Tracheal and bronchial injuries: causes, symptoms, diagnosis, treatment

The trachea may be damaged, deviated or compressed in the cervical and thoracic regions. Damaging factors may include firearms (bullets, shrapnel, etc.), stabbing and cutting weapons, blows with blunt objects, compression, bruises from falls from a height, etc. Tracheal and bronchial injuries may be open or closed, direct or indirect. Foreign bodies also belong to traumatic injuries of the trachea and bronchi.

Wounds of the cervical trachea. This section of the trachea is limited from above by the cricoid cartilage of the larynx, from below by the jugular notch, and from the front it is well protected by fatty tissue, the isthmus and body of the thyroid gland, and the anterior cervical muscles.

Open wounds of the cervical trachea are divided, just like wounds of the larynx, into gunshot wounds, stab wounds, and ruptures due to blows from hard objects penetrating deep into the neck.

Gunshot wounds are the most severe, as they are not limited to damage to the trachea, but cause significant damage to surrounding tissues and organs, which is caused by both the direct impact of the wounding projectile and the hydrodynamic shock wave. Frontal penetrating wounds, especially bullet wounds, usually damage the upper section of the esophagus, and can penetrate into the bodies of the VI, VII cervical and I thoracic vertebrae, and into the spinal canal. Diagonal and lateral gunshot wounds damage the vascular-nerve bundle with fatal bleeding when the common carotid artery is injured.

The most severe are shrapnel gunshot wounds to the trachea, which are often associated with wounds to the larynx, thyroid gland, large vessels and nerves. Such wounds on the battlefield, as a rule, end in the death of the victim. Only in rare cases, in the absence of wounds to large arteries and veins, emergency provision of breathing and urgent evacuation of the victim to the surgical department of a field military hospital, the life of the wounded can be saved.

Puncture wounds occur due to careless handling of piercing objects, most often when falling on them (knitting needle, scissors), during fencing competitions (epee, rapier) or during hand-to-hand combat or bayonet exercises. A puncture wound of the trachea can be extremely small but deep, causing subcutaneous emphysema and hematoma. If the wound is caused by a piercing and cutting weapon and is large enough, then bloody air bubbles are released through it during exhalation and coughing. When coughing, bloody foamy bubbling sputum is released into the oral cavity, the voice is weakened, and respiratory movements are superficial. Many of these wounds, if the thyroid gland and large vessels are not damaged, heal spontaneously with prophylactic use of antibiotics and prescription of antitussives. In other cases, bleeding with blood entering the trachea, mediastinal emphysema compressing the trachea, and, as a consequence, rapidly increasing obstructive asphyxia occur. In these cases, urgent surgical intervention with wound revision is indicated, ensuring breathing, stopping bleeding and draining the wound cavity. In emergency cases, the tracheal wound is used to insert a tracheotomy cannula into it, subsequently the patient is transferred to breathing through a regular tracheostomy, and the tracheal wound is sutured.

In the vast majority of cases, cut wounds are inflicted with a knife or razor. In transverse wounds, as a rule, the uppermost sections of the trachea are damaged, and the same phenomena occur, but only in a more pronounced form, as in stab wounds. In cut wounds, one or both recurrent nerves can be damaged, which leads to a corresponding paralysis of the posterior cricoarytenoid muscles. Large vessels are usually not damaged, but bleeding from smaller vessels can be quite profuse, which leads to significant blood loss. Usually, such victims need to be provided with qualified medical care at the scene of the incident, which should consist of breathing rehabilitation, temporary stopping of bleeding, and only after that - evacuation to a specialized surgical department (operating room). With such a wound, when the sternocleidomastoid and other muscles are crossed, the wound appears extensive, the victim's head is thrown back, independent flexion of the cervical spine is impossible. With each exhalation, bloody foam splashes out of the wound, with inhalation, blood and foamy sputum are sucked into the trachea. The victim is motionless, silent, horror is imprinted in the eyes. In such conditions, the victim should be laid on his side, the edges of the wound should be spread apart and an attempt should be made to insert a cannula or an endotracheal tube into the trachea, the bleeding arteries should be clamped and ligated, the wound should be tamped with "sinusitis" tampons and a bandage should be applied. If there are no signs of traumatic shock, then it is necessary to limit the administration of sedatives, diphenhydramine and atropine and in this form and condition, the patient should be evacuated to the nearest specialized surgical department.

Closed injuries of the cervical trachea occur most often as a result of a strong blow with a blunt object applied to the anterior surface of the neck, when hanging by the "stool jump method" or by throwing a lasso loop around the neck followed by a strong jerk. In these cases, a rupture, fracture or compression of the trachea may occur. Very rarely, a rupture of the trachea can occur spontaneously with a strong cough push that sharply increases the pressure in the subglottic space or a sudden sharp extension in the cervical spine with tension of the trachea.

Tracheal contusion is most often masked by manifestations of a contusion of the soft tissues of the anterior surface of the neck, unless it is manifested by the release of bloody sputum. Usually, with immobilization of the neck and physical rest, recovery occurs quickly. But often such an injury is combined with a contusion of the larynx, as evidenced by a sharp pain syndrome, aphonia, laryngeal edema, stridor breathing. Such a combination poses a risk of acute asphyxia, especially if there are fractures of the laryngeal cartilages.

Tracheal fractures may occur as a result of a bruise or a sudden strong inhalation, sharply increasing the intratracheal air pressure. In the first case, longitudinal fractures of several cartilages occur along the midline of their arches; in the second case, the inter-annular ligament ruptures. Hematoma and emphysema of the mediastinum develop rapidly, and asphyxia often occurs. Emergency care in such cases consists of tracheal intubation or lower tracheotomy.

Internal damage to the trachea should also include wedged foreign bodies, which with their sharp edges can injure the mucous membrane and cause secondary inflammation by infecting the wound. Usually, after removal of such a foreign body, healing occurs quickly.

Damage to the thoracic trachea and bronchi occurs as a result of severe contusion or crushing of the chest (falling from a height onto a protruding hard object, being run over by a wheel, being hit by a steering wheel during a head-on collision of cars, etc.). Often, damage to the thoracic trachea is accompanied by corresponding damage to the main bronchi, from crushing and fractures to their complete rupture. As a rule, the lung tissue is also subject to traumatic impact with ruptures of the parenchyma, small bronchi and alveoli. In this case, hemato- and pneumothorax, atelectasis of the corresponding part of the lung occurs.

With such injuries, the patient is in a state of shock from the very beginning with a pronounced reflex disorder of respiratory and cardiac activity. With concomitant contusion or compression of the heart, especially with a rupture of the pericardium, cardiac arrest occurs with immediate death. A rupture of the aorta also leads to the same outcome.

The outcome of damage to the thoracic trachea and bronchi depends on the severity of the injury, which is often incompatible with life, and the timeliness of providing life-saving care (anti-shock therapy, cardiac stimulation, oxygen and hemostatic therapy), a complete rupture of the trachea leads to death at the scene of the incident, in case of compression and fracture of the tracheal rings, emergency thoracotomy is performed if restoring breathing by non-surgical means is ineffective. Treatment of such victims is within the competence of a resuscitator and a thoracic surgeon.