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Tracheobronchial Tear
Article Last Updated: Sep 13, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: David W Light IV, MD, Staff Physician, Department of Radiology, Memorial Hermann Memorial City Hospital
David W Light, IV, is a member of the following medical societies: American Medical Association, Radiological Society of North America, and Texas Medical Association
Coauthor(s):
J Michael Holbert, MD, Associate Professor, Department of Radiology, Scott and White Memorial Hospital and Clinic;
Mark L Montgomery, MD, Vice Chair of Education, Assistant Professor and Course Coordinator, Department of Radiology, Texas A&M College of Medicine; Consulting Staff, Divisions of Interventional Radiology and Diagnostic Imaging, Scott and White Clinic
Editors: Jeffrey A Miller, MD, Associate Professor of Clinical Radiology, University of Medicine and Dentistry of New Jersey; Associate Chief of Service, Department of Radiology, Veterans Affairs of New Jersey Health Care System; Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand; Eric J Stern, MD, Director of Thoracic Imaging, Professor of Radiology and Medicine, Departments of Radiology and Internal Medicine, Harborview Medical Center, University of Washington School of Medicine; Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute; Eugene C Lin, MD, Consulting Staff, Department of Radiology, Virginia Mason Medical Center
Author and Editor Disclosure
Synonyms and related keywords:
tracheal rupture, bronchial rupture, airway rupture, tracheal laceration, bronchial laceration, airway laceration, tracheal fracture, bronchial fracture, airway fracture, tracheal avulsion, bronchial avulsion, airway avulsion, tracheal injury, bronchial injury, airway injury
Background
Tracheobronchial tears are rare injuries that are usually related to blunt trauma that involves a partial or complete laceration or puncture of the tracheal or bronchial wall. For excellent patient education resources, visit eMedicine's Procedures Center. Also, see eMedicine's patient education article Bronchoscopy.
Pathophysiology
Tracheobronchial tears can be caused by the following:
- Shearing forces between the fixed carina or proximal bronchus and the mobile distal bronchi/lungs in a deceleration injury
- Rapid anteroposterior compression of the chest that causes lateral traction on the lungs and tearing of the bronchus from the fixed carina
- Rupture that results from an abrupt increase in pressure against a closed glottis
- Compression of the trachea between the sternum and spinal column
- Blunt trauma to the cervical trachea
- Necrosis that results from compromised mucosal blood flow after overinflation of an endotracheal tube (ETT) cuff
- Perforation by a stylet or ETT
- Other penetrating injuries
Frequency
United States
Tracheobronchial injuries occur in 0.4-1.5% of patients with major blunt trauma and are found in 2.8-5.4% of trauma-related autopsies. Tracheobronchial tears also have been reported in 18% of autopsies after the administration of emergency intubation; however, because minor injuries are often not identified, the actual frequency of this condition may remain unknown.
International
Few data are available regarding the frequency of tracheobronchial tears.
Mortality/Morbidity
Death occurs in approximately 30% of patients with tracheobronchial tears, with 50% of fatalities occurring within the first hour of the injury. Mortality may be related to an inadequate airway, tension pneumothorax, occlusion of the airway by protrusion of the esophagus into the tear, or accompanying injuries. In two thirds of survivors, the diagnosis is delayed, occasionally for many years, resulting in complications such as airway stenosis, atelectasis, pneumonia, mediastinitis, sepsis, and decreased pulmonary capacity.
Race
No specific data are available regarding racial predilection for this condition.
Sex
Blunt trauma accounts for the preponderance of all tracheobronchial injuries. Tracheobronchial injury from blunt trauma is 3 times more common in males, because blunt trauma involves males much more often than females. However, because women's tracheas are smaller, females have a greater chance of iatrogenic injury from ETTs.
Age
A higher incidence of serious chest trauma is seen in patients younger than 40 years; therefore, overall, tracheobronchial tears are seen more often in younger patients. Patients older than 40 years who suffer blunt chest trauma and who have diabetes, or who are generally in poor medical condition, are at higher risk for tracheobronchial tears. As in women, children have smaller tracheas and thus have a greater possible risk of iatrogenic injury from ETTs.
Anatomy
Multiple anatomic variables and common mechanisms of injury account for local susceptibility to tracheobronchial tears. The trachea and proximal bronchi have varying amounts of cartilaginous support, which strengthens them against injury, but the posterior tracheal membrane is unsupported by cartilaginous rings. Occasionally, blunt trauma to the anterior neck results in rupture of the cervical trachea; this is usually a longitudinal tear of the posterior tracheal membrane. During intubation, ETTs and stylets are naturally directed against the relatively weaker posterior tracheal membrane; therefore, intubation-related injuries are more common in the posterior trachea. Cartilaginous support decreases progressively from the trachea to the distal bronchi, which are more membranous than cartilaginous. The stronger proximal cartilage framework tends to fix the trachea and proximal bronchi in place, whereas the distal bronchi and lungs are more mobile. Consequently, deceleration injuries from blunt trauma typically occur at the transition zone between the fixed and mobile bronchus, within 2.5 cm of the carina. The left main bronchus is relatively protected by a longer mediastinal course. Although several studies have found right bronchial injury to be more common, several other investigators have reported an equal distribution between left and right bronchial injuries. The larger main bronchi are at higher risk of rupture than the smaller peripheral bronchi during a sudden increase in pressure because, according to Laplace law, in a cylindrical body, wall tension (T) equals internal pressure (P) times internal radius (R), or: T = P X R.
Clinical Details
Clinical signs of tracheobronchial tears include the following:
- Dyspnea
- Cough
- Hemoptysis
- Cyanosis
- Cervical subcutaneous emphysema
- Tracheal shift
- Persistent pneumothorax following satisfactory placement of a thoracostomy tube
- Signs of airway obstruction
Immediate treatment for this condition depends on the patient's condition and the presence of any associated injuries. At a minimum, emergency bronchoscopic confirmation of the diagnosis and location is important if a tracheobronchial tear is suspected. This procedure may aid in placing the ETT cuff beyond the injury or selectively intubating the unaffected bronchus. Short lacerations of the upper one third of the trachea are occasionally treated with antibiotics and intubation beyond the level of the injury. In addition, some small or peripheral bronchial tears may be treated conservatively; however, nonoperative treatment can result in scarring and stenosis. Surgical repair is indicated when a transmural tear that is longer than 1 cm causes a pneumothorax that is unrelieved by tube thoracostomy. Severe trauma may require resection of the damaged tissue. Although the importance of early diagnosis and primary repair is indisputable, successful repair as long as 11 years after the initial injury has been reported.
Preferred Examination
Chest radiography is the standard initial screening examination for evaluation of most chest conditions, including possible tracheobronchial injury; however, computed tomography (CT) scanning is preferred if a tracheobronchial tear is suspected. In appropriate circumstances, multiplanar or virtual endoscopic reconstructions from the CT scan data can be performed to clarify questionable findings. Definitive diagnosis of a tracheobronchial tear is made by bronchoscopy or surgical exploration. If clinical or radiographic findings suggest airway injury, diagnostic bronchoscopy is recommended.
Limitations of Techniques
Conventional radiography and CT scanning play important roles in the imaging of tracheobronchial tears. Although imaging findings can be highly suggestive in certain instances, radiography and CT scanning are often nonspecific for evaluating tracheobronchial tears.
Aorta, Trauma
Esophagus, Tear
Other Problems to Be Considered
Cervical spine trauma
Chest trauma
Neck trauma
Findings
Radiographic findings of tracheobronchial tears reflect the location and extent of the injury or injuries.
- In 10% of affected patients, the tear is incomplete, with preservation of the peritracheal or peribronchial connective tissue sheath or sealing of the tear by fibrin. In these patients, the injury is not apparent on radiographs.
- In the most severely injured patients, the airway separates completely at the site of the injury with a visibly obvious distortion of the tracheobronchial anatomy. A pneumomediastinum, pneumothorax, or both are usually present in these extensive injuries.
- The location of the tear is important in determining whether a pneumomediastinum or pneumothorax develops. Tears within the mediastinal pleura cause a pneumomediastinum; tears beyond the mediastinal pleura cause a pneumothorax.
- Because the left main bronchus has a longer mediastinal course than the right main bronchus, injury to the left main bronchus is more likely to cause a pneumomediastinum, whereas injury to the right main bronchus is more likely to cause a pneumothorax.
- Note that in severe injuries, both a pneumomediastinum and a pneumothorax may be present.
- A pathognomonic indication of tracheobronchial tears, the fallen-lung sign, is visible in some patients with severe injury.1
- In an uncomplicated pneumothorax, the bronchus remains fixed at the hilum, and the peripheral lung retracts from the parietal pleura toward the hilum.
- With complete laceration of the main bronchus, the bronchus may become partially or completely detached, allowing the lung to fall into a dependent lateral position and producing the fallen-lung sign.
- Other important radiographic findings that are associated with tracheobronchial tears include incorrect location or overdistention of the ETT cuff and a persistent pneumothorax that is unrelieved by appropriate placement of a thoracostomy tube.1, 2
- A bayonet deformity or bronchial discontinuity may be present, and if the tear causes obstruction, peripheral consolidation or atelectasis without air bronchograms may be seen (see Images 1-29).
- In the typical traumatic transection of the cervical trachea, the infrahyoid muscle ruptures and the suprahyoid muscle retracts, raising the hyoid bone. Abnormal hyoid bone elevation suggests a cervical tracheal tear.
Degree of Confidence
The most specific signs of tracheobronchial tears are of an appropriately placed ETT that clearly extends beyond the expected tracheal lumen and a classic fallen-lung sign.1, 2 Other signs are less conclusive and usually require bronchoscopic confirmation.
False Positives/Negatives
Tracheobronchial tears may not be visible if the tracheal mucosa remains intact or is sealed by fibrin.
Findings
CT scanning is the imaging method of choice for evaluating a possible tracheobronchial tear because this modality clarifies and confirms the radiographic signs of tracheobronchial tears (Pictures 31-47) and, occasionally, adds unique information.
- With the patient in the supine position, the affected lung falls posterolaterally away from the hilum in the CT scan variation of the fallen-lung sign.
- A small pneumothorax or pneumomediastinum is more easily visible on CT scans than on radiographs.
- Subtle airway discontinuity or irregularity and small focal peritracheal or peribronchial gas collections are observed much better on CT scans.
- Active bleeding from the lacerated airway can occasionally be identified on enhanced CT scan images.
Degree of Confidence
In some instances, definitive evidence of a tracheobronchial tear is depicted on CT scans. If the diagnosis remains in doubt, reformatted images along the luminal axis of the airway or virtual endoscopy may be helpful. The high-quality images that are obtainable with multidetector CT scanners allow excellent virtual endoscopic reconstructions. In other instances, the findings are inconclusive and should be interpreted in the proper clinical context.
False Positives/Negatives
CT scanning can be falsely negative, particularly in relatively minor injuries, and bronchoscopy should be performed in patients with a strong clinical suggestion of a tracheobronchial tear.
Findings
Magnetic resonance imaging (MRI) shows findings similar to those seen on CT scanning. The primary strengths of MRI are a multiplanar display and high tissue contrast. However, these strengths are offset by the relative difficulty in preparing the patient for MRI, the fact that monitoring trauma patients is more difficult during the imaging examination, and the lower availability of MRI.
Degree of Confidence
As with CT scanning, the more common findings of tracheobronchial tears in MRI are variable, nonspecific, and only suggestive. MRI occasionally may be useful in depicting the location and extent of injury in this condition.
False Positives/Negatives
As with conventional radiography and CT scanning, MRI can be falsely negative, particularly in relatively minor injuries and in patients with a strong clinical suggestion of a tracheobronchial tear.
Findings
Patients with tracheobronchial tears have diverse presentations on ventilation-perfusion (V/Q) scans, depending on the severity of the injury.
- In minor injuries in which there is intact blood flow and no airway obstruction or pneumothorax, a tracheobronchial tear is not detectable.
- If the tracheobronchial trauma causes partial or complete airway obstruction without an associated vascular injury, normal physiologic response diminishes perfusion to the region of impaired ventilation, yielding a V/Q mismatch.
- In the most severe injuries, in which there is disruption of airflow and perfusion, a matched defect is visible.
Although these physiologic responses are identifiable on V/Q imaging, CT scanning and bronchoscopy are more specific in the diagnosis of tracheobronchial tears.
Degree of Confidence
The degree of confidence is low with nuclear imaging.
False Positives/Negatives
As with other imaging studies, false-negative examinations can occur in cases in which there are minor injuries.
Findings
Angiography is not a primary procedure for evaluating patients who have tracheobronchial trauma; however, angiography is often used to assess any associated thoracic trauma. If active bleeding is present at the tracheobronchial tear, it can be visible on aortography or pulmonary angiography.
Degree of Confidence
The degree of confidence is low with angiography.
False Positives/Negatives
Angiography does not demonstrate a tracheobronchial tear if the tear is not actively bleeding.
In patients in whom tracheal or bronchial stenosis complicates a tracheobronchial tear, a stent may be used to maintain the airway.
Medical/Legal Pitfalls
- Complications that are related to the delayed diagnosis of tracheobronchial tears are the most important medicolegal pitfalls.
| Media file 1:
Animated cine images from virtual bronchoscopy (see Images 2-29). The animation begins with a view of the carina and advances distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 3-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2, 4-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-3 and 5-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-4, 6-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-5, 7-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-6, 8-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-7, 9-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-8, 10-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-9, 11-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-10, 12-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-11, 13-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-12, 14-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-13, 15-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-14, 16-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-15, 17-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-16, 18-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-17, 19-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-18, 20-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-19, 21-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-20, 22-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-21, 23-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-22, 24-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-23, 25-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-24, 26-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-25, 27-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-26, 28-29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-27 and 29). |
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Cine image from virtual bronchoscopy (see the animation in Image 1, and view the still images in Images 2-28). |
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| Media file 30:
Frontal chest radiograph from a 26-year-old man after major trauma. This image shows complete opacification of the right hemithorax without air bronchograms, abrupt termination of the right mainstem bronchus, and multiple upper right rib fractures. |
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| Media file 31:
10-mm axial computed tomography (CT) scan of the chest with the lung window settings beginning at the level of the carina. This and the following images (also see Images 32-33) demonstrate abrupt termination of the right main bronchus and complete opacification of the right hemithorax without air bronchograms. |
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| Media file 32:
10-mm axial computed tomography (CT) scan of the chest with the lung window settings beginning at the level of the carina. These images (also see Images 31 and 33) demonstrate abrupt termination of the right main bronchus and complete opacification of the right hemithorax without air bronchograms. |
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| Media file 33:
10-mm axial computed tomography (CT) scan of the chest with the lung window settings beginning at the level of the carina. These images (also see Images 31-32) demonstrate abrupt termination of the right main bronchus and complete opacification of the right hemithorax without air bronchograms. |
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10-mm axial computed tomography (CT) scan of the chest with the mediastinal window settings beginning at the level of the carina. This and the following images (also see Images 35-37) show multiple right rib fractures and a moderate-sized pleural effusion. There is mediastinal shift toward the side of injury. Fluid density is present in the right main bronchus, probably representing hemorrhage. |
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| Media file 35:
10-mm axial computed tomography (CT) scan of the chest with the mediastinal window settings beginning at the level of the carina. These images (also see Images 34 and 36-37) show multiple right rib fractures and a moderate-sized pleural effusion. There is mediastinal shift toward the side of injury. Fluid density is present in the right main bronchus, probably representing hemorrhage. |
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| Media file 36:
10-mm axial computed tomography (CT) scan of the chest with the mediastinal window settings beginning at the level of the carina. These images (also see Images 34-35 and 37) show multiple right rib fractures and a moderate-sized pleural effusion. There is mediastinal shift toward the side of injury. Fluid density is present in the right main bronchus, probably representing hemorrhage. |
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| Media file 37:
10-mm axial computed tomography (CT) scan of the chest with the mediastinal window settings beginning at the level of the carina. These images (also see Images 34-36) show multiple right rib fractures and a moderate-sized pleural effusion. There is mediastinal shift toward the side of injury. Fluid density is present in the right main bronchus, probably representing hemorrhage. |
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| Media file 38:
5-mm axial computed tomography (CT) scan image with the lung window settings beginning at the level of the carina. This and the following images (also see Images 39-42) again demonstrate abrupt termination of the right main bronchus, complete opacification of the right hemithorax with few air bronchograms, subcutaneous emphysema, a moderate-sized anterior pneumothorax, and a pneumomediastinum. Note that the azygos vein is outlined by mediastinal gas. The superior segment of the left lower lobe is atelectatic. |
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| Media file 39:
5-mm axial computed tomography (CT) scan images with the lung window settings beginning at the level of the carina. These images (also see Images 38 and 40-42) again demonstrate abrupt termination of the right main bronchus, complete opacification of the right hemithorax with few air bronchograms, subcutaneous emphysema, a moderate-sized anterior pneumothorax, and a pneumomediastinum. Note that the azygos vein is outlined by mediastinal gas. The superior segment of the left lower lobe is atelectatic. |
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| Media file 40:
5-mm axial computed tomography (CT) scan with the lung window settings beginning at the level of the carina. These images (also see Images 38-39 and 41-42) again demonstrate abrupt termination of the right main bronchus, complete opacification of the right hemithorax with few air bronchograms, subcutaneous emphysema, a moderate-sized anterior pneumothorax, and a pneumomediastinum. Note that the azygos vein is outlined by mediastinal gas. The superior segment of the left lower lobe is atelectatic. |
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| Media file 41:
5-mm axial computed tomography (CT) scan with the lung window settings beginning at the level of the carina. These images (also see Images 38-40 and 42) again demonstrate abrupt termination of the right main bronchus, complete opacification of the right hemithorax with few air bronchograms, subcutaneous emphysema, a moderate-sized anterior pneumothorax, and a pneumomediastinum. Note that the azygos vein is outlined by mediastinal gas. The superior segment of the left lower lobe is atelectatic. |
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Media type: CT
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| Media file 42:
5-mm axial computed tomography (CT) scan with the lung window settings beginning at the level of the carina. These images (also see Images 38-41) again demonstrate abrupt termination of the right main bronchus, complete opacification of the right hemithorax with few air bronchograms, subcutaneous emphysema, a moderate-sized anterior pneumothorax, and a pneumomediastinum. Note that the azygos vein is outlined by mediastinal gas. The superior segment of the left lower lobe is atelectatic. |
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| Media file 43:
5-mm axial computed tomography (CT) scan with the mediastinal window settings beginning at the level of the carina. This and the following images (also see Images 44-47) show loculated right pleural effusion, longitudinal sternal fracture, and right rib fractures. |
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| Media file 44:
5-mm axial computed tomography (CT) scan with the mediastinal window settings beginning at the level of the carina. These images (also see Images 43 and 45-47) show loculated right pleural effusion, longitudinal sternal fracture, and right rib fractures. |
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| Media file 45:
5-mm axial computed tomography (CT) scan with the mediastinal window settings beginning at the level of the carina. These images (also see Images 43-44 and 46-47) show loculated right pleural effusion, longitudinal sternal fracture, and right rib fractures. |
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| Media file 46:
5-mm axial computed tomography (CT) scan with the mediastinal window settings beginning at the level of the carina. These images (also see Images 43-45 and 47) show loculated right pleural effusion, longitudinal sternal fracture, and right rib fractures. |
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| Media file 47:
5-mm axial computed tomography (CT) scan with the mediastinal window settings beginning at the level of the carina. These images (also see Images 43-46) show loculated right pleural effusion, longitudinal sternal fracture, and right rib fractures. |
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Tracheobronchial Tear excerpt Article Last Updated: Sep 13, 2007
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