What is the management of tracheal deviation?

Management of Tracheal Deviation

The management of tracheal deviation requires prompt identification of the underlying cause and implementation of appropriate interventions to maintain airway patency, with special consideration for difficult airway management techniques including videolaryngoscopy and potential need for surgical airway access in severe cases. 1

Assessment and Initial Management

• Immediate supplemental oxygen should be provided to maintain SpO₂ >92% while preparing for definitive management 2
• Waveform capnography should be used at the beginning of the assessment as it is invaluable when managing compromised airways 3
• Perform a systematic evaluation of the airway in all unstable patients with tracheal deviation, as failure to do so contributes to airway-related deaths 3
• The anatomical location of the trachea and surrounding structures (particularly carotid arteries) must be confirmed before any surgical intervention to ensure safe airway management 1

Airway Management Strategies

Intubation Approaches

• Videolaryngoscopy is strongly recommended for patients with tracheal deviation as it increases intubation success with minimal cervical movement 3
• A bougie should be used during direct laryngoscopy attempts in patients with tracheal deviation to improve success rates 3, 4
• Consider using smaller endotracheal tubes (e.g., 6.0 mm inner diameter) to facilitate intubation in cases of tracheal deviation 3
• Fiberoptic bronchoscopy should be immediately available for patients with tracheal deviation to assist with difficult intubation or to inspect the airway for abnormalities 3, 4

Surgical Airway Considerations

• In cases where intubation is impossible due to severe tracheal deviation, scalpel cricothyroidotomy is the recommended front of neck airway (FONA) technique 3
• For patients with known tracheal deviation requiring tracheostomy, consider using transillumination from a flexible bronchoscope and point-of-care ultrasound to delineate the altered course of the trachea 5
• If a patient's tracheostomy has been recently removed, re-cannulation of the stoma may be possible but should not delay FONA if needed 3

Management of Specific Causes

Thyroid Disease

• Early surgical intervention is recommended whenever radiographic evidence of tracheal deviation becomes manifest in patients with benign thyroid disease, as sudden airway occlusion may be unpredictable 6
• Patients with multinodular goiter and thyroiditis are at higher risk for tracheal compression and should be monitored closely 6

Post-Intubation Care

• The depth of tracheal tube insertion should be documented on the bedside chart and checked each shift or if respiratory deterioration occurs 3
• Cuff pressure should be maintained at 20-30 cm H₂O to prevent mucosal injury that could worsen tracheal deviation 3, 2
• Humidification and regular tracheal suction should be employed to reduce avoidable tube blockage 3, 2
• Intravenous corticosteroids for at least 12 hours may be beneficial to reduce airway edema in patients with tracheal deviation requiring intubation 3, 2

Monitoring and Follow-up

• Deterioration in a patient with tracheal deviation should prompt immediate systematic evaluation of the airway, including waveform capnography 3
• A chest X-ray should be performed after intubation to confirm appropriate tracheal tube insertion depth and identify complications such as pneumothorax 3, 7
• Patients with tracheal deviation should be positioned with 35° head-up elevation to help reduce airway swelling 3, 2
• Warning signs requiring immediate attention include stridor, obstructed pattern of breathing, agitation, and increasing oxygen requirements 3

Special Considerations

• For patients with kyphoscoliosis causing tracheal deviation and stenosis, consider placing the tube tip above the area of resistance and packing saline-soaked gauzes around the tracheal inlet to minimize gas leakage 4
• In cases of burns or thermal injury with tracheal deviation, obtain specialist advice early from a burns center and consider early intubation before airway swelling worsens 3
• For patients with difficult airways and tracheal deviation, consider using an airway exchange catheter during extubation to facilitate reintubation if needed 3, 2

Common Pitfalls and Caveats

• Do not attempt blind insertion of a tracheal tube in patients with tracheal deviation as this is unreliable and not recommended 3
• Avoid multiple intubation attempts as this increases the risk of cardiac arrest, particularly in critically ill patients with tracheal deviation 3
• Never ignore a patient who is agitated or complains of difficulty breathing, even if objective signs are absent, as this may indicate impending airway compromise 3
• Be aware that tracheal deviation may be associated with vascular anomalies (such as tortuous brachiocephalic arteries), which pose a risk of massive hemorrhage during percutaneous tracheostomy 1