Management of Bronchial Rupture After Blunt Chest Trauma in Children
Bronchial rupture due to blunt chest trauma in pediatric patients is a rare yet life-threatening injury, often complicated by delayed diagnosis and post-treatment complications. This study retrospectively analyzed nine pediatric cases to outline diagnostic challenges, surgical interventions, postoperative complications, and long-term outcomes, emphasizing the critical role of early recognition and tailored management strategies.
Clinical Presentation and Mechanisms of Injury
The cohort included six males and three females, with an average age of 5.4 years (range: 2.5–9.7 years). Mechanisms of injury varied, including motor vehicle accidents (44%, 4/9), falls from height (22%, 2/9), crushing injuries (11%, 1/9), and blunt trauma from other causes (22%, 2/9). Initial symptoms predominantly included chest pain (89%, 8/9) and shortness of breath (67%, 6/9). Associated injuries were common, with rib fractures occurring in 78% (7/9) of patients, affecting ribs 1–9 and often involving multiple contiguous ribs. Long bone fractures (33%, 3/9), head trauma (33%, 3/9), and abdominal injuries (11%, 1/9) were also noted.
Diagnostic Challenges and Timing
Delayed diagnosis, defined as an interval exceeding 48 hours from injury, occurred in 67% (6/9) of patients, with a mean diagnostic delay of 15 days (range: 1–34 days). Among transferred patients (78%, 7/9), persistent air leakage, atelectasis, or pneumomediastinum after chest tube insertion prompted further evaluation. Diagnostic tools included chest X-rays, three-dimensional computed tomography (3D-CT), and bronchoscopy. 3D-CT demonstrated complete bronchial occlusion in all cases, while bronchoscopy confirmed complete transection of the main bronchus (left in 56%, 5/9; right in 44%, 4/9) and revealed granulation tissue in those with delayed diagnoses (5/9).
Surgical Management and Techniques
Definitive surgical repair was performed via posterolateral thoracotomy through the fourth or fifth intercostal space. Key technical steps included:
- Airway Management: Single-lumen endotracheal tube placement under bronchoscopic guidance into the non-injured bronchus.
- Debridement and Anastomosis: Devitalized tissue was excised, and mucosa-to-mucosa end-to-end anastomosis was performed. The cartilaginous bronchial wall was reconstructed using interrupted non-absorbable sutures, while the membranous portion utilized running absorbable sutures.
- Tension Reduction: Hilar mobilization and incision of the inferior pulmonary ligament were employed to minimize anastomotic tension, particularly in cases requiring extensive debridement.
- Lobectomy: Two patients underwent lobectomy due to severe parenchymal destruction or distal bronchial involvement.
Postoperative Complications and Management
Complications arose in 67% (6/9) of patients, primarily bronchial stenosis (6/9). Granulation tissue formation correlated strongly with delayed diagnosis, particularly in children under three years old (3/9), necessitating repeated interventions. Balloon dilation and cryotherapy were standard initial treatments, but refractory stenosis required bronchial stent placement in two patients (Patients 6 and 8). Pulmonary function tests in these cases revealed mixed ventilation disturbances, reflecting both large and small airway impairment.
Long-Term Outcomes and Follow-Up
Median follow-up was 24 months (range: 8–34 months). Mild stenosis occurred in six patients, asymptomatic in older children but problematic in younger ones. Patients under three years with delayed diagnoses required prolonged therapy, including stent insertion. Stent-related re-interventions were necessary for removal, and pneumonectomy was avoided to preserve lung function.
Algorithm for Early Diagnosis and Intervention
The authors propose a structured diagnostic pathway for suspected bronchial rupture:
- Initial Assessment: Recognize clinical clues such as persistent air leak, pneumomediastinum, or non-resolving atelectasis post-chest tube insertion.
- Imaging: Immediate 3D-CT to identify bronchial discontinuity or occlusion.
- Bronchoscopy: Confirm the extent of injury and plan surgical access.
- Surgical Timing: Expedite repair once diagnosed to minimize granulation and fibrosis.
Age-Related Prognostic Factors
Younger age (≤3 years) and diagnostic delays synergistically worsened outcomes. Narrow pediatric bronchi compounded technical challenges, increasing anastomotic tension and stenosis risk. Despite similar surgical techniques, younger patients exhibited higher rates of granulation and required aggressive adjunct therapies, highlighting the need for age-specific management protocols.
Technical Refinements and Future Directions
The study underscores the importance of mucosa-to-mucosa anastomosis to reduce granulation. Anterior bronchial wall repair with interrupted non-absorbable sutures minimized tension, particularly in delayed cases. Future strategies may include bioengineered stents or growth-sparing techniques to accommodate pediatric airway development.
Conclusion
Bronchial rupture in children demands heightened suspicion, especially in transferred patients with unresolved chest trauma sequelae. Early 3D-CT and bronchoscopy are pivotal for timely diagnosis, while meticulous surgical repair and postoperative surveillance optimize outcomes. Younger children and diagnostic delays portend higher complication risks, necessitating individualized therapeutic approaches. Stent placement emerges as a salvage option for refractory stenosis, though long-term implications require further study.
doi.org/10.1097/CM9.0000000000000173
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