Snapshot A 4-year-old boy presents to the emergency department with his mother for shortness of breath. Two days prior to presentation, the patient developed a headache and cough. He was being symptomatically managed with acetaminophen; however, he started to develop "noises" while breathing and appears uncomfortable. His temperature is 102°F (38.9°C), blood pressure is 80/55 mmHg, pulse is 115/min, and respirations are 30/min with an oxygen saturation of 99%. The patient is given inhaled epinephrine, which did not improve his symptoms. Radiography of the chest demonstrates subglottic tracheal narrowing. 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 login to view 5 more bullets 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 login to view 1 more bullet location soft tissues of the trachea risk factors antecedent viral infection leading to airway mucosal damage login to view 4 more bullets 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 login to view 1 more bullet poor air entry poor mental status Imaging Radiography recommended views lateral neck anteroposterior findings steeple sign login to view 2 more bullets 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 login to view 1 more bullet Nonoperative bronchoscopy indication login to view 2 more bullets Complications Pneumonia Acute respiratory distress syndrome Septic shock Toxic shock syndrome Cardiorespiratory arrest