Tracheal Trauma (Windpipe Injury)

What is Tracheal Trauma (Windpipe Injury)?

The trachea, also known as the windpipe, is like a tube that starts at the base of the neck and extends to the chest, connecting the throat and voice box to the lungs. This tube is divided into two parts: one in the neck (cervical portion) and the other in the chest (thoracic portion). The trachea splits into two smaller tubes (right and left primary bronchi) which deliver air in and out of the lungs. The structure of the trachea includes 18 to 22 ring-like parts, which are firm at the front and sides but soft at the back. It receives blood supply from a branch of the subclavian artery in the neck and bronchial arteries branching from the main body artery (aorta) in the chest. Located near important body structures like the esophagus, nerves, thyroid, arteries, veins, and spinal cord, an injury to the trachea often involves injury to these structures too.

Injuries to the trachea are not common but can be caused by medical procedures, inhalation of harmful substances, sharp or blunt force injuries. Such injuries happen quickly, like from a stabbing or crushing force, or slowly, like from a medical tube inflated too much and pressed against the trachea for a long time. The trachea might get a cut, twist, or linear tear, with different levels of tissue damage. Many experts think that tracheal injuries are often overlooked because medical procedure-related injuries aren’t reported enough and victims of harmful injuries often die before reaching the hospital. Tracheal injuries can also involve injury to nearby structures like the neckbones, blood vessels, or digestive tract. This can lead to serious health concerns and risk of death. Therefore, it’s critical to diagnose and surgically repair the trachea early to avoid complications and breathing problems.

Spotting tracheal injuries early is crucial to prevent further health problems or death. A person with tracheal injury might have different symptoms depending on their injury and the effect on nearby structures. Common signs in urgent cases include a condition where air leaks into the skin, chest, or around the lungs with or without breathing failure. Other symptoms can be coughing up bloody mucus, feeling short of breath, having difficulty swallowing, air in the abdominal cavity, and chest pain. Most frequently seen signs of trachea injury are breathing pain, air leak in the chest, air around the lungs, and air leak under the skin.

When managing a tracheal injury, it’s crucial to consider the patient’s injuries, symptoms, and type of injury to the trachea, often needing a team of different healthcare professionals. The first step in treating a tracheal injury is to secure a clear breathing path and address other injuries. Often, a breathing tube is placed into the windpipe using a camera device while the patient is awake, and the tube goes beyond the site of the injury. Based on the cause, depth, and other accompanying injuries, the repair of the tear can be done either conservatively or surgically. But even with early detection and proper management, complications like reduced lung function, infection, inability to speak, or narrowing of the trachea might occur.

What Causes Tracheal Trauma (Windpipe Injury)?

Damage to the windpipe, or trachea, is usually caused by accidents or medical procedures. These could be sudden events like a stab or crash, or slower ones like a breathing tube putting too much pressure on the windpipe over a long time. This sort of damage can happen in the parts of the windpipe in the neck or chest. Typically, any damage in the neck is more visible, but injury to the chest area might be overlooked.

When damage is done to the airways, it is usually a bronchial injury, especially in the case of blunt trauma. This happens because the bronchi, or the air passages, are quite rigid and can be disrupted by shearing forces.

There are different types of injuries that can cause tracheal damage:

Penetrating injuries can happen to the neck and chest, and in these cases, it’s crucial to watch out for potential windpipe damage. While this kind of injury often happens in the neck parts of the windpipe, it can happen anywhere along the windpipe and affect any nearby structures. Gunshot wounds need to be treated with extra caution due to the blast force.

Blunt force trauma is the most common cause of windpipe injury. This can happen from direct hits, squeezing or strangling, severe bending or straightening of the neck, or crush injuries to the chest. These types of injuries are most commonly seen in car accidents. Blunt trauma usually damages the chest part of the windpipe and can cause other injuries in the chest and neck. If the windpipe in the neck is damaged by blunt trauma, it is usually the hard, cartilage regions that are affected.

Injuries from medical procedures can also cause windpipe damage. These can include injuries from tracheostomy (a surgical procedure to create an opening in the neck for breath), intubation (inserting a tube down the throat), and bronchoscopy (looking at the airways through a thin viewing device). These procedures can lead to complications depending on the emergency situation, the skills of the healthcare professional, improper use of a certain tool, and adjusting the tube when the cuff is blocked. People aged 50-70, those with a higher body mass index, females, and long-term steroid users are at higher risk of windpipe damage from medical procedures.

Inhalation or aspiration injuries can also damage the endotrachea, which is the inner part of the windpipe. This can occur through inhaling harmful or hot gas, steam, fumes, or swallowing foreign objects. These injuries damage the mucus lining of the windpipe, causing inflammation, ulcers, and softening the cartilaginous parts of the windpipe.

Risk Factors and Frequency for Tracheal Trauma (Windpipe Injury)

Tracheal trauma, or injury to the windpipe, is believed to be underreported, making it difficult to fully understand its occurrence rate. These injuries can be life-threatening with more than 80% of people suffering from them not surviving the journey to the hospital. It is estimated that for every 125,000 cases, one patient will present at the emergency room with a laryngotracheal injury. However, some have suggested that this incidence could be as high as 1 in 30,000.

Tracheal injuries are not very common in cases of blunt chest injury, occurring in roughly 2.1% to 5.3% of these patients. When they do occur, they are generally caused by blunt trauma to the chest. This can include direct blows, compression, strangulation, or rapid movement injuries. About 60% of the injuries to the larynx (the voice box) come from blunt trauma.

The trachea and the larynx in the upper airway can also be injured. Two-thirds of these injuries involve the cervical trachea, the part of the windpipe in the neck, while the final third involve the larynx. Despite being relatively rare, stab wounds to the neck can most commonly hurt the trachea. Tracheal injuries are especially common in patients with simultaneous neck, blood vessel, or digestive tract injuries. If a person dies because of such a stab wound, it’s usually linked to the blood vessel injury, not the airway injury.

Failed or incorrect intubation attempts – a process where a tube is inserted into the trachea to assist with breathing – can also cause fatal injuries. According to some reports, tracheal injury due to this procedure is calculated to occur in 0.005% to 0.37% of cases. Often, these injuries need surgical reconstruction of the trachea and are usually linked to tracheostomies and endotracheal intubation. The most common among these are tube cuff injuries.

The occurrence of inhalation injuries can be seen in 10% to 20% patients admitted with burn injuries. In a shocking turn of events, up to 25% of patients requiring surgery for acute laryngotracheal trauma do not show any physical signs of injury at first, and symptoms may only appear after 24 to 48 hours. Therefore, being highly vigilant is important in order to identify hidden injuries, as a delay in diagnosis and treatment can lead to worse outcomes.

Finally, the death rate in patients with acute trauma to the trachea is quite high, reported to be within 15% to 40% range, depending on the injury mechanism and classification.

Signs and Symptoms of Tracheal Trauma (Windpipe Injury)

Tracheal trauma, or injury to the windpipe, can present in different ways depending on the cause of the injury and what other bodily structures are involved. Common signs of this condition in an emergency setting include subcutaneous emphysema, pneumomediastinum, and pneumothorax, which can occur with or without respiratory failure. Additional symptoms could be blood-tinged spit, coughing up blood, shortness of breath, difficulty swallowing, pneumoperitoneum, and chest pain.

Interestingly, in about 85% of cases, the first symptom noticed is a hoarse voice. Some people, about 25% of cases, may cough up blood due to damage to the lining of the windpipe, and severe cases could indicate vascular injury. Occasionally, symptoms may not appear immediately but rather show up later when tracheal injuries happen unintentionally during medical procedures, like extubation or endotracheal tube trauma, because the tube’s cuff temporarily seals the injured area.

Such injuries should be suspected in patients with multiple trauma or those on mechanical ventilation showing persistent pneumothorax (collapsed lung) or air leakage or experiencing acute respiratory distress right after extubation. Importantly, diagnosing tracheal trauma based on symptoms alone is tricky as other conditions, like rib fractures and traumatic chest injury, can present similarly.

In cases of subacute tracheal injuries, such as tracheoesophageal fistulas (abnormal connection between the trachea and esophagus) and laryngotracheal stenosis (narrowing of the windpipe), symptoms may include cough, aspiration (breathing foreign objects into the airways), fever, difficulty swallowing, coughing up blood, and chest pain.

Hoarse voice
Blood-tinged spit
Coughing up blood
Shortness of breath
Difficulty swallowing
Pneumoperitoneum
Chest pain
Cough
Aspiration
Fever

Upon physical examination, meaningful findings might be stridor (a high-pitched wheezing sound), cyanosis (bluish discoloration of the skin), dyspnea (difficulty breathing), voice changes or hoarseness, subcutaneous emphysema, and mediastinal crunch (a crunching sound heard on auscultation). The combination of dyspnea, stridor, and hoarseness is called the “laryngeal triad” and is indicative of laryngotracheal trauma. However, the absence of these signs does not rule out a tracheal injury, as patients might not show any symptoms for the first 24 to 48 hours. Swelling, a changed shape of the thyroid cartilage (Adam’s apple), crepitus (crackling sound), or a decreased breathing rate might also be observed. If air bubbles are coming out from a penetrating neck wound, this indicates a tracheobronchial injury.

Testing for Tracheal Trauma (Windpipe Injury)

For someone experiencing tracheal trauma, they’re likely to be treated based on the ABCs (Airway, Breathing, and Circulation) when they first get to the emergency room. Because this kind of injury can quickly get worse, and patients might need to lie flat, doctors tend to manage their airway quickly. They’ll usually use a double setup (preparing for cricothyrotomy) and consider awake intubation due to concerns about collapsing airway structures. Other treatments could include suctioning secretions to help with ventilation and oxygen supply, setting up IV access, and starting fluid resuscitation when needed.

Once their airway is secure, doctors will continue their full examination of the patient. The tools they often use to assess a tracheal injury include x-rays or computed tomography (CT) scans of the neck or chest, or a bronchoscopy. An x-ray is usually the first step to spot things like a pneumothorax, pneumomediastinum, or tracheal deviation which can suggest a tracheal injury. If the patient is stable, a CT scan of the neck and chest is the best way to visualize other conditions and injuries.

However, if the patient’s airway isn’t secure, a CT scan isn’t ideal since lying down for the scan could lead to an airway collapse. Up to 70% of patients with acute tracheobronchial injury will have a pneumothorax; 60% will have pneumomediastinum and cervical emphysema. While CT is better than x-rays, it might miss injuries due to adjacent swelling, bleeding, or secretions. But, CT can also spot injuries to areas near the trachea, and vascular disruptions when IV contrast is used. A CT angiogram may be performed to check for injuries in the blood vessels, particularly the carotid artery in patients with tracheobronchial trauma.

Bronchoscopy is the best method to diagnose tracheal trauma as it allows doctors to visualize (for example, the location and severity) tracheal injuries and plan the best course of action. Tracheal injuries are mainly classified using the Schaefer Classification System, and this system helps doctors understand the severity of the tracheal injury to make decisions about treatment. Other classifications like the Cardillo Tracheal Injury Classification system have also been proposed recently.

Treatment Options for Tracheal Trauma (Windpipe Injury)

Tracheal trauma refers to injuries to the windpipe, and managing this condition involves evaluating the patient’s symptoms and the type of injury. According to the Schaefer Classification System, the seriousness of the tracheal injury could guide the treatment plan.

When a patient presents with a tracheal injury, the first and most crucial step is to ensure a safe open airway and treat other associated injuries. It’s important to diagnose tracheal trauma early to prevent making the injury worse, especially during the standard process of securing the airway often used in emergencies.

The best way to secure the airway in patients with tracheal injuries involves being awake and using a flexible bronchoscope, a device used to see the inside of the airways and lungs. This approach is beneficial because it limits the lack of oxygen and loss of muscle tone. Rapid loss of oxygen can be very dangerous and in certain cases, a different technique might be more suitable, such as rigid bronchoscopy with inhalation induction. This technique is particularly helpful if there are obstructions, but it’s harder for patients who can’t extend their neck due to cervical instability. In cases with repeated unsuccessful attempts to secure the airway with a tube, a tracheostomy may be required.

Conservative management could work better than surgical intervention in some cases, such as minor or accidental injuries to the trachea. As a part of the treatment, the patient may receive humidified oxygen, antibiotics, steroids, and specific medications. They will also need to maintain head elevation, voice rest, and undergo regular observation in a critical care setting. In certain conditions and patients, surgical adhesive glue and stenting might also be beneficial.

Surgical intervention might be necessary for more severe tracheal injuries. The kind of surgical technique used will depend on the site and severity of the injury. After accessing the injured area, the wound should be thoroughly cleaned and closed using absorbable stitches. In extreme cases, particularly when the trachea is completely cut, specific complex surgical procedures may be required to restore it.

After surgery, the patient will likely need a period of head immobilization, antibiotic coverage, incentives to improve ventilation, and possibly additional treatments such as steroids and cough suppressants. This comprehensive management strategy aims to restore lung function and reduce complications.

Damage to the windpipe, also known as the trachea, often happens through blunt or sharp injuries. In such cases, it’s also very likely that nearby structures get damaged. These can include:

The larynx (voice box)
The bronchi (major air passages)
The lung tissue
The esophagus (food pipe)
Certain nerves in the neck like the recurrent laryngeal nerve and the vagus nerve
Important blood vessels like the carotid arteries and jugular veins, and those in the lung and heart
The surrounding muscles

There are also other possible causes for the patient’s symptoms, which could include:

Other reasons causing low oxygen levels and shortness of breath (for example, a collapsed lung or injury to the lung tissue)
An airway blockage possibly accompanied by changes in the patient’s consciousness level due to a head injury or facial trauma
Injuries to major blood vessels in the chest and neck that could cause a growing blood clot

What to expect with Tracheal Trauma (Windpipe Injury)

Getting quick and effective medical care can lead to better health outcomes and prevent issues like scar tissue, infections, and other complications. However, mortality rates have decreased from 36% (pre-1950) to 9% in 2001, largely due to earlier detection of issues, associated injuries, and the root cause of the disease/injury.

It’s been observed that tracheal injuries caused by blunt force fare better than those caused by crushing. Surprisingly, when tracheal traumas were associated with other injuries, the tracheal injury was found to be the cause of fatality in 40% to 100% of the cases. Importantly, detecting these issues early and treating them appropriately lead to satisfactory outcomes for more than 90% of patients.

Possible Complications When Diagnosed with Tracheal Trauma (Windpipe Injury)

Tracheal injuries can result in serious complications right away, with the most immediate being the collapse of the airway. However, even if managed appropriately, there are many other potential problems that must be considered. These could include lung infections, severe body-wide infections, and failures of multiple organ systems – all of which significantly increase the risk of death. There might also be a long-lasting reduction in lung function due to conditions like atelectasis and bronchiectasis.

Here are a few of the other complications that might occur as an aftermath of a tracheal injury:

Inhaling foreign matter into the lungs (aspiration)
Collection of air in the space around the lungs (pneumothorax)
Blockage in the airway due to a build-up of blood or inflammation
Long-term narrowing of the air passage due to scar tissue (chronic stenosis)
Issues involving voice production, generally after an impact injury, more so if treatment is delayed by over 24 hours
Abnormal opening between the windpipe and the oesophagus (Tracheoesophageal fistula)
Damage to the recurrent laryngeal nerve
Infections related to the lung and surgical wounds.

In addition, bubbles of air trapped under the skin (subcutaneous emphysema) or air collection in the chest cavity (pneumomediastinum) can occur. These conditions could lead to a growing blockage in the air passage and a dangerous situation where the air bubbles enter the bloodstream.

Recovery from Tracheal Trauma (Windpipe Injury)

After a surgical procedure to fix a trachea injury, it is essential to take several steps for proper post-surgery care:

* In cases where surgery was performed, the neck should be held at a bend (often called Pearson position) for 1 to 2 weeks. This helps to relieve pressure from the repaired area of the airway.
* The head of the bed should be raised to reduce swelling.
* It is advisable to take broad-spectrum antibiotics as a precaution.
* Lastly, make sure that the balloon inside the trachea (endotracheal balloon) doesn’t cover the repaired area as this could hinder healing.

Preventing Tracheal Trauma (Windpipe Injury)

Tracheal injuries, which can happen due to medical procedures or accidents, are mostly avoidable. Both doctors and patients can help to lessen the chance of these injuries. Doctors can use low-pressure cuffs on breathing tubes, ensure the right sized tubes are used and avoid over-inflation. It’s also important for doctors to use styles and bougies correctly to avoid harming the windpipe. Additionally, if a difficult intubation is anticipated or an injury to the windpipe is suspected, doctors can use a flexible bronchoscope. This device allows them to see potential injuries and prevents them from making incorrect insertions and worsening the injury.

Continuous training in advanced trauma handling for healthcare professionals can also lower the death rate associated with tracheal injuries. Improvements in vehicle safety features, like seat belts and airbags, have a big part to play as they can help decrease injuries caused by car accidents. Safety measures like using neck protection while riding motorcycles or all-terrain vehicles can also help prevent windpipe injuries. Furthermore, reducing the number of suicides can also help in decreasing preventable tracheal injuries.

Frequently asked questions

Tracheal trauma, also known as windpipe injury, refers to injuries to the trachea, which is the tube that connects the throat and voice box to the lungs. These injuries can be caused by medical procedures, inhalation of harmful substances, or sharp or blunt force injuries. They can result in various symptoms and complications, and early diagnosis and surgical repair are crucial to prevent further health problems or death.

Tracheal trauma (windpipe injury) is relatively rare.

Signs and symptoms of Tracheal Trauma (Windpipe Injury) include: - Subcutaneous emphysema - Pneumomediastinum - Pneumothorax (collapsed lung) - Blood-tinged spit - Coughing up blood - Shortness of breath - Difficulty swallowing - Pneumoperitoneum - Chest pain - Hoarse voice (noticed in about 85% of cases) - Coughing up blood (in about 25% of cases) - Vascular injury (in severe cases) - Delayed symptoms in cases of unintentional tracheal injuries during medical procedures - Persistent pneumothorax or air leakage in patients with multiple trauma or on mechanical ventilation - Acute respiratory distress after extubation - Subacute tracheal injuries may present with cough, aspiration, fever, difficulty swallowing, coughing up blood, and chest pain - Physical examination findings may include stridor, cyanosis, dyspnea, voice changes or hoarseness, subcutaneous emphysema, mediastinal crunch, swelling, changed shape of the thyroid cartilage, crepitus, decreased breathing rate, and air bubbles coming out from a penetrating neck wound indicating tracheobronchial injury.

Tracheal trauma, or windpipe injury, can occur due to accidents, medical procedures, inhalation or aspiration injuries, and blunt force trauma.

The doctor needs to rule out the following conditions when diagnosing Tracheal Trauma (Windpipe Injury): 1. Damage to nearby structures such as the larynx (voice box), bronchi (major air passages), lung tissue, esophagus (food pipe), certain nerves in the neck (recurrent laryngeal nerve and vagus nerve), important blood vessels (carotid arteries and jugular veins, and those in the lung and heart), and surrounding muscles. 2. Other reasons causing low oxygen levels and shortness of breath, such as a collapsed lung or injury to the lung tissue. 3. An airway blockage possibly accompanied by changes in the patient's consciousness level due to a head injury or facial trauma. 4. Injuries to major blood vessels in the chest and neck that could cause a growing blood clot.

The types of tests that are needed for Tracheal Trauma (Windpipe Injury) include: 1. X-rays or computed tomography (CT) scans of the neck or chest: These tests can help identify conditions such as pneumothorax, pneumomediastinum, or tracheal deviation that may suggest a tracheal injury. 2. Bronchoscopy: This is the best method to diagnose tracheal trauma as it allows doctors to visualize the location and severity of tracheal injuries and plan the best course of action. 3. CT angiogram: This test may be performed to check for injuries in the blood vessels, particularly the carotid artery in patients with tracheobronchial trauma. It is important to note that the choice of test depends on the stability of the patient's airway. If the airway is not secure, a CT scan may not be ideal as lying down for the scan could lead to an airway collapse.

The treatment for tracheal trauma involves evaluating the patient's symptoms and the type of injury. The seriousness of the tracheal injury, as determined by the Schaefer Classification System, guides the treatment plan. The first step is to ensure a safe open airway and treat any associated injuries. Securing the airway is typically done using a flexible bronchoscope, which allows for a better view of the airways and lungs. In some cases, a different technique, such as rigid bronchoscopy with inhalation induction, may be used. Conservative management, including humidified oxygen, antibiotics, steroids, and specific medications, may be sufficient for minor or accidental injuries. Surgical intervention may be necessary for more severe injuries, with the specific technique depending on the site and severity of the injury. After surgery, the patient may need head immobilization, antibiotics, incentives to improve ventilation, and additional treatments to restore lung function and reduce complications.

When treating Tracheal Trauma (Windpipe Injury), there are several potential side effects and complications that may occur. These include: - Collapse of the airway - Lung infections - Severe body-wide infections - Failures of multiple organ systems - Long-lasting reduction in lung function (atelectasis and bronchiectasis) - Aspiration (inhaling foreign matter into the lungs) - Pneumothorax (collection of air in the space around the lungs) - Airway blockage due to blood or inflammation - Chronic stenosis (long-term narrowing of the air passage due to scar tissue) - Issues with voice production - Tracheoesophageal fistula (abnormal opening between the windpipe and the esophagus) - Damage to the recurrent laryngeal nerve - Infections related to the lung and surgical wounds - Subcutaneous emphysema (bubbles of air trapped under the skin) - Pneumomediastinum (air collection in the chest cavity)

The prognosis for tracheal trauma (windpipe injury) can vary depending on the severity of the injury and the promptness of medical care. However, it is important to note that tracheal injuries can be life-threatening, with a death rate reported to be within the range of 15% to 40%, depending on the mechanism and classification of the injury. Early detection and appropriate treatment can lead to satisfactory outcomes for more than 90% of patients. Mortality rates have decreased over time due to earlier detection and treatment.

An otolaryngologist or a thoracic surgeon.