History

Fact Explanation
Fever Tracheitis is almost always a bacterial infection in trachea. Bacteria invade the tracheal mucosa and stimulate both local and systemic inflammatory responses. Causing a febrile response. Common pathogens are Staphylococcus aureus, Streptococcal species and Haemophilus influenzae type B. Tracheitis may occur secondary to viral respiratory illness, such as croup. Such a patient can have a viral upper respiratory tract infection characterized by rhinorrhea, cough, fever and sore throat for up to one week before acutely presenting with high fever. [1,2,3,4]
Stridor Local inflammatory response results in production of thick, mucopurulent exudates, ulceration and sloughing of the tracheal mucosa. This can result in a variable degree of upper airway obstruction. Stridor is a high-pitched musical breath sound resulting from turbulent air flow. Stridor is of rapid onset and inspiratory. Other commoner and more serious possible conditions such as epiglottis and croup should be excluded. [1,2,3,4]
Cough Is a common symptom of tracheitis. It is bark like or brassy. Cough occurs as reflex which helps to clear the upper airway from secretions. Most patients hesitate to cough as it is painful. Cough is usually productive with purulent sputum. [1,2,3]
Hoarseness Due to the mild inflammation in the vocal apparatus, an impairment in the ability to produce voice can be witnessed. [1,2,4]
No drooling This is an important negative finding; unlike in epiglottitis, those with bacterial tracheitis are usually able to swallow their oral secretions and therefore do not present with drooling. [1,2]
Respiratory distress Usually at presentation there is severe upper airway obstruction. Labored breathing is the cardinal feature.[1,2,4]
Generalized ill look Patient usually looks pale, lethargic or inconsolably irritable. Bacterial tracheitis is primarily a disease of children between the ages of 6 months and 14 years. Incidence peaks around 3-8 years of age. Males are more commonly affected. [1,2]
References
  1. AL-MUTAIRI, B., KIRK,V. Bacterial tracheitis in children: Approach to diagnosis and treatment [online], Paediatr Child Health. Jan 2004, 9(1), 25–30. [viewed 28 April 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719512/
  2. KASIAN,G.F. et al. Bacterial tracheitis in children [online] . CMAJ, 1989, 140, 1, 46 [viewed 28 April 2014]. Available from: http://www.researchgate.net/profile/Koravangattu_Sankaran/publication/20514611_Bacterial_tracheitis_in_children/file/d912f507c555f223c4.pdf
  3. GRAF,J.,F.STEIN. Tracheitis in pediatric patients [online] . Semin Pediatr Infect Dis,17,11-13. [viewed 28 April 2014]. Available from: http://faculty.ksu.edu.sa/16635/Lectures/Tracheitis%20in%20pediatric%20patients.pdf
  4. MHANNA,M.J. I.S.ELSHEIKH, D.M.SUPER. Risk Factors and Outcome of Ventilator Associated Tracheitis (VAT) in Pediatric Trauma Patients [online], Pediatr Pulmonol. 2013 Feb, 48(2), 176–181. [viewed 28 April 2014]. Available from: doi:10.1002/ppul.22588.

Examination

Fact Explanation
Stridor Upper airway obstruction due to the local inflammation results in stridor. [1]
Hoarseness Mild inflammation in the vocal apparatus cause hoarseness of voice. [1,2,4]
Respiratory distress Recessions, dyspnea, nasal flaring and cyanosis are cardinal features. [1,2]
No sniffing position This is an important negative finding which helps to exclude epiglottis. [1]
No drooling of saliva This is an important negative finding which helps to exclude epiglottis. [1]
Tracheal tenderness Clinicians familiar with bacterial tracheitis describe marked tracheal tenderness. [1]
References
  1. AL-MUTAIRI, B., KIRK,V. Bacterial tracheitis in children: Approach to diagnosis and treatment [online], Paediatr Child Health. Jan 2004, 9(1), 25–30. [viewed 28 April 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719512/
  2. KASIAN,G.F. et al. Bacterial tracheitis in children [online] . CMAJ, 1989, 140, 1, 46 [viewed 28 April 2014]. Available from: http://www.researchgate.net/profile/Koravangattu_Sankaran/publication/20514611_Bacterial_tracheitis_in_children/file/d912f507c555f223c4.pdf
  3. GRAF,J.,F.STEIN. Tracheitis in pediatric patients [online] . Semin Pediatr Infect Dis,17,11-13. [viewed 28 April 2014]. Available from: http://faculty.ksu.edu.sa/16635/Lectures/Tracheitis%20in%20pediatric%20patients.pdf

Differential Diagnoses

Fact Explanation
Epiglottis An emergency that needs to be ruled out. Caused by Haemophilus influenzae infection. Rapid onset high fever, sore throat and stridor. Cough is uncommon. Dysphagia results in drooling of the saliva. On examination,patient is pale, toxic and prefers to sit in the “sniffing position”. Usually occurs between the age of 2 – 7 years. [1,2]
Croup Common cause of upper airway obstruction, secondary to a viral infection of larynx, trachea and bronchi. Parainfluenza is the most common causative organism. Usually occurs between the age of 6 months to 3 years. The patient may present with fever, rhinorrhea, nasal congestion, barking cough, inspiratory stridor and respiratory distress which will worsens at night. [1,2]
Foreign body aspiration Patient presents with a history of aspiration. An acute onset stridor with no fever. [1]
References
  1. AL-MUTAIRI, B., KIRK,V. Bacterial tracheitis in children: Approach to diagnosis and treatment [online], Paediatr Child Health. Jan 2004, 9(1), 25–30. [viewed 28 April 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719512/
  2. GRAF,J.,F.STEIN. Tracheitis in pediatric patients [online] . Semin Pediatr Infect Dis,17,11-13. [viewed 28 April 2014]. Available from: http://faculty.ksu.edu.sa/16635/Lectures/Tracheitis%20in%20pediatric%20patients.pdf

Investigations - for Diagnosis

Fact Explanation
Plain X-ray of the neck On anteroposterior (AP) views, subglottic narrowing (Steeple sign) can be observed similar to croup. Clouding of tracheal air column or irregular tracheal margin (candle dripping sign) are found on lateral view. However, these findings are neither specific nor diagnostic for tracheitis. Sometimes radiological findings suggestive of concurrent pneumonia can be noted. Radiographs are contraindicated in any child suspected of having epiglottitis until the diagnosis has been confirmed and the airway stabilized. [1,2]
Laryngotracheobronchoscopy The definitive diagnosis of tracheitis can be made with Laryngotracheobronchoscopy. This investigation should be performed preferably in the operative suite by a pediatric otolaryngologist. Visual evidence of tracheal inflammation, subglottic narrowing, presence of purulent tracheal secretions and pseudomembranes are diagnostic. Bronchoscopy is also helpful for the exclusion of other diagnoses such as epiglottitis. At the same time, secretions can be easily obtained and sent for culture and antibiotic sensitivity test. Subsequent aerobic and anaerobic bacterial cultures, as well as indicated viral cultures, should be obtained during the procedure. This can also done in therapeutic intention by means of performing tracheal toilet and stripping the purulent membranes. [1,2]
Bacterial culture and Gram stain of tracheal secretions Sample collection is done at the time of Laryngotracheobronchoscopy. Identification of the pathogen is usual (62% to 87%) presuming no prior treatment with antibiotics. [1]
Full blood count White blood cell count is normal or slightly increased. Neutrophil leukocytosis is non specific. [1,2]
References
  1. AL-MUTAIRI, B., KIRK,V. Bacterial tracheitis in children: Approach to diagnosis and treatment [online], Paediatr Child Health. Jan 2004, 9(1), 25–30. [viewed 28 April 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719512/
  2. KASIAN,G.F. et al. Bacterial tracheitis in children [online] . CMAJ, 1989, 140, 1, 46 [viewed 28 April 2014]. Available from: http://www.researchgate.net/profile/Koravangattu_Sankaran/publication/20514611_Bacterial_tracheitis_in_children/file/d912f507c555f223c4.pdf

Management - General Measures

Fact Explanation
Paracetamol ( acetaminophen) Paracetamol is important as an antipyretic and analgesic. Pain management is essential to avoid cough suppression as it can lead to a failure to clear secretions.[1]
Physiotherapy Physiotherapy to encourage coughing and secretion clearance is also a valuable part of treatment. It is particularly helpful for older children who may be suppressing cough due to discomfort. [1]
References
  1. AL-MUTAIRI, B., KIRK,V. Bacterial tracheitis in children: Approach to diagnosis and treatment [online], Paediatr Child Health. Jan 2004, 9(1), 25–30. [viewed 28 April 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719512/

Management - Specific Treatments

Fact Explanation
Secure the airway Endotracheal intubation is frequently required for stabilization of the airway. The decision to intubate is made on the severity of symptoms and likelihood of further deterioration. Endotracheal tube size needs to be a smaller size than what is normally required for the age. However, agitating the child by any means should be avoided because movements of the membrane can cause further deterioration. In such instances bag-valve-mask ventilation should be considered. Children managed without endotracheal intubation need close observation. [1,2,3,4]
Aggressive clearance of the airway Pulmonary clearance is more effective with an endotracheal tube in situ so that suctioning can be done frequently. [1,2]
Antibiotic therapy Broad spectrum intravenous antibiotics should be started empirically once the airway is secure. A third generation cephalosporin (eg, cefotaxime, ceftriaxone) combined with a beta-lactamase resistant penicillin (eg, cloxacillin) is the first line therapy. If methicillin-resistant Staphylococcus aureus is suspected vancomycin should be considered. Clindamycin should be considered if anaerobes are considered. Cefotaxime is the drug of choice for Moraxella infection. An antibiotic course of 10 to 14 days is recommended. Intravenous therapy is recommended till the child is afebrile for 48 hours. [1,2,4]
References
  1. AL-MUTAIRI, B., KIRK,V. Bacterial tracheitis in children: Approach to diagnosis and treatment [online], Paediatr Child Health. Jan 2004, 9(1), 25–30. [viewed 28 April 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719512/
  2. KASIAN,G.F. et al. Bacterial tracheitis in children [online] . CMAJ, 1989, 140, 1, 46 [viewed 28 April 2014]. Available from: http://www.researchgate.net/profile/Koravangattu_Sankaran/publication/20514611_Bacterial_tracheitis_in_children/file/d912f507c555f223c4.pdf
  3. MHANNA,M.J. I.S.ELSHEIKH, D.M.SUPER. Risk Factors and Outcome of Ventilator Associated Tracheitis (VAT) in Pediatric Trauma Patients [online], Pediatr Pulmonol. 2013 Feb, 48(2), 176–181. [viewed 28 April 2014]. Available from: doi:10.1002/ppul.22588.
  4. GRAF,J.,F.STEIN. Tracheitis in pediatric patients [online] . Semin Pediatr Infect Dis,17,11-13. [viewed 28 April 2014]. Available from: http://faculty.ksu.edu.sa/16635/Lectures/Tracheitis%20in%20pediatric%20patients.pdf