Except in patients with a tracheostomy or endotracheal tube, bacterial tracheitis is an uncommon infectious cause of acute upper airway obstruction. It is currently more prevalent than acute epiglottitis in children who have received Haemophilus type B vaccine. Patients may present with crouplike symptoms, such as barking cough, stridor, and fever; however, patients with bacterial tracheitis do not respond to standard croup therapy (racemic epinephrine) and instead require treatment with antibiotics and may experience acute respiratory decompensation.[1, 2, 3, 22]
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.[4, 5]
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.
Although the pathogenesis of bacterial tracheitis is unclear, mucosal damage or impairment of local immune mechanisms due to a preceding viral infection, an injury to the trachea from recent intubation, or trauma may predispose the airway to invasive infection with common pyogenic organisms.
United States
Tan and Manoukian reported that 500 children were hospitalized for croup at one pediatric hospital over a 32-month period.[6] 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.
A study that described the frequency and severity of complications in hospitalized children younger than 18 years with seasonal influenza (during 2003-2009) and 2009 pandemic influenza A(H1N1) (during 2009-2010) reported that out of 7293 children hospitalized with influenza, less than 2% had complications from tracheitis. However, along with other rare complications, tracheitis was associated with a median hospitalization duration of more than 6 days, with 48%-70% of children requiring intensive care.[7]
International
According to a recent study, bacterial tracheitis remains a rare condition, with an estimated incidence of approximately 0.1 cases per 100,000 children per year.[8]
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.
In most epidemiologic studies, male cases are preponderant. Gallagher et al reported a male-to-female predominance of 2:1.[9]
Bacterial tracheitis may occur in any pediatric age group. Gallagher et al reported 161 cases of patients younger than 16 years.[9] 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.
Symptoms of bacterial tracheitis may be intermediately between those of epiglottitis and croup. Presentation is either acute or subacute.
The following physical findings may be noted:
The following causes have been noted:
Obtain bacterial culture and Gram stain of tracheal secretions and blood cultures in patients with suspected bacterial tracheitis.
Radiography of the neck may be indicated.
Laryngotracheobronchoscopy is indicated.
Treatment of bacterial tracheitis consists of the following:
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.
The following consultations may be indicated:
Clinical Context: Provides empiric therapy against etiologic agents, specifically penicillinase-producing strains of Staphylococcus.
Clinical Context: Provides empiric therapy, especially against H influenzae, and modest activity against anaerobes.
Clinical Context: May be used in severe cases or in cases with a history of allergies instead of oxacillin for coverage of gram-positive organisms (eg, S aureus, S pyogenes).
Clinical Context: Use in combination with chloramphenicol in patients who are allergic to penicillin. Clindamycin in combination with cefuroxime is an acceptable regimen for patients who are not allergic.
Empiric antimicrobial therapy in bacterial tracheitis must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Patient should complete an appropriate course (usually 10 d) of oral antibiotics.
Consider extubation when bacterial tracheitis appears to be resolving, especially with decreased secretions suctioned from the endotracheal tube.
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.
The following complications have been reported:
A retrospective study by Gross et al, in which four patients who received antibiotic treatment for bacterial laryngotracheitis showed improvement in presumed iatrogenic laryngotracheal stenosis, suggested that airway bacterial growth is significantly involved in adult postintubation airway injury. The patients had a history of intubation and/or tracheostomy, with complete resolution of upper airway obstruction seen in three of the patients after laryngotracheitis treatment and significant improvement of airway status seen in the fourth.[15]
Steeple sign.
Steeple sign.
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