Bacterial Tracheitis

Aka: Bacterial Tracheitis, Pseudomembranous Croup

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II. Epidemiology

  1. Affects older children than in croup
  2. Peaks at ages 3 to 8 years (but may occur in infants and toddlers)
  3. Most common in fall and winter months

III. Pathophysiology

  1. Tracheal Bacterial Infection
  2. Secondary infection of viral Upper Respiratory Infection (e.g. croup)
    1. Viral Infection and immune inflammatory response damage the upper airway
    2. Predisposes to Bacterial seeding of the trachea
  3. Tracheal inflammation
    1. Tracheal edema
    2. Thick purulent mucous
    3. Tracheal Mucosal Ulceration and sloughing
  4. Airway obstruction
    1. Results from subglottic and tracheal narrowing from inflammatory response

IV. Risk Factors

  1. Upper Respiratory Infection
  2. Chronic Tracheostomy dependent patients (infection from colonizing organisms)

V. Causes: Bacterial

  1. Staphylococcus aureus (including MRSA)
  2. Streptococcus species (Pneumococcus, Streptococcus Pyogenes)
  3. Moraxella catarrhalis
  4. Haemophilus Influenza
  5. Anaerobic Bacteria

VI. Symptoms

  1. Prodrome of upper respiratory symptoms (e.g. rhonorrhea, cough, congestion, Pharyngitis)
  2. Anterior Neck Pain
  3. Rapidly progresses to severe life-threatening illness
    1. Fever (abrupt onset)
    2. Hoarseness or Stridor
    3. Productive and painful cough
    4. Thick muous airway secretions
    5. Toxic, ill appearance

VII. Signs

  1. Toxic appearance
  2. High Fever
  3. Difficulty controlling secretions (Drooling, unable to swallow)
  4. Purulent airway secretions
  5. Respiratory distress
  6. Trachea may be tender
  7. Does not respond to Croup therapies
    1. Unresponsive to Racemic Epinephrine or mist therapy

VIII. Imaging

  1. Lateral Neck Xray
    1. Tracheal pseudomembrane
    2. Necrotic epithelium subdivides trachea lumen
    3. Croup findings (e.g. steeple sign) may coexist, as it may have preceded Bacterial Tracheitis
  2. Nasolaryngoscopy or Bronchoscopy (typically by ENT or intensivists)
    1. Epiglottis is typically normal (or mildly erythematous)
    2. Tracheal pseudomembranes
    3. Purulent secretions

IX. Differential Diagnosis

  1. See Pediatric Airway Obstruction Causes
  2. See Stridor
  3. Laryngo-tracheo Bronchitis (Croup)
  4. Epiglottitis

X. Diagnosis

  1. Bacterial Tracheitis is initially a clinical diagnosis in the emergent setting
    1. No laboratory or imaging study is definitively diagnostic for Bacterial Tracheitis
    2. Exercise caution in nasolarygnoscopy in
    3. ENT may confirm diagnosis under direct visualization

XI. Management

  1. Keep patient calm (same tenets for croup, Epiglottitis, Foreign Body Aspiration)
  2. Emergent management
    1. See Rapid Cardiopulmonary Asessment in Children
    2. See ABC Management
    3. See Respiratory Distress in the Newborn
    4. See Newborn Resuscitation
    5. See Pediatric Sepsis
  3. Endotracheal Intubation
    1. Should be performed by most experienced at difficult airway
    2. Ideally performed in operating room or ICU with double setup for surgical airway
    3. Have available Endotracheal Tube sizes that are 1-2 sizes smaller than normally used for patient size
  4. Broad Spectrum Antibiotics including coverage for MRSA
    1. Antibiotics are similar to those for Epiglottitis
    2. Example: Vancomycin and Ceftriaxone

XII. References

  1. Dahan, Campbell and Melville (2020) Crit Dec Emerg Med 34(11): 3-10
  2. Mehta and Eliason (2024) Crit Dec Emerg Med 38(6): 27-35

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