Bacterial tracheitis

Background

• Bacterial infection of tracheal epithelium
  • Often secondary infection after viral illness
  • S. Aureus most common, also strep spp, H. Influenza and anaerobes
• Peak age is 3-5 years old
  • Occurs throughout childhood and adulthood

Clinical Features

• Severely ill child, starts out as viral prodrome
  • Followed by inspiratory and expiratory stridor, resp distress, and copious purulent secretions
• Difficult to differentiate from croup and epiglottis
  • Severe decompensation, high fever, purulent secretions help differentiate
  • May also have concomitant pneumonia
• May have been treated with racemic epinephrine and steroids for croup, with no clinical improvement

Differential Diagnosis

Pediatric stridor

<6 Months Old

• Laryngotracheomalacia
  • Accounts for 60%
  • Usually exacerbated by viral URI
  • Diagnosed with flexible fiberoptic laryngoscopy
• Vocal cord paralysis
  • Stridor associated with feeding problems, hoarse voice, weak and/or changing cry
  • May have cyanosis or apnea if bilateral (less common)
• Subglottic stenosis
  • Congenital vs secondary to prolonged intubation in premies
• Airway hemangioma
  • Usually regresses by age 5
  • Associated with skin hemangiomas in beard distribution
• Vascular ring/sling

>6 Months Old

• Croup
  • viral laryngotracheobronchitis
  • 6 mo - 3 yr, peaks at 2 yrs
  • Most severe on 3rd-4th day of illness
  • Steeple sign not reliable- diagnose clinically
• Epiglottitis
  • H flu type B
    • Have higher suspicion in unvaccinated children
  • Rapid onset sore throat, fever, drooling
  • Difficult airway- call anesthesia/ ENT early
• Bacterial tracheitis
  • Rare but causes life-threatening obstruction
  • Symptoms of croup + toxic-appearing = bacterial tracheitis
• Foreign body (sudden onset)
  • Marked variation in quality or pattern of stridor
• Retropharyngeal abscess
  • Fever, neck pain, dysphagia, muffled voice, drooling, neck stiffness/torticollis/extension

Diagnosis

• Clinical diagnosis
• Gram stain with predominance of one organism, differentiating from colonization
• XR neck may show subglottic narrowing with ragged tracheal epithelium
• CXR may show concominant Pneumonia
• Emergent bronchoscopy is diagnostic and therapeutic

Treatment

• Intubation, emergent, usually necessary
• Bronchoscopy to confirm dx, rule out supraglottic pathology
• Antibiotics
  • Third generation cephalosporin (cefotaxime or ceftriaxone)
  • PLUS MRSA coverage, options below depending on prevalence of CA-MRSA
    • Clindamycin 40 mg/kg/d IV divided q8hr
    • OR vancomycin 45 mg/kg/d IV divided q8hr

Disposition

• ICU admit
• Often require prolong intubation, 4-5 days