Traumatic injuries to the trachea and bronchi: a narrative review

OBJECTIVE: In this narrative review, we aim to provide a definition of traumatic tracheo-bronchial injuries as well as an approach to their diagnosis and management, including operative and non-operative strategies. BACKGROUND: Traumatic tracheo-bronchial injuries are relatively uncommon, but are associated with a high mortality, both at the scene and among patients who survive to hospital. Management often requires an emergency airway, usually intubation over a flexible bronchoscope, followed by definitive repair. METHODS: The published literature on the diagnosis and management of traumatic airway injuries was searched through PubMed. Additional references were identified from the bibliography of relevant publications identified. The evidence was then summarized in a narrative fashion, incorporating the authors’ knowledge, experience, and perspective on the topic. CONCLUSIONS: Definitive diagnosis of traumatic tracheo-bronchial injuries usually involves direct visualization through liberal use of bronchoscopy in addition to cross-sectional imaging to evaluate for associated injuries, notably to the great vessels and esophagus. Important considerations for management include concerns for airway obstruction, uncontrolled air leak, and mediastinitis. Early repair of injuries recognized acutely is favored in attempts to prevent the development of airway stenosis. Key operative principles include exposure, conservative debridement to preserve length when possible, creation of a tension-free anastomosis, preservation of the blood supply, and creation of a tracheostomy, particularly in polytrauma patients. An interposition muscle flap is also required, specifically in the setting of combined esophageal and airway injuries. Patients with penetrating injuries tend to have more favorable outcomes, possibly on account of fewer concomitant injuries. Selective non-operative management is also an option in the subset of patients with iatrogenic injuries to the posterior membranous wall of the trachea, and includes broad-spectrum antibiotics and surveillance bronchoscopy.