eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Bacterial Tracheitis

Author: Sujatha Rajan, MD, Assistant Professor of Pediatrics, Albert Einstein School of Medicine; Consulting Staff, Department of Pediatrics, Division of Pediatric Infectious Diseases, Schneider Children's Hospital, North Shore-Long Island Jewish Health System
Coauthor(s): Kathryn Clark Emery, MD, Associate Professor, Department of Pediatrics, University of Colorado Health Sciences Center; Consulting Staff, Department of Emergency Medicine, Children's Hospital of Denver; Sunil K Sood, MBBS, DCh, MD, Professor of Clinical Pediatrics, Department of Pediatrics, Albert Einstein College of Medicine; Chief, Pediatric Infectious Diseases, Firm Director, Pediatric Unit, Schneider Children's Hospital at North Shore, North Shore University Hospital
Contributor Information and Disclosures

Updated: Jun 23, 2009

Introduction

Background

Although bacterial tracheitis is an uncommon infectious cause of acute upper airway obstruction, it is currently more prevalent than acute epiglottitis. Patients may present with crouplike symptoms, such as barking cough, stridor, and fever; however, patients with bacterial tracheitis do not respond to standard croup therapy and may experience acute respiratory decompensation.¹

Pathophysiology

Bacterial tracheitis is a diffuse inflammatory process of the larynx, trachea, and bronchi with adherent or semiadherent mucopurulent membranes within the trachea. The major site of disease is at the cricoid cartilage level, the narrowest part of the trachea. Acute airway obstruction may develop secondary to subglottic edema and sloughing of epithelial lining or accumulation of mucopurulent membrane within the trachea. Signs and symptoms are usually intermediate between those of epiglottitis and croup.

Bacterial tracheitis may be more common in the pediatric patient because of the size and shape of the subglottic airway. The subglottis is the narrowest portion of the pediatric airway, assuming a funnel-shaped internal dimension. In this smaller airway, relatively little edema can significantly reduce the diameter of the pediatric airway, increasing resistance to airflow and work of breathing. With appropriate airway support and antibiotics, most patients improve within 5 days.

Frequency

United States

Tan and Manoukian reported that 500 children were hospitalized for croup at one pediatric hospital over a 32-month period.² Approximately 98% had viral croup, and 2% had bacterial tracheitis. Cases usually occur in the fall or winter months, mimicking the epidemiology of viral croup.

International

According to a recent study, bacterial tracheitis remains a rare condition, with an estimated incidence of approximately 0.1 cases per 100,000 children per year.³

Mortality/Morbidity

The predominant morbidity and mortality is related to the potential for acute upper airway obstruction and induced hypoxic insults. The mortality rate has been estimated at 4-20%. In the acute phase, patients generally do well if the airway is adequately managed and if antibiotic therapy is promptly initiated.

Sex

In most epidemiologic studies, male cases are preponderant. Gallagher et al reported a male-to-female predominance of 2:1.⁴

Age

Bacterial tracheitis may occur in any pediatric age group. Gallagher et al reported 161 cases of patients younger than 16 years.⁴ The age range was from 3 weeks to 16 years, with a mean age of 4 years. This is in contrast to viral laryngotracheobronchitis, which occurs in patients aged 6 months to 3 years.

Clinical

History

• Symptoms of bacterial tracheitis may be intermediately between those of epiglottitis and croup. Presentation is either acute or subacute.
• In the classic presentation patients present acutely with fevers, toxic appearance, stridor, tachypnea, respiratory distress, and high WBC counts. Cough is frequent and not painful.
• In a study by Salamone et al, a significant subset of older children (mean age, 8 y) did not have severe clinical symptoms.⁵
• The prodrome is usually an upper respiratory infection, followed by progression to higher fever, cough, inspiratory stridor, and a variable degree of respiratory distress.
• Patients may acutely decompensate with worsening respiratory distress due to airway obstruction from a purulent membrane that has loosened.
• Patients have been reported to present with symptoms and signs of bacterial tracheitis and multiorgan failure due to exotoxin-producing strains of Staphylococcus aureus or Streptococcus pyogenes in the trachea.
• A high index of suspicion for bacterial tracheitis is needed in children with viral croup–like symptoms who do not respond to standard croup treatment or clinically worsen.

Physical

• Inspiratory stridor (with or without expiratory stridor)
• Barklike or brassy cough
• Hoarseness
• Worsening or abruptly occurring stridor
• Varying degrees of respiratory distress
  • Retractions
  • Dyspnea
  • Nasal flaring
  • Cyanosis
• Sore throat, odynophagia
• Dysphonia
• No drooling
• No specific position of comfort (The patient may lie supine.)

Causes

• S aureus: Community-associated methicillin-resistant S aureus (CA-MRSA) has recently emerged as an important agent in the United States; this could result in a greater frequency of MRSA strains that cause tracheitis.
• S pyogenes, Streptococcus pneumoniae, and other alpha hemolytic streptococcal species
• Moraxella catarrhalis: Recent reports suggest it is a leading cause of bacterial tracheitis and associated with increased intubation.
• Haemophilus influenzae type B (Hib): This cause is less common since the introduction of the Hib vaccine.
• Klebsiella species
• Pseudomonas species
• Anaerobes
• Peptostreptococcus species
• Bacteroides species
• Prevotella species
• Other
  • Mycoplasma pneumoniae
  • Mycobacterium tuberculosis (endobronchial disease)

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• Respiratory Failure (Pediatrics: Cardiac Disease and Critical Care Medicine)