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Injury to the Middle Lobe Bronchus and Pulmonary Artery: An Unusual Pattern
Injury to the Middle Lobe Bronchus and Pulmonary Artery: An Unusual Pattern A. Zapolanski, M.D., R. Ilves, M.D., F.R.C.S.(C), andT. R. J. Todd, M.D., F.R.C.S.(C) ABSTRACT An unusual bronchovascular injury at the level of the middle lobe bronchus is reported. Three patients with middle lobe bronchial avulsion associated with rupture of the pulmonary artery are discussed. Treatment emphasizes prophylactic control of the proximal pulmonary artery.
Injuries to the trachea and major bronchi are usually the result of blunt trauma. Classic experience [l-31 and a collective review of the literature [4] suggest that major, trauma-induced bronchial injury associated with pulmonary arterial damage is uncommon. Recently, however, we encountered three patients who suffered injury to the middle lobe bronchus and bronchus intermedius, with concomitant injury to the adjacent pulmonary artery. The nature of the injury in and management of these patients are the subjects of this article. Case Reports Patient 1 A 22-year-old man was involved in a motor vehicle accident that resulted in bilateral pneumothoraces. After insertion of bilateral intercostal drains, ventilation became difficult due to the escape of large amounts of the delivered ventilatory volume from the right intercostal tube. Bronchoscopy verified the clinical suspicion of a bronchial tear, which was seen to be located at the origin of the right middle lobe bronchus. The patient was immediately taken to the operating room after insertion of a Robertshaw double-lumen endotracheal tube, and a right posterolateral thoracotomy was performed.
From the Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, Ont, Canada. Accepted for publication Jan 27, 1982. Address reprint requests to Dr. Todd, Eaton Wing North 10-228, Toronto General Hospital, Toronto, Ont, Canada M5G 1L7.
Operation showed that the lower lobe had enormous horizontal and vertical lacerations throughout its substance; three of the tears were large enough that a hand could be inserted down to the depths of the hilum. The fissure was noted to be complete, and the bronchial tear could be seen at its base. Although there was subpleural blood staining, no hematoma was present in the fissure. When the fissure was dissected, however, immediate hemorrhage resulted. The hemorrhage was controlled by application of pressure while proximal tourniquet control of the pulmonary artery was achieved. Once the pulmonary artery had been secured, it became evident that there was a large tear in the artery in the fissure extending back to the recurrent branch of the upper lobe. The bronchial injury in this patient involved complete avulsion of the middle lobe from the bronchus intermedius, with the tear extending into the bronchus intermedius almost to the upper lobe orifice (Figure). We elected to perform a middle and lower lobectomy, which was easily accomplished. The patient did well postoperatively, and bronchoscopy at the time of discharge from the hospital was unremarkable. Patient 2 A 27-year-old pedestrian was involved in a motor vehicle accident. After tube thoracostomy was performed, his chest drain was seen to bubble excessively, and his right lung was noted to be atelectatic. Bronchoscopy in the operating room revealed a large transverse tear at the root of the right middle lobe. A doublelumen left Robertshaw tube was inserted, and a right thoracotomy was performed by a surgeon unfamiliar with Patient 1. The fissures were seen to be complete. By separating the middle and lower lobes, a major laceration could be observed between the bronchi. The pulmonary artery was noted to have subadventitial discoloration, but no hematoma
156 0003-4975/83/020156-03$01.50 0 1982 by The Society of Thoracic Surgeons
157 Zapolanski et al: Injury to Middle Lobe Bronchus and PA
Injuries encountered in the three patients described in the text. Linear lacerations in the pulmonary artery were encountered in all three patients. These lacerations extended from the superior segmental artery to the lower lobe up to and beyond the recurrent branch to the right upper lobe.
was present. Retraction of the pulmonary artery to facilitate suturing of the bronchus was followed by substantial hemorrhage, which was controlled with packing prior to placement of a tourniquet around the right main pulmonary artery. Reassessment of the injury indicated an arterial tear similar to the one found in the first patient. The tear was sutured with 6-0 Prolene sutures and subsequently the bronchial tear was repaired with interrupted 4-0 Vicryl sutures. The patient’s postoperative course was unremarkable, and bronchoscopy prior to discharge verified a well-healed repair with no stenosis. Patient 3
A 24-year-old woman was involved in a motor vehicle accident that resulted in a right tension pneumothorax. An intercostal drain and endotracheal tube were inserted in the patient, who had been taken to an outlying hospital prior to transfer. Despite the tube thoracostomy, a 50% pneumothorax was noted clinically and radiologically upon admission to Toronto General Hospital. A significant portion of the patient’s tidal volume was lost through the inter-
costal drain. Bronchoscopy revealed a large tear at the origin of the middle lobe bronchus. A double-lumen Robertshaw endotracheal tube was inserted, and the patient was taken to the operating room. A right posterolateral thoracotomy was performed. The major and minor fissures were complete, and a bronchial tear could be visualized in the depths without frank hematoma. Even though no arterial injury was initially identified, our previous experience led us to place a tourniquet around the right main pulmonary artery. Subsequent dissection of the fissure did reveal a tear in the pulmonary artery, extending from the superior segmental artery of the lower lobe to the recurrent artery of the upper lobe. Primary repair using 5-0 Prolene sutures was accomplished. The middle lobe bronchus had been avulsed from the bronchus intermedius with two longitudinal tears extending superiorly from either side of the middle lobe orifice to the upper lobe bronchus. This created a large flap of bronchial wall based on the middle lobe bronchus. The middle lobe was excised, and the bronchial flap sutured with 3-0 Vicryl. As the bronchial and arterial suture lines were apposed for much of their respective lengths, the pericardium was opened and a pericardial flap created to cover the bronchial suture line. There were no postoperative complications, and bronchoscopy at discharge revealed a well-healed suture line.
Comment One of the earliest reports on injuries to the tracheobronchial tree was published by Seuvre [5] in 1873. However, appropriate management and repair were not achieved until 1949, by Griffith [6]. Injuries to the major branches of the respiratory tree vary from minor lacerations to major tears and complete disruption. Associated ruptures of the lung parenchyma, pulmonary vessels, and esophagus are considered rare [4]. In closed trauma to the chest, the vessels tend to be spared from injury because of their compliance and low intraluminal pressure [71. Deceleration probably contributes little to injuries of the pulmonary vessels [3]. Injuries to the tracheobronchial tree may be
158 The Annals of Thoracic Surgery Vol 35 No 2 February 1983
diagnosed by various signs and symptoms. A pneumothorax that fails to evacuate upon adequate tube thoracostomy, associated with a large air leak, is common. Aspirated blood or bronchial cartilage, or the entrapment of mediastinal soft tissue within the bronchial defect, may lead to atelectasis and failure to expand the lung, even in the absence of a bronchopleural fistula. The purpose of this report is to draw attention to an unusual pattern of associated bronchovascular injury and to the need for specific management, namely, prophylactic control of the right main pulmonary artery prior to attempting bronchial repair. It is assumed that the intimate relationship of the middle lobe bronchus, bronchus intermedius, and pulmonary artery presents an anatomical arrangement favoring the occurrence of a combined injury. Proximal vascular control is the key to the successful management of such injuries. In the past, it was not our practice to routinely gain control of the pulmonary artery during repair of bronchial injuries. We also wish to emphasize that at the time of thoracotomy in these three patients, there was no evidence of arterial disruption until the fissure was dissected; moreover, the fissures were completely developed in all three patients. As a
result of our experience, we now recommend proximal control of the pulmonary artery prior to dissection of the fissure in patients undergoing surgery for major bronchial disruptions at this level. Use of this practice will prevent the difficulties encountered in our first two patients and allow for a smoother operative procedure, as in Patient 3. The type of resection or repair performed will then depend on the nature of the bronchovascular injury and on the extent of any associated parenchymal damage.
References 1. Cohn R: Non-penetrating wounds of the lungs and bronchi. Surg Clin North Am 52:585,1972 2. Collins J,Katharanadhan B, McConchie I: Rupture of major bronchi resulting from closed chest injuries. Thorax 28:371, 1973 3. Neugebauer M,Fine J, Hoyt T: Traumatic rupture of the trachea and right mainstem bronchus. J Trauma 14:265,1974 4. Urschel H, Razzuk M: Management of acute traumatic injuries of tracheo-bronchial tree. Surg Gynecol Obstet 136:113,1973 5. Seuvre M: Ccrasement par une roue d’omnibus: rupture de la bronche droite. Bull SOC Anat (Paris) 48:680, 1873 6. Griffith JL: Fracture of the bronchus. Thorax
4:105,1949 7. Carter R, Wareham E, Brewer LA: Rupture of the bronchus following closed chest trauma. Am J Surg 104:177,1962
Injuries to the trachea and major bronchi are usually the result of blunt trauma. Classic experience [l-31 and a collective review of the literature [4] suggest that major, trauma-induced bronchial injury associated with pulmonary arterial damage is uncommon. Recently, however, we encountered three patients who suffered injury to the middle lobe bronchus and bronchus intermedius, with concomitant injury to the adjacent pulmonary artery. The nature of the injury in and management of these patients are the subjects of this article. Case Reports Patient 1 A 22-year-old man was involved in a motor vehicle accident that resulted in bilateral pneumothoraces. After insertion of bilateral intercostal drains, ventilation became difficult due to the escape of large amounts of the delivered ventilatory volume from the right intercostal tube. Bronchoscopy verified the clinical suspicion of a bronchial tear, which was seen to be located at the origin of the right middle lobe bronchus. The patient was immediately taken to the operating room after insertion of a Robertshaw double-lumen endotracheal tube, and a right posterolateral thoracotomy was performed.
From the Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, Ont, Canada. Accepted for publication Jan 27, 1982. Address reprint requests to Dr. Todd, Eaton Wing North 10-228, Toronto General Hospital, Toronto, Ont, Canada M5G 1L7.
Operation showed that the lower lobe had enormous horizontal and vertical lacerations throughout its substance; three of the tears were large enough that a hand could be inserted down to the depths of the hilum. The fissure was noted to be complete, and the bronchial tear could be seen at its base. Although there was subpleural blood staining, no hematoma was present in the fissure. When the fissure was dissected, however, immediate hemorrhage resulted. The hemorrhage was controlled by application of pressure while proximal tourniquet control of the pulmonary artery was achieved. Once the pulmonary artery had been secured, it became evident that there was a large tear in the artery in the fissure extending back to the recurrent branch of the upper lobe. The bronchial injury in this patient involved complete avulsion of the middle lobe from the bronchus intermedius, with the tear extending into the bronchus intermedius almost to the upper lobe orifice (Figure). We elected to perform a middle and lower lobectomy, which was easily accomplished. The patient did well postoperatively, and bronchoscopy at the time of discharge from the hospital was unremarkable. Patient 2 A 27-year-old pedestrian was involved in a motor vehicle accident. After tube thoracostomy was performed, his chest drain was seen to bubble excessively, and his right lung was noted to be atelectatic. Bronchoscopy in the operating room revealed a large transverse tear at the root of the right middle lobe. A doublelumen left Robertshaw tube was inserted, and a right thoracotomy was performed by a surgeon unfamiliar with Patient 1. The fissures were seen to be complete. By separating the middle and lower lobes, a major laceration could be observed between the bronchi. The pulmonary artery was noted to have subadventitial discoloration, but no hematoma
156 0003-4975/83/020156-03$01.50 0 1982 by The Society of Thoracic Surgeons
157 Zapolanski et al: Injury to Middle Lobe Bronchus and PA
Injuries encountered in the three patients described in the text. Linear lacerations in the pulmonary artery were encountered in all three patients. These lacerations extended from the superior segmental artery to the lower lobe up to and beyond the recurrent branch to the right upper lobe.
was present. Retraction of the pulmonary artery to facilitate suturing of the bronchus was followed by substantial hemorrhage, which was controlled with packing prior to placement of a tourniquet around the right main pulmonary artery. Reassessment of the injury indicated an arterial tear similar to the one found in the first patient. The tear was sutured with 6-0 Prolene sutures and subsequently the bronchial tear was repaired with interrupted 4-0 Vicryl sutures. The patient’s postoperative course was unremarkable, and bronchoscopy prior to discharge verified a well-healed repair with no stenosis. Patient 3
A 24-year-old woman was involved in a motor vehicle accident that resulted in a right tension pneumothorax. An intercostal drain and endotracheal tube were inserted in the patient, who had been taken to an outlying hospital prior to transfer. Despite the tube thoracostomy, a 50% pneumothorax was noted clinically and radiologically upon admission to Toronto General Hospital. A significant portion of the patient’s tidal volume was lost through the inter-
costal drain. Bronchoscopy revealed a large tear at the origin of the middle lobe bronchus. A double-lumen Robertshaw endotracheal tube was inserted, and the patient was taken to the operating room. A right posterolateral thoracotomy was performed. The major and minor fissures were complete, and a bronchial tear could be visualized in the depths without frank hematoma. Even though no arterial injury was initially identified, our previous experience led us to place a tourniquet around the right main pulmonary artery. Subsequent dissection of the fissure did reveal a tear in the pulmonary artery, extending from the superior segmental artery of the lower lobe to the recurrent artery of the upper lobe. Primary repair using 5-0 Prolene sutures was accomplished. The middle lobe bronchus had been avulsed from the bronchus intermedius with two longitudinal tears extending superiorly from either side of the middle lobe orifice to the upper lobe bronchus. This created a large flap of bronchial wall based on the middle lobe bronchus. The middle lobe was excised, and the bronchial flap sutured with 3-0 Vicryl. As the bronchial and arterial suture lines were apposed for much of their respective lengths, the pericardium was opened and a pericardial flap created to cover the bronchial suture line. There were no postoperative complications, and bronchoscopy at discharge revealed a well-healed suture line.
Comment One of the earliest reports on injuries to the tracheobronchial tree was published by Seuvre [5] in 1873. However, appropriate management and repair were not achieved until 1949, by Griffith [6]. Injuries to the major branches of the respiratory tree vary from minor lacerations to major tears and complete disruption. Associated ruptures of the lung parenchyma, pulmonary vessels, and esophagus are considered rare [4]. In closed trauma to the chest, the vessels tend to be spared from injury because of their compliance and low intraluminal pressure [71. Deceleration probably contributes little to injuries of the pulmonary vessels [3]. Injuries to the tracheobronchial tree may be
158 The Annals of Thoracic Surgery Vol 35 No 2 February 1983
diagnosed by various signs and symptoms. A pneumothorax that fails to evacuate upon adequate tube thoracostomy, associated with a large air leak, is common. Aspirated blood or bronchial cartilage, or the entrapment of mediastinal soft tissue within the bronchial defect, may lead to atelectasis and failure to expand the lung, even in the absence of a bronchopleural fistula. The purpose of this report is to draw attention to an unusual pattern of associated bronchovascular injury and to the need for specific management, namely, prophylactic control of the right main pulmonary artery prior to attempting bronchial repair. It is assumed that the intimate relationship of the middle lobe bronchus, bronchus intermedius, and pulmonary artery presents an anatomical arrangement favoring the occurrence of a combined injury. Proximal vascular control is the key to the successful management of such injuries. In the past, it was not our practice to routinely gain control of the pulmonary artery during repair of bronchial injuries. We also wish to emphasize that at the time of thoracotomy in these three patients, there was no evidence of arterial disruption until the fissure was dissected; moreover, the fissures were completely developed in all three patients. As a
result of our experience, we now recommend proximal control of the pulmonary artery prior to dissection of the fissure in patients undergoing surgery for major bronchial disruptions at this level. Use of this practice will prevent the difficulties encountered in our first two patients and allow for a smoother operative procedure, as in Patient 3. The type of resection or repair performed will then depend on the nature of the bronchovascular injury and on the extent of any associated parenchymal damage.
References 1. Cohn R: Non-penetrating wounds of the lungs and bronchi. Surg Clin North Am 52:585,1972 2. Collins J,Katharanadhan B, McConchie I: Rupture of major bronchi resulting from closed chest injuries. Thorax 28:371, 1973 3. Neugebauer M,Fine J, Hoyt T: Traumatic rupture of the trachea and right mainstem bronchus. J Trauma 14:265,1974 4. Urschel H, Razzuk M: Management of acute traumatic injuries of tracheo-bronchial tree. Surg Gynecol Obstet 136:113,1973 5. Seuvre M: Ccrasement par une roue d’omnibus: rupture de la bronche droite. Bull SOC Anat (Paris) 48:680, 1873 6. Griffith JL: Fracture of the bronchus. Thorax
4:105,1949 7. Carter R, Wareham E, Brewer LA: Rupture of the bronchus following closed chest trauma. Am J Surg 104:177,1962