Assessment of the trachea is a standard component of any routine physical examination. It involves evaluating the position of the trachea and detecting tracheal deviation from the midline. This is a serious clinical finding and the cause should be immediately identified and treated.
 

What is Tracheal Deviation?

When pressure increases within the chest cavity, the trachea may shift to one side, typically the side where the pressure is lower, or there is less lung volume. This abnormal position of the trachea can result in symptoms such as coughing, difficulty breathing, wheezing, and chest pain.
 

How Do You Detect Tracheal Deviation on Physical Exam? (Bickley et al., 2021)

As you perform your head-to-toe assessment and progress down to the neck, pause to inspect the trachea for any deviation from the normal midline position. A shift from midline could be subtle and may be difficult to detect upon visual inspection. Then carefully palpate for deviation by placing a finger along one side of the trachea and check for any space between it and the sternocleidomastoid (SCM) muscle. Compare this to the other side of the trachea. The space should be symmetric. Next auscultate the breath sounds over the trachea and listen for stridor, a high-pitched sound caused by severe subglottic or tracheal obstruction. This is a respiratory emergency that requires immediate attention. If the patient is not experiencing any difficulty breathing, a chest X-ray will help confirm the diagnosis and the need for further workup.
 

What Causes Tracheal Deviation?

There are many causes of tracheal deviation including:

• Neck injury, trauma, pneumothorax, bleeding
• Multinodular goiter
• Tumors, cancer, mediastinal lymphoma
• Pleural effusion
• Pneumonectomy
• Atelectasis
• Pleural fibrosis
• Pulmonary fibrosis

Treatment will depend on severity and will focus on correcting the underlying cause. Treatments include breathing exercises to improve atelectasis, thoracentesis to equalize pressure in the chest cavity, chest tube insertion to remove air or fluid in the pleural space, or surgery to remove a tumor or other obstructing structure.
 

References:
 
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer Health: Philadelphia.
 
Hinkle, J. (2021). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (15^th ed.). Wolters Kluwer Health.  https://wolterskluwer.vitalsource.com/books/9781975161057