturing and endtoend anastomosis of the bronchus should be performed as soon as possible. There are 3 advantages for this choice below:(1)In the early traumatic stage, the bronchus rupture wounds are less adhensive to the tissue around them so that the rupture ends can more easily be found more easily to do anastomosis.(2)It is only necessary to trim the two ends of fresh bronchus rupture and to cut down the inferior pulmonary ligament but to isolate bronchus so that the anastomosis could be done without tension. (3)The shorter the time of the posttraumatic atelectasis lasted, the better the vital pulmonary function recovered. As for some patients whose diagnosis could not be made in the early traumatic stage or whose bronchus anastomosis could be impossible because the patients condition would not be available, they will have to wait months to years for surgical treatment, if the wound lung has not been ruined, the bronchus endtoend anstomosis should be performed on these patients as well as possible. One patient of this group was well ventilated after a successful anastomosis was finished one year and 8 month later. But the pneumonectomy should be performed if there are pulmonary infection respectively occurred or the septic lesion of lung during operation. Generally speaking, the shorter the time from trauma is, the higher the occurrence of the atelectasis lung expand again, the better the lung function recover.
Anesthesia intubations: It is a prerequisite for the bronchus anastomosis to assure the air exchange of patients during operation. To solve the patients ventilation issue, the doublelumen tube could be available. Another alternative is to insert a smallsize tracheal tube through the surgical field to the distal end of the traumatic bronchus after being connected to respiratory machine so as to keep the gas exchange in healthy and traumatic lung. 8 patients of this group with successful anastomosis were accompanied with doublelumen tube. The whole procedures were carried out smoothly.
（本文图片见封三）
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1 Department of Cardiothoracic Surgery,The Third Xiangya Hospital,Central South University,Changsha 410013,China
2 Department of Cardiology,Yiyang Central Hospital,Yiyang 413000,China
3 Department of Cardiothoracic Surgery,The Second Xiangya Hospital,Central South University,Changsha 410013,China
4 Department of Surgery,University of Pittsburgh Medical Center,Pittsburgh,Pennsylvania,PA 15213,U.S.A
* Corresponding author.The Third Xiangya Hospital,Central South University,Changsha 410013,China
(编辑：黄鉴一)