Acute tracheobronchial injuries: Impact of imaging on diagnosis and management implications

PURPOSE: To evaluate the role of chest radiography, single-slice CT and 16-row MDCT in the direct evidence of tracheobronchial injuries. METHODS: Patients with acute tracheobronchial injury were identified from the registry of our level 1 trauma center during a 5-year period ending July 2005. Findings at chest radiograph and CT were compared to those shown at bronchoscopy. RESULTS: Eighteen patients with tracheobronchial injury - three patients with cervical trachea injury, eight with thoracic trachea injury and seven with bronchial injury - were identified. Twelve patients had a blunt trauma (67%), six patients had a penetrating (iatrogenic) injury (33%). Chest radiograph directly identified the site of tracheal injury in four cases, showing overdistension of the endotracheal cuff in three cases and displacement of the endotracheal tube in one case. At the level of the bronchi, chest radiograph demonstrated only one injury. CT directly identified the site of tracheal injury in all the cases showing the overdistension of the endotracheal cuff at the level of the thoracic trachea (three cases), posterior herniation of the endotracheal cuff at the thoracic trachea (three cases), lateral endotracheal cuff herniation at the thoracic trachea (one case), tracheal wall discontinuity at the cervical (one case) and at the thoracic trachea (one case) and displacement of endotracheal tube at the cervical trachea (two cases). At the level of the bronchi, CT correctly showed the site of injury in six case including: discontinuity of the left main bronchial wall (two cases), the "fallen lung" sign (one case), right main bronchial wall enlargement (one case), discontinuity of the right middle bronchial wall (two cases). In one case, CT showed just direct "air leak" at the level of the carina suggesting main bronchus injury. This finding was confirmed by bronchoscopy. CONCLUSION: Chest radiograph was helpful for the assessment of iatrogenic tracheal injuries. CT detected the site of blunt tracheobronchial injuries in 94% of the cases. Multiplanar 16-row MDCT reconstructions, were essential for the optimal surgical approach.