tracheobronchial injury tracheobronchial injury tracheobronchial injury is damage to the tracheobronchial tree (the airway structure involving the trachea and bronchi). it can result from blunt or penetrating trauma to the neck or chest, inhalation of harmful fumes or smoke, or aspiration of liquids or objects. tracheobronchial injuryreconstruction of the trachea and bronchi with x-ray computed tomography showing disruption of the right main bronchus with abnormal lucency (arrow)specialtyemergency medicine though rare, tbi is a serious condition; it may cause obstruction of the airway with resulting life-threatening respiratory insufficiency. other injuries accompany tbi in about half of cases. of those people with tbi who die, most do so before receiving emergency care, either from airway obstruction, exsanguination, or from injuries to other vital organs. of those who do reach a hospital, the mortality rate may be as high as 30%. tbi is frequently difficult to diagnose and treat. early diagnosis is important to prevent complications, which include stenosis (narrowing) of the airway, respiratory tract infection, and damage to the lung tissue. diagnosis involves procedures such as bronchoscopy, radiography, and x-ray computed tomography to visualize the tracheobronchial tree. signs and symptoms vary based on the location and severity of the injury; they commonly include dyspnea (difficulty breathing), dysphonia (a condition where the voice can be hoarse, weak, or excessively breathy), coughing, and abnormal breath sounds. in the emergency setting, tracheal intubation can be used to ensure that the airway remains open. in severe cases, surgery may be necessary to repair a tbi. signs and symptoms pneumothoraces of both lungs (large arrows), pneumomediastinum (small arrow) and subcutaneous emphysema in a patient with complete disruption of the right bronchus. air leak was continual despite suction. signs and symptoms vary depending on what part of the tracheobronchial tree is injured and how severely it is damaged. there are no direct signs of tbi, but certain signs suggest the injury and raise a clinician's suspicion that it has occurred. many of the signs and symptoms are also present in injuries with similar injury mechanisms such as pneumothorax. dyspnea and respiratory distress are found in 76–100% of people with tbi, and coughing up blood has been found in up to 25%. however, isolated tbi does not usually cause profuse bleeding; if such bleeding is observed it is likely to be due to another injury such as a ruptured large blood vessel. the patient may exhibit dysphonia or have diminished breath sounds, and rapid breathing is common. coughing may be present, and stridor, an abnormal, high-pitched breath sound indicating obstruction of the upper airway can also occur. damage to the airways can cause subcutaneous emphysema (air trapped in the subcutaneous tissue of the skin) in the abdomen, chest, neck, and head. subcutaneous emphysema, present in up to 85% of people with tbi, is particularly indicative of the injury when it is only in the neck. air is trapped in the chest cavity outside the lungs (pneumothorax) in about 70% of tbi. especially strong evidence that tbi has occurred is failure of a pneumothorax to resolve even when a chest tube is placed to rid the chest cavity of the air; it shows that air is continually leaking into the chest cavity from the site of the tear. air can also be trapped in the mediastinum, the center of the chest cavity (pneumomediastinum). if air escapes from a penetrating injury to the neck, a definite diagnosis of tbi can be made. hamman's sign, a sound of crackling that occurs in time with the heartbeat, may also accompany tbi. causes injuries to the tracheobronchial tree within the chest may occur due to penetrating forces such as gunshot wounds, but are more often the result of blunt trauma. tbi due blunt forces usually results from high-energy impacts such as falls from height and motor vehicle accidents; the injury is rare in low-impact mechanisms. injuries of the trachea cause about 1% of traffic-related deaths. other potential causes are falls from high places and injuries in which the chest is crushed. explosions are another cause. gunshot wounds are the commonest form of penetrating trauma that cause tbi. less commonly, knife wounds and shrapnel from motor vehicle accidents can also penetrate the airways. most injuries to the trachea occur in the neck, because the airways within the chest are deep and therefore well protected; however, up to a quarter of tbi resulting from penetrating trauma occurs within the chest. injury to the cervical trachea usually affects the anterior (front) part of the trachea. certain medical procedures can also injure the airways; these include tracheal intubation, bronchoscopy, and tracheotomy. the back of the trachea may be damaged during tracheotomy. tbi resulting from tracheal intubation (insertion of a tube into the trachea) is rare, and the mechanism by which it occurs is unclear. however, one likely mechanism involves an endotracheal tube catching in a fold of membrane and tearing it as it is advanced downward through the airway. when an endotracheal tube tears the trachea, it typically does so at the posterior (back) membranous wall. unlike tbi that results from blunt trauma, most iatrogenic injuries to the airway involve longitudinal tears to the back of the trachea or tears on the side that pull the membranous part of the trachea away from the cartilage. excessive pressure from the cuff of an endotracheal tube can reduce blood supply to the tissues of the trachea, leading to ischemia and potentially causing it to become ulcerated, infected, and, later, narrowed. the mucosal lining of the trachea may also be injured by inhalation of hot gases or harmful fumes such as chlorine gas. this can lead to edema (swelling), necrosis (death of the tissue), scar formation, and ultimately stenosis. however, tbi due to inhalation, foreign body aspiration, and medical procedures is uncommon. mechanism the structures in the tracheobronchial tree are well protected, so it normally takes a large amount of force to injure them. in blunt trauma, tbi is usually the result of violent compression of the chest. rapid hyperextension of the neck, usually resulting from vehicle crashes, can also injure the trachea, and trauma to the neck can crush the trachea against the vertebrae. a crush injury of the larynx or cervical trachea can occur in head-on collisions when the neck is hyperextended and strikes the steering wheel or dashboard; this has been called a "dashboard injury". the larynx and cervical trachea may also be injured in front-on collisions by the seat belt. although the mechanism is not well understood, tbi due to blunt trauma is widely thought to be caused by any combination of three possible mechanisms: an increase in pressure within the airways, shearing, and pulling apart. the first type of injury, sometimes called an "explosive rupture", may occur when the chest is violently compressed, for example when a driver strikes the steering wheel in a vehicle accident or when the chest is crushed. the pressure in the airways, especially the larger airways (the trachea and bronchi), quickly rises as a result of the compression, because the glottis reflexively closes off the airways. when this pressure exceeds the elasticity of the tissues, they burst; thus the membranous part of the trachea is more commonly affected by this mechanism of injury than cartilaginous portions. the second mechanism may occur when the chest is suddenly decelerated, as occurs in vehicle accidents, producing a shearing force. the lungs are mobile in the chest cavity but their movement is more restricted near the hilum. areas near the cricoid cartilage and carina are fixed to the thyroid cartilage and the pericardium respectively; thus if the airways move, they can tear at these points of fixation. the third mechanism occurs when the chest is compressed from front to back, causing it to widen from side to side. the lungs adhere to the chest wall because of the negative pressure between them and the pleural membranes lining the inside of the chest cavity; thus when the chest widens, they are pulled apart. this creates tension at the carina; the airway tears if this tensile force exceeds its elasticity. this mechanism may be the cause of injury when the chest is crushed. most tbi are probably due to a combination of these three mechanisms. when airways are damaged, air can escape from them and be trapped in the surrounding tissues in the neck (subcutaneous emphysema) and mediastinum (pneumomediastinum); if it builds up to high enough pressures there, it can compress the airways. massive air leaks from a ruptured airway can also compromise the circulation by preventing blood from returning to the heart from the head and lower body; this causes a potentially deadly reduction in the amount of blood the heart is able to pump out. blood and other fluids can build up in the airways, and the injury can interfere with the patency of the airway and interfere with its continuity. however, even if the trachea is completely transected, the tissues surrounding it may hold it together enough for adequate air exchange to occur, at least at first. anatomy diagram of the larynx, trachea and bronchi the trachea and bronchi form the tracheobronchial tree. the trachea is situated between the lower end of the larynx and the center of the chest, where it splits into the two bronchi at a ridge called the carina. the trachea is stabilized and kept open by rings made of cartilage that surround the front and sides of the structure; these rings are not closed and do not surround the back, which is made of membrane. the bronchi split into smaller branches and then to bronchioles that supply air to the alveoli, the tiny air-filled sacs in the lungs responsible for absorbing oxygen. an arbitrary division can be made between the intrathoracic and cervical trachea at the thoracic inlet, an opening at the top of the thoracic cavity. anatomical structures that surround and protect the tracheobronchial tree include the lungs, the esophagus, large blood vessels, the rib cage, the thoracic spine, and the sternum. children have softer tracheas and a more elastic tracheobronchial trees than adults; this elasticity, which helps protect the structures from injury when they are compressed, may contribute to the lower incidence of tbi in children. diagnosis a patient with traumatic complete disruption of the right bronchus. computed tomography scan following emergency chest tube drainage. axial 1.25 mm thick sections with a lung window. (a) persistent bilateral pneumothorax, pneumomediastinum and extensive subcutaneous emphysema. (b) multiple lucencies around the right bronchial tree (curved arrow) precluding the correct recognition of the bronchial rupture. (c) the macklin effect around the right lower pulmonary vein (white arrow). (d) coronal view demonstrating multiple areas of alveolar consolidation in the right upper and lower lobes: intraparenchymal lucencies resulting from lung lacerations are visible on the right side (thick arrows). rapid diagnosis and treatment are important in the care of tbi; if the injury is not diagnosed shortly after the injury, the risk of complications is higher. bronchoscopy is the most effective method to diagnose, locate, and determine the severity of tbi, and it is usually the only method that allows a definitive diagnosis. diagnosis with a flexible bronchoscope, which allows the injury to be visualized directly, is the fastest and most reliable technique. in people with tbi, bronchoscopy may reveal that the airway is torn, or that the airways are blocked by blood, or that a bronchus has collapsed, obscuring more distal (lower) bronchi from view. chest x-ray is the initial imaging technique used to diagnose tbi. the film may not have any signs in an otherwise asymptomatic patient. indications of tbi seen on radiographs include deformity in the trachea or a defect in the tracheal wall. radiography may also show cervical emphysema, air in the tissues of the neck. x-rays may also show accompanying injuries and signs such as fractures and subcutaneous emphysema. if subcutaneous emphysema occurs and the hyoid bone appears in an x-ray to be sitting unusually high in the throat, it may be an indication that the trachea has been severed. tbi is also suspected if an endotracheal tube appears in an x-ray to be out of place, or if its cuff appears to be more full than normal or to protrude through a tear in the airway. if a bronchus is torn all the way around,