Bacterial Tracheitis, Emergency Medicine

Basics

Description

A tracheal infection potentially causing acute airway obstruction. Also known as bacterial croup and laryngotracheobronchitis. Exudative tracheitis can refer to a less severe form of disease
Usually secondary bacterial infection of trachea, complicating antecedent viral infection, or less commonly, instrumentation
Fatal in 0-20%
Tracheal membrane formation, purulent discharge, subglottic edema, erosions, with normal epiglottis
Classically presents with prodrome similar to croup followed by rapid deterioration and loss of airway patency
Mean age 5 yr; rarely occurs in adults
More common in children than epiglottitis, presumably due to success of Haemophilus influenzae immunization
More frequent August-December

Patients may present with a fairly benign course, followed by rapid deterioration, with respiratory distress, toxic appearance, and acute airway obstruction.

Etiology

Staphylococcus aureus (with occ. methicillin-resistant S. aureus [MRSA])
Moraxella catarrhalis
Streptococcus pneumoniae
Group A streptococcal species
Pseudomonas aeruginosa
H. influenzae type B
Escherichia coli
Anaerobes
Klebsiella pneumoniae
Nocardia
Associated with influenza A (including H1N1) and B, parainfluenza, adenovirus, and RSV viral infections
Aspergillus, HSV in immunocompromised hosts (HIV)

Diagnosis

Signs and Symptoms

History
Usually preceding viral infection with acute deterioration in course of illness
Physical Exam

Fever
Cough
Retractions
Inspiratory/expiratory stridor
Toxic appearance
Hoarseness
Cyanosis
Nasal flaring
Sore throat/neck pain
Dysphonia (drooling uncommon)
Complications:
- Respiratory:
  - Airway obstruction
  - Subglottic stenosis
  - Pulmonary edema
  - Pneumothorax
  - ARDS
  - Endotracheal tube (ETT) plugging
- Infection:
  - Septic shock
  - Toxic shock syndrome (TSS)
  - Pneumonia
  - Retropharyngeal cellulitis
- Cardiopulmonary arrest
- Renal failure

Essential Workup

Clinical assessment and management of airway takes priority over diagnostic workup; secure airway, optimally in operating room under controlled conditions.
Ensure adequate oxygenation before proceeding:
- Pulse oximetry

Diagnosis Tests & Interpretation

Lab

WBC variably elevated
Blood cultures usually negative
Request tracheal cultures from endoscopist/surgeon.

Imaging
Radiographs of neck soft tissue:

If done, perform in ED; accompany and monitor at all times.
Tracheal margin irregularities
Subglottic narrowing
Clouding of tracheal air column
Irregular intratracheal densities
Normal epiglottis

Diagnostic Procedures/Surgery

Flexible fiberoptic laryngoscopy:
- Permits direct visualization of epiglottis
- Mucosal edema
- Subglottic edema, secretions, membrane
Bronchoscopy:
- Direct visualization of trachea
- Laryngotracheal inflammation and erosions
- Mucopurulent secretions
- Membranes
- Therapeutic stripping of membranes
- Enables direct culture of material

Differential Diagnosis

Infection:
- Croup (failure to respond to treatment, older age, rapid deterioration or toxic appearance should raise suspicion for bacterial tracheitis rather than croup.)
- Epiglottitis
- Peritonsillar abscess
- Retropharyngeal abscess
- Uvulitis
- Laryngeal diphtheria
Angioedema
Intraluminal obstruction:
- Foreign body aspiration
Caustic ingestion
Trauma

Treatment

Pre-Hospital

Assess airway/breathing:
- Supplemental oxygen
- Racemic epinephrine aerosol if easily tolerated
- Reassurance; avoid agitating child
Bag-valve-mask (BVM) ventilation if in respiratory failure
Intubate if unable to maintain airway with BVM and other measures.
Immediate transport
Notify receiving ED of airway status.

Initial Stabilization/Therapy

Airway management:

Anticipate difficult airway
Intubation required in ~75% (40-100%) of patients. More frequently required in younger patients. Active airway management ensures stable airway and facilitates suctioning.
Intubation should ideally be performed in the operating room with surgical airway backup.
Select an ETT 1-2 sizes smaller than usual for age/size.
Meticulous ETT care and suctioning
If BVM ventilation needed, use appropriately sized mask with 2-hand seal.
Supplemental humidified oxygen

Ed Treatment/Procedures

Continue monitoring of ventilation and oxygenation.
IV fluids, bolus, as necessary
Bronchoscopy if not rapidly deteriorating:
- Assess need for intubation
- Therapeutic stripping of membranes
IV antibiotics to cover typical pathogens:
- Ceftriaxone and nafcillin or vancomycin
- Vancomycin or clindamycin for penicillin-allergic patients
- Consider corticosteroid therapy

Medication

Ceftriaxone: 50 mg/kg IV, max. 2 g
Nafcillin: 50 mg/kg IV; max. 2 g
Ampicillin/sulbactam: 50 mg/kg IV; max. 3 g
Vancomycin: 15 mg/kg IV; max. 1 g
Clindamycin: 10 mg/kg IV; max. 1 g
Racemic epinephrine: 2.25% solution diluted 1:8 with water in doses of 2-4 mL via aerosol
Dexamethasone: 0.6 mg/kg IV

First Line
Ceftriaxone plus nafcillin
Second Line
Vancomycin or clindamycin:

Consider if penicillin allergic, and in areas of high prevalence of MRSA

Follow-Up

Disposition

Admission Criteria
All patients with suspected or documented bacterial tracheitis:

Admit to PICU.
PICU length of stay varies from 3-9 days.

Discharge Criteria
None
Issues for Referral
Critical care, otolaryngologist, or pulmonologist should be consulted.

Followup Recommendations

Few long-term complications

Pearls and Pitfalls

Consider in patients with croup-like illness who rapidly deteriorate.
May be more severe in younger patients due to narrower tracheal diameters.

Additional Reading

Hopkins BS, Johnson KE, Ksiazek JM, et al. H1N1 influenza presenting as bacterial tracheitis. Otolaryngol Head Neck Surg. 2010;142:612-614.
Hopkins A, Lahiri T, Salerno R, et al. Changing epidemiology of life-threatening upper airway infections: The re-emergence of bacterial tracheitis. Pediatrics. 2006;118:1418-1421.
Huang YL, Peng CC, Chiu NC, et al. Bacterial tracheitis in pediatrics: 12 year experience at a medical center in Taiwan. Pediatr Int. 2009;51:110-113.
Salamone FN, Bobbitt DB, Myer CM, et al. Bacterial tracheitis reexamined: Is there a less severe manifestation? Otolaryngol Head Neck Surg. 2004;131:871-876.
Tebruegge M, Pantadazidou A, Thorburn K, et al. Bacterial tracheitis: A multi-centre perspective. Scand J Infect Dis. 2009;41:548-557.

Codes

ICD9

464.4 Croup
464.11 Acute tracheitis with obstruction
464.21 Acute laryngotracheitis with obstruction

ICD10

J04.11 Acute tracheitis with obstruction
J05.0 Acute obstructive laryngitis [croup]

SNOMED

85915003 Laryngotracheobronchitis
71186008 Croup (disorder)
8519009 acute tracheitis with obstruction (disorder)

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