Kiser and colleagues performed a meta-analysis of the literature from 1873 to 1996, looking specifically at blunt intra-thoracic tracheobronchial injuries. They identified 256 injuries, of which 59 % were the result of motor-vehicle collisions and 27 % were the result of crush injury. The median time to diagnosis was 9-days with 47 % of cases involving the right bronchus and 32 % involving the left bronchus (52 % of patients with right bronchial injuries and 14 % with left sided bronchial injuries were diagnosed within 24-h) [9].

Investigators at the Ratchaburi Hospital in Thailand reported on 11 tracheobronchial injuries in 10 years (7 penetrating and 4 blunt). Pneumothorax was present in two patients, subcutaneous emphysema was present in three patients, and dyspnea was in four. The authors concluded that a delay in diagnosis was the leading factor resulting in increased morbidity [10]. Similarly, Cassada et al., found that a delay in diagnosis was the single most important factor leading to poor outcome [11].

As diagnostic modalities have advanced, the identification of injury to the esophagus has become easier to accomplish in an expeditious and noninvasive manner. A 1977 report from the Journal of Trauma describes the case of a young man status-post motorcycle collision with multiple injuries, which on the fourth day of his hospitalization manifested with mediastinitis and empyema. Surgical exploration revealed the presence of an esophageal perforation, which was successfully treated with drainage [12]. In the current era of enhanced imaging techniques and the wide availability of invasive procedures for diagnosis, clinicians are able to more quickly recognize and intervene with such lesions.

The management of esophageal injury has remained largely unchanged for the past five decades. Some have sought to define the role of endoscopic stenting in esophageal perforation, finding a greater risk of death with stenting than with surgery [13]. This led the authors to conclude that operative therapy is preferred. Thus, the primary goals of treatment remain: primary repair, wide drainage, and possible diversion if anatomic repair is impossible or physiology is exceedingly altered [14].

Clinical examination can lead the astute physician to suspect injury based on physical findings. Stridor, subcutaneous emphysema, pneumothorax with air leak, and bubbling from epidermal lacerations should increase suspicion of major airway injury.

An adequate airway is essential. A 1999 series from The University of Tennessee Medical Center at Knoxville showed 55 % of patients with tracheobronchial injury were stable on supplemental oxygen alone and did not require urgent intubation [11]. Great caution must be exercised as partial or complete transection of proximal airways can make the procedure difficult or impossible, leading to adverse outcomes. Liberal usage of laryngoscopy and fiberoptic bronchoscopy in this situation will ensure good visualization and assist with placement of a secure airway.

If transection of the trachea occurs in the neck, one may see two visible lumens. In this instance, intubation of the distal lumen with any available endotracheal tube or devise is wise (Fig. 8.2). A surgical airway remains an option in the unstable patient or in patient’s unable to be successfully intubated. After ensuring temporary airway, definitive airway management can be established when the patient is stable.

Bronchoscopy and direct visualization of a mucosal defect remain the optimal study for diagnosis of tracheobronchial injury (Fig. 8.3). If bronchoscopy is performed under general endotracheal anesthesia, the clinician must withdraw the endotracheal tube over the bronchoscope to visualize the entirety of the proximal trachea. Bronchoscopy can be performed in either a trauma resuscitation area or an operating room; however, the operating room gives the surgeon the option of additional adjunctive measures as deemed necessary, including operative therapy. Distance from the incisors should be recorded, along with proximity to the carina.

In the patient with major airway injury that requires mechanical ventilation, decreased pressures will lessen the air leak and assist in oxygenation and ventilation. Airway pressure release ventilation (APRV) is a mode of ventilation frequently employed, which allows the patient to comfortably breathe and avoid dis-synchrony with the ventilator. Maintaining the lowest possible pressures to maintain oxygenation is wise.

CT imaging can be utilized as an adjunct to evaluate for tracheal injury [15] (Fig. 8.4). CT imaging of the neck offers the advantage of evaluating the vasculature and esophagus, in addition to the central airways. In a retrospective review, Chen et al. found CT to be 85 % sensitive in identification of tracheal injury, and the authors concluded that CT can aid in selecting patients that require bronchoscopy for definitive diagnosis [16]. In penetrating injury, the added advantage of assessing trajectory and determining structures at risk of injury makes axial imaging attractive [17]. In the rare case of suspected tracheal transection after blunt injury, axial imaging in a stable patient with CT may be an adjunct to direct visualization with bronchoscopy [18].

Nonoperative approaches to tracheobronchial injury have been described [19, 20], but operative therapy remains the preferred method of definitive treatment. Initial operative management of tracheobronchial injuries begins with appropriate setup of the operating room and operating equipment. A sternal saw, vascular instruments, and a variety of endotracheal and tracheostomy tubes should be available. Fiberoptic bronchoscopy and appropriately trained anesthesia providers are mandatory. The surgeon should be prepared to perform intra-operative bronchoscopy to assist in identification of the injury. A double-lumen endotracheal tube may be required if single-lung ventilation is desired for a thoracic approach to a bronchial injury.

Cervical injuries involving the trachea are most easily approached via a collar incision performed in approximately 2-fingerbreadths above the sternal notch. This incision is carried down through the platysma and sub-platysmal flaps are created. The strap muscles are divided in the midline. The thyroid isthmus can then be retracted cephalad to further increase exposure of the trachea as it enters the mediastinum. Alternatively, the thyroid isthmus can be divided. If the injury extends into the mediastinum, a partial sternal split can be performed without performing a full sternotomy (Fig. 8.5). In the face of a concomitant vascular or esophageal injury, the collar incision can be extended superiorly or inferiorly in the plane anterior to the sternocleidomastoid muscle.

The thoracic trachea, right mainstem bronchus, and proximal left mainstem bronchus are best approached via a right posterolateral thoracotomy performed through the fourth intercostal space (Fig. 8.6). Distal left mainstem bronchus injuries are best approached via a left posterolateral thoracotomy. Though lateral decubitus positioning provides optimal exposure of the intra-thoracic tracheobronchial structures, the surgeon must recognize that access to other body cavities is exceedingly limited.

Primary repair of tracheal injury is desirable if possible. A single layer of absorbable, monofilament suture is utilized to primarily repair the injury. Running or interrupted sutures can be utilized. Smaller diameter structures are best repaired in an interrupted fashion to avoid narrowing of the airway. Stellate areas should be sharply debrided back to healthy appearing tracheal tissues. Given the mobile nature of the trachea, resection of up to 2–4 cm of trachea with primary anastomosis is feasible (Fig. 8.7) with mobilization. Multiple techniques have been described for tracheal mobilization, including: division of the inferior pulmonary ligament, cervical flexion, and mobilization of the hilum of the lung. If tension is present on the anastomosis after mobilization, the chin can be sutured to the patient’s chest. Mobilization of the trachea should proceed in the anterior and posterior planes as the blood supply comes in laterally. Suture lines are preferably buttressed with autologous and well-vascularized tissue present in the region of repair (intercostal muscle, pleura, pericardial, strap muscle (Fig. 8.8), or omental flaps). Occasionally, the tracheal injury is located only in the posterior membranous portion. Some can be managed nonoperatively. If repair is necessary, they are best approached by opening the trachea anteriorly. The injured trachea is then repaired from the inside. It is necessary to precisely define the level of injury before opening the trachea. This is best done with intraoperative bronchoscopy. The light from the bronchoscope can be seen via the anterior trachea, making the repair as simple as possible. The endotracheal tube must be withdrawn to allow for adequate visualization of the injury. The maneuver may need to be repeated to be sure adequate oxygenation and ventilation is maintained. The anterior trachea is then closed as described above.