Lower airway injuries and anaesthesia.

Purpose: The perioperative management of lower airway injuries is a difficult clinical problem. Since few reviews present the management of this injury from an anaesthetic perspective, we undertook a literature review of this topic.

Sources: A computerized search of the National Library of Medicine database using tracheal or bronchial injury as key words produced 140 English language citations. An eight-year chart review outlining our experience in an urban Canadian setting is also presented.

Findings: The most frequent findings in patients with injury to the lower airway are dyspnoea and surgical emphysema. Other findings include cough, haemoptysis, sucking neck or chest wounds, mediastinal emphysema or pneumothorax. Endoscopy with a fiberoptic scope is the technique of choice for diagnosis, airway management and as a preparatory step in planning of the surgical repair. An airway technique employing direct vision is preferable to blind attempts during tracheal intubation. The use of a double lumen endobronchial tube or selective endobronchial intubation may be needed to achieve adequate pulmonary ventilation. A number of prospective randomized clinical trials comparing conventional mechanical ventilation with high frequency jet ventilation in patients with acute lung injury have demonstrated no difference in effectiveness of ventilation or oxygenation.

Conclusions: Patients with lower airway injuries usually present when they are least expected and are a challenge to manage. The clinical presentation of a lower airway injury may be overt or subtle. Resuscitation and anaesthetic management are directed towards control of the airway, maintenance of adequate pulmonary ventilation and management of blood loss.