Updated: 9/4/2020

Bacterial Tracheitis

Review Topic
  • 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. 
  • 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
  • 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
  • Radiography 
    • recommended views
      • lateral neck
      • anteroposterior
    • findings
      • steeple sign 
        • subglottic tracheal narrowing 
          • nonspecific findings that can be seen in viral croup
  • Labs
    • white blood cell count
      • highly variable, as patients can have mild leukopenia or leukocytosis
  • 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")
  • Pneumococcus vaccination
  • Measle and influenza vaccination
  • 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
  • Pneumonia
  • Acute respiratory distress syndrome
  • Septic shock
  • Toxic shock syndrome
  • Cardiorespiratory arrest

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