4．気管・気管支損傷

Tracheobronchial Injury

気管・気管支損傷は外傷性と医原性に大別される．気管・気管支損傷の緊急手術の必要性は，気管・気管支の損傷部位および程度の評価はもとより，呼吸および全身状態の重症度により決定される．外傷性，医原性にかかわらず，気管・気管支損傷を救命するためには迅速かつ的確な診断，呼吸管理，治療が不可欠である．本稿では，気管・気管支損傷の臨床像，診断，治療について述べる．

Tracheobronchial injurie （TBI） is rare but potentially life threatening. Blunt trauma of the chest and post-intubation injury are the most common cause of TBI. Clinical findings of TBI are subcutaneous emphysema, pneumomediastinum, and pneumothorax. Chest computed tomography （CT） and bronchoscopy are important examination for TBI to evaluate of injured site and condition. Most traumatic or iatrogenic TBIs occurred within 2.5 cm of the carina and/or main bronchus.

Early diagnosis and early treatment are important to improve the long-term results of TBI. In principle, blunt traumatic TBI excluded membranous minor laceration should be operated immediately, if possible. Surgical procedures are usually selected single closure or end to end anastomosis with or without débridement. Right thoracotomy is often suitable for repair of carina or main bronchus in closed trauma. Recently transcervical repair of iatrogenic distal membranous tracheal laceration is reported.

Conservative treatment of iatrogenic TBI cause by single lumen tube may be a save option in patients with stable spontaneous breathing, no other injury （such as esophagus）, and small to moderate rupture. Left main bronchial rupture caused by double lumen tube during right thoracic surgery is critical situation. Throughout the operation expert cooperation between surgeon and anesthetist is important.