Open tracheal injury is rare but can lead to disastrous consequences such as massive bleeding, airway obstruction or failure and aspiration of blood. We present a case of open tracheal injury of a man who tried to attempt suicide using a knife. In this case, the initial management was securing the airway by attempting orotracheal intubation. However, it was unsuccessful when the tube came out from the laceration wound. Intubation was then re-attempted through the distal cut-end of the trachea in the face of airway failure. A quick initial assessment and anticipation of a failed airway should always be the top priority in any emergency physician managing these cases. Direct intubation through the laceration wound might be the only option when all else fail and your patient is crashing.
Keywords: intubation, laceration, trachea
Blunt traumatic tracheobronchial injury is rare, but can be potentially life-threatening. It accounts for only 0.5%-2% of all trauma cases. Patients may present with non-specific signs and symptoms, requiring a high index of suspicion with accurate diagnosis and prompt treatment. A 26-year-old female was brought into the emergency department after sustained a blunt trauma to the chest from a high impact motor vehicle accident. She presented with signs of respiratory distress and extensive subcutaneous emphysema from the chest up to the neck. Her airway was secured and chest drain was inserted for right sided pneumothorax. CT of the neck and thorax revealed a collapsed right middle lung lobe with a massive pneumothorax, raising the suspicion of a right middle lobe bronchus injury. Diagnosis was confirmed by bronchoscopy. In view of the difficulty in maintaining her ventilation and persistent pneumothorax with a massive air leak, immediate right thoracotomy via posterolateral approach was performed. The right middle lobar bronchus tear was repaired. There were no intra- or post-operative complications. She made an uneventful recovery. She was asymptomatic at her first month follow-up. A repeated chest X-ray showed expanded lungs. Details of the case including clinical presentation, imaging and management were discussed with an emphasis on the early uses of bronchoscopy in case of suspected blunt traumatic tracheobronchial injury. A review of the current literature of tracheobronchial injury management was presented.
A motorcyclist was involved in a motor vehicle accident and presented with respiratory distress and neck swelling with surgical emphysema. He sustained gross tracheal injury, severe pneumothoraces and lung contusions. As intubation was successful, the tracheal injury was not addressed immediately in view of the other severe respiratory problems. Evidence of aspiration lead to further investigations which confirmed the diagnosis 22 days post trauma. Thyrotracheal anastomosis was carried out without stenting. A complete cricotracheal separation is a rare event and can be easily overlooked in the emergency department.
Intubation was difficult and traumatic in a 40-year-old patient presented for emergency oesophagoscopy because the diagnosis of stylohyoid ligament calcification was not suspected. High probability of stylohyoid ligament calcification should be suspected when there is difficulty in lifting the epiglottis and fibre-optic laryngoscopy is suggested as the best way to tackle this problem to prevent trauma and possible risk of regurgitation and aspiration especially in emergency situation.
Laryngotracheal separation is a rare variant of laryngeal trauma. However it is life threatening and potentially fatal. Patients with this injury usually succumb at the site of the accident itself. Here we present two cases of laryngotracheal separation of different etiology and of different outcomes. The treatment advocated for laryngotracheal separation is initially airway stabilization followed by formal repair of the transected trachea. However both our cases illustrates that the outcomes can be different and that a long term treatment plan should be individualized to each patient.
Penetrating neck trauma present difficult management issues by virtue of their rarity. Undiagnosed laryngotracheal injuries have serious implications, especially in the context of multiple trauma, where other injuries overshadow that of the laryngotracheal complex. This is a case of a schizophrenic patient with multiple self-inflicted cuts on his throat and abdomen. Injuries include open, comminuted laryngeal complex lacerations with vocal cord avulsion, as well as evisceration of small bowel. Adequate assessment using both direct laryngoscopy and rigid endoscopy, coupled with open exploration, allowed optimal exposure and fixation of the larynx in the anatomical configuration. The post-operative outcome of the airway and voice remained satisfactory at follow-up. A high index of suspicion coupled with adequate surgical approach allowed establishment of a functional larynx.
Tracheobronchial injuries are uncommon and a high level of suspicion is needed for immediate diagnosis and prompt treatment. In this case series, two rare cases of tracheobronchial injuries is described showing variable clinical presentations with different levels of injury. Our first case was seen in a 20 years old male whom had a direct impact on the neck and presented with upper tracheal injury. On arrival, this patient was in respiratory distress and had bilateral pneumothorax. Bilateral chest tube was inserted with subsequent neck exploration. During the neck exploration, anastomosis of the injured trachea was performed. The second case was represented by a 35 years old man with right main bronchial injury. Upon initial presentation, this patient appeared well and was comfortable under room air. However he gradually deteriorated one week after the trauma requiring surgical intervention. Eventually a thoracotomy with primary anastomosis of the bronchial tear was performed. Details of both cases including clinical presentation, imaging and procedures done will be discussed in this article.
Airway stem/progenitor epithelial cells (AECs) are notable for their differentiation capacities in response to lung injury. Our previous finding highlighted the regenerative capacity of AECs following transplantation in repairing tracheal injury and reducing the severity of alveolar damage associated acute lung injury in a rabbit model. The goal of this study is to further investigate the potential of AECs to re-populate the tracheal epithelium and to study their stimulatory effect on inhibiting pro-inflammatory cytokines, epithelial cell migration and proliferation, and epithelial-to-mesenchymal transition (EMT) process following tracheal injury. Two in vitro culture assays were applied in this study; the direct co-culture assay that involved a culture of decellularised tracheal epithelium explants and AECs in a rotating tube, and indirect co-culture assay that utilized microporous membrane-well chamber system to separate the partially decellularised tracheal epithelium explants and AEC culture. The co-culture assays provided evidence of the stimulatory behaviour of AECs to enhance tracheal epithelial cell proliferation and migration during early wound repair. Factors that were secreted by AECs also markedly suppressed the production of IL-1β and IL-6 and initiated the EMT process during tracheal remodelling.
Tracheal tears are not as uncommon as initially thought. The resultant insufficiency and hypoxia can be life-threatening. The keystone in management is early recognition and diagnosis. Immediate surgical repair is essential.
Aerosol-based cell therapy has emerged as a novel and promising therapeutic strategy for treating lung diseases. The goal of this study was to determine the safety and efficacy of aerosol-based airway epithelial cell (AEC) delivery in the setting of acute lung injury induced by tracheal brushing in rabbit. Twenty-four hours following injury, exogenous rabbit AECs were labelled with bromodeoxyuridine and aerosolized using the MicroSprayer® Aerosolizer into the injured airway. Histopathological assessments of the injury in the trachea and lungs were quantitatively scored (1 and 5 days after cell delivery). The aerosol-based AEC delivery appeared to be a safe procedure, as cellular rejection and complications in the liver and spleen were not detected. Airway injury initiated by tracheal brushing resulted in disruption of the tracheal epithelium as well as morphological damage in the lungs that is consistent with acute lung injury. Lung injury scores were reduced following 5 days after AEC delivery (AEC-treated, 0.25 ± 0.06 vs. untreated, 0.53 ± 0.05, P trachea, AEC delivery led to an upsurge in epithelium regeneration and repair. Re-epithelialization was significantly increased 5 days after treatment (AEC-treated, 91.07 ± 2.37% vs. untreated, 62.99 ± 7.39%, P
To illustrate a case of an iatrogenic mucosal tear in the trachea which caused a one-way valve effect, obstructing the airway and manifesting as post-extubation stridor.
Tracheal tear after endotracheal intubation is extremely rare. The role of silicone Y-stent in the management of tracheal injury has been documented in the previous studies. However, none of the studies have mentioned the deployment of silicone Y-stent via rigid bronchoscope with the patient solely supported by extracorporeal membrane oxygenation (ECMO) without general anaesthesia delivered via the side port of the rigid bronchoscope. We report a patient who had a tracheal tear due to endotracheal tube migration following a routine video-assisted thoracoscopic surgery sympathectomy, which was successfully managed with silicone Y-stent insertion. Procedure was done while she was undergoing ECMO; hence, no ventilator connection to the side port of the rigid scope was required. This was our first experience in performing Y-stent insertion fully under ECMO, and the patient had a successful recovery.