695

Early Radiographic Signs of

Tracheal Rupture

R. James Rollins1 Early diagnosis and repair of tracheal rupture are necessary to prevent acute tension
Irena Tocino2 pneumothorax, airway obstruction, and chronic tracheal stenosis. Few reliable radio-
graphic signs of tracheal rupture have been proposed. We diagnosed seven cases of
tracheal rupture, two related to blunt trauma and five resulting from tracheal intubation.
American Journal of Roentgenology 1987.148:695-698.

Early radiographic signs included (1) orientation of the distal portion of the endotracheal
tube to the right relative to the lumen of the trachea with an overdistended endotracheal
balloon cuff, (2) migration of the balloon toward the endotracheal tube tip, and (3)
pneumomediastinum and subcutaneous emphysema. In four cases, the overdistended
balloon with distal migration preceded the pneumomediastinum by several hours.
An overdistended balloon in a patient after tracheal intubation or blunt chest trauma
should suggest tracheal rupture.

Tracheal rupture is an uncommon but serious complication of chest trauma [1-

5] and intubation [6-1 3]. Prompt diagnosis and surgical repair may prevent tension
pneumothorax, ventilatory failure, and airway obstruction [1 ], as well as tracheal-
bronchial stenosis, mediastinitis, sepsis, and pulmonary fibrosis [2-4]. Despite the
importance of early diagnosis, late detection of such injuries is still common [4, 14,
1 5], reflecting a low clinical suspicion and the absence of reliable radiographic signs
of tracheal rupture.

Materials and Methods

During a 4-year period, seven cases of tracheal rupture were treated at the LOS and VA
hospitals in Salt Lake City. The patients were all women ranging in age from 22 to 88 years,
and none had a history of tracheal abnormalities. Five of the seven cases were intubation
related; of these four were intubated by inexperienced operators (paramedics, interns, or
residents). Unsuccessful attempts were initially made in each case, three nasal-tracheal and
two oral-tracheal. None of the operators recalls using vigorous effort. Recorded cuff pressures
never exceeded 23 cm H20 (normal, less than 28 cm H20) [1 6]. The radiographic and clinical
Received July 25, 1986; accepted after revision
October 29, 1986. signs of tracheal rupture in the two chest trauma cases appeared after intubation and positive
pressure ventilation. All chest radiographs were obtained in the supine position with a 50-in.
‘Division of Critical Care Medicine, LOS Hospi-
tal, Salt Lake City, Utah 84143, and Department of (1 28 cm) focal film distance. The horizontal diameter of the balloon was measured at its
Medicine, Division of Respiratory, Critical Care, and widest point, and the distance between the inferior border of the balloon and the tip of the
Occupational (Pulmonary) Medicine, University of endotracheal tube was used to estimate balloon migration. All ruptures occurred in the
Utah College of Medicine, 50 N. Medical Dr., Salt
membranous trachea, three ending above the carina, three extending into the right mainstem
Lake City, Utah 84132.
2()epartment of Radiology, LOS Hospital, Eighth
bronchus, and one into the left mainstem bronchus. Diagnosis was confirmed at bronchoscopy
Ave. and C St., Salt Lake City, UT 84143. Address
in five patients with chest CT showing the endotracheal tube outside the trachea in two. Six
patients had successful repairs of the tracheal ruptures within 24 hr of the injuries; the
reprint requests to I. Tocino.
seventh was judged inoperable. Three patients died of organ failure unrelated to the tracheal
AJR 148:695-698, April 1987
0361 -803x/87/1 484-0695 rupture, three patients were discharged without evidence of stricture on repeat bronchoscopy,
C American Roentgen Ray Society and one patient was discharged without repair or repeat bronchoscopy.
 696 ROLLINS AND TOCINO AJR:148, April 1987

Results taneously on the chest radiograph in each case) eventually

developed in all cases; three on the initial chest radiograph
Retrospective review of the clinical chart and chest radio- and four several hours after the tracheal injury (one each 3,
graphs of seven patients with proven tracheal rupture re- 4, 5.5, and 9 hr after injury). Pneumothorax appeared in five
vealed the following findings before definitive diagnosis. In cases-two on the initial chest radiograph and three several
seven cases, the endotracheal tube was oriented with its hours after the injury (one each 4, 5.5, and 9 hr after injury).
distal portion to the right relative to the lumen of the trachea. In no case did the pneumothorax precede subcutaneous or
In six of these cases, the balloon diameter was more than 2.8 mediastinal emphysema.
cm (range, 2.8-4.3) (Fig. 1A). The normal female tracheal
diameter is less than 2.0 cm [1 7]; the average male tracheal
Discussion
diameter is 2.43 cm. In six cases, the distance between the
balloon and the endotracheal tube tip was less than 1 .2 cm One of the earliest descriptions of tracheal rupture was
(range, 0-1 .2 cm) (Fig. 1 B). The normal distance is more than recorded in 1 848 [2]. Subsequently, several series of trau-
2.5 cm. Pneumomediastinum and subcutaneous emphysema matic tracheal rupture [1 3, 5, 1 5, 1 8] and case reports of
,

were present in seven cases (Fig. 1 B). intubation-related rupture [6-1 3] have been published. All
A right oblique orientation with a balloon diameter greater emphasize early diagnosis and prompt surgical repair, yet few
than 2.8 cm was noted on the first chest radiograph after delineate early clinical or radiographic signs indicative of tra-
intubation or blunt trauma in six cases. In four cases the cheal rupture. In fact, delayed diagnosis is still common [4,
appearance of the endotracheal tube in a right oblique orien- 14, 15, 1 9]. Previously reported radiographic and clinical signs
tation distal to the carina with an overdistended balloon of tracheal rupture include pneumothorax, pneumomedias-
preceded any evidence of pneumomediastinum and subcu- tinum, subcutaneous emphysema, and respiratory distress,
American Journal of Roentgenology 1987.148:695-698.

taneous emphysema by 3 to 9 hr (Fig. 2). In these same all of which can be present without rupture. In fact, these
cases, migration of the balloon toward the endotracheal tube signs are variably reported to be present in only 50-85% of
tip occurred after repositioning the endotracheal tube and cases with rupture [1, 3, 15, 18].
before the appearance of subcutaneous or mediastinal em- The distal portion of the endotracheal tube was displaced
physema. In two other cases, an overdistended balloon and to the right, and an overdistended balloon was present in all
a reduced balloon-to-tip distance were present at the time cases (except one in which there was no visible balloon) and
subcutaneous and mediastinal emphysema were noted preceded subcutaneous or mediastinal emphysema in four
(Fig. 3). cases. The observation of an overdistended balloon in these
Subcutaneous and mediastinal emphysema (noted simul- cases raises the question of whether this was the cause of

Fig. 1.-Chest radiographs and CT in patient with tracheal rupture.

A, After intubation, endotracheal tube is in right mainstem bronchus with a balloon diameter of 3.2 cm (white arrows) and a balloon-to-tip distance of
3.5cm (black arrows). There is no evidence of pneumomediastinum.
B, After repositioning of endotracheal tube, overdistended balloon (white arrows) has migrated to tip of endotracheal tube (black arrow). Pneumome-
diastinum and subcutaneous emphysema are now present.
C, CT scan through upper mediastinum shows laceration of posterior tracheal wall (arrows) with overdistended balloon protruding into mediastinum.
 AJR:148, April 1987 TRACHEAL RUPTURE 697
American Journal of Roentgenology 1987.148:695-698.

Fig. 2.-Supine chest radiographs after emergency intubation resulting in tracheal rupture. Fig. 3.-Initial chest radiograph after blunt
A, Overdistended balloon with a diameter of 4.3 cm (white arrows) is located 2.6 cm from tip of chest trauma. Overdistended balloon (arrows) Is
endotracheal tube (black arrows). Right oblique orientation of endotracheal tube is well illustrated in located at tip of endotracheal tube. Pneumome-
this case. diastinum, subcutaneous emphysema, and bilat-
B, Migration of balloon toward tip of endotracheal tube (white arrows) and pneumomediastinum eral pneumothoraces are present. At surgery,
appeared after 9 hr of mechanical ventilation and manipulation of endotracheal tube. tracheal tear extended toward right main bron-
chus, and endotracheal tube was found outside
of tracheal lumen.

the rupture or its sequela. In only one published case is trauma) and found that none had a balloon diameter greater
tracheal rupture clearly related to overdistension and rupture than 2.5 cm or a balloon-to-tip distance smaller than 1 .5 cm.
of the balloon; in this case the balloon was inadvertently Migration of the balloon toward the endotracheal tube tip
connected to pressurized oxygen [7]. Tracheal damage has occurred in all cases (except one in which there was no visible
been shown to be a function of the cuff-to-tracheal wall balloon); in four cases, migration occurred before subcuta-
pressure and not of the absolute cuff volume. In rabbits, a neous and mediastinal emphysema. In the standard NCC
cuff-to-tracheal wall pressure greater than capillary perfusion high-volume, low-pressure endotracbeal tube, the distal mar-
pressure (28-41 cm H2O) causes ischemia and subsequent gin of the balloon is attached 2.5 cm from the tip. When filled
necrosis [1 6, 20]. In our cases, the measured cuff pressure with less than 1 0 ml of air, this distance may appear even
never exceeded 23 cm H2O before or after a distended balloon greater than 2.5 cm radiographically. Two possible mecha-
was observed. It is unlikely that tracheal damage resulted nisms may be responsible for this migration: (1) continued
from the overdistended balloon. Instead, because of the tra- injection of air into the cuff, causing distal expansion of the
cheal rupture, an increasing amount of intracuff air was re- balloon, or (2) withdrawal of the endotracheal tube without
quired to raise the cuff-to-tracheal wall pressure to the usual complete deflation of the balloon, which allows it to anchor at
20-25 cm H2O pressure and to seal the airway. The balloon the site of the rupture. In four cases this finding appeared
then herniated through the tracheal tear into the mediastinum after repositioning of the endotracheal tube, while in two other
(Fig. 1 C). Both the high-volume, low-pressure endotracheal cases balloon migration was present at the time of the first
tube (Hi-Lo) and the low-volume, high-pressure endotracheal chest radiograph. Because all of the endotracheal tubes in
tube (Lo-Pro) can easily be filled with 60 ml of air, producing our cases involved the large-volume Hi-Lo cuff, we do not
a distended (>4 cm) balloon. Both tubes are manufactured know if the small-volume Lo-Pro balloon will migrate toward
by the National Catheter Corporation (NCC), Argyle, NY. the endotracheal tube tip when overdistended in tracheal
An overdistended balloon does not always indicate tracheal rupture.
rupture. It may be seen when (1) the balloon is located in the Mediastinal and subcutaneous emphysema eventually de-
esophagus, (2) a patient is chronically intubated [21], or (3) veloped in all cases.Extravasation of air into the mediastinum
preintubation tracheal enlargement or chronic obstructive pul- is expected with intrathoracic tracheal rupture. If the rupture
monary disease is present. After these three conditions were freely communicates with the pleural space, a pneumothorax
excluded, we conducted a radiographic review of 50 recently may develop. Pneumomediastinum is not pathognomonic of
intubated patients at LDS Hospital (38 after trauma, 12 non- tracheal rupture. Alveolar rupture secondary to blunt chest
 698 ROLLINS AND TOCINO AJR:148, April 1987

trauma or positive pressure ventilation and esophageal rup- 7. Tomvall 55, Jackson KH. Tracheal rupture: complication of cuffed endo-
tracheal tube. Chest 1971;59:237-239
ture are other causes. The appearance of subcutaneous
8. Kumar SM,
Pandit 5K, Cohen PJ. Tracheal laceration associated with
emphysema and mediastinal emphysema after repositioning endotrachealanesthesia. Anesthesiology 1977;47:298-299
of the endotracheal tube in four of seven cases suggests (1) 9. Patel KD, Palmer SK, Phillips MF. Mainstem bronchial rupture during
initial balloon occlusion of the tear and/or (2) enlargement of general anesthesia. Anesth Anaig 1979;58:59-61
the rupture because the cuff was not fully deflated during 10. Orta DA, Cousar JE, Yergin BM, Olsen GN. Tracheal laceration with
massive subcutaneous emphysema: a rare complication of endotracheal
tube movement.
intubation. Thorax 1979;34:665-669
Early recognition of tracheal rupture is necessary to de- 1 1 . Guemelli N, Bragaglia RB, Briccoli A, Mastrorilli M, Vecchi R. Tracheo-
crease morbidity and mortality. After blunt chest trauma or bronchial ruptures due to cuffed Cation’s tubes. Ann Thorac Surg
recent intubation, the presence of an endotracheal tube with 1979;28:66-67
12. Freiberger JJ. An unusual presentation of an airway tear. Anesthesiology
its distal portion oriented to the right with a distended balloon,
1984;61 :204-206
a reduced distance from balloon to endotracheal tube tip, 13. Smith BAC, Hopkinson RB. Tracheal rupture during anesthesia. Anesthesia
with or without pneumomediastinum, should prompt further 1984;39:894-898
investigation of the airway with either chest CT or bronchos- 14. Amauchi W, Birolini 0, Branco P, do Oliveira MR. Injuries to the tracheo-
copy to confirm the presence and extent of tracheal rupture. bronchial tree in closed trauma. Thorax 1983;38:923-928
15. Jones WS, Mavroudis C, Richardson JO, Gray LA, HoweWR. Management
of tracheobronchial disruption resulting from blunt trauma. Surgery
1984;95:319-322
16. Nordin V. The trachea and cuff-induced tracheal injury. Acta Otolaryngol
REFERENCES
[Suppi] (Stockh) 1977;345:7-56
1. Hood RM, Sloan HE. Injuries of the trachea and major bronchi. J Thorac 1 7. Mackenzie CF, Shin B, Whitley N, Heinch M. Human tracheal circumference
Cardiovasc Surg 1959;38:458-480 as an indicator of correct cuff size (abstr). Anesthesiology 1980;53:541A
American Journal of Roentgenology 1987.148:695-698.

2. Burke JF. Early diagnosis of traumatic rupture of the bronchus. JAMA 1 8. Grover FL, Eliestad C, Arom Ky, Root HO, Cruz AB, Trinkle JK. Diagnosis
1962;181 :682-686 and management of major tracheobronchial injuries. Ann of Thorac Surg
3. Chesterman JT, Satsangi PN. Rupture of the trachea and bronchi by 1979;28:384-391
closed injury. Thorax 1966;21 :21-27 19. Harvey-Smith W, Bush W, Northrop C. Traumatic bronchial rupture. AJR
4. Eastridge CE, Hughes FA. Tracheobronchial injury caused by blunt trauma. 1980;134:1189-1193
Am Rev Respir Dis 1970101:230-237 20. Bemhard WN, Yost L, Joynes 0, Cathalis 5, Tumdor FH. Intracuff pres-
5. Bertelsen S, Howitz P. Injuries of the trachea and bronchi. Thorax sures in endotracheal and tracheostomy tubes. Chest 1985:87:720-725
1972;27: 188-1 94 21. Khan F, Reddy NC. Enlarging intratracheal tube cuff diameter: a quantita-
6. Thompson OS, Read RC. Rupture of the trachea following endotracheal tive roentgenographic study of its value in the early prediction of serious
intubation. JAMA 1968;204:995-997 tracheal damage. Ann Thorac Surg 1977;24:49-53