A previously healthy, 22-year-old farmer is brought to the emergency department after a tractor ran over his chest. The patient was intubated in the field because of respiratory distress. In the emergency department, blood pressure is 74/40 mm Hg, pulse is 132/min, and pulse oximetry is 84% on 100% FiO₂. On examination, the trachea is deviated to the left and breath sounds are absent in the right lung. A right-sided chest tube is placed, after which the patient's blood pressure and pulse oximetry normalize. The rest of the trauma survey is notable for bruising over the anterior chest and crackling of the neck and chest skin on palpation. Heart sounds are normal, and the abdomen is nondistended and soft. Chest x-ray confirms appropriate endotracheal and chest tube placement and reveals multiple rib fractures, right pneumothorax, pneumomediastinum, and subcutaneous emphysema. Two hours later, the chest tube drainage system has a persistent large air leak, despite an adequate seal at the chest wall and all connection points. Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

This patient with blunt thoracic trauma (eg, chest run over by a tractor) has evidence of extensive extrapulmonary air, with both a tension pneumothorax (absent breath sounds, tracheal deviation, hypotension) and crepitus (crackling of the neck and chest skin). Even after appropriate treatment of the tension pneumothorax with tube thoracostomy, there is a persistent large air leak. This suggests continuous, rapid extrapulmonary air accumulation from a tracheobronchial injury that allows (due to the larger diameter of the proximal airway) a large quantity of air to escape with each breath. Tracheobronchial injury should be considered in any patient with thoracic trauma and extensive extrapulmonary air. Bronchoscopy, which can directly visualize the lumen of the tracheobronchial tree, is the definitive test for diagnosis and can be easily performed through the endotracheal tube in intubated patients, such as this one. High-resolution CT scan can diagnose major injuries but may miss small tears. Most patients require operative repair. (Choice A) In some mechanically ventilated patients with hypoxemia, increasing positive end-expiratory pressure (PEEP) can help keep alveoli open at the end of the expiratory phase and improve oxygen diffusion. This patient is no longer hypoxemic; in addition, for conditions affecting the large airways (eg, tracheobronchial injury) rather than the alveoli, changes in PEEP (eg, 5 cm H₂O) would not have a significant impact. (Choice B) Insertion of an additional chest tube is indicated if the existing one is inadequate (eg, small diameter limiting the ability to adequately drain fluid). This patient's chest tube is functioning well (ie, draining large amounts of air), so the source of the large air leak (ie, tracheobronchial injury) should be investigated. (Choice D) Talc pleurodesis obliterates the pleural space to prevent recurrence of frequent pleural effusion (eg, malignant effusion) or pneumothorax (eg, chronic obstructive pulmonary disease). It is not used for primary treatment. In addition, pleurodesis requires physical contact between the visceral and parietal pleurae, which is likely not present in this patient with a large air leak due to tracheobronchial injury. (Choice E) Repositioning the endotracheal tube is appropriate if chest x-ray reveals malpositioning (eg, tip in the right mainstem bronchus). However, this patient's chest x-ray confirms appropriate placement. Educational objective: Tracheobronchial injury should be considered in patients with thoracic trauma and extensive extrapulmonary air (eg, chest tube with persistent large air leak). Bronchoscopy can confirm the diagnosis prior to operative repair. References: Blunt tracheobronchial trauma. (http://www.ncbi.nlm.nih.gov/pubmed/30054080) Update on the diagnosis and treatment of tracheal and bronchial injury. (http://www.ncbi.nlm.nih.gov/pubmed/28203437)

A Previously Healthy, 22-Year-Old Farmer Is Brought to the Emergency