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Tracheitis, Bacterial
Mary Cataletto, MD, FAAP, FCCP
image BASICS
  • Acute, potentially life-threatening infraglottic bacterial infection following a primary viral infection, usually parainfluenzae or influenza viruses
    • Direct laryngoscopy reveals marked subglottic edema and thick mucopurulent secretions, sometimes causing pseudomembranes.
  • System(s) affected: pulmonary
  • Synonym(s): laryngotracheobronchitis; pseudomembranous croup; bacterial croup
  • Estimated incidence: 4 to 8 per 1,000,000 (1)
  • First cases described prior to 1950; resurgence of cases has been noted since 1979.
  • Peak incidence in children: fall and winter
  • Mean age: 5 years (1)
  • Infections in adolescents and adults have been reported.
  • Predominant sex: male > female (2:1)
  • Accounts for 5-14% of upper airway obstruction in children requiring critical care services
  • Rare illness
  • Most common potentially life-threatening upper airway infection in children
  • Methicillin-resistant Staphylococcus aureus (MSRA) may contribute to changing epidemiology and virulence.
  • Staphylococcus aureus (most common pediatric cause): Consider MRSA.
  • Haemophilus influenzae type B
  • Streptococcus pyogenes group A
  • Streptococcus pneumoniae
  • Moraxella catarrhalis (associated with higher intubation rate; more frequent in younger children)
  • Often polymicrobial
No known genetic predisposition
  • Periods of increased seasonal activity of respiratory viruses
  • Reports following adenoidectomy, with chronic tracheal aspiration, with evidence of other concurrent infections, including sinusitis, otitis, pneumonia, or pharyngitis
  • Standard precautions, with scrupulous attention to hand washing, especially when caring for tracheostomy patients
  • Vaccination against viruses that may predispose to bacterial tracheitis
  • Consider anatomic abnormalities or foreign body as well as recent pharyngeal or laryngeal surgery.
  • Predisposing: Down syndrome, immunodeficiency, subglottic hemangioma, tracheoesophageal fistula repair, tracheobronchomalacia
  • Viral coinfection may occur.
  • May present with fever and systemic toxicity or as more localized disease
  • Careful history and physical exam are the best methods to distinguish bacterial tracheitis from croup and other rare causes of upper airway obstruction.
FEVER >38°C (100.4°F)
  • Toxic appearance
  • Variable degree of respiratory distress (2)
    • Tachypnea
    • Inspiratory stridor (2)
  • Voice and cry usually normal
  • Drooling uncommon
  • Severe croup (viral)
  • Spasmodic croup
  • Diphtheria in nonvaccinated patients
  • Retropharyngeal abscess
  • Epiglottitis
  • Pneumonia
  • Foreign body aspiration
  • Routine laboratory studies are not required to make the diagnosis.
  • Radiographs are neither definitive nor diagnostic.
  • Tracheal endoscopy provides a definitive diagnosis (1,3)[C].
Initial Tests (lab, imaging)
  • Bacterial cultures of tracheal secretions are required for culture isolates and sensitivities.
  • Rapid antigen or polymerase chain reaction (PCR)-based testing for respiratory viruses may be helpful.
  • Routine laboratory studies may not be helpful.
  • Blood cultures rarely positive
  • CBC results may vary.
    • WBC count may show marked leukocytosis or may be normal.
    • Increased band cell count
  • Radiographs may be normal, but exudates may mimic the findings in foreign body aspiration.
  • Pneumonic infiltrates are common.
  • Anteroposterior (AP) and lateral neck x-rays show subglottic and tracheal narrowing (i.e., steeple sign on AP film) with haziness and radiopaque linear or particulate densities (crusts).
  • In patients with risk of acute respiratory obstruction, either do not obtain x-rays or monitor carefully.
Follow-Up Tests & Special Considerations
Follow chest film if suspect pneumonia.
Diagnostic Procedures/Other
  • Direct laryngoscopy and tracheoscopy is diagnostic and demonstrates
    • Normal supraglottic structures
    • Marked subglottic erythema and edema
    • Ulcerations
    • Epithelial sloughing
    • Copious mucopurulent secretions ± plaques or pseudomembranes
  • Obtain Gram stain and aerobic, anaerobic, and viral cultures of tracheal secretions during the procedure.
Test Interpretation
  • Tracheal biopsy is rarely indicated but may be considered in immunodeficient child or child with ulcerative colitis.
  • Diffuse inflammation of larynx, trachea, and bronchi
  • Mucopurulent exudate; microabscesses may be present.
  • Semiadherent membranes (containing numerous neutrophils and cellular debris) may be identified within the trachea.
  • Treat as potentially life-threatening airway emergency.
  • Children with suspected or actual bacterial tracheitis should be cared for in a pediatric ICU (1)[C].
  • Assess and monitor respiratory status; supplemental oxygen may be required.
  • Airway protection and support, as necessary (at least 50% require intubation; some studies report up to 100%)
  • Ventilatory support may be required.
  • Suctioning
  • Different clinical course in previously healthy children compared with those with artificial airway

  • Empiric therapy should cover the most common pathogens until sensitivities are available: antistaphylococcal agent (vancomycin or clindamycin) and a 3rd-generation cephalosporin (e.g., ceftriaxone or cefotaxime) (1,3)[C].
  • In the case of technology-dependent children with tracheostomy, make initial antibiotic choices based on previous tracheal culture.
  • Narrow regimen when pathogens and sensitivities available (1,3)[C]
  • Contraindications: Refer to the manufacturer's literature for each drug.
  • Precautions: Refer to the manufacturer's literature for each drug. Avoid aminoglycosides in patients with previous hearing loss.
  • Significant possible interactions: Refer to the manufacturer's literature for each drug.
All children with suspected or actual bacterial tracheitis should be cared for in a pediatric ICU by a pediatric critical care team that may include the following subspecialists: pediatric intensivist, infectious disease specialist, pulmonologist, and/or otolaryngologist.
  • At present, evidence is lacking to establish the effect of heliox inhalation in the treatment of croup in children.
  • For technology-dependent children with artificial airway:
    • Initial antibiotic choices should cover most recent tracheal aspirate isolates and then be refined according to culture and sensitivity results.
    • Adjunctive aerosol therapy may be helpful, particularly when multidrug-resistant organisms are present.
  • Tracheostomy is usually not necessary.
  • Therapeutic bronchoscopy may be necessary to facilitate removal of inspissated secretions.
  • Tracheal membranes may require removal.
  • Aggressive supportive care and airway protection are paramount.
  • Initial treatment of choice for bacterial tracheitis is broad-spectrum antibiotic coverage.
  • Children with tracheitis and artificial airways present unique challenges: Tracheoscopy is important in establishing diagnosis in this population.
  • Be vigilant for possible MRSA.
Pediatric Considerations
  • True pediatric emergency
  • Admission to ICU
  • Maintain airway: often difficult due to copious secretions
    • Endotracheal or nasotracheal intubation usually needed, especially in infants and children <4 years of age
    • Much less likely to need intubation if child >8 years of age
    • Advantage of intubation is the ability to clear trachea and bronchi of secretions and pseudomembranes.
  • Vigorous pulmonary toilet to clear airway of secretions
  • Hydration, humidification, antibiotics
Admission Criteria/Initial Stabilization
  • Suspected or confirmed diagnosis of tracheitis
  • Respiratory distress
  • Artificial airway
  • Provide calm, quiet environment for child once endoscopy and cultures are done.
  • Airway monitoring
  • Frequent suctioning
  • Monitor fluid balance.
  • Establish and maintain open lines of communication with child and parents.
Discharge Criteria
No longer in need of acute care
Patient Monitoring
Children with artificial airways will require ongoing follow-up.
Varies with clinical situation
Keep immunizations up to date.
  • Intubation generally 3 to 11 days
  • Usually requires 3 to 7 days of hospitalization
  • With effective early recognition and management, complete recovery can be expected.
  • Cardiopulmonary arrest and death have occurred.
1. Kuo CY, Parikh SR. Bacterial tracheitis. Pediatr Rev. 2014;35(11):497-499.
2. Tebruegge M, Pantazidou A, Thorburn K, et al. Bacterial tracheitis: a multi-centre perspective. Scand J Infect Dis. 2009;41(8):548-557.
3. American Academy of Pediatrics. Pediatric Pulmonology. Elk Grove Village, Illinois, IL: American Academy of Pediatrics; 2011:955.
Additional Reading
  • Hopkins A, Lahiri T, Salerno R, et al. Changing epidemiology of life-threatening upper airway infections: the reemergence of bacterial tracheitis. Pediatrics. 2006;118(4):1418-1421.
  • Huang YL, Peng CC, Chiu NC, et al. Bacterial tracheitis in pediatrics: 12 year experience at a medical center in Taiwan. Pediatr Int. 2009;51(1):110-113.
  • Loftis L. Acute infectious upper airway obstructions in children. Semin Pediatr Infect Dis. 2006;17(1): 5-10.
  • Shah S, Sharieff GQ. Pediatric respiratory infections. Emerg Med Clin North Am. 2007;25(4):961-979.
  • Vorwerk C, Coats T. Heliox for croup in children. Cochrane Database Syst Rev. 2010;(2):CD006822.
See Also
Croup (Laryngotracheobronchitis); Epiglottitis
  • J04.10 Acute tracheitis without obstruction
  • J04.11 Acute tracheitis with obstruction
  • J05.0 Acute obstructive laryngitis [croup]
Clinical Pearls
  • Bacterial tracheitis is an acute, potentially lifethreatening, infraglottic bacterial infection following a primary viral infection that accounts for 5-14% of upper airway obstructions in children requiring critical care services.
  • Children with suspected or actual bacterial tracheitis should be cared for in a pediatric ICU.
  • Endoscopy provides a definitive diagnosis (2).
  • Initial treatment of choice for bacterial tracheitis is broad-spectrum antibiotic coverage, aggressive airway protection, and supportive care (2).