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Tracheobronchial injury
Injury to the trachea or a main bronchus is suspected when a pneumothorax fails to resolve despite a drain, with a massive air leak and spreading subcutaneous emphysema; bronchoscopy makes the diagnosis, and bronchoscope-guided intubation beyond the injury secures ventilation before surgical repair.
Why it matters in the exam
Tracheobronchial injuries are rare but lethal, and most patients with severe injury die before reaching hospital. In blunt trauma most injuries lie within 2.5 cm of the carina, more often in the right main bronchus. The exam shows a patient after a crash with a pneumothorax, a drain inserted, and still a lung that does not expand and continuous bubbling — the picture that should raise the suspicion. Further findings: extensive subcutaneous emphysema of the neck and face, mediastinal air and haemoptysis. A typical radiological sign is the "fallen lung" — the lung drops down and laterally, away from the hilum, instead of collapsing towards it as in an ordinary pneumothorax. Late diagnosis leads to bronchial stenosis, chronic atelectasis and infection.
Treatment starts with the airway: intubation guided by a flexible bronchoscope to pass the tube beyond the injury, or selective intubation of the healthy lung, with low ventilation pressures. A second drain is sometimes needed for a large leak, and strong suction that increases the leak should not be added. Early surgical repair with absorbable sutures: the cervical trachea through a neck incision; the lower trachea, the carina and the right main bronchus through a right thoracotomy; and the left main bronchus through a left thoracotomy. A small, clean tear in the posterior membranous wall of the trachea, for example after difficult intubation, with stable ventilation and no ongoing leak, can be managed conservatively with close observation.
Combined injury of the trachea and oesophagus is possible in penetrating neck and mediastinal injury, so the oesophagus must be checked as well. Iatrogenic tracheal injury occurs mainly after emergency or difficult intubation, after percutaneous tracheostomy and in oesophageal surgery, and is sometimes found only when the patient develops subcutaneous emphysema after the procedure.
Key points
- Persistent pneumothorax with massive leak — suspect it.
- Bronchoscopy makes the diagnosis.
- Intubate beyond the injury.
- Right for the carina and right bronchus, left for the left bronchus.
- Small stable membranous tear — conservative.
Summary table
| Finding or situation | Meaning | Action |
|---|---|---|
| Unresolved pneumothorax and massive leak despite a drain | Suspected bronchial injury | Bronchoscopy |
| "Fallen lung" on X-ray | Main bronchus transection | Bronchoscopy and surgery |
| Large tear or transection | Ventilation failure | Intubation beyond the injury and early repair |
| Small membranous tear, stable ventilation | Stable injury | Conservative treatment and observation |
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Sources
- ATLS Advanced Trauma Life Support Student Course Manual, 10th edition (2018) — Thoracic trauma
- Mattox, Moore, Feliciano: Trauma, 9th edition (2020) — Trachea, bronchi and esophagus
- Shields' General Thoracic Surgery, 8th edition (2019) — Tracheobronchial injuries
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.