Bacterial tracheitis

Bacterial tracheitis is a condition characterized by profuse exudates and pseudomembranes due to severe bacterial infection of the trachea. It can occur as a primary bacterial infection or following a viral illness. The most common manifestation is stridor in young children. Bacterial tracheitis is similar to viral croup and epiglottitis; however, affected individuals typically have higher fevers, are ill-appearing, and have severe respiratory symptoms that do not respond to treatments (e.g., with nebulized epinephrine). Patients usually require immediate stabilization and airway management before proceeding to bronchoscopy for diagnostic confirmation and treatment. Additional treatment includes broad-spectrum antibiotics and ICU management. If left untreated, bacterial tracheitis may progress to complete airway obstruction, sepsis, and death.

This article only addresses bacterial tracheitis in patients with native airways; disease characteristics and management are different in patients with artificial airways.

• Rare; primarily occurs in children < 6 years of age ^[1]
• ♂ > ♀ ^[1][2]
• More common during the fall and winter ^[1]

Epidemiological data refers to the US, unless otherwise specified.

• Staphylococcus aureus (most common) ^[3][4]
• Others: H. influenzae, S. pneumoniae, S. pyogenes, M. catarrhalis ^[3][4]

• Preceding viral upper respiratory tract infection: productive cough, hoarseness, sore throat ^[5]
• Severe rapidly progressing symptoms (within 2–10 hours) ^[4]
  • Unwell appearance
  • High fever
  • Signs of respiratory distress
  • Life-threatening airway obstruction: signs of impending respiratory failure

In contrast to croup, the symptoms of bacterial tracheitis do not improve with nebulized epinephrine. ^[6]

Approach ^[4][5][6]

• Stabilization with difficult airway management and respiratory support
• Give empiric IV antibiotics.
• Urgently consult ENT for direct visualization; bronchoscopy confirms the diagnosis and can treat airway obstruction.
• Consider supportive studies to rule out differential diagnoses of pediatric stridor.
• Admit to ICU for further management. ^[2]

Bacterial tracheitis is an airway emergency. Do not delay treatment to obtain diagnostic studies.

Immediate stabilization ^[5][6][7][8]

Most patients (> 75%) have severe airway compromise requiring intubation and intensive care management. ^[5][6][8]

• Respiratory support: if there are signs of airway compromise and/or signs of respiratory distress
  • Supplemental oxygen
  • Consider suctioning. ^[9]
• Prepare for difficult intubation: if patients are hypoxic and/or in severe distress
  • Intubate in the operating room if possible. ^[7][10]
  • Calculate ET tube size and then use a tube 1–2 mm smaller than predicted for age. ^[2][11]
  • Have the most experienced clinician perform the intubation.
• Immediate hemodynamic support: if there are clinical features of shock

In children with signs of airway compromise, minimize any agitation, as this can worsen airway obstruction.

Medical therapy ^[5][7][12]

• Empiric IV antibiotics with antistreptococcal and antistaphylococcal coverage for 7–10 days
  • Vancomycin (off-label) ^[12][13][14]
  • PLUS one of the following:
    • Ceftriaxone (off-label)
    • Ampicillin/sulbactam (off-label) ^[12]
    • If anaphylaxis to beta-lactams: ciprofloxacin (off-label) ^[12]
• Supportive treatment (e.g., antipyretics, IV fluids) as needed
• Consider glucocorticoids to reduce airway edema. ^[15][16]

Direct visualization ^[5][6]

• Goals
  • Diagnostic confirmation
  • Relief of airway obstruction
    • Debridement (e.g., stripping pseudomembranes, suctioning exudates)
    • Repeated treatments may be necessary.
  • Collection of microbiological studies (e.g., gram stain, culture)
• Modalities: bronchoscopy, flexible laryngoscopy ^[6]
• Findings include: ^[5]
  • Inflamed trachea and subglottis
  • Thick mucopurulent exudates
  • Pseudomembrane
  • Mucosal necrosis

Additional studies ^[5]

• Laboratory studies ^[5]
  • CBC: May show nonspecific findings; left-shift is common.
  • Blood cultures: typically negative; consider for patients with severe infection (e.g., signs of sepsis)
• Imaging ^[5]
  • X-ray neck; (AP and lateral): may show subglottic narrowing (steeple sign) and/or tracheal wall irregularities ^[4]
  • X-ray chest (AP and lateral): may show focal infiltrates ^[5]

• See “Differential diagnoses of pediatric inspiratory stridor.”

The differential diagnoses listed here are not exhaustive.

• Sepsis
• Septic shock
• Toxic shock syndrome
• Acute respiratory distress syndrome
• Residual subglottic stenosis
• Postobstructive pulmonary edema

We list the most important complications. The selection is not exhaustive.

• Give supplemental oxygen.
• Prepare for intubation and anticipate a difficult airway.
• Intubate in the operating room if possible.
• Have the most experienced clinician perform intubation.
• Give empiric IV antibiotics (e.g., ceftriaxone and vancomycin).
• Start supportive therapy (antipyretics, IV fluids).
• Urgently consult ENT for bronchoscopy to confirm the diagnosis and debride the trachea.
• Admit to the ICU.