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Bacterial Tracheitis, Emergency Medicine

Basics

Description

- Infection: - Septic shock - Toxic shock syndrome (TSS) - Pneumonia - Retropharyngeal cellulitis

- Cardiopulmonary arrest - Renal failure

- Bronchoscopy: - Direct visualization of trachea - Laryngotracheal inflammation and erosions - Mucopurulent secretions - Membranes - Therapeutic stripping of membranes - Enables direct culture of material

- Assess airway/breathing: - Supplemental oxygen - Racemic epinephrine aerosol if easily tolerated - Reassurance; avoid agitating child

  • 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 obstructionSubglottic stenosisPulmonary edemaPneumothoraxARDSEndotracheal tube (ETT) pluggingInfection:Septic shockToxic shock syndrome (TSS)PneumoniaRetropharyngeal cellulitisCardiopulmonary arrestRenal 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:

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 epiglottisMucosal edemaSubglottic edema, secretions, membrane
  • Bronchoscopy:Direct visualization of tracheaLaryngotracheal inflammation and erosionsMucopurulent secretionsMembranesTherapeutic stripping of membranesEnables 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.)EpiglottitisPeritonsillar abscessRetropharyngeal abscessUvulitisLaryngeal diphtheria
  • Angioedema
  • Intraluminal obstruction:
  • Caustic ingestion
  • Trauma

Treatment

Pre-Hospital

  • Assess airway/breathing:Supplemental oxygenRacemic epinephrine aerosol if easily toleratedReassurance; 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 intubationTherapeutic stripping of membranes
  • IV antibiotics to cover typical pathogens:Ceftriaxone and nafcillin or vancomycinVancomycin or clindamycin for penicillin-allergic patientsConsider 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.

See Also (Topic, Algorithm, Electronic Media Element)

  • Epiglottitis, pediatric
  • Epiglottitis, adult
  • Croup

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)