04 Dec

Fiberoptic Bronchoscopy in the Evaluation of Acute Chest and Upper Airway Trauma: Results

Pneumothorax was the most common finding, occurring in 37 patients. Subcutaneous emphysema was present in 31 patients, pulmonary contusion in 22, hemothorax in 21, mediastinal emphysema in 16, flail chest in ten, atelectasis and collapse in ten, and hemoptysis in five (Table 1). Flexible fiberoptic bronchoscopy was of diagnostic value in 28 patients (53 percent) (Table 2). Traumatic lesions of the trachea or major bronchi were found in eight patients; three had involvement of the trachea, four had involvement of the major bronchi, and one had involvement of both. One patient who was involved in a motor vehicle accident was found to have a complete tracheal transection. This was surgically repaired, but the patient later died following the development of a tracheoinnominate artery fistula and tracheal dehiscence. Here

One patient injured in a motor vehicle accident had macerated mucosa below the vocal cords, which was interpreted as representing a tear in the mucosa or possibly a fracture of the thyroid cartilage. This was later found at surgery to represent a complete cricotracheal separation. The injury was repaired, and the patient survived. A patient who was crushed between the chassis and box of a truck had a laceration in the posterior wall of the trachea, along with a complete transection of the right main-stem bronchus and distortion and narrowing of the left main-stem bronchus. One patient injured in a motor vehicle accident had a small tear in the distal membranous trachea, and another had a tear between the right middle and lower lobar bronchi, through which the pediatric bronchoscope could be passed and mediastinal structures could be seen. A right middle and lower lobectomy was performed because of severe right middle lobar contusion. One patient who sustained a crushing injury had a vertical laceration of the right main-stem bronchus. One patient involved in a motor vehicle accident had a small area of mucosal trauma in the lingular bronchus, and another had a contusion of the right main-stem bronchus, along with aspirated food. Several pulmonary parenchymal tears were found at surgery. The patient died, and no additional traumatic pulmonary lesions were found at autopsy.
Distal hemorrhage interpreted as representing pulmonary contusion was found in seven patients. Bronchoscopy was useful in the management of two of these patients by facilitating the subsequent placement of a double-lumen endotracheal tube. In addition, one patient also had the placement of a Fogarty balloon catheter for tamponade. Surgery was later performed in some of these patients, at which time pulmonary contusion was always confirmed. Flexible fiberoptic bronchoscopy revealed aspirated material in a total of three patients. Eight patients had mucous plugging and thick secretions.
Three patients had supraglottic lesions detected by FFB. The hanging patient had an avulsive supraglottic tear causing glottic obstruction. The patient from the airplane crash had distortion and narrowing of the supraglottic space. A bullet entry site 1 cm above the cords was identified in the patient with the gunshot wound, although the exit site was not seen.
Table 1—Physical and Radiographic Findings in 53 Patients with Acute Trauma to the Chest and Upper Airway Who Underwent FFB

Finding Total Bronchoscopy of Value Bronchoscopy Not of Value
Pneumothorax 37 (70) 16(57) 21(84)
Subcutaneous emphysema 31(58) 15(54) 16(64)
Pulmonary contusion 22(42) 11 (39) 11(44)
Hemothorax 21(40) 10(36) 11(44)
Mediastinal emphysema 16(30) 11 (39) 5(20)
Flail chest 10 (19) 2(7) 8(32)
Atelectasis 10 (19) 7(25) 3(12)
Hemoptysis 5(9) 3(11) 2(8)
Total patients 53(100) 28(100) 25(100)

Table 2—Bronchoscopic Findings in 53 Patients with Acute Trauma to the Chest and Upper Airway

Finding Patients(percent)
Tracheal transection 1(2)
Tracheal laceration 3(6)
Bronchial transection 1(2)
Bronchial laceration 2(4)
Bronchial contusion 2(4)
Distal hemorrhage/pulmonary contusion 7(13)
Aspirated material 3(6)
Mucous plugging/thick secretions 8(15)
Supraglottic tear with glottic obstruction 1(2)
Distortion and narrowing of supraglottic space 1(2)
Bullet entry site 1(2)

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