- Email: [email protected]
Traumatic rupture of right mainstem bronchus in a child
The Journal of Emergency
Medu?e.
Vol 4. pp 443-447.
Pnntec in the USA
1986
l
Copyright
i 1986 Petgamon Journals
Ltd
Pediatrics TRAUMATIC RUPTURE OF RIGHT MAINSTEM BRONCHUS IN A CHILD Mary J. Hughes, DO, Oliver W. Hayes, DO, Steven R. Guertin, MD, and James E. McGillicuddy,
MD
The Division
of Emergency Medicine, College of Osteopathic Medlclne, Mlchlgan State University and in cooperation with Michigan State University Affiliated Hospitals Emergency Medicine Residency. Reprint address: Mary Hughes, DO, B 318 West Fee Hall, Dlvlslon of Emergency Medictne, College of Osteopathic Medicine, Michigan State University, East Lansing, MI 48824
0 Abstract-We report a case of a ‘I-year-old boy who sustained a ruptured right mainstem bronchus in a motor vehicle accident. The clinical presentation, pathophysiology, and diagnosis of tracheobronchial injuries secondary to nonpenetrating thoracic trauma are discussed. 0 Keywords-chest; trauma; tracheobronchial rupture; tension pneumothorax
Introduction Rupture of the tracheobronchial tree sulting from blunt trauma t? the thorax relatively rare. However, this injury can fatal and the clinical parameters must carefully sought and monitored.”
reis be be
Case Report A 7-year-old boy was brought to the emergency department by a basic emergency medical service ambulance after being struck by a truck. The patient remem-
-~ ____ RECEIVED:
bered walking along the roadside when he was “run over from behind.” The assessment at the scene revealed an alert boy able to speak and complaining of difficulty in breathing. He was in respiratory distress, tachypneic, with perioral cyanosis and bilateral breath sounds that were diminished on the right side. The patient’s vital signs were as follows: blood pressure, 1lo/60 mm Hg; pulse rate, 150 beats per minute; and respirations, 48/min. There were no obvious sites of hemorrhage or deformities. The patient was placed on high-flow oxygen via a rebreather mask, his cervical spine was immobilized using a backboard, tape, and sandbags, and he was transported. On arrival at the emergency department, the initial physical examination revealed an alert boy in obvious respiratory distress, with a patent upper airway. The patient was noted to have perioral cyanosis and a respiratory rate of 48 breaths per minute. Auscultation of his chest revealed bilateral breath sounds that were diminished on the right side. The patient’s pulse rate was 150 beats per minute and blood
Clinical Communications features articles on the assessment and management of both adult and childhood emergencies. Clinical Communications/Pediatrics is coordinated by Roger Barkin, MD, of the University of Colorado. 2 May 1985; ACCEPTED:
16 December 1985 443
0736-4679/86
$3.00
+ .OO
M. J. Hughes,
Figure 1. Preliminary
chest x-ray.
pressure was 114/60 mm Hg. Good distal pulses were present. Initial management of this patient included high-flow oxygen via a rebreather mask. Needle thoracostomy and immediate chest tube insertion was considered, but owing to the patient’s unchanged clinical status and rapid availability of x-ray equipment an initial chest x-ray study was performed. The cervical spine was maintained with sandbags, tape, and a backboard. A cardiac monitor was applied and an intravenous line (IV) of lactated Ringer’s solution was started. Further examination noted that the neck and face were greatly swollen and that subcutaneous emphysema was present in the neck. Petechiae were noted on the right cheek and a right ptosis was present. Breath sounds were judged to be harsh on the left and diminished over the right lung fields. The patient’s cardiac examination revealed normal heart sounds, a regular rate and rhythm, without murmurs or extra sounds, but tachycardic. The abdomen was soft to palpation, with tenderness in both upper quadrants, greater on the right; bowel sounds were absent. There was a large abrasion over the right
0. W. Hayes, S. R. Guertin, J. E. McGillicuddy
Figure 2. Chest x-ray after insertion tubes.
of chest
upper arm and shoulder, and subcutaneous air was present in the right axilla. The preliminary chest film (Figure 1) showed a large right pneumothorax with pneumomediastinum, and a fractured left clavicle. Approximately five minutes after arrival within the emergency department a needle thoracostomy was performed in the right second intercostal space, and a right chest tube was inserted in the midaxillary line. Continuous bubbling of air was noted in the water-sealed bottle. Mental status and vital signs remained unchanged. Repeat chest films revealed good position of the first chest tube, but failure to reexpand the lung. A second chest tube was inserted and partial resolution of the pneumothorax was noted on the third chest x-ray study (Figure 2). Initial central venous pressure was 20 cm water, via a left femoral vein catheter. Initial cervical spine and pelvic studies were normal. The hemoglobin was 13.0 g/dL, and the hematocrit was 38%. The ECG demonstrated sinus tachycardia. The WBC, coagulation profile, and electrolytes were unremarkable. Results of arterial blood gasses were as follows:
Rupture
Figure
of Bronchus
3. Injury
445
in a Child
to bronchus.
1. Initial: pH 7.21, PO, 54, pC0, 55,satu ration 79.8%, forced inspiratory oxygen (FIo,) = 100% (drawn on arrival) 2. 30 minutes after first arterial blood gas and after insertion of two chest tubes: pH 7.23, po, 75, pco2 56, saturation 92.2070, FIo, = 100% 3. 90 minutes after insertion of chest tubes: pH 7.28, po, 67, pco2 49, saturation 90.1%, FIo, = 100% Based on the persistence of the right pneumothorax despite two functioning chest tubes, the presumptive diagnosis of right tracheobronchial injury was made. Bronchoscopy was considered prior to chest surgery; however, it was felt that a delay prior to surgery might be deleterious to the patient. Surgical exploration demonstrated disruption of the right mainstem bronchus at two levels (Figure 3). The bronchi to the right upper and middle lobes were massively shattered, preventing repair and thus resulted in resection of both the right upper and middle lobes. The bronchus to the right lower lobe was partially severed and was surgically repaired. In the abdomen there was a small liver laceration that was superficial and had obtained adequate hemostasis; therefore, no surgical repair was required. During his postoperative course the right ptosis resolved on the first day, and recovery from the laparotomy was uneventful. Serial chest x-ray studies continued to reveal poor aeration of the right
lung, and on the fifth postoperative day he underwent bronchoscopy with removal of a large mucus plug in the right lower lobe bronchus. He then made an uneventful recover. His orthopedic injuries included a fractured left clavicle, a displaced fracture of the coracoid process of the right scapula, and separation of the right acromioclavicular joint. These were managed with a clavicle strap and right shoulder sling. The patient was discharged on the tenth postoperative day in good condition.
Discussion Although the exact mechanism of tracheobronchial disruption is unknown, several theories have been proposed.‘+’ These include: 1. A sudden decrease in the anteroposterior diameter of the chest with a concomitant increase in the transverse diameter, resulting in traction at the carina, with tearing of the bronchial tree. 2. A closed glottis at the time of impact accompanied by crush injury to the thorax, resulting in intratracheal pressure greater than the elasticity of the tracheobronchial tree with subsequent rupture. 3. Rapid deceleration producing shearing forces at points of fixation, such as the cricoid cartilage and the carina, resulting in disruption. 4. Direct blunt injury to the cervical trachea producing disruption. The incidence of traumatic tracheobronchial injury is difficult to assess. Some patients are slow to exhibit symptoms of this injury. However, the apparent incidence is lower than that of other intrathoracic injuries such as aortic rupture.3,LCJTwo studies of traffic fatalities report that the incidence of tracheobronchial disruptions is between 0.85% and 2.8%. Right- and
446
M. J. Hughes,
left-sided injuries are equal in occurrence, and 80% of the injuries occur within 2.5 cm of the carina.3v lo-r3 Clinical manifestations of tracheobronchial disruption depend on the site and size of the tear as well as the time from injury to diagnosis. Early in the course of injury, the airway integrity may be maintained by the stiffness of the cartilage.14 There appear to be two distinct clinical patterns associated with tracheobronchial disruption. These depend on the presence or absence of free communication between the tear and the pleural cavity. Free communication with the pleural space results in a large pneumothorax with respiratory distress, large amounts of subcutaneous air, and mediastinal emphysema. These findings were present in this patient. Furthermore, in patients with free communication injuries, insertion of a chest tube results in continuous bubbling in the water-sealed bottle and fails to reexpand the lung, as typified by this patient. When there is little or no communication between the tear and the pleural cavity, pneumothorax is small or absent and responds well to tube thoracostomy. Mediastinal emphysema may be the only radiographic finding in this group of patients.3l7, 15-17 Disruptions may be complete or incomplete. Complete disruptions that are undiagnosed at the time of injury may result in later atelectasis of the distal segment. Because this distal segment does not communicate with the proximal airway, it is unlikely to become infected, and these patients may be able to undergo late reconstructive surgery with significant improvement in pulmonary function.7~10~17~18 Serious concomitant injuries to the other
0. W. Hayes, S. R. Guertin,
J. E. McGillicuddy
intrathoracic structures occur in approximately 50% of the reported cases. If major airway injury is suspected, early bronchoscopy should be done. The esophagus should be evaluated for associated esophageal injuries by esophagoscopy or diatrizoate meglumine (Gastrografin) swallow3Js Early evaluation of the aorta by computed tomography or arteriography should also be considered. Primary repair of a disruption of the tracheobronchial tree is the treatment of choice. Delayed diagnosis and treatment have been reported up to several years after the injury.6 Such delays are generally associated with serious complications.‘0~‘8 Summary
Injuries to the trachea and major bronchi are associated with blunt chest trauma, specifically with crush-type injury to the chest. These injuries most often occur in motor vehicle accidents. Although the exact mechanism of tracheobronchial disruption in closed chest injury is not completely understood, a number of explanations have been proposed. Since the acute diagnosis of tracheobronchial injury may be missed, the diagnosis must be sought in any patient with thoracic trauma, especially those patients with dyspnea, pneumothorax, and mediastinal and subcutaneous emphysema. The initial management of patients with tracheobronchial injury consists of standard measures of airway maintenance and tube thoracostomy. Bronchoscopy appears to be the most reliable diagnostic measure. Early primary surgical repair is the treatment of choice for disruption of the tracheobronchial tree.3J0x’6
REFERENCES 1. Beall AC, George NP, Harris HH: Surgical management of tracheal trauma. J Trauma 1967; 7: 248-256. 2. Eijgelaar A, Homan van der Heide JN: A reliable early symptom of bronchial or tracheal rupture. Thorax 1970; 25:116-125. 3. Kirsh MM, Orringer MB, Behrendt DM, et al:
Management of tracheobronchial disruption secondary to nonpenetrating trauma. Ann Thoruc Surg 1976; 22:93-101. 4. Neugebauer MK, Fine JB, Hoyt TW: Traumatic rupture of the trachea and right mainstem bronthus. J Trauma 1974; 265-269. 5. Le TS, Wright BD: Tracheobronchial disruption:
Rupture
of Bronchus
in a Child
Delayed diagnosis. Ann Emerg Me& 1980; 9: 2655261. 6. Hurwitz SS, Conlan AA, Nicoloau N: Traumatic rupture of the right main bronchus. S Afr &fed J 1982; 61:248-250. 7. Urschel HC, Razzuk MA: Management of acute traumatic injuries of tracheobronchial tree. Surg GynecolObstet 1973; 136:113-117. 8. Grover FL, Ellestad C, Arom KV, et al: Diagnosis and management of major tracheobronchial injuries. Ann Thorac Surg 1979; 28:384-391. 9. Bertelsen S, Howitz P: Injuries of the trachea and bronchi. Thorax 1972; 27:188-194. 10. Chesterman JT, Satsangi PN: Rupture of the trachea and bronchi by closed injury. Thorax 1966; 21:21-27. 11. Mazzei EA, Mulder DC: Closed-chest injuries to the trachea and bronchus. Arch Surg 1970; 100: 677-680. 12. Mills SA, Johnston FR, Hudspeth AS, et al:
447
Clinical spectrum of blunt tracheobronchial disruption. Illustrated by Seven Cases. J Thorac Carciovasc Surg 1982; 84:49-58. 13. Burke JF: Early diagnosis of traumatic rupture of the bronchus. JAMA 1962; 181:682-686. 14. Guest JL, Anderson JN: Major airway injury in closed chest trauma. Chest 1977; 72:63-66. 15. Jones WS, Mavroudis C, Richardson D, et al: Management of tracheobronchial disruption resulting from blunt trauma. Surgery 1984; 95: 3 19-322. 16. Eastridge CE, Hughes FA, Pate JW, et al: Tracheobronchial injury caused by blunt trauma. Am Rev Respir Dis 970; 1011230-237. 17. Reynolds J, Christensen EE: Early radiologic signs of bronchial rupture. Tex Med 1968; 64: 50-60. 18. Hood RM, Sloan HE: Injuries of the trachea and major bronchi. J Thorac Cardiovasc Surg 1959; 38:458-480.
Medu?e.
Vol 4. pp 443-447.
Pnntec in the USA
1986
l
Copyright
i 1986 Petgamon Journals
Ltd
Pediatrics TRAUMATIC RUPTURE OF RIGHT MAINSTEM BRONCHUS IN A CHILD Mary J. Hughes, DO, Oliver W. Hayes, DO, Steven R. Guertin, MD, and James E. McGillicuddy,
MD
The Division
of Emergency Medicine, College of Osteopathic Medlclne, Mlchlgan State University and in cooperation with Michigan State University Affiliated Hospitals Emergency Medicine Residency. Reprint address: Mary Hughes, DO, B 318 West Fee Hall, Dlvlslon of Emergency Medictne, College of Osteopathic Medicine, Michigan State University, East Lansing, MI 48824
0 Abstract-We report a case of a ‘I-year-old boy who sustained a ruptured right mainstem bronchus in a motor vehicle accident. The clinical presentation, pathophysiology, and diagnosis of tracheobronchial injuries secondary to nonpenetrating thoracic trauma are discussed. 0 Keywords-chest; trauma; tracheobronchial rupture; tension pneumothorax
Introduction Rupture of the tracheobronchial tree sulting from blunt trauma t? the thorax relatively rare. However, this injury can fatal and the clinical parameters must carefully sought and monitored.”
reis be be
Case Report A 7-year-old boy was brought to the emergency department by a basic emergency medical service ambulance after being struck by a truck. The patient remem-
-~ ____ RECEIVED:
bered walking along the roadside when he was “run over from behind.” The assessment at the scene revealed an alert boy able to speak and complaining of difficulty in breathing. He was in respiratory distress, tachypneic, with perioral cyanosis and bilateral breath sounds that were diminished on the right side. The patient’s vital signs were as follows: blood pressure, 1lo/60 mm Hg; pulse rate, 150 beats per minute; and respirations, 48/min. There were no obvious sites of hemorrhage or deformities. The patient was placed on high-flow oxygen via a rebreather mask, his cervical spine was immobilized using a backboard, tape, and sandbags, and he was transported. On arrival at the emergency department, the initial physical examination revealed an alert boy in obvious respiratory distress, with a patent upper airway. The patient was noted to have perioral cyanosis and a respiratory rate of 48 breaths per minute. Auscultation of his chest revealed bilateral breath sounds that were diminished on the right side. The patient’s pulse rate was 150 beats per minute and blood
Clinical Communications features articles on the assessment and management of both adult and childhood emergencies. Clinical Communications/Pediatrics is coordinated by Roger Barkin, MD, of the University of Colorado. 2 May 1985; ACCEPTED:
16 December 1985 443
0736-4679/86
$3.00
+ .OO
M. J. Hughes,
Figure 1. Preliminary
chest x-ray.
pressure was 114/60 mm Hg. Good distal pulses were present. Initial management of this patient included high-flow oxygen via a rebreather mask. Needle thoracostomy and immediate chest tube insertion was considered, but owing to the patient’s unchanged clinical status and rapid availability of x-ray equipment an initial chest x-ray study was performed. The cervical spine was maintained with sandbags, tape, and a backboard. A cardiac monitor was applied and an intravenous line (IV) of lactated Ringer’s solution was started. Further examination noted that the neck and face were greatly swollen and that subcutaneous emphysema was present in the neck. Petechiae were noted on the right cheek and a right ptosis was present. Breath sounds were judged to be harsh on the left and diminished over the right lung fields. The patient’s cardiac examination revealed normal heart sounds, a regular rate and rhythm, without murmurs or extra sounds, but tachycardic. The abdomen was soft to palpation, with tenderness in both upper quadrants, greater on the right; bowel sounds were absent. There was a large abrasion over the right
0. W. Hayes, S. R. Guertin, J. E. McGillicuddy
Figure 2. Chest x-ray after insertion tubes.
of chest
upper arm and shoulder, and subcutaneous air was present in the right axilla. The preliminary chest film (Figure 1) showed a large right pneumothorax with pneumomediastinum, and a fractured left clavicle. Approximately five minutes after arrival within the emergency department a needle thoracostomy was performed in the right second intercostal space, and a right chest tube was inserted in the midaxillary line. Continuous bubbling of air was noted in the water-sealed bottle. Mental status and vital signs remained unchanged. Repeat chest films revealed good position of the first chest tube, but failure to reexpand the lung. A second chest tube was inserted and partial resolution of the pneumothorax was noted on the third chest x-ray study (Figure 2). Initial central venous pressure was 20 cm water, via a left femoral vein catheter. Initial cervical spine and pelvic studies were normal. The hemoglobin was 13.0 g/dL, and the hematocrit was 38%. The ECG demonstrated sinus tachycardia. The WBC, coagulation profile, and electrolytes were unremarkable. Results of arterial blood gasses were as follows:
Rupture
Figure
of Bronchus
3. Injury
445
in a Child
to bronchus.
1. Initial: pH 7.21, PO, 54, pC0, 55,satu ration 79.8%, forced inspiratory oxygen (FIo,) = 100% (drawn on arrival) 2. 30 minutes after first arterial blood gas and after insertion of two chest tubes: pH 7.23, po, 75, pco2 56, saturation 92.2070, FIo, = 100% 3. 90 minutes after insertion of chest tubes: pH 7.28, po, 67, pco2 49, saturation 90.1%, FIo, = 100% Based on the persistence of the right pneumothorax despite two functioning chest tubes, the presumptive diagnosis of right tracheobronchial injury was made. Bronchoscopy was considered prior to chest surgery; however, it was felt that a delay prior to surgery might be deleterious to the patient. Surgical exploration demonstrated disruption of the right mainstem bronchus at two levels (Figure 3). The bronchi to the right upper and middle lobes were massively shattered, preventing repair and thus resulted in resection of both the right upper and middle lobes. The bronchus to the right lower lobe was partially severed and was surgically repaired. In the abdomen there was a small liver laceration that was superficial and had obtained adequate hemostasis; therefore, no surgical repair was required. During his postoperative course the right ptosis resolved on the first day, and recovery from the laparotomy was uneventful. Serial chest x-ray studies continued to reveal poor aeration of the right
lung, and on the fifth postoperative day he underwent bronchoscopy with removal of a large mucus plug in the right lower lobe bronchus. He then made an uneventful recover. His orthopedic injuries included a fractured left clavicle, a displaced fracture of the coracoid process of the right scapula, and separation of the right acromioclavicular joint. These were managed with a clavicle strap and right shoulder sling. The patient was discharged on the tenth postoperative day in good condition.
Discussion Although the exact mechanism of tracheobronchial disruption is unknown, several theories have been proposed.‘+’ These include: 1. A sudden decrease in the anteroposterior diameter of the chest with a concomitant increase in the transverse diameter, resulting in traction at the carina, with tearing of the bronchial tree. 2. A closed glottis at the time of impact accompanied by crush injury to the thorax, resulting in intratracheal pressure greater than the elasticity of the tracheobronchial tree with subsequent rupture. 3. Rapid deceleration producing shearing forces at points of fixation, such as the cricoid cartilage and the carina, resulting in disruption. 4. Direct blunt injury to the cervical trachea producing disruption. The incidence of traumatic tracheobronchial injury is difficult to assess. Some patients are slow to exhibit symptoms of this injury. However, the apparent incidence is lower than that of other intrathoracic injuries such as aortic rupture.3,LCJTwo studies of traffic fatalities report that the incidence of tracheobronchial disruptions is between 0.85% and 2.8%. Right- and
446
M. J. Hughes,
left-sided injuries are equal in occurrence, and 80% of the injuries occur within 2.5 cm of the carina.3v lo-r3 Clinical manifestations of tracheobronchial disruption depend on the site and size of the tear as well as the time from injury to diagnosis. Early in the course of injury, the airway integrity may be maintained by the stiffness of the cartilage.14 There appear to be two distinct clinical patterns associated with tracheobronchial disruption. These depend on the presence or absence of free communication between the tear and the pleural cavity. Free communication with the pleural space results in a large pneumothorax with respiratory distress, large amounts of subcutaneous air, and mediastinal emphysema. These findings were present in this patient. Furthermore, in patients with free communication injuries, insertion of a chest tube results in continuous bubbling in the water-sealed bottle and fails to reexpand the lung, as typified by this patient. When there is little or no communication between the tear and the pleural cavity, pneumothorax is small or absent and responds well to tube thoracostomy. Mediastinal emphysema may be the only radiographic finding in this group of patients.3l7, 15-17 Disruptions may be complete or incomplete. Complete disruptions that are undiagnosed at the time of injury may result in later atelectasis of the distal segment. Because this distal segment does not communicate with the proximal airway, it is unlikely to become infected, and these patients may be able to undergo late reconstructive surgery with significant improvement in pulmonary function.7~10~17~18 Serious concomitant injuries to the other
0. W. Hayes, S. R. Guertin,
J. E. McGillicuddy
intrathoracic structures occur in approximately 50% of the reported cases. If major airway injury is suspected, early bronchoscopy should be done. The esophagus should be evaluated for associated esophageal injuries by esophagoscopy or diatrizoate meglumine (Gastrografin) swallow3Js Early evaluation of the aorta by computed tomography or arteriography should also be considered. Primary repair of a disruption of the tracheobronchial tree is the treatment of choice. Delayed diagnosis and treatment have been reported up to several years after the injury.6 Such delays are generally associated with serious complications.‘0~‘8 Summary
Injuries to the trachea and major bronchi are associated with blunt chest trauma, specifically with crush-type injury to the chest. These injuries most often occur in motor vehicle accidents. Although the exact mechanism of tracheobronchial disruption in closed chest injury is not completely understood, a number of explanations have been proposed. Since the acute diagnosis of tracheobronchial injury may be missed, the diagnosis must be sought in any patient with thoracic trauma, especially those patients with dyspnea, pneumothorax, and mediastinal and subcutaneous emphysema. The initial management of patients with tracheobronchial injury consists of standard measures of airway maintenance and tube thoracostomy. Bronchoscopy appears to be the most reliable diagnostic measure. Early primary surgical repair is the treatment of choice for disruption of the tracheobronchial tree.3J0x’6
REFERENCES 1. Beall AC, George NP, Harris HH: Surgical management of tracheal trauma. J Trauma 1967; 7: 248-256. 2. Eijgelaar A, Homan van der Heide JN: A reliable early symptom of bronchial or tracheal rupture. Thorax 1970; 25:116-125. 3. Kirsh MM, Orringer MB, Behrendt DM, et al:
Management of tracheobronchial disruption secondary to nonpenetrating trauma. Ann Thoruc Surg 1976; 22:93-101. 4. Neugebauer MK, Fine JB, Hoyt TW: Traumatic rupture of the trachea and right mainstem bronthus. J Trauma 1974; 265-269. 5. Le TS, Wright BD: Tracheobronchial disruption:
Rupture
of Bronchus
in a Child
Delayed diagnosis. Ann Emerg Me& 1980; 9: 2655261. 6. Hurwitz SS, Conlan AA, Nicoloau N: Traumatic rupture of the right main bronchus. S Afr &fed J 1982; 61:248-250. 7. Urschel HC, Razzuk MA: Management of acute traumatic injuries of tracheobronchial tree. Surg GynecolObstet 1973; 136:113-117. 8. Grover FL, Ellestad C, Arom KV, et al: Diagnosis and management of major tracheobronchial injuries. Ann Thorac Surg 1979; 28:384-391. 9. Bertelsen S, Howitz P: Injuries of the trachea and bronchi. Thorax 1972; 27:188-194. 10. Chesterman JT, Satsangi PN: Rupture of the trachea and bronchi by closed injury. Thorax 1966; 21:21-27. 11. Mazzei EA, Mulder DC: Closed-chest injuries to the trachea and bronchus. Arch Surg 1970; 100: 677-680. 12. Mills SA, Johnston FR, Hudspeth AS, et al:
447
Clinical spectrum of blunt tracheobronchial disruption. Illustrated by Seven Cases. J Thorac Carciovasc Surg 1982; 84:49-58. 13. Burke JF: Early diagnosis of traumatic rupture of the bronchus. JAMA 1962; 181:682-686. 14. Guest JL, Anderson JN: Major airway injury in closed chest trauma. Chest 1977; 72:63-66. 15. Jones WS, Mavroudis C, Richardson D, et al: Management of tracheobronchial disruption resulting from blunt trauma. Surgery 1984; 95: 3 19-322. 16. Eastridge CE, Hughes FA, Pate JW, et al: Tracheobronchial injury caused by blunt trauma. Am Rev Respir Dis 970; 1011230-237. 17. Reynolds J, Christensen EE: Early radiologic signs of bronchial rupture. Tex Med 1968; 64: 50-60. 18. Hood RM, Sloan HE: Injuries of the trachea and major bronchi. J Thorac Cardiovasc Surg 1959; 38:458-480.