Medical Care
Treatment of bacterial tracheitis consists of the following:
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Airway
Maintenance of an adequate airway is of primary importance. [18]
Avoid agitating the child. If the patient's respiratory status deteriorates, it is usually because of movement of the membrane, and bag-valve-mask ventilation should be effective.
If intubation is required, use an endotracheal tube 0.5-1 size smaller than expected in order to minimize trauma in the inflamed subglottic area. Frequent suctioning and high air humidity is necessary to maintain endotracheal tube patency; therefore, use the most appropriate-sized tube (without causing trauma). Most patients (57-100%) require eventual intubation.
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Intravenous access and medication
Once the airway is stabilized, obtain intravenous access for initiation of antibiotics.
Antibiotic regimens have traditionally included a third-generation cephalosporin (eg, cefotaxime, ceftriaxone) and a penicillinase-resistant penicillin (eg, oxacillin, nafcillin). More recently, clindamycin (40 mg/kg/d intravenously [IV], divided every 8 h) has been used instead of penicillinase-resistant penicillin against community acquired–methicillin-resistant S aureus (CA-MRSA) in places where resistance rates of CA-MRSA to clindamycin is low. [19]
Vancomycin (45 mg/kg/d IV, divided every 8 h), with or without clindamycin, should be started in patients who appear toxic or have multiorgan involvement or if MRSA is prevalent in the community.
Further outpatient care
Patient should complete an appropriate course (usually 10 d) of oral antibiotics.
Surgical Care
Tracheostomy is rarely necessary unless injury or trauma to the airway has caused scarring and documented narrowing of the airway. Tracheostomy is necessary if the patient has failed extubations despite appropriate medical management or if intubation is prolonged. Pulmonary toilet is potentially better with tracheostomy.
Further inpatient care
Consider extubation when bacterial tracheitis appears to be resolving, especially with decreased secretions suctioned from the endotracheal tube.
Transfer
Transfer is required for patients in respiratory distress, patients in need of a pediatric intensive care unit, and patients who need a pediatric-sized bronchoscope.
Consultations
The following consultations may be indicated:
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Otorhinolaryngologist - For endoscopic procedures and acute airway management
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Pediatric intensivist - Necessary because of potential for acute decompensation
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Steeple sign.
