Basics
Description
Infection of the trachea associated with airway inflammation and obstruction
- Acute tracheitis: sudden onset; higher morbidity and mortality
- Subacute tracheitis: indolent presentation and course; more common among children with prolonged intubation, tracheostomy, and/or underlying respiratory or neurologic conditions
Epidemiology
- Viral prodrome common
- Increased incidence during viral respiratory season (fall and winter): up to 75% coinfected with influenza A
- Gender predisposition unclear (2:1 male-to-female ratio has been reported)
- 3% mortality rate
General Prevention
- Routine childhood immunization with Haemophilus influenzae type b, influenza, measles, and pneumococcal vaccines
- Avoid overaggressive suctioning of children with artificial airways.
Pathophysiology
- Epithelial damage from a viral infection or mechanical trauma (e.g., endotracheal intubation, surgical procedure) occurs in the trachea at the level of the cricoid cartilage. As a result, the damaged tissue is more susceptible to bacterial superinfection.
- Mucosal damage characterized by marked subglottic edema, copious purulent secretions, and a pseudomembrane (mucosal lining, inflammatory products, and bacteria). These changes lead to marked airway obstruction.
- Toxic shock syndrome may be a consequence if the infection is associated with toxin-producing strains of Staphylococcus aureus or Streptococcus pyogenes.
Etiology
- Bacteria
- Staphylococcus aureus (most common), group A ²-hemolytic Streptococcus, Moraxella catarrhalis, nontypeable H. influenzae, Streptococcus pneumoniae
- Pseudomonas aeruginosa and other gram-negative enteric bacteria have been associated with nosocomial infections.
- Mycobacterium tuberculosis, Mycoplasma pneumoniae, Corynebacterium diphtheriae, H. influenzae type b, and respiratory anaerobic bacteria are uncommon pathogens.
- Viruses: Influenza, parainfluenza, respiratory syncytial, herpes simplex, and measles viruses have been found with bacterial pathogen(s).
- Fungi: seen with underlying immunodeficiency disorders or chronic steroid use
Diagnosis
History
- Hyperpyrexia; nonpainful, brassy cough; noisy respirations; lethargy; dyspnea; rapid progression of airway occlusion (hours to a few days)
- Hoarseness, dysphagia, neck pain, drooling, and croupy cough are less common with bacterial tracheitis.
- Presence of upper airway infection
- Lack of clinical improvement with racemic epinephrine should raise the suspicion for tracheitis.
- An indolent progression of symptoms, including increase of supplemental oxygen requirement and tracheal secretions (thicker and color changes), may be seen in subacute tracheitis.
- Affects any age (peak age 1 " 6 years)
Physical Exam
- Toxic appearance; anxious, agitated, or lethargic; labored breathing with signs of severe respiratory distress (e.g., air hunger posture, retractions); pallor or cyanosis; severe stridor; concomitant signs of pneumonia
- Deviated uvula suggests a peritonsillar abscess.
- Asymmetric lung sounds are often found in patients with foreign bodies in the airway.
- Generalized lymphadenopathy and splenomegaly are clues for infectious mononucleosis.
Diagnostic Tests & Interpretation
Imaging
- Radiographs must be completed in controlled settings by personnel who are trained in airway management.
- Lateral and anteroposterior neck films: Findings include distention of the hypopharynx, subglottic narrowing, and irregularity of the tracheal wall owing to mucosal sloughing or the presence of a pseudomembrane.
- Chest radiograph: Obtain if pneumonia, which may be concurrent, is suspected.
Diagnostic Procedures/Other
- Laryngoscopy or bronchoscopy
- Direct visualization and suctioning of obstructed airway is both diagnostic and therapeutic.
- Findings include a red, edematous, and/or eroded trachea and bronchi with purulent secretions and pseudomembrane.
- Consider in an ill-appearing child with an unclear diagnosis or when the child 's condition does not respond to current management
- Tracheal bacterial culture (for aerobic and anaerobic bacteria): the gold standard for diagnosis
- Tracheal Gram stain for pathogens and white blood cells (especially polymorphonuclear leukocytes): helps differentiate bacterial infection from colonization
- Blood culture: rarely helpful in diagnosis (<50% positive)
- CBC: little diagnostic value but may show leukocytosis with a left shift
- ESR and/or C-reactive protein: may be elevated
Differential Diagnosis
- Infectious
- Epiglottitis/supraglottitis (presence of supraglottic inflammation)
- Laryngotracheitis (croup)
- Peritonsillar and parapharyngeal abscesses
- Retropharyngeal abscess
- Infectious mononucleosis (Epstein-Barr virus)
- Diphtheria (rare)
- Environmental
- Aspiration or inhalation of a caustic substance, including alkali products (e.g., oven cleaner) or smoke
- Foreign body aspiration
- Generalized allergic reaction or anaphylaxis leading to angioedema
- Tumors (rare)
- Papillomas secondary to human papillomavirus
- Hamartoma and inflammatory pseudotumor
- Laryngeal tumors
- Trauma
- Posttraumatic tracheal stenosis
- Blunt trauma to neck
- Congenital
- Tracheal stenosis
- Vascular ring and slings
- Laryngotracheal web and clefts
- Laryngotracheomalacia
- Vocal cord paralysis
- Arnold-Chiari malformation
Alert
- Watch for sudden deterioration from tracheal inflammation and secretions. Continuous monitoring is necessary.
- Bacterial tracheitis must be considered in all children with sudden upper respiratory distress and hyperpyrexia.
Treatment
Medication
Select antibiotic therapy based on Gram stain and culture results of tracheal secretions and the most likely pathogens. Also consider known prior colonization and institutional pathogens in children with preexisting artificial airway and hospital-acquired infections:
- Mild illness
- Empiric therapy with amoxicillin-clavulanic acid or a 2nd-generation cephalosporin for 10 " 14 days (50 mg/kg/24 h depending on the antibiotic used)
- Consider a semisynthetic penicillin such as dicloxacillin (40 mg/kg/24 h) if H. influenzae type b vaccine completed and clindamycin (10 " 30 mg/kg/24 h) if presence of a penicillin allergy or MRSA suspected
- Moderate to severe illness
- Empiric therapy with an antistaphylococcal agent such as clindamycin plus a 3rd-generation cephalosporin or with ampicillin-sulbactam
- Consider vancomycin IV (60 " 80 mg/kg/24 h) if a hospital-acquired infection (MRSA) is present or in cases of toxic shock pending culture results.
- Anaerobic, pseudomonas, and other gram-negative coverage should be considered in children not responding to initial therapy or having preexisting artificial airways.
- In contrast to croup, nebulized racemic epinephrine and steroids do not provide significant relief.
- Duration: based on clinical response; usually 10 " 14 days
Additional Therapies
General Measures
- Support by stabilizing circulation, airway, breathing (ABCs).
- Maintain airway.
- Initiate IV, oxygen, and monitor.
- Rapid assessment of ABCs is essential with emphasis on airway control.
- Supplemental oxygen is usually needed.
- Pediatric ICU care is initially recommended.
- Anticipate and prepare for emergent endotracheal intubation and tracheostomy.
- Endoscopy with suctioning and debridement is often necessary for diagnosis and therapy.
- Subsequent airway suctioning and monitoring prevents adverse outcomes.
- Increased ventilatory support is often required for children with preexisting artificial airways.
Ongoing Care
Follow-up Recommendations
- Routine surveillance cultures in children with artificial airways are not recommended. They usually represent colonization in an asymptomatic patient.
- Signs to watch for:
- Toxic appearance, excessive secretions, persistent fever, or worsening respiratory distress after introducing antibiotics suggest a resistant organism, an unusual pathogen, or a different diagnosis.
- Recurrent respiratory distress, especially stridor, with subsequent respiratory tract infections suggests underlying tracheal stenosis.
- Sudden deterioration on a ventilator may indicate endotracheal tube obstruction, pneumothorax, or mechanical problems.
Diet
NPO until the airway is stabilized and the patient is able to tolerate oral foods
Prognosis
- Most children recover without any sequelae.
- Younger patients are more likely to require intubations and longer hospital stays.
- Children at risk for subacute tracheitis are more likely to have recurrent episodes.
Complications
- Atelectasis
- Pulmonary edema and pneumonia
- Septicemia
- Staphylococcal toxin syndromes (e.g., toxic shock syndrome)
- Prolonged mechanical ventilation with associated complications (including air leak, infection, pneumothorax, and tracheal stenosis)
- Subglottic stenosis
- Respiratory failure and arrest
- Death (<3.7%)
Additional Reading
- Hopkins A, Lahiri T, Salerno R, et al. Changing epidemiology of life-threatening upper airway infections: the reemergence of bacterial tracheitis. Pediatrics. 2006;118(4):1418 " 1421. [View Abstract]
- Salamone FN, Bobbit DB, Myer CM, et al. Bacterial tracheitis reexamined: is there a less severe manifestation. Otolaryngol Head Neck Surg. 2004;131(6):871 " 876. [View Abstract]
- Tebruegge M, Pantazidou A, Thorburn K, et al. Bacterial tracheitis: a multi-centre perspective. Scand J Infect Dis. 2009;41(8):548 " 557. [View Abstract]
- Tebruegge M, Pantazidou A, Yau C. Bacterial tracheitis " tremendously rare, but truly important: a systemic review. J Pediatr Infect Dis. 2009;4:199 " 209.
Codes
ICD09
- 464.10 Acute tracheitis without mention of obstruction
- 464.11 Acute tracheitis with obstruction
- 464.30 Acute epiglottitis without mention of obstruction
- 464.20 Acute laryngotracheitis without mention of obstruction
ICD10
- J04.10 Acute tracheitis without obstruction
- J04.11 Acute tracheitis with obstruction
- J05.10 Acute epiglottitis without obstruction
- J04.2 Acute laryngotracheitis
SNOMED
- 26650005 Acute tracheitis
- 8519009 acute tracheitis with obstruction (disorder)
- 232432003 Pediatric acute epiglottitis and supraglottitis (disorder)
- 64375000 Acute laryngotracheitis (disorder)
FAQ
- Q: How can you differentiate a child with severe croup from one with tracheitis?
- A: Infectious croup and tracheitis can present with similar features of fever, toxic appearance, respiratory distress, and stridor. Direct endoscopic visualization and culture of the upper airway is the test of choice to distinguish these medical conditions. Croup is commonly associated with parainfluenza virus and a "steeple sign " of the upper trachea on an anteroposterior neck radiograph.
- Q: Is influenza A virus a common pathogen of tracheitis?
- A: This subject is controversial. Influenza A virus is frequently recovered from tracheal cultures in children who present with tracheitis. It remains unclear, though, whether this virus is a pathogen or predisposing factor in tracheitis.
- Q: Is the supraglottic area usually involved in tracheitis?
- A: No. Unlike with epiglottitis, the supraglottic region is usually spared in tracheitis. Lack of supraglottic involvement suggests bacterial tracheitis rather than epiglottitis.