Tracheal deviation is an abnormal shift of the trachea from its usual midline position in the neck (except for its slight normal shift to the right at the carina). It indicates an underlying thoracic or mediastinal condition that disturbs pressure or volume balance within the chest. In some cases — such as tension pneumothorax — it is a medical emergency.

Pathophysiology

• Pressure or volume changes in one hemithorax displace mediastinal structures and the trachea.

• Pull mechanism: Conditions that collapse or scar a lung (e.g., atelectasis, fibrosis, TB) draw the trachea toward the affected side.

• Push mechanism: Processes increasing intrathoracic pressure or volume (e.g., tension pneumothorax, large pleural effusion, mediastinal mass) push the trachea away from the affected side.

• Anatomical variations (e.g., elongated aortic arch) may mimic pathologic deviation, especially in older adults.

History and Physical Examination

History

• Onset and progression of deviation (sudden vs gradual)

• Respiratory symptoms: dyspnea, chest pain, cough, stridor, wheeze

• Past history: lung or heart disease, thyroid enlargement, TB, trauma, surgery

• Smoking, occupational exposures

Physical Examination

• Inspection: Look for visible displacement of the trachea, asymmetry of chest expansion, use of accessory muscles

• Palpation: Place index finger in suprasternal notch; compare trachea position to midline

• Percussion & auscultation: Dullness, hyperresonance, breath sound changes

• Check for: Subcutaneous emphysema, jugular venous distension, neck masses, venous engorgement of chest wall

Medical causes

Emergency interventions

• Rapidly assess airway, breathing, circulation

• Look for tachypnea, dyspnea, cyanosis, asymmetric chest movement, absent breath sounds, stridor, anxiety

• Place in semi-Fowler’s position if stable

• Provide high-flow oxygen

• Insert large-bore I.V. line

• If tension pneumothorax suspected: immediate needle decompression followed by chest tube

• Prepare for intubation if respiratory failure is imminent

Special considerations

• Deviation often signals serious intrathoracic disease: monitor respiratory and hemodynamic status continuously.

• Keep emergency airway equipment nearby.

• Arrange investigations: Chest X-ray, CT scan, bronchoscopy, ultrasound, arterial blood gases, ECG.

Patient counseling

• Teach coughing and deep-breathing exercises to optimize lung expansion.

• Advise prompt reporting of breathing difficulty, sudden chest pain, or stridor.

• Discuss smoking cessation, infection control (TB), and follow-up imaging as indicated.

Pediatric pointers

Children may deteriorate quickly due to small airway diameter; early recognition of tension pneumothorax or mediastinal mass is critical.

Geriatric pointers

A rightward tracheal deviation may be normal in older adults with an elongated, atherosclerotic aortic arch; interpret findings with overall clinical picture.

References

1. Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. Mosby Elsevier; 2008.

2. Sommers MS, Brunner LS. Pocket Diseases. F.A. Davis; 2012.

3. Light RW. Pleural Diseases. 6th ed. Lippincott Williams & Wilkins; 2013.

4. Broaddus VC et al. Murray & Nadel’s Textbook of Respiratory Medicine. 7th ed. Elsevier; 2021.