AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Bacterial tracheitis is an uncommon infectious cause of acute upper airway obstruction. Patients may present with crouplike symptoms, such as barking cough, stridor, and fever; however, patients with bacterial tracheitis do not respond to standard therapy and may experience acute respiratory decompensation.

Pathophysiology

Bacterial tracheitis is a diffuse inflammatory process of the larynx, trachea, and bronchi with adherent or semiadherent mucopurulent membranes within the trachea. The major site of disease is at the cricoid cartilage level, the narrowest part of the trachea. Acute airway obstruction may develop secondary to subglottic edema and sloughing of epithelial lining or accumulation of mucopurulent membrane within the trachea. Signs and symptoms are usually intermediate between those of epiglottitis and croup.

Bacterial tracheitis may be more common in the pediatric patient because of the size and shape of the subglottic airway. The subglottis is the narrowest portion of the pediatric airway, assuming a funnel-shaped internal dimension. In this smaller airway, relatively little edema can significantly reduce the diameter of the pediatric airway, increasing resistance to airflow and work of breathing. With appropriate airway support and antibiotics, most patients improve within 5 days.

Frequency

United States

Tan and Manoukian reported that 500 children were hospitalized for croup at one pediatric hospital over a 32-month period. Approximately 98% had viral croup, and 2% had bacterial tracheitis. Cases usually occur in the fall or winter months, mimicking the epidemiology of viral croup.

Mortality/Morbidity

The predominant morbidity and mortality is related to the potential for acute upper airway obstruction and induced hypoxic insults. The mortality rate has been estimated at 4-20%. In the acute phase, patients generally do well if the airway is adequately managed and if antibiotic therapy is promptly initiated.

Sex

In most epidemiologic studies, male cases are preponderant. Gallagher et al reported a male-to-female predominance of 2:1.

Age

Bacterial tracheitis may occur in any pediatric age group. Gallagher et al reported 161 cases of patients younger than 16 years. The age range was from 3 weeks to 16 years, with a mean age of 4 years. This is in contrast to viral laryngotracheobronchitis, which occurs in patients aged 6 months to 3 years.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Symptoms may be intermediate between those of epiglottitis and croup. Presentation is either acute or subacute. Patients may have high fevers, toxic appearance, stridor, respiratory distress, and high WBC counts. Cough is frequent. In the subacute presentation, children experience several days of viral croup–like symptoms and either do not respond to standard treatment or clinically worsen.
• The prodrome is usually an upper respiratory infection, followed by progression to higher fever, cough, inspiratory stridor, and a variable degree of respiratory distress.
• Patients may acutely decompensate with worsening respiratory distress due to airway obstruction from a purulent membrane that has loosened.
• Patients have been reported to present with symptoms and signs of bacterial tracheitis and multiorgan failure due to exotoxin-producing strains of Staphylococcus aureus or Streptococcus pyogenes in the trachea.

Physical

• Inspiratory stridor (with or without expiratory stridor)
• Barklike or brassy cough
• Hoarseness
• Worsening or abruptly occurring stridor
• Varying degrees of respiratory distress
• • Retractions
  • Dyspnea
  • Nasal flaring
  • Cyanosis
• Sore throat, odynophagia
• Dysphonia
• No drooling
• No specific position of comfort (The patient may lie supine.)

Causes

• S aureus (Community-acquired methicillin-resistant S aureus (CA-MRSA) has recently emerged in the United States is important; this could result in a greater frequency of MRSA strains that cause tracheitis.)
• Streptococcal species, especially S pyogenes
• Moraxella catarrhalis (Recent reports suggest it is a leading cause of bacterial tracheitis.)
• Haemophilus influenzae type B (Hib) (This cause is less common since the introduction of the Hib vaccine.)
• Klebsiella species
• Pseudomonas species
• Anaerobes
• • Peptostreptococcus species
  • Bacteroides species
  • Prevotella species
  • Mycobacterium tuberculosis (endobronchial disease)

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Uvulitis

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Obtain bacterial culture and Gram stain of tracheal secretions and blood cultures.

Imaging Studies

• Radiography of the lateral neck
• • Neither definitive nor essential
  • Portable, not in the radiology suite, only in the stable patient
  • May reveal subglottic narrowing on anteroposterior (AP) views and may reveal clouding of tracheal air column or irregular tracheal margin on lateral view
  • Concretions of epithelium and inflammatory cells possibly mimicking a foreign body

Procedures

• Laryngotracheobronchoscopy
• • Only definitive means of diagnosis
  • Direct visualization and culture of purulent tracheal secretions
  • May be therapeutic by performing tracheal toilet and stripping purulent membranes
  • Pediatric-sized bronchoscopes and experts at pediatric airway management not available at all facilities

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

• Airway
• • Maintenance of an adequate airway is of primary importance.
  • Avoid agitating the child. If the patient's respiratory status deteriorates, it is usually because of movement of the membrane, and bag-valve-mask ventilation should be effective.
  • If intubation is required, use an endotracheal tube 0.5-1 size smaller than expected in order to minimize trauma in the inflamed subglottic area. Frequent suctioning and high air humidity is necessary to maintain endotracheal tube patency; therefore, use the most appropriate-sized tube (without causing trauma). Most patients (57-100%) require eventual intubation.
• Intravenous access and medication
• • Once the airway is stabilized, obtain intravenous access for initiation of antibiotics.
  • Antibiotic regimens have traditionally included a penicillinase-resistant penicillin and a third-generation cephalosporin or clindamycin in patients who are allergic to penicillin.
  • Vancomycin, with or without clindamycin, should be started in patients who appear toxic or have multiorgan involvement or if methicillin-resistant S aureus is prevalent in the community.

Surgical Care

• Tracheostomy
• • Tracheostomy is rarely necessary unless injury or trauma to the airway has caused scarring and documented narrowing of the airway. Tracheostomy is necessary if the patient has failed extubations despite appropriate medical management or if intubation is prolonged.
  • Pulmonary toilet is potentially better with tracheostomy.

Consultations

• Otorhinolaryngology - For endoscopic procedures and acute airway management
• Pediatric intensivist - Necessary because of potential for acute decompensation

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Drug Category: Antibiotic agents

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Consider extubation when infection appears to be resolving, especially with decreased secretions suctioned from the endotracheal tube.

Further Outpatient Care

• Patient should complete an appropriate course (usually 10 d) of oral antibiotics.

Transfer

• Transfer is required for patients in respiratory distress, patients in need of a pediatric intensive care unit, and patients who need a pediatric-sized bronchoscope.

Complications

• Pneumonia – Reported in 19-60% of cases
• Septicemia
• Toxic shock
• Adult respiratory distress syndrome (ARDS)
• Endotracheal tube complications
• • Plugging, accidental extubation
  • Postextubation stridor, subglottic stenosis
• Anoxic encephalopathy
• Cardiorespiratory arrest

Prognosis

• Once the patient is past the acute phase, complete recovery is expected.

Patient Education

• Keep immunizations up-to-date.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Always consider epiglottitis, foreign body, and bacterial tracheitis before settling for a diagnosis of croup.

Special Concerns

• Predisposing conditions may include the following:
• • Down syndrome
  • Anatomic abnormalities such as subglottic hemangioma, tracheobronchomalacia, tracheoesophageal fistula repair
  • Immunodeficiency
  • Preceding viral infection, especially parainfluenza

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Bernstein T, Brilli R, Jacobs B. Is bacterial tracheitis changing? A 14-month experience in a pediatric intensive care unit. Clin Infect Dis. Sep 1998;27(3):458-62. [Medline].
• Brook I. Aerobic and anaerobic microbiology of bacterial tracheitis in children. Pediatr Emerg Care. Feb 1997;13(1):16-8. [Medline].
• Cherry JD. Croup (laryngitis, laryngotracheitis, spasmodic croup, and laryngotracheobronchitis). Textbook of Pediatric Infectious Diseases. 1998;234-238.
• Donnelly BW, McMillan JA, Weiner LB. Bacterial tracheitis: report of eight new cases and review. Rev Infect Dis. Sep-Oct 1990;12(5):729-35. [Medline].
• Eckel HE, Widemann B, Damm M, Roth B. Airway endoscopy in the diagnosis and treatment of bacterial tracheitis in children. Int J Pediatr Otorhinolaryngol. Aug 1993;27(2):147-57. [Medline].
• Gallagher PG, Myer CM 3d. An approach to the diagnosis and treatment of membranous laryngotracheobronchitis in infants and children. Pediatr Emerg Care. Dec 1991;7(6):- Myer CM 3d. [Medline].
• Rotta AT, Wiryawan B. Respiratory emergencies in children. Respir Care. Mar 2003;48(3):248-58; discussion 258-60. [Medline].
• Tan AK, Manoukian JJ. Hospitalized croup (bacterial and viral): the role of rigid endoscopy. J Otolaryngol. Feb 1992;21(1):48-53. [Medline].

Article Last Updated: Oct 19, 2006