Primary repair of rupture of a main and lobar bronchus

Abstract

A 16-year-oJ[d boy was transferred from another hospital to our department because of clinical suspicion of a bronchial rupture after blunt chest trauma. He had been in a traffic accident as the driver of a small motorcycle. On admission he was intubated, nonsedated, and anxious. He had hypotension, tachycardia, and massive subcutaneous emphysema over the chest, the Upper part of the abdomen, and in the neck. A small thoracic catheter was in place. A roentgenogram of the chest made in the referring hospital showed a complete pneumothorax on the right side with extensive subcutaneous and mediastinal emphysema. He had a stable pelvic fracture, confirmed by radiography. The patient was sedated. An arterial pressure line, a jugular catheter, and a larger thoracic drain were placed. A major air leak was detected. A flexible bronchoscope, inserted in the emergency department, revealed a large defect of the right main bronchus just distal to the carina. The patient was then taken to the operating room for urgent thoracotomy. After placement of a single-lumen endotracheal tube into the left main bronchus, the patient was positioned on his left side and a right posterolateral thoracotomy above the fifth rib was performed. The right lung had collapsed and the right upper lobe contained a large intrapulmonary hematoma. A complex, double bronchial rupture was present--a complete transection of the right main bronchus and an incomplete rupture of the right lower lobe bronchus. The cartilaginous portion of the main bronchus was transected transversely about i cm distal to the carina. The membranous portion had ruptured transversely more proximally at the level of the carina. The two transection planes were connected by a double longitudinal tear at the junction between the cartilaginous and membranous parts of the right main bronchus (Fig. 1). The right lower lobar bronchus had an incomplete transverse rupture about half the circumference of the bronchus and 0.5 cm distal to the ostium of the bronchus for the right middle lobe. Both ruptures were