Bronchial rupture from penetrating, perforating, or compressive cervical or thoracic injuries can lead to complete tracheal, mainstem bronchial, or lobar bronchial detachment. Although rare in children, bronchial rupture presents significant risks, including dyspnea, respiratory failure, and potentially fatal airway obstruction, and is often overlooked or diagnosed late in clinical settings. Prompt diagnosis and intervention are prognostically crucial.^[1,2] Between January 2013 and December 2023, four children (two male and two female) with bronchial rupture were admitted to the Pediatric Surgical Intensive Care Unit (ICU) at Children’s Hospital, Zhejiang University School of Medicine. Here, we share our experience of patient management.

The injury mechanisms of the four children included traffic accidents (two), falls from a height (one), and blunt impact injury (one). All injuries were classified as closed.

Patient 1 was an 8-year-old boy who presented to the emergency department (ED) 6 h after a traffic accident. Before admission, he had chest compressions, resulting in facial petechiae and subsequent rapid and labored breathing. Initial evaluation at a local hospital revealed bilateral pulmonary contusions and bilateral pneumothoraces (predominantly left-sided) with 80% lung compression on chest computed tomography (CT). On admission, his heart rate (HR) was 130 beats/min, respiratory rate (RR) was 55 breaths/min, and oxygen saturation (SpO₂) was 95% with mask oxygen. Paradoxical respiration, diminished bilateral chest wall movements, and bilaterally reduced breath sounds were observed. An immediate left-sided thoracostomy with closed drainage was performed. Despite mask oxygen supplementation, the SpO₂ decreased with worsening subcutaneous emphysema. Bronchial rupture was suspected, and thoracic surgery consultation was conducted after endotracheal intubation. Emergency thoracotomy revealed a 1-cm tear near the left mainstem bronchus-upper lobe bronchus junction, with almost complete separation. The lesion was suture-repaired. Ventilatory support was withdrawn 20 h postoperatively, with the patient breathing 34-46 breaths/min on mask oxygen. The patient was transferred from the ICU to a general ward on postoperative day (POD) 6. Follow-up chest radiography revealed no residual pneumothorax. He was discharged in good health on POD 13.

Patient 2 was a 4-year-10-month-old girl and admitted to the ED 11 h after crush injury by a heavy object. She complained of right upper limb and chest pain, and the exact injury site was unclear. A CT scan at a local hospital revealed a right-sided pneumothorax with 80% lung compression, an obscured right bronchial view, and multiple right-sided rib fractures. On admission, her HR was 132 beats/min, RR was 40 breaths/min, and SpO₂ was 99% with mask oxygen. Subcutaneous emphysema was noted in the right chest wall, neck, and shoulder area, with left-sided tracheal deviation, pronounced tenderness over the right chest, and decreased breath sounds on the right compared with those on the left. Urgent chest radiography revealed tension pneumothorax on the right, with 80%-90% lung collapse, mediastinal emphysema, suspected right main bronchial rupture, and right-sided second and third rib fractures. Immediate right-sided chest tube insertion was followed by an emergency thoracotomy, revealing a 0.8-cm right upper lobe bronchial laceration below the carina, which was sutured intraoperatively. Ventilator withdrawal occurred 75 h postoperatively. Bronchoscopy on POD 10 revealed granulation tissue in the right main and intermediate bronchi. The patient was transferred from the ICU on POD 11 and discharged on POD 15.

Patient 3 was a 4-year-old boy and admitted after being unconscious for more than a day following a car accident. A CT scan at a local hospital revealed a large right-sided pneumothorax, minor pleural effusion, extensive subcutaneous emphysema in the neck, chest, and abdominal wall, minimal mediastinal air, and exudative pulmonary changes. Chest tube insertion and mechanical ventilation were initiated. Owing to his critical condition, he was transferred to our hospital with an endotracheal tube in place. On arrival, he was unconscious, with coarse breath sounds and extensive rales bilaterally. Continuous right-sided chest drainage was performed. Management included ongoing mechanical ventilation, chest drainage, norepinephrine for blood pressure maintenance, and antibiotics. Worsening subcutaneous emphysema prompted a repeat chest radiograph, confirming increased extra-pulmonary gas accumulation. On day 5, CT suggested lower bronchial rupture (Figure 1). On day 6, exploratory surgery revealed complete right main bronchial transection at the carina. Under extracorporeal circulation, sleeve resection and tracheal and carinal reconstruction were performed via interrupted sutures with 3-0 absorbable threads. Ventilatory support was withdrawn on POD 5, and ICU discharge occurred on POD 12.

Patient 4 was an 8-year-6-month-old girl and admitted to the ED after a fall. Upon examination, her pulse was 132 beats/min, RR was 40 breaths/min, and SpO₂ was 99% with ventilatory support. Cervical surgical emphysema was palpable, and breath sounds were reduced bilaterally. CT revealed a left lung contusion with extensive atelectasis, a large left-sided hemopneumothorax, a right lung contusion, mediastinal air, and subcutaneous emphysema in the anterior chest, neck, shoulders, back, and buttocks. Left-sided chest tube insertion, infection control, and other supportive treatments were initiated. A follow-up CT suggested possible distal left main bronchial rupture (Figure 2). On day 7, thoracotomy revealed a complete break in the left main bronchus, which was repaired via the sleeve technique. Ventilator support was withdrawn on POD 7, and bronchoscopy on POD 9 revealed inflammatory changes and postoperative bronchial reconstruction. The patient was transferred out of the ICU on POD 13.

All patients survived during their hospital stay. No patients developed postoperative bronchial anastomotic leaks, and successful weaning from mechanical ventilation was achieved in all patients. No further surgical interventions were necessary on the basis of postoperative follow-up assessments. Over follow-up periods ranging from 3 months to 10 years, the patient 2 experienced early bronchial stenosis episodes requiring frequent oxygen supplementation. The remaining patients had no significant respiratory infections or other functional respiratory abnormalities.

Thoracic trauma, particularly from motor vehicle accidents, is the primary cause of bronchial rupture. This trend, driven by economic development and increased vehicle use, suggests a potential rise in pediatric cases, which aligns with the previous literature.^[3]

The mechanisms of bronchial rupture can be categorized as follows: bilateral bronchi experiencing lateral traction leading to rupture at the carina when the thorax undergoes significant external force, increased airway pressure due to vocal cord closure and breath-holding during chest and airway impact, and direct force applied to fixed points over the bronchi.^[4] Herein, bronchial ruptures in our patients occurred within 2.5 cm of the carina, which is consistent with Cheaito’s report suggesting that the right main bronchus is more susceptible to rupture,^[5] although our findings mirror those of Kiser’s,^[6] indicating equal likelihood for both sides.

Patients with severe chest trauma whose tension pneumothoraces and lung collapse persist despite closed chest drainage and mechanical ventilation, respectively, pose challenges. Radiographically, a characteristic “fallen lung” sign may be indicative;^[7] however, prompt CT with airway reconstruction is advisable when feasible, as CT imaging and virtual bronchoscopy increase the diagnostic accuracy to 94%-100%.^[8] Patients 3 and 4 revealed bronchial rupture on CT with airway reconstruction. Fiberoptic bronchoscopy is the gold standard for diagnosis and surgical guidance. Its wide availability has proven valuable,^[9]with bronchoscopic findings matching intraoperative observations regarding rupture location and length. Although only one preoperative bronchoscopy was performed in our patients without conclusive rupture identification, intraoperative bronchoscopic guidance was used for intubation in all patients. Preoperative bedside bronchoscopy is now considered feasible and appropriate. Moreover, postoperative bronchoscopy aids in monitoring inflammation, infection, and granulation tissue formation.^[3]

Prompt thoracostomy with closed drainage is crucial for managing massive pneumothoraces, especially in closed injuries, as it immediately alleviates tension pneumothoraces and helps assess trauma severity. All four patients in this study required mechanical ventilation to maintain vital signs. Immediate surgical intervention is imperative for pediatric bronchial ruptures,^[10] as conservative management exacerbates this condition. After conservative therapy, patients 3 and 4 were found to have complete bronchial transections intraoperatively, with the patient 3 requiring extracorporeal membrane oxygenation support for repair. Postoperative management included mechanical ventilation, enhanced respiratory care, antimicrobial therapy, and maintenance of chest drain patency.

In conclusion, although rare, bronchial rupture in children poses significant risks, emphasizing the need for prompt diagnosis and intervention. Selective CT with 3D reconstruction is advisable when patients are hemodynamically stable. Bedside fiberoptic bronchoscopy, when available, is an invaluable diagnostic tool. An aggressive surgical strategy is imperative for strong suspicion or confirmation. Integrating fiberoptic bronchoscopy preoperatively, intraoperatively, and postoperatively significantly enhances the assessment and management of bronchial disruptions, thereby optimizing patient outcomes.

Funding: None.

Ethical approval: The study adhered to the principles of the Declaration of Helsinki and was approved by the Ethics Committee of Children’s Hospital, Zhejiang University School of Medicine (approval number: 2024-IRB-0128-P-01).

Conflicts of interest: The authors declare that they have no conflicts of interest.

Contributors: YYB: data collection, visualization, manuscript writing (original version, manuscript writing - edits and revision); JY, LJG, CNG, and LH: literature search, data collection; LHT: manuscript writing (original version, manuscript writing, edits, and revision). All authors contributed significantly to the manuscript, read and approved the final version of the manuscript.