趙永祥，范欽明，胡景雲，張 權，胡冬煦，楊進福，朱 樾【摘要】 目的探討外傷性主支氣管斷裂的診斷和手術 治療 效果。方法胸片、CT和纖維支氣管鏡是診斷支氣管斷裂的主要方法。結果11例均行支氣管斷端吻合，術後肺膨脹良好，肺功能基本恢復。結論主支氣管斷裂的診斷一旦確立，應儘快手術治療，能獲得良好的療效。
【關鍵詞】支氣管；破裂；診斷；外科；治療
【Abstract】 ObjectiveTo study the diagnosis and surgical treatment for traumatic main bronchial rupture.MethodsChest Xrays，CT and fiberoptic bronchoscopy were the main means to confirm the diagnosis.Bronchial endtoend anastomosis were performed in 10 patients and pneumonectomy on one case because of infection.ResultsAll the lungs were well ventilated and lung function recovered.ConclusionMain bronchial rupture occurs relatively rarely.Early diagnosis and operative intervention save lives.
【Key words】bronchi；rupture；diagnosis；surgery；treatment
Acute injuries of bronchial system are rare and lifethreatening situations， which can cause acute asphyxia［1，2］. Main bronchial rupture，a rare but potentially fatal condition，results from blunt/penetrating chest and has different clinical pictures［3～6］，occurrences of these injuries are only about 0.8% of all chest injuries. Since 1994，we have treated totally 11 cases，the diagnosis and surgical treatment for these cases are reported here.
1 Clinical information
1.1General information The information was obtained by reviewing the operative records and archive files from 1994 to 2003 at our hospitals. The group consisted of 11 patients (male：7 cases，female： 4 cases) with penetrating or blunt bronchial injuries who were revealed in the emergency department (see Fig.1，2). All injuries involved the main stem bronchi. The right main bronchial rupture consisted of 4 cases，while the left main bronchial 7 cases. The shortest time of trauma was 7 days，the longest time was one year and half. Clinical findings： the most common presenting signs of airway disruption were dyspnea，pneumothorax，mediastinum and subcutaneous emphysema in 8 cases，hemoptysis in 5 cases. In 7 patients the atelectasis were found in 10 days to 3 months after trauma. Radiology： chest Xray showed that complete transaction of a main bronchus might result in the classic signs of atelectasis，「absent hilum」 or a collapsing of the lung away from the hilus toward the diaphragm，known as the falling lung sign of kumpe. CT showed the site of stenosis and the secondary consequences of airway narrowing have been useful in the delayed setting and may directly reveal bronchial rupture or stenosis. Fiberoptic brochoscopy： the bronchial cutoff in 4 patients was found，location of bronchial stenosis，edema and the distance between the cutoff and bronchial bifuraction could be seen.
1.2Surgical treatment Bronchial rupture were reconstructed successfully by 「end to end」anastomosis in 10 patients of this group (see Table 1).After operation，the lobes were well ventilated. One right lung resection in a patient with right bronchus rupture was performed due to pulmonary infection. All the patients were discharged after uneventful postoperative and following periods，whose blood gas analysis and vital capacity were also improved obviously.
Table 1 Patients』lesion sites and surgical treatment
2 Discussion
2.1Diagnosis The clinical findings for most patients with traumatic main bronchial rupture are complicated because thEir clinical symptoms can be lessened through closed drainage so that is for us to timely make an earlier diagnosis for them. Because of this，the onethird of patients can be saved by timely making diagnosis and correct treatment. The diagnosis for the bronchial rupture is based upon clinical，radiological，and endoscopical finding. The clinical presentations for the bronchial rupture in the earlier traumatic stage constitute 2 types. Type Ⅰ： bronchial crack is connected to pleural cavity， whose clinical finding showed dyspnea and traumatic pneumothorax. 6 patients out of this group belonged to this type. Type Ⅱ： bronchial crack is covered with the mediastinal pleural so as not to directly be gotten through the pleural cavity. The clinical finding showed mediastinum and subcutaneous emphysema. 6 patients out of the current group belonged to this type. The surgical treatment could be performed on these patients due to the initial diagnosis of airway injury missed. Granulation tissue and stricture of the bronchus with develop within the first 1 to 4 weeks and will usually lead to symptoms， signs and radiological findings of pneumonia， bronchiectasis， atelectasis， and absent. Wheezing and postobstructive pneumonia are the common presentations of bronchial stenosis so that the atelectasis occurred. The pnenumonia occurred in 8 patients of this group within 10 days to 3 months after injury.
Radiological finding： In the earlier stage of patients， Xray sign are traumatic pneumothorax， mediastinal and subcutaneous emphysema and 「fallen lung with absent hilum」(signs of complete bronchial transaction)［7］. In the current group， the phenomenon was not so often. In the late stage of patients， the atelectasis of the whole injured lung occured. CT showed the rupture looked like the blind tube end.
Fiberoptic bronchoscopy is the most effective diagnostic tool in case of suspected airway injury［8～13］. Moreover， fiberoptic bronchoscopy allows a rather clear determination of the extent and depth of the rupture establishing a further important parameter for the choice of treatment. For emergency bronchoscopy， which was done under anesthesia， we chose a flexible endoscope inserted through an endotracheal tube， the latter being uncuffed in order not to increase the damage and to be readily repositioned for inspection of the rims of the rupture. This technique enabled sufficient ventilation， a meticulous inspection， and a clearcut positioning of the endotracheal tube once the investigation was finished， without any need for changing endoscopic divices. In 9 patients of our group the tentative diagnosis was confirmed by fiberoptic bronchoscopy.
【關鍵詞】支氣管；破裂；診斷；外科；治療
【Abstract】 ObjectiveTo study the diagnosis and surgical treatment for traumatic main bronchial rupture.MethodsChest Xrays，CT and fiberoptic bronchoscopy were the main means to confirm the diagnosis.Bronchial endtoend anastomosis were performed in 10 patients and pneumonectomy on one case because of infection.ResultsAll the lungs were well ventilated and lung function recovered.ConclusionMain bronchial rupture occurs relatively rarely.Early diagnosis and operative intervention save lives.
【Key words】bronchi；rupture；diagnosis；surgery；treatment
Acute injuries of bronchial system are rare and lifethreatening situations， which can cause acute asphyxia［1，2］. Main bronchial rupture，a rare but potentially fatal condition，results from blunt/penetrating chest and has different clinical pictures［3～6］，occurrences of these injuries are only about 0.8% of all chest injuries. Since 1994，we have treated totally 11 cases，the diagnosis and surgical treatment for these cases are reported here.
1 Clinical information
1.1General information The information was obtained by reviewing the operative records and archive files from 1994 to 2003 at our hospitals. The group consisted of 11 patients (male：7 cases，female： 4 cases) with penetrating or blunt bronchial injuries who were revealed in the emergency department (see Fig.1，2). All injuries involved the main stem bronchi. The right main bronchial rupture consisted of 4 cases，while the left main bronchial 7 cases. The shortest time of trauma was 7 days，the longest time was one year and half. Clinical findings： the most common presenting signs of airway disruption were dyspnea，pneumothorax，mediastinum and subcutaneous emphysema in 8 cases，hemoptysis in 5 cases. In 7 patients the atelectasis were found in 10 days to 3 months after trauma. Radiology： chest Xray showed that complete transaction of a main bronchus might result in the classic signs of atelectasis，「absent hilum」 or a collapsing of the lung away from the hilus toward the diaphragm，known as the falling lung sign of kumpe. CT showed the site of stenosis and the secondary consequences of airway narrowing have been useful in the delayed setting and may directly reveal bronchial rupture or stenosis. Fiberoptic brochoscopy： the bronchial cutoff in 4 patients was found，location of bronchial stenosis，edema and the distance between the cutoff and bronchial bifuraction could be seen.
1.2Surgical treatment Bronchial rupture were reconstructed successfully by 「end to end」anastomosis in 10 patients of this group (see Table 1).After operation，the lobes were well ventilated. One right lung resection in a patient with right bronchus rupture was performed due to pulmonary infection. All the patients were discharged after uneventful postoperative and following periods，whose blood gas analysis and vital capacity were also improved obviously.
Table 1 Patients』lesion sites and surgical treatment
2 Discussion
2.1Diagnosis The clinical findings for most patients with traumatic main bronchial rupture are complicated because thEir clinical symptoms can be lessened through closed drainage so that is for us to timely make an earlier diagnosis for them. Because of this，the onethird of patients can be saved by timely making diagnosis and correct treatment. The diagnosis for the bronchial rupture is based upon clinical，radiological，and endoscopical finding. The clinical presentations for the bronchial rupture in the earlier traumatic stage constitute 2 types. Type Ⅰ： bronchial crack is connected to pleural cavity， whose clinical finding showed dyspnea and traumatic pneumothorax. 6 patients out of this group belonged to this type. Type Ⅱ： bronchial crack is covered with the mediastinal pleural so as not to directly be gotten through the pleural cavity. The clinical finding showed mediastinum and subcutaneous emphysema. 6 patients out of the current group belonged to this type. The surgical treatment could be performed on these patients due to the initial diagnosis of airway injury missed. Granulation tissue and stricture of the bronchus with develop within the first 1 to 4 weeks and will usually lead to symptoms， signs and radiological findings of pneumonia， bronchiectasis， atelectasis， and absent. Wheezing and postobstructive pneumonia are the common presentations of bronchial stenosis so that the atelectasis occurred. The pnenumonia occurred in 8 patients of this group within 10 days to 3 months after injury.
Radiological finding： In the earlier stage of patients， Xray sign are traumatic pneumothorax， mediastinal and subcutaneous emphysema and 「fallen lung with absent hilum」(signs of complete bronchial transaction)［7］. In the current group， the phenomenon was not so often. In the late stage of patients， the atelectasis of the whole injured lung occured. CT showed the rupture looked like the blind tube end.
Fiberoptic bronchoscopy is the most effective diagnostic tool in case of suspected airway injury［8～13］. Moreover， fiberoptic bronchoscopy allows a rather clear determination of the extent and depth of the rupture establishing a further important parameter for the choice of treatment. For emergency bronchoscopy， which was done under anesthesia， we chose a flexible endoscope inserted through an endotracheal tube， the latter being uncuffed in order not to increase the damage and to be readily repositioned for inspection of the rims of the rupture. This technique enabled sufficient ventilation， a meticulous inspection， and a clearcut positioning of the endotracheal tube once the investigation was finished， without any need for changing endoscopic divices. In 9 patients of our group the tentative diagnosis was confirmed by fiberoptic bronchoscopy.
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