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Updated: Sep 4 2020

Bacterial Tracheitis

  • 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
          • 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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