Tracheal deviation
Normally, the trachea is located at the midline of the neck—except at the bifurcation, where it shifts slightly toward the right. Visible deviation from its normal position signals an underlying condition that can compromise pulmonary function and possibly cause respiratory distress. A hallmark of life-threatening tension pneumothorax, tracheal deviation occurs in disorders that produce a mediastinal shift due to asymmetrical thoracic volume or pressure. (See Detecting slight tracheal deviation, page 766.)
Emergency interventions
If you detect tracheal deviation, be alert for signs and symptoms of respiratory distress (tachypnea, dyspnea, decreased or absent breath sounds, stridor, nasal flaring, accessory muscle use, asymmetrical chest expansion, restlessness, and anxiety). If possible, place the patient in semi-Fowler’s position to aid respiratory excursion and improve oxygenation. Give supplemental oxygen, and intubate the patient if necessary. Insert an I.V. line for fluid and drug administration. In addition, palpate the neck and chest for subcutaneous crepitation, a sign of tension pneumothorax. Chest tube insertion may be necessary to release trapped air or fluid and to restore normal intrapleural and intrathoracic pressure gradients.
History
If the patient doesn’t display signs of distress, ask about a history of pulmonary or cardiac disorders, surgery, trauma, or infection. If he smokes, determine how much. Ask about associated signs and symptoms, especially breathing difficulty, pain, and cough.
Medical causes
Atelectasis
Extensive lung collapse can produce tracheal deviation toward the affected side. Respiratory findings include dyspnea, tachypnea, pleuritic chest pain, a dry cough, dullness on percussion, decreased vocal fremitus and breath sounds, inspiratory lag, and substernal or intercostal retraction.
Hiatal hernia
Intrusion of abdominal viscera into the pleural space causes tracheal deviation toward the unaffected side. The degree of attendant respiratory distress depends on the extent of herniation. Other effects include pyrosis, regurgitation or vomiting, and chest or abdominal pain.
Kyphoscoliosis
This disorder can cause rib cage distortion and mediastinal shift, producing tracheal deviation toward the compressed lung. Respiratory effects include a dry cough, dyspnea, asymmetrical chest expansion and, possibly, asymmetrical breath sounds. Backache and fatigue are also common.
Mediastinal tumor
This type of tumor commonly produces no symptoms in its early stages; however, a large mediastinal tumor can press against the trachea and nearby structures, causing tracheal deviation and dysphagia. Other late findings include stridor, dyspnea, a brassy cough, hoarseness, and stertorous respirations with suprasternal retraction. The patient may experience shoulder, arm, or chest pain as well as edema of the neck, face, or arm. His neck and chest wall veins may be dilated.
Pleural effusion
A large pleural effusion can shift the mediastinum to the contralateral side, producing tracheal deviation. Related effects include a dry cough, dyspnea, pleuritic chest pain, pleural friction rub, tachypnea, decreased chest motion, decreased or absent breath sounds, egophony, flatness on percussion, decreased tactile fremitus, fever, and weight loss.
Pulmonary fibrosis
Asymmetrical fibrosis can cause tracheal deviation as the mediastinum shifts toward the affected side. Associated findings reflect the underlying condition and pattern of fibrosis. Dyspnea, cough, clubbing, malaise, and fever commonly occur.
Pulmonary tuberculosis
In a large cavitation, tracheal deviation toward the affected side accompanies asymmetrical chest excursion, dullness on percussion, increased tactile fremitus, amphoric breath sounds, and inspiratory crackles. Insidious early effects include fatigue, anorexia, weight loss, fever, chills, and night sweats. A productive cough, hemoptysis, pleuritic chest pain, and dyspnea develop as the disease progresses.
Retrosternal thyroid
This anatomic abnormality can displace the trachea. The gland is felt as a movable neck mass above the suprasternal notch. Dysphagia, cough, hoarseness, and stridor are common. Signs of thyrotoxicosis may be present.
Tension pneumothorax
This acute, life-threatening condition produces tracheal deviation toward the unaffected side. It’s marked by a sudden onset of respiratory distress with sharp chest pain, a dry cough, severe dyspnea, tachycardia, wheezing, cyanosis, accessory muscle use, nasal flaring, air hunger, and asymmetrical chest movement. Restless and anxious, the patient may also develop subcutaneous crepitation in the neck and upper chest, decreased vocal fremitus, decreased or absent breath sounds on the affected side, jugular vein distention, and hypotension.
Thoracic aortic aneurysm
This disorder usually causes the trachea to deviate to the right. Highly variable associated findings may include stridor, dyspnea, wheezing, a brassy cough, hoarseness, and dysphagia. Edema of the face, neck, or arm may occur with distended chest wall and jugular veins. The patient may also experience substernal, neck, shoulder, or low back pain as well as paresthesia or neuralgia.
Special considerations
Because tracheal deviation usually signals a severe underlying disorder that can cause respiratory distress at any time, monitor the patient’s respiratory and cardiac status constantly, and make sure that emergency equipment is readily available. Prepare the patient for diagnostic tests, such as chest X-rays, bronchoscopy, an electrocardiogram, and arterial blood gas analysis.
Pediatric pointers
Keep in mind that respiratory distress typically develops more rapidly in children than in adults.
Geriatric pointers
In elderly patients, tracheal deviation to the right commonly stems from an elongated, atherosclerotic aortic arch, but this deviation isn’t considered abnormal.
Pictures
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
Other Book Chapters Related to Throat symptoms
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Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Throat symptoms
» Next page: Dysphagia (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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