Airway Injuries

  • Luigia Romano
  • Antonio Pinto
  • Ciro Acampora
  • Nicola Gagliardi
  • Sonia Fulciniti
  • Massimo Silva


Among patients suffering chest blunt trauma, tracheo-bronchial injury is rare, occurring in only 0.8–2% of cases. In addition, tracheal or bronchial rupture can be determined by intubation manoeuvre and post-intubation injuries. Also penetrating injuries to the neck and thorax are often the cause of a tracheo-bronchial tear. However, high speed traffic accidents are the most frequent cause of tracheal and bronchial injuries.

Depending on the depth of damage, a wide spectrum of lesions may occur and can determine, as consequence, a mucosal-tracheal stenosis, tracheo-malacia and full-thickness stricture.

Tracheal rupture is associated with a higher morbidity and mortality.

It is supposed that 50% of patients die at the trauma scene from severe respiratory insufficiency or other associated injuries, especially significant thoracic cage harm, lung lacerations and thoracic aorta tear. In patients that survive, airway injuries have an overall mortality rate of 30%.

Most major airway injuries are not recognized early. Diagnosis of tracheal rupture may be delayed as a result of its rare incidence, subtle and non-specific clinical and radiological manifestation and for the presence of additional clinical findings of other more common associated injuries of the chest, the abdomen and the brain.

A significant number of cases are undiagnosed until complications develop either at the site of rupture, such as bronchial stenosis or dilatation, or in the lung distal to the rupture, such as atelectasis and recurrent infections.

In fact, in two thirds of airway injuries, the diagnosis is delayed with subsequent high morbidity for serious complications, such as recurrent pneumonia, empyema, pulmonary abscesses, mediastinitis, airway obstruction and atelectasis.

Generally, the most frequent symptoms of all blunt airway injuries are dyspnoea (76–100%), hoarseness (46%), subcutaneous emphysema (35–85%) and haemoptysis (14–25%).

Pain associated with swallowing and skin contusion, neck emphysema, pneumo-mediastinum and hoarseness are clinical findings that can allow to suspect the diagnosis.

Other symptoms are dyspnoea, cough, bloody saliva, haemoptysis and dysphagia. These symptoms are frequently associated with physical features as cyanosis, pneumothorax, vocal cord paralysis, aphonia and subcutaneous emphysema diffused also into shoulders and chest fat planes.

CT is considered the more relevant diagnostic tool in patients with blunt chest trauma, following the basic and essential chest X-ray film. CT can clearly demonstrate the fat planes, vessels, larynx, trachea, bronchus and oesophagus traumatic lesions, and it is the most important preoperative diagnostic imaging modality for determining the location, extent and type of airway lesions.


Blunt thoracic trauma Cervical trachea injury Mediastinal trachea tear Airway traumatic injury Tracheo-bronchial disruption Intubation manoeuvre airway injury Tracheo-bronchial partial lesions Post-intubation tracheal stenosis 


  1. 1.
    Conn JH, Hardy JD, Fain WR, et al. Thoracic trauma: analysis of 1022 cases. J Trauma. 1963;3:22–40.CrossRefGoogle Scholar
  2. 2.
    Shorr RM, Critten M, Indeck M, et al. Blunt thoracic trauma: analysis of 515 patients. Ann Surg. 1987;206:200–5.CrossRefGoogle Scholar
  3. 3.
    Lee RB. Traumatic injury of the cervicothoracic trachea and major bronchi. Chest Surg Clin N Am. 1997;7:285–304.PubMedGoogle Scholar
  4. 4.
    Glinjongol C, Pakdirat B. Management of tracheobronchial injuries: a 10 year experience at Ratchaburi Hospital. J Med Assoc Thail. 2005;88:32–40.Google Scholar
  5. 5.
    Bertelsen S, Howitz P. Injuries of the trachea and bronchi. Thorax. 1972;27:188–94.CrossRefGoogle Scholar
  6. 6.
    Wiot JF. Tracheobronchial trauma. Semin Roentgenol. 1983;18:15–22.CrossRefGoogle Scholar
  7. 7.
    Kaewlai R, Avery LL, Asrani AV, et al. Multidetector CT of blunt thoracic trauma. Radiographics. 2008;28:1555–70.CrossRefGoogle Scholar
  8. 8.
    Symbas PN, Justics AG, Ricketts RR. Rupture of the airways from blunt trauma: treatment of complex injuries. Ann Thorac Surg. 1992;54:177–83.CrossRefGoogle Scholar
  9. 9.
    Karmy-Jones R, Wood DE. Traumatic injury to the trachea and bronchus. Thorac Surg Clin. 2007;17:35–46.CrossRefGoogle Scholar
  10. 10.
    Kiser AC, O’Brien SM, Detterbeck FC. Blunt tracheobronchial injuries: treatment and outcomes. Ann Thorac Surg. 2001;71:2059–65.CrossRefGoogle Scholar
  11. 11.
    Sangster GP, Gonzales-Beicos A, Carbo AL, et al. Blunt traumatic injuries of the lung parenchyma, pleura, thoracic wall and intratoracic airways; multidetector computer tomography imaging findings. Emerg Radiol. 2007;14:297–310.CrossRefGoogle Scholar
  12. 12.
    Burke JF. Early diagnosis of traumatic rupture of the bronchus. JAMA. 1962;181:682–6.CrossRefGoogle Scholar
  13. 13.
    Valerio P, Ivan M, Francisco R, et al. Survival after traumatic complete laryngotracheal transection. Am J Emerg Med. 2008;26(837):e3–4.Google Scholar
  14. 14.
    Loh KS, Irish JC. Traumatic complications of intubation and other airway management procedures. Anesthesiol Clin North Am. 2002;20:953–69.CrossRefGoogle Scholar
  15. 15.
    Cassada DC, Munyikwa MP, Monitz MP, et al. Acute injuries of the trachea and major bronchi: importance of early diagnosis. Ann Thorac Surg. 2000;69:1563–7.CrossRefGoogle Scholar
  16. 16.
    Rossbach MM, Johnson SB, Gomez MA, et al. Management of major tracheobronchial ruptures: a 28 year experience. Ann Thorac Surg. 1998;65:182–6.CrossRefGoogle Scholar
  17. 17.
    Tcherveniak A, Tchalakov P, Tcherveniak P. Traumatic and iatrogenic lesions of the trachea and bronchi. Eur J Cardiothorac Surg. 2001;19:19–24.CrossRefGoogle Scholar
  18. 18.
    Trupka A, Waydhas C, Hallfeldt KK, et al. Value of thoracic computed tomography in the first assessment of severely injured patients with blunt chest trauma: results of a prospective study. J Trauma. 1997;43:405–11.CrossRefGoogle Scholar
  19. 19.
    Hood RM, Sloan HE. Injuries of the trachea and major bronchi. J Thorac Cardiovasc Surg. 1959;38:458–80.PubMedGoogle Scholar
  20. 20.
    Silverman PM, Zeiberg AS, Sessions RB, et al. Helical CT of the upper airway: normal and abnorml findings on three-dimensional reonstructed images. AJR. 1995;165:541–6.CrossRefGoogle Scholar
  21. 21.
    Macklin MT, Macklin CC. Malignant interstitial emphysema of the lungs and mediastinum. Medicine. 1944;23:281–358.CrossRefGoogle Scholar
  22. 22.
    Tocino IM, Miller MH. Mediastinal trauma and other acute mediastinal conditions. J Thorac Imag. 1987;2:79–100.CrossRefGoogle Scholar
  23. 23.
    Chesteman JT, Satsangi PH. Rupture of the trachea and bronchi by closed injury. Thorax. 1966;21:21–7.CrossRefGoogle Scholar
  24. 24.
    Stark P. Imaging of tracheobronchial injuries. J Thoracic Imaging. 1995;10:206–19.CrossRefGoogle Scholar
  25. 25.
    Epelman M, Ofer A, Klein V, et al. CT diagnosis of traumatic rupture in children. Pediatr Radiol. 2002;1(32):888–91.CrossRefGoogle Scholar
  26. 26.
    Chen JD, Shanmuganathan K, Mirvis SE, et al. Using CT to diagnose tracheal rupture. AJR. 2001;176:1273–80.CrossRefGoogle Scholar
  27. 27.
    Meislin HW, Iserson KV, Kaback KR. Airway trauma. Emerg Med Clin North Am. 1983;1:295–312.PubMedGoogle Scholar
  28. 28.
    Thack D, Defrance P, Delcour C, et al. The CT fallen lung sign. Eur Radiol. 2000;10:719–21.CrossRefGoogle Scholar
  29. 29.
    Wintermark M, Schnyder P, Wicky S. Blunt traumatic rupture of a main bronchus: spiral CT demonstration of the fallen lung sign. Eur Radiol. 2001;11:409–11.CrossRefGoogle Scholar
  30. 30.
    Almasi M, Andrasovska M, Koval J. Blunt external trauma to the trachea: report of two cases. B-ENT. 2005;1:93–6.PubMedGoogle Scholar
  31. 31.
    Kirsh MM, Orriger MB, Behrendt DM, et al. Management of tracheobronchial disruption secondary to nonpenetrating trauma. Ann Thorac Surg. 1976;22:93–101.CrossRefGoogle Scholar
  32. 32.
    Rollins RJ, Tocino I. Early radiographic signs of tracheal rupture. AJR. 1987;148:695–8.CrossRefGoogle Scholar
  33. 33.
    Ejigelaar A, Homan van der Heide JN. A reliable early symptom of bronchial or tracheal rupture. Thorax. 1970;25:120–5.CrossRefGoogle Scholar
  34. 34.
    Karaaslan T, Meuli R, Androux R, et al. Traumatic chest lesions in patients with severe head trauma: a comparative study with computed tomography and conventional chest roentgenograms. J Trauma. 1995;39:1081–6.CrossRefGoogle Scholar
  35. 35.
    Atkins BZ, Abbate S, Fisher SR, et al. Current management of laryngotracheal trauma: case report and literature review. J Trauma. 2004;56:185–90.CrossRefGoogle Scholar
  36. 36.
    Nishiumi N, Maitani F, Yamada S, et al. Chest radiography assessment of tracheobronchial disruption associated with blunt chest trauma. J Trauma. 2002;53:372–7.CrossRefGoogle Scholar
  37. 37.
    Macklin CC. Transport of air along sheats of pulmonic blood vessells from alveoli to mediastinum: clinical implications. Arch Inter Med. 1939;64:913–26.CrossRefGoogle Scholar
  38. 38.
    Balci AE, Eren N, Eren S, et al. Surgical tratment of post traumatic tracheobronchial injuries: 14 year experience. Eur J Cardiothorac Surg. 2002;22:984–9.CrossRefGoogle Scholar
  39. 39.
    Mussi A, Ambrogi MC, Ribecchini A, et al. Acute major airway injuries: clinical features and management. Eur J Cardiothorac Surg. 2001;20:46–51.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Luigia Romano
    • 1
  • Antonio Pinto
    • 1
  • Ciro Acampora
    • 1
  • Nicola Gagliardi
    • 1
  • Sonia Fulciniti
    • 1
  • Massimo Silva
    • 1
  1. 1.Department of RadiologyA.O.R.N. A. CardarelliNaplesItaly

Personalised recommendations