Tracheitis

Tracheitis: Excerpt from The 5-Minute Pediatric Consult

Charles A. Pohl, MD

Tracheitis - BASICS

Tracheitis - description

Infection of the trachea associated with airway inflammation and obstruction:

• Acute tracheitis: Sudden onset; higher morbidity and mortality
• Subacute tracheitis: Indolent presentation and course; more common among children with prolonged intubation, tracheostomy, and/or underlying respiratory or neurologic conditions

Tracheitis - general prevention

• Routine childhood immunization with Haemophilus influenzae type B and pneumococcal vaccines
• Influenza vaccination in children identified and targeted by the American Academy of Pediatrics
• Avoid overaggressive suctioning of children with artificial airways.

Tracheitis - epidemiology

• Viral prodrome common
• Increased incidence during viral respiratory season (fall and winter): Up to 75% coinfected with influenza A
• Gender predisposition unclear (2:1 male-to-female ratio has been reported)

Tracheitis - pathophysiology

• Epithelial damage from a viral infection or mechanical trauma (endotracheal intubation, surgical procedure) occurs in the trachea at the level of the cricoid cartilage. As a result, the damaged tissue is more susceptible to bacterial superinfection.
• Mucosal damage characterized by marked subglottic edema, copious purulent secretions, and a pseudomembrane (mucosal lining, inflammatory products, and bacteria). These changes lead to marked airway obstruction.
• Toxic shock syndrome may be a consequence if the infection is associated with toxin-producing strains of Staphylococcus aureus or Streptococcus pyogenes.

Tracheitis - etiology

• Bacteria:
  • Staphylococcus aureus (most common), group A β-hemolytic streptococcus, Moraxella catarrhalis, and nontypeable H. influenzae
  • Pseudomonas aeruginosa, other Gram-negative enteric bacteria have been associated with nosocomial infections.
  • Mycobacterium tuberculosis, Mycoplasma pneumoniae, Corynebacterium diphtheria, H. influenzae type B, and respiratory anaerobic bacteria are uncommon pathogens.
• Viruses: Influenza, parainfluenza, respiratory syncytial, herpes simplex, and measles viruses have been found with bacterial pathogen(s).
• Fungi: Seen with underlying immunodeficiency disorders or chronic steroid use

Tracheitis - DIAGNOSIS

Tracheitis - signs & symptoms

Tracheitis - history

• Hyperpyrexia; nonpainful, brassy cough; noisy respirations; lethargy; dyspnea; rapid progression of airway occlusion (hours to a few days)
• Hoarseness, dysphagia, neck pain, drooling, and croupy cough are less common.
• Presence of upper airway infection
• Lack of clinical improvement with racemic epinephrine should raise the suspicion for tracheitis.
• An indolent progression of symptoms, including increase of supplemental oxygen requirement and tracheal secretions (thicker and color changes), may be seen in subacute tracheitis.
• Affects any age (peak age 2–6 years)

Tracheitis - physical exam

• Toxic appearance; anxious, agitated, or lethargic; labored breathing with signs of severe respiratory distress (air hunger posture, retractions); pallor or cyanosis; severe stridor; concomitant signs of pneumonia
• Deviated uvula suggests a peritonsillar abscess.
• Asymmetric lung sounds are often found in patients with foreign bodies in the airway.
• Generalized lymphadenopathy and splenomegaly are clues for infectious mononucleosis.

Tracheitis - tests

• Laryngoscopy or bronchoscopy:
  • Direct visualization and suctioning of obstructed airway is both diagnostic and therapeutic.
  • Findings include a red, edematous and/or eroded trachea and bronchi with purulent secretions and pseudomembrane.
  • Consider in an ill-appearing child with an unclear diagnosis or when the child’s condition does not respond to current management.
• Tracheal bacterial culture (for aerobic and anaerobic bacteria): The gold standard for diagnosis
• Tracheal Gram stain for pathogens and white blood cells (especially polymorphonuclear leukocytes): Helps differentiate bacterial infection from colonization
• Blood culture: Rarely helpful in diagnosis (<50% positive)
• CBC: Little diagnostic value, but may show leukocytosis with a left shift
• ESR and/or C-reactive protein: May be elevated

Tracheitis - imaging

• Radiographs must be completed in controlled settings by personnel who are trained in airway management.
• Lateral and anteroposterior neck films: Findings include distention of the hypopharynx, subglottic narrowing, and irregularity of the tracheal wall owing to mucosal sloughing or the presence of a pseudomembrane.
• Chest radiograph: Obtain if pneumonia, which may be concurrent, is suspected.

Tracheitis - differencial diagnosis

• Infectious:
  • Epiglottitis/Supraglottitis (presence of supraglottic inflammation)
  • Peritonsillar and parapharyngeal abscesses
  • Retropharyngeal abscess
  • Infectious mononucleosis (Epstein–Barr virus)
  • Diphtheria (rare)
• Environmental:
  • Aspiration or inhalation of a caustic substance, including alkali products (e.g., oven cleaner) or smoke
  • Foreign body aspiration
  • Generalized allergic reaction or anaphylaxis leading to angioedema
• Tumors (rare):
  • Papillomas secondary to human papillomavirus
  • Hamartoma and inflammatory pseudotumor
  • Laryngeal tumors
• Trauma:
  • Post-traumatic tracheal stenosis
  • Blunt trauma to neck
• Congenital:
  • Tracheal stenosis
  • Vascular ring and slings
  • Laryngotracheal web and clefts
  • Laryngotracheomalacia
  • Vocal cord paralysis
  • Arnold–Chiari malformation

• Watch for sudden deterioration from tracheal inflammation and secretions. Continuous monitoring is necessary.
• Bacterial tracheitis must be considered in all children with sudden upper respiratory distress and hyperpyrexia.

Tracheitis - TREATMENT

Tracheitis - general measures

• Support by stabilizing airway, breathing, circulation (ABCs)
• Maintain airway
• Initiate IV, ORapid assessment of ABCs is essential with emphasis on airway control.
• Supplemental oxygen is usually needed.
• Anticipate and prepare for emergent endotracheal intubation and tracheostomy.
• Endoscopy with suctioning and debridement is often necessary for diagnosis and therapy.
• Subsequent airway suctioning and monitoring prevents adverse outcomes.
• Increased ventilatory support is often required for children with pre-existing artificial airways.

Tracheitis - diet

NPO until airway stabilized and patient is able to tolerate oral foods.

Tracheitis - nursing

• Suction secretions
• Monitor closely

Tracheitis - medication

Select antibiotic therapy based on gram stain and culture results of tracheal secretions. Also consider known prior colonization and institutional pathogens in children with pre-existing artificial airway and hospital-acquired infections.

• Mild illness:
  • Empiric therapy with amoxicillin–clavulanic acid or a 2nd-generation cephalosporin for 10–14 days (25–45 mg/kg per 24 hours depending on the antibiotic used)
  • Consider a semisynthetic penicillin such as dicloxacillin (15–25 mg/kg per 24 hours) if H. influenzae type B vaccine completed and clindamycin (10–30 mg/kg per 24 hours) if presence of a penicillin allergy
• Moderate to severe illness:
  • Empiric therapy with a 2nd- or 3rd-generation cephalosporin or with ampicillin–sulbactam
  • Consider vancomycin (40 mg/kg per 24 hours) if a hospital-acquired infection is present or if pneumococcal resistance is suspected.
• Anaerobic, pseudomonas, and other Gram-negative coverage should be considered in children not responding to initial therapy or having pre-existing artificial airways.
• In contrast to croup, nebulized racemic epinephrine does not provide significant relief.
• Duration: Based on clinical response; usually 10–14 days

Tracheitis - FOLLOW UP

• Routine surveillance cultures in children with artificial airways are not recommended. They usually represent colonization in an asymptomatic patient.
• Signs to watch for:
  • Toxic appearance, excessive secretions, persistent fever, or worsening respiratory distress after introducing antibiotics suggest a resistant organism, an unusual pathogen, or a different diagnosis.
  • Recurrent respiratory distress, especially stridor, with subsequent respiratory tract infections suggests underlying tracheal stenosis.
  • Sudden deterioration on a ventilator may indicate endotracheal tube obstruction, pneumothorax, or mechanical problems.

Tracheitis - prognosis

• Most children recover without any sequelae.
• Younger patients are more likely to require intubations and longer hospital stays.
• Children at risk of subacute tracheitis are more likely to have recurrent episodes.

Tracheitis - complications

• Atelectasis
• Pulmonary edema and pneumonia
• Septicemia
• Staphylococcal toxin syndromes (e.g., toxic shock syndrome)
• Prolonged mechanical ventilation with associated complications (including air leak, infection, pneumothorax, and tracheal stenosis)
• Subglottic stenosis
• Respiratory failure and arrest
• Death (<3.7%)

Tracheitis - bibliography

1. Chambers HF. Community-associated MRSA resistance and virulence converge. N Engl J Med. 2005;352:1485–1487.
2. Hopkins A, Lahiri T, Salerno R, et al. Changing epidemiology of life-threatening upper airway infections: The reemergence of bacterial tracheitis. Pediatrics. 2006;118:1418–1421.
3. Stevenson MD, Gonzalez del Rey JA. Upper airway obstruction: Infectious cases. Clin Pediatr Emerg Care. 2002;3:163–172.
4. Ward MA. Emergency department management of acute respiratory infections. Semin Respir Infect. 2002;17:65–71.

Tracheitis - CODES

Tracheitis - icd9

464.1 Acute tracheitis

Tracheitis - FAQ

• Q: How can you differentiate a child with severe croup from one with tracheitis?
• A: Infectious croup and tracheitis can present with similar features of fever, toxic appearance, respiratory distress, and stridor. Direct endoscopic visualization and culture of the upper airway is the test of choice to distinguish these medical conditions. Croup is commonly associated with parainfluenza virus and a “steeple sign” of the upper trachea on an anteroposterior neck radiograph.
• Q: Is influenza A virus a common pathogen of tracheitis?
• A: This subject is controversial. Influenza A virus is frequently recovered from tracheal cultures in children who present with tracheitis. It remains unclear, though, whether this virus is a pathogen or predisposing factor in tracheitis.
• Q: Is the supraglottic area usually involved in tracheitis?
• A: No. Unlike epiglottitis, the supraglottic region is usually spared and can help aid in the diagnosis of bacterial tracheitis.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

More About Tracheitis

• Back to disease: Tracheitis: Introduction
• Next Book Extract About Tracheitis: Surveys relating to Tracheitis
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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