Characteristic Pulmonary Finding in Traumatic Complete Transection of a Main-stem Bronchus

Abstract

The incidence of severe chest injuries and direct trauma to the tracheobronchial tree has risen sharply during the past two decades, owing to the widespread increase in mechanization and high-speed travel (1, 2). Prompt diagnosis and immediate surgical reconstruction of the trachea and bronchi are mandatory to prevent stricture, loss of function, and death. A radiologic pulmonary finding apparently not recorded previously has been observed—the lung appears to fall away from the mediastinum. It is believed to be characteristic, at least in the case reported below, of complete transection of a main-stem bronchus. Case Report A 35-year-old woman was involved in an automobile accident and brought to the Emergency Ward of the Massachusetts General Hospital. She was semiconscious and in respiratory distress. The right half of the chest showed a flailing motion, massive subcutaneous emphysema was spread over the chest and neck, and the abdomen was soft and not distended. A drainage tube was inserted into the right hemithorax, thus releasing a small amount of bloody fluid. Following this, radiographs of the head, neck, and chest (Fig. 1) were obtained in the supine position. These revealed fractures of the mandible, second cervical vertebra, right clavicle, and right first, second, third, and fourth ribs. There was a right pneumothorax with 60 per cent collapse of the lung, as well as mediastinal and subcutaneous emphysema. A tentative diagnosis of traumatic complete transection of the right main-stem bronchus was made, and an operation was performed immediately. The right main-stem bronchus was found to be completely transected 1.5 cm distal to the carina. The major blood vessels were intact, however, and no injury to the diaphragm was found. The bronchus was successfully reconstructed. The patient recovered, and physical examination and radiographs of the chest three and one-half months later (Fig. 2) were normal. Discussion Complete transection of a main-stem bronchus is rare. Of the 130 surgically and pathologically proved cases reported in the literature and reviewed by Burke (1), 86 per cent of all bronchial ruptures involved the main-stem bronchus. Among these, 51 per cent were right-sided, 47 per cent were left-sided, and 2 per cent involved both main-stem bronchi. In addition to pneumothorax, mediastinal emphysema, and subcutaneous emphysema, which may occur with a severe chest injury, an acute injury to the bronchus may include air surrounding the bronchus, sharp angulation or obstruction in the course of an air-filled bronchus, and tension pneumothorax, as reported in the literature (2–4, 9–11). Persistent atelectasis is likely to follow.