Background: Tracheobronchial tear is a rare injury usually related to blunt trauma that involves a partial or complete laceration or puncture of the tracheal or bronchial wall.
Pathophysiology: Tracheobronchial tear can be caused by the following:
- Shearing forces between the fixed carina or proximal bronchus and
the mobile distal bronchi/lungs in a deceleration injury
- Rapid anteroposterior compression of the chest causing lateral
traction on the lungs and tearing of the bronchus from the fixed
carina
- Rupture resulting from an abrupt increase in pressure against a
closed glottis
- Compression of the trachea between the sternum and spinal column
- Blunt trauma to the cervical trachea
- Necrosis resulting from compromised mucosal blood flow after
overinflation of an endotracheal tube cuff
- Perforation by a stylet or endotracheal tube
- Other penetrating injury
Frequency:
- In the US: Tracheobronchial injury occurs in 0.4-1.5% of major blunt trauma patients and is found in 2.8-5.4% of trauma-related autopsies. Tracheobronchial tear also has been reported in 18% of autopsies after emergency intubation; however, since minor injuries often are not identified, the actual frequency of tracheobronchial tear may remain unknown.
- Internationally: Little data are available on the frequency of tracheobronchial tear.
Mortality/Morbidity: Death occurs in approximately 30% of patients with tracheobronchial tears, with 50% of fatalities occurring within the first hour. Mortality may be related to an inadequate airway, tension pneumothorax, occlusion of the airway by protrusion of the esophagus into the tear, or accompanying injuries. In two thirds of survivors, diagnosis is delayed, occasionally for many years, resulting in complications such as airway stenosis, atelectasis, pneumonia, mediastinitis, sepsis, and decreased pulmonary capacity.
Race: No specific data are available regarding racial predilection.
Sex: Blunt trauma accounts for the preponderance of all tracheobronchial injuries. Tracheobronchial injury from blunt trauma is 3 times more common in males, because blunt trauma involves males much more often than females. Women have a greater chance of iatrogenic injury from endotracheal tubes, because their tracheas are smaller.
Age: A higher incidence of serious chest trauma is seen in patients younger than 40 years; therefore, tracheobronchial tear is seen more often in younger patients overall. Patients older than 40 years who suffer blunt chest trauma and who have diabetes, or generally are in poor medical condition, are at higher risk for tracheobronchial tear. As in women, children have a greater possibility of iatrogenic injury from endotracheal tubes, because their tracheas are smaller.
Anatomy: Multiple anatomic variables and common mechanisms of injury account for local susceptibility to tracheobronchial tears. The trachea and proximal bronchi have varying amounts of cartilaginous support, which strengthens them against injury, but the posterior tracheal membrane is unsupported by cartilaginous rings. Occasionally, blunt trauma to the anterior neck results in rupture of the cervical trachea; this usually is a longitudinal tear of the posterior tracheal membrane.
Endotracheal tubes and stylets are directed naturally against the relatively weaker posterior tracheal membrane during intubation; therefore, intubation-related injuries are more common in the posterior trachea. Cartilaginous support decreases progressively from the trachea to the distal bronchi, which are more membranous than cartilaginous.
The stronger proximal cartilage framework tends to fix the trachea and proximal bronchi in place, while the distal bronchi and lungs are more mobile. Consequently, deceleration injury from blunt trauma typically occurs at the transition zone between the fixed and mobile bronchus, within 2.5 cm of the carina. The left main bronchus is relatively protected by a longer mediastinal course. While several studies have found right bronchial injury to be more common, several others have reported an equal distribution between left and right bronchial injuries. The larger main bronchi are at higher risk of rupture than the smaller peripheral bronchi during a sudden increase in pressure, since according to Laplace law, in a cylindrical body, wall tension (T) equals internal pressure (P) times internal radius (R) or T = P X R.
Clinical Details: Clinical signs of tracheobronchial tear include the following:
- Dyspnea
- Cough
- Hemoptysis
- Cyanosis
- Cervical subcutaneous emphysema
- Tracheal shift
- Persistent pneumothorax following satisfactory placement of a thoracostomy tube
- Signs of airway obstruction
- Cough
Immediate treatment depends on the patient’s condition and associated injuries. At a minimum, emergency bronchoscopic confirmation of the diagnosis and location is important if tracheobronchial tear is suggested. This may aid in placing the endotracheal tube cuff beyond the injury or selectively intubating the unaffected bronchus.
Short lacerations of the upper one third of the trachea occasionally are treated with antibiotics and intubation beyond the level of injury. In addition, some small or peripheral bronchial tears may be treated conservatively; however, nonoperative treatment can result in scarring and stenosis.
Surgical repair is indicated when a transmural tear longer than 1 cm causes a pneumothorax that is unrelieved by tube thoracostomy. Severe trauma may require resection of the damaged tissue.
Although the importance of early diagnosis and primary repair is indisputable, successful repair as long as 11 years after injury has been reported.
Preferred Examination: Chest radiography is the standard initial screening examination for evaluation of most chest conditions, including possible tracheobronchial injury; however, CT is preferred if tracheobronchial tear is suggested. In appropriate circumstances, multiplanar or virtual endoscopic reconstructions from the CT data can be performed to clarify questionable findings.
Definitive diagnosis of tracheobronchial tear is made by bronchoscopy or surgical exploration. If clinical or radiographic findings suggest airway injury, diagnostic bronchoscopy is recommended.
Limitations of Techniques: Conventional radiography and CT play important roles in imaging of tracheobronchial tear. Although imaging findings can be highly suggestive in certain instances, radiography and CT often are nonspecific for evaluating tracheobronchial tear.
DIFFERENTIALS
Esophagus, Tear
Other Problems to be Considered:
Cervical spine trauma
Neck trauma
Chest trauma
Aorta trauma
X-RAY
Findings: Radiographic findings in tracheobronchial tear reflect the location and extent of injury.
- In 10% of patients, the tear is incomplete, with preservation of the
peritracheal or peribronchial connective tissue sheath or sealing of
the tear by fibrin. In these patients, the injury is not apparent on
radiographs.
- In the most severely injured patients, the airway separates
completely at the site of injury with a visibly obvious distortion of
tracheobronchial anatomy. Pneumothorax and/or pneumomediastinum
usually are present in these extensive injuries.
- The location of the tear is important in determining whether
pneumomediastinum or pneumothorax develops. Tears within the
mediastinal pleura cause a pneumomediastinum; tears beyond the
mediastinal pleura cause a pneumothorax.
- Since the left main bronchus has a longer mediastinal course than
the right, injury to the left main bronchus is more likely to cause a
pneumomediastinum, while injury to the right main bronchus is more
likely to cause a pneumothorax.
- Note that in severe injuries, both pneumomediastinum and
pneumothorax may be present.
- A pathognomonic indication of tracheobronchial tear, the fallen
lung sign, is visible in some patients with severe injury.
- In an uncomplicated pneumothorax, the bronchus remains fixed at the
hilum, and the peripheral lung retracts from the parietal pleura
toward the hilum.
- With complete laceration of the main bronchus, the bronchus may
become partially or completely detached, allowing the lung to fall
into a dependent lateral position and producing the fallen lung sign.
- Other important radiographic findings associated with
tracheobronchial tear include incorrect location or overdistention of
the endotracheal tube cuff and persistent pneumothorax unrelieved by
appropriate placement of a thoracostomy tube.
- A bayonet deformity or bronchial discontinuity may be present, and
if the tear causes obstruction, peripheral consolidation or
atelectasis without air-bronchograms may be seen (Pictures
1-29).
- In the typical traumatic transsection of the cervical trachea, the infrahyoid muscle ruptures and the suprahyoid muscle retracts, raising the hyoid bone. Abnormal hyoid bone elevation suggests cervical tracheal tear.
Degree of Confidence: The most specific signs of tracheobronchial tear are of an appropriately placed endotracheal tube extending clearly beyond the expected tracheal lumen and a classic fallen lung sign. Other signs are less conclusive and usually require bronchoscopic confirmation.
False Positives/Negatives: Tracheobronchial tear may not be visible if the tracheal mucosa remains intact or is sealed by fibrin.
CAT SCAN
Findings: CT is the imaging method of choice for evaluating possible tracheobronchial tear because it clarifies and confirms the radiographic signs of tracheobronchial tear (Pictures 31-48) and, occasionally, adds unique information.
- With the patient in the supine position, the affected lung falls
posterolaterally away from the hilum in the CT variation of the fallen
lung sign.
- A small pneumothorax or pneumomediastinum is more easily visible on
CT than on radiography.
- Subtle airway discontinuity or irregularity and small focal
peritracheal or peribronchial gas collections are observed much better
on CT.
- Active bleeding from the lacerated airway occasionally can be identified on enhanced CT images.
Degree of Confidence: In some instances, definite evidence of tracheobronchial tear is depicted. If the diagnosis remains in doubt, reformatted images along the luminal axis of the airway or virtual endoscopy may be helpful. The high quality images obtainable with multi-detector CT scanners allow excellent virtual endoscopic reconstructions. In other instances, findings are inconclusive and should be interpreted in the proper clinical context.
False Positives/Negatives: CT can be falsely negative, particularly in relatively minor injuries, and bronchoscopy should be performed in patients with a strong clinical suggestion of tracheobronchial tear.
MRI
Findings: The primary strengths of MRI are multiplanar display and high tissue contrast. However, these strengths are offset by the relative difficulty in preparing the patient for MRI, the fact that monitoring trauma patients is more difficult during the examination, and the lower availability of MRI.
MRI shows findings similar to those seen on CT.
Degree of Confidence: As in CT, the more common findings in MRI are variable, nonspecific, and only suggestive. MRI occasionally may be useful in depicting the location and extent of injury in tracheobronchial tear.
False Positives/Negatives: As in conventional radiography and CT, MRI can be falsely negative, particularly in relatively minor injuries, and in patients with a strong clinical suggestion of tracheobronchial tear.
NUCLEAR MEDICINE
Findings: Patients with tracheobronchial tear have diverse presentations on ventilation-perfusion scans, depending on the severity of injury.
- In minor injuries with intact blood flow and no airway obstruction
or pneumothorax, a tracheobronchial tear is not detectable.
- If the tracheobronchial trauma causes partial or complete airway
obstruction without associated vascular injury, normal physiologic
response diminishes perfusion to the region of impaired ventilation,
yielding a ventilation-perfusion mismatch.
- In the most severe injuries, with disruption of airflow and perfusion, a matched defect is visible.
While these physiologic responses are identifiable on ventilation-perfusion imaging, CT and bronchoscopy are more specific in the diagnosis of tracheobronchial tear.
Degree of Confidence: Degree of confidence is low.
False Positives/Negatives: As in other imaging studies, false-negative examinations can occur with minor injuries.
ANGIOGRAPHY
Findings: Angiography is not a primary procedure for evaluating patients with tracheobronchial trauma; however, angiography often is used to assess associated thoracic trauma. If active bleeding is present at the tracheobronchial tear, it can be visible on aortography or pulmonary angiography.
Degree of Confidence: Degree of confidence is low.
False Positives/Negatives: Angiography does not demonstrate a tear if the tracheobronchial tear is not bleeding actively.
INTERVENTION
Intervention: In patients in whom tracheal or bronchial stenosis complicates a tracheobronchial tear, a stent may be used to maintain the airway.
Medical/Legal Pitfalls:
- Complications related to delayed diagnosis of tracheobronchial tear are the most important medicolegal pitfalls.
PICTURES
| Caption: Picture 1. Tracheobronchial tear. Animation of images 2-29. Cine images from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 2. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 3. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 4. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 5. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 6. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 7. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 8. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 9. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 10. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 11. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 12. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 13. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 14. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 15. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 16. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 17. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 18. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 19. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 20. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 21. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 22. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 23. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 24. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 25. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 26. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 27. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 28. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 29. Tracheobronchial tear. Cine images (Images 2-29) from virtual bronchoscopy begin with a view of the carina and advance distally into the right main bronchus. An obstruction of the right main bronchus is consistent with a bronchial tear. | |
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| Caption: Picture 30. Tracheobronchial tear. A 26-year-old man after major trauma. Frontal chest radiograph shows complete opacification of the right hemithorax without air bronchograms, abrupt termination of the right mainstem bronchus (arrow), and multiple upper right rib fractures. | |
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| Picture Type: X-RAY | |
| Caption: Picture 31. Tracheobronchial tear. 10-mm axial CT images of the chest with lung window settings beginning at the level of the carina demonstrate abrupt termination of the right main bronchus (arrows) and complete opacification of the right hemithorax without air bronchograms. | |
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| Picture Type: CT | |
| Caption: Picture 32. Tracheobronchial tear. 10-mm axial CT images of the chest with lung window settings beginning at the level of the carina demonstrate abrupt termination of the right main bronchus (arrows) and complete opacification of the right hemithorax without air bronchograms. | |
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| Picture Type: CT | |
| Caption: Picture 33. Tracheobronchial tear. 10-mm axial CT images of the chest with lung window settings beginning at the level of the carina demonstrate abrupt termination of the right main bronchus (arrows) and complete opacification of the right hemithorax without air bronchograms. | |
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| Picture Type: CT | |
| Caption: Picture 34. Tracheobronchial tear. 10-mm axial CT images of the chest with mediastinal window settings beginning at the level of the carina show multiple right rib fractures and a moderate-sized pleural effusion. There is mediastinal shift toward the side of injury. Fluid density is present in the right main bronchus (arrowhead), probably representing hemorrhage. | |
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| Picture Type: CT | |
| Caption: Picture 35. Tracheobronchial tear. 10-mm axial CT images of the chest with mediastinal window settings beginning at the level of the carina show multiple right rib fractures and a moderate-sized pleural effusion. There is mediastinal shift toward the side of injury. Fluid density is present in the right main bronchus (arrowhead), probably representing hemorrhage. | |
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| Picture Type: CT | |
| Caption: Picture 36. Tracheobronchial tear. 10-mm axial CT images of the chest with mediastinal window settings beginning at the level of the carina show multiple right rib fractures and a moderate-sized pleural effusion. There is mediastinal shift toward the side of injury. Fluid density is present in the right main bronchus (arrowhead), probably representing hemorrhage. | |
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| Picture Type: CT | |
| Caption: Picture 37. Tracheobronchial tear. 10-mm axial CT images of the chest with mediastinal window settings beginning at the level of the carina show multiple right rib fractures and a moderate-sized pleural effusion. There is mediastinal shift toward the side of injury. Fluid density is present in the right main bronchus (arrowhead), probably representing hemorrhage. | |
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| Picture Type: CT | |
| Caption: Picture 38. Tracheobronchial tear. 5-mm axial CT images with lung window settings beginning at the level of the carina again demonstrate abrupt termination of the right main bronchus (arrows), complete opacification of the right hemithorax with few air bronchograms, subcutaneous emphysema, a moderate-sized anterior pneumothorax, and a pneumomediastinum. The azygos vein is outlined by mediastinal gas (arrowheads). The superior segment of the left lower lobe is atelectatic. | |
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| Picture Type: CT | |
| Caption: Picture 39. Tracheobronchial tear. 5-mm axial CT images with lung window settings beginning at the level of the carina again demonstrate abrupt termination of the right main bronchus (arrows), complete opacification of the right hemithorax with few air bronchograms, subcutaneous emphysema, a moderate-sized anterior pneumothorax, and a pneumomediastinum. The azygos vein is outlined by mediastinal gas (arrowheads). The superior segment of the left lower lobe is atelectatic. | |
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| Picture Type: CT | |
| Caption: Picture 40. Tracheobronchial tear. 5-mm axial CT images with lung window settings beginning at the level of the carina again demonstrate abrupt termination of the right main bronchus (arrows), complete opacification of the right hemithorax with few air bronchograms, subcutaneous emphysema, a moderate-sized anterior pneumothorax, and a pneumomediastinum. The azygos vein is outlined by mediastinal gas (arrowheads). The superior segment of the left lower lobe is atelectatic. | |
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| Picture Type: CT | |
| Caption: Picture 41. Tracheobronchial tear. 5-mm axial CT images with lung window settings beginning at the level of the carina again demonstrate abrupt termination of the right main bronchus (arrows), complete opacification of the right hemithorax with few air bronchograms, subcutaneous emphysema, a moderate-sized anterior pneumothorax, and a pneumomediastinum. The azygos vein is outlined by mediastinal gas (arrowheads). The superior segment of the left lower lobe is atelectatic. | |
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| Picture Type: CT | |
| Caption: Picture 42. Tracheobronchial tear. 5-mm axial CT images with lung window settings beginning at the level of the carina again demonstrate abrupt termination of the right main bronchus (arrows), complete opacification of the right hemithorax with few air bronchograms, subcutaneous emphysema, a moderate-sized anterior pneumothorax, and a pneumomediastinum. The azygos vein is outlined by mediastinal gas (arrowheads). The superior segment of the left lower lobe is atelectatic. | |
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| Picture Type: CT | |
| Caption: Picture 43. Tracheobronchial tear. 5-mm axial CT images with mediastinal window settings beginning at the level of the carina show loculated right pleural effusion, longitudinal sternal fracture (open arrow), and right rib fractures (arrowheads). | |
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| Picture Type: CT | |
| Caption: Picture 44. Tracheobronchial tear. 5-mm axial CT images with mediastinal window settings beginning at the level of the carina show loculated right pleural effusion, longitudinal sternal fracture (open arrow), and right rib fractures (arrowheads). | |
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| Picture Type: CT | |
| Caption: Picture 45. Tracheobronchial tear. 5-mm axial CT images with mediastinal window settings beginning at the level of the carina show loculated right pleural effusion, longitudinal sternal fracture (open arrow), and right rib fractures (arrowheads). | |
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| Picture Type: CT | |
| Caption: Picture 46. Tracheobronchial tear. 5-mm axial CT images with mediastinal window settings beginning at the level of the carina show loculated right pleural effusion, longitudinal sternal fracture (open arrow), and right rib fractures (arrowheads). | |
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| Picture Type: CT | |
| Caption: Picture 47. Tracheobronchial tear. 5-mm axial CT images with mediastinal window settings beginning at the level of the carina show loculated right pleural effusion, longitudinal sternal fracture (open arrow), and right rib fractures (arrowheads). | |
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| Picture Type: CT | |