Updated: 9/4/2020

Bacterial Tracheitis

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Snapshot
  • A 5-year-old boy presents to the emergency department with his mother for worsening shortness of breath. The mother reports that approximately 2 days ago, he was developing fevers and a cough but was otherwise doing well. However, the patient appears more fatigued and making "noises" when he's breathing. His temperature is 102°F (38.9°C), blood pressure is 75/50 mmHg, pulse is 110/min, and respirations are 28/min with an oxygen saturation of 93%. The patient is given inhaled epinephrine, which did not improve his symptoms. Physical examination is notable for nasal flaring and intercostal retractions. The patient is started on intravenous fluids and empiric antibiotics and was intubated for airway protection and admitted to the pediatric intensive care unit for further monitoring. 
Introduction
  • Overview
    • decribes a bacterial infection affecting the soft tissues of the trachea
      • most commonly occurs in the setting of previous airway mucosal damage (e.g., prior viral infection)
      • most common bacterial isolate is Staphylococcus aureus
        • other common bacterial organisms include
          • Streptococcus pneumoniae
          • Streptococcus pyogenes
          • Moraxella catarrhalis
          • Haemiphilus influenze strains (e.g., Hib)
      • poor response to inhaled epinephrine is supportive of bacterial tracheitis
      • patients are best managed in pediatric intensive care unit, and it is imperative to ensure the patient's airway is maintained
  • Epidemiology
    • incidence
      • unknown in the United States
    • demographic
      • slight male predominance
      • most commonly within the first 6 years of life
        • however, can occur at any age
    • location
      • soft tissues of the trachea
    • risk factors
      • antecedent viral infection leading to airway mucosal damage
        • parainfluenza
        • influenza A and B
        • respiratory syncytial virus
        • rhinovirus
      • aspiration from bacterial upper respiratory tract infections (e.g., streptococcal pharyngitis)
      • after tonsillectomy
  • Pathophysiology
    • pathogenic bacteria invade the trachea, leading to a local and systemic inflammatory response
      • results in mucopurulent exudates and ulceration of the tracheal mucosa, resulting in possible upper airway obstruction 
  • Associated conditions
    • prior upper respiratory tract viral infections
  • Prognosis
    • full recovery with no long-term morbidity is typically expected
Presentation
  • Symptoms
    • prodromal symptoms (antecedent viral infection, typically 1-3 days before severe symptoms develop)
      • fever
      • cough
    • signs of airway obstruction
      • stridor
      • dyspnea
  • Physical exam
    • signs of airway obstruction
      • respiratory accessory muscle use
        • marked restractions
      • poor air entry
      • poor mental status
Imaging
  • Radiography 
    • recommended views
      • lateral neck
      • anteroposterior
    • findings
      • steeple sign 
        • subglottic tracheal narrowing 
          • nonspecific findings that can be seen in viral croup
Studies
  • Labs
    • white blood cell count
      • highly variable, as patients can have mild leukopenia or leukocytosis
Differential
  • Viral croup
    • key distinguishing factors
      • caused by parainfluenza virus
      • patients are less toxic appearing than bacterial tracheitis
      • good response to inhaled epinephrine
  • Epiglottitis
    • key distinguishing factors
      • patients are prefer being in the tripod posture
      • radiography demonstrates an enlarged epiglottis ("thumb sign")
Prevention
  • Pneumococcus vaccination
  • Measle and influenza vaccination
Treatment
  • Pharmacologic
    • vancomycin with a third-generation cephalosporin or ampicillin-sulbactam
      • indication
        • first-lime empiric antibiotic treatment
  • Nonoperative
    • bronchoscopy
      • indication
        • evaluation of the airway in patients without respiratory failure
        • removal of tracheal exudates and purulent secretions in patients without respiratory failure
Complications
  • Pneumonia
  • Acute respiratory distress syndrome
  • Septic shock
  • Toxic shock syndrome
  • Cardiorespiratory arrest

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