Tracheitis in Children: a 2018 Update

Tracheitis in Pediatric PatientsOh, the cacophony of coughing: it is like the theme music to the Pediatric ED during the winter months. While often benign, we do need to consider many conditions that may be the cause (ex, Pneumonia, Bronchiolitis, Asthma, Heart Failure). There is also a particularly characteristic cough that often leads to the triage team giving you the “diagnosis” of Croup. Croup can be “fun” to manage – it is a clinical diagnosis that you can treat and you can make the kid feel better – but, what do you do when the “croup” doesn’t respond like you’d expect? Recurrent Croup and “Croup” that fails therapy desires specific attention. You may be dealing with Tracheitis! Let us take a moment to update ourselves on Tracheitis in children!

 

Tracheitis in Children: Basics

  • It is Dangerous!
    • It can be a true medical emergency.
    • While rare, it has emerged as the most common potentially life-threatening upper airway infections in children. [Hopkins, 2006]
    • Traditionally, described as leading to critically ill and toxic appearing patients.
      • Thick exudative plaques can obstruct the airway!
    • Epidemiology has been shown to be changing, though, and can present with less severe disease. [Casazza, 2018]
  • It’s All Connected!
    • Ok, this is obvious, but we often think of conditions as being isolated… pneumonia is in the lungs, croup is the trachea, pharyngitis is in the pharynx…
    • But, those processes can overlap adjacent regions.
    • Isolated Tracheitis is rare. [Blot, 2017]
      • Inflammation usually affects continuous structures also.
      • Larngotracheitis, tracheobronchitis, laryngotracheobronchitis (which also refers to croup)
  • Pediatric Bacterial Tracheitis:
    • Should be considered when there is a toxic appearance or poor/no response to therapies (ex, steroids, racemic epi). [Blot, 2017]
    • Now most likely due to S. Aureus, often MSSA. [Casazza, 2018; Tebruegge, 2009; Hopkins, 2006]
    • H. influenzae was once most common, but now reduced frequency due to HiB vaccine (although still ~16% of cases).
    • Viral Coinfection can be seen in ~30% of cases. [Casazza, 2018; Blot, 2017; Tebruegge, 2009]
      • Typically will have had a “viral prodrome.”
      • May have even begun as viral Croup or “the Flu.”

 

Tracheitis in Children: Presentation

  • It’s Challenging to Diagnosis!
    • With the overlapping conditions and the more common entities presenting similarly, it can be difficult to pick up on.
    • Standard imaging does not reliably diagnosis it.
    • It can present dramatically or subtly.
    • Requires high index of suspicion for subtle cases.
  • Presentation:
    • May look similar to: [Blot, 2017]
    • Symptoms similar to other causes of airway obstruction. [Blot, 2017]
      • Tachypnea
      • Stridor
      • Hoarse voice
      • Cough (may be productive or may have coughing fits — hmmm, like pertussis)
      • Dyspnea and agitation
      • Fever
        • Fever is not always seen with viral croup…
        • More frequently seen with bacterial tracheitis, although not necessary.
    • Nosocomial / healthcare associated tracheitis presents differently. [Blot, 2017]
      • Patients with tracheostomy may have bacterial colonization of their stoma that then infects their adjacent trachea.
      • Patients with endotracheal tubes can develop ventilator-associated bacterial infection.
      • May present with fever, increased secretions, change in secretions, or increased oxygen requirement.
  • Community Acquired Bacterial Tracheitis – It’s a Spectrum
    • May present with Toxic Appearance.
      • Once taught to be the primary form.
      • Recent study had only 17% presenting with Toxic Appearance. [Casazza, 2018]
    • May actually be a continuum.
      • Mild Upper Respiratory Infection -> Severe Bacterial Tracheitis
      • “Exudative Tracheitis” is used to describe cases with exudate, but without systemic toxicity. [Casazza, 2018]

 

Tracheitis in Children: Management

  • Toxic appearing?
    • Treat similarly to what you would with Epiglottitis.
    • Keep patient calm.
    • Have patient taken to the OR for rigid bronchoscopy and, likely, intubation.
  • Not exactly Toxic appearing, but not quite right?
    • Have High Index of Suspicion!
      • Patients with atypical course or who don’t respond to therapies are waving the red flag at you!
        • Just diagnosed last week with Croup and now with recurrent stridor?
        • Seemed like croup, but Racemic Epinephrine and Dexamethasone has made no difference?
      • Bacterial Tracheitis should be considered with:
        • Worsening stridor
        • Respiratory distress
        • High fever
        • Orthopnea
        • Dysphagia
    • Plain Films may help.
      • PA and Lateral neck films and Chest Xray are often discussed. [Blot, 2017]
      • CXR can show concomitant pneumonia (which would support bacterial tracheitis)
      • PA/Lat neck films may show Steeple sign and an uneven/ragged tracheal wall concerning for intraluminal tracheal membranes.
    • Flexible endoscopes can help! [Blot, 2017; Shargorodsky, 2010]
      • Calling your ENT consultants early.
      • Bedside scope or scope in the OR to evaluate the supraglottic structures is helpful:
        • May show mucosal edema, pseudomembranes, ulcerations, microabscesses, and purulent secretions that don’t clear.
        • Can rule-out epiglottis.
      • If scope is abnormal, then would need full bronchoscopy.
  • Treat the Patient!
    • Look for signs of SHOCK and treat with Fluids and Pressors as needed.
    • Ampicillin-clavulanic acid and a 3rd generation cephalosporin are typically selected to treat bacterial tracheitis. [Blot, 2017; Tebruegge, 2009]

 

Moral of the Morsel

  • Be careful of “Recurrent Croup.” It may be bacterial tracheitis.
  • Needing multiple doses of Racemic Epinephrine? Rethink that croup diagnosis.
  • Don’t overlook Bacterial Tracheitis just because the patient is not toxic appearing.

 

References

Casazza G1,2, Graham ME1,2, Nelson D2,3, Chaulk D2,3, Sandweiss D2,3, Meier J1,2. Pediatric Bacterial Tracheitis-A Variable Entity: Case Series with Literature Review. Otolaryngol Head Neck Surg. 2018 Oct 23:194599818808774. PMID: 30348058. [PubMed] [Read by QxMD]

Blot M1, Bonniaud-Blot P2, Favrolt N3, Bonniaud P3, Chavanet P4, Piroth L4. Update on childhood and adult infectious tracheitis. Med Mal Infect. 2017 Nov;47(7):443-452. PMID: 28757125. [PubMed] [Read by QxMD]

O’Niel MB1, Chun RH, Conley SF. Ulcerative lesions as a rare cause of laryngotracheitis in the pediatric population. Am J Otolaryngol. 2013 Sep-Oct;34(5):541-4. PMID: 23535210. [PubMed] [Read by QxMD]

Mhanna MJ1, Elsheikh IS, Super DM. Risk factors and outcome of Ventilator Associated Tracheitis (VAT) in pediatric trauma patients. Pediatr Pulmonol. 2013 Feb;48(2):176-81. PMID: 22532511. [PubMed] [Read by QxMD]

Shargorodsky J1, Whittemore KR, Lee GS. Bacterial tracheitis: a therapeutic approach. Laryngoscope. 2010 Dec;120(12):2498-501. PMID: 21108480. [PubMed] [Read by QxMD]

Tebruegge M1, Pantazidou A, Thorburn K, Riordan A, Round J, De Munter C, Walters S, Curtis N. Bacterial tracheitis: a multi-centre perspective. Scand J Infect Dis. 2009;41(8):548-57. PMID: 19401934. [PubMed] [Read by QxMD]

Alvarez-Uria G1, Surinach JM, Ventura A, de la Rosa D, de Gracia J, Fernandez-Sevilla T. Herpetic tracheitis and polybacterial pneumonia in an immunocompetent young man is herpes tracheitis involved in the pathogenesis of bacterial pneumonia? J Clin Virol. 2008 Feb;41(2):164-5. PMID: 18054276. [PubMed] [Read by QxMD]

Hopkins A1, Lahiri T, Salerno R, Heath B. Changing epidemiology of life-threatening upper airway infections: the reemergence of bacterial tracheitis. Pediatrics. 2006 Oct;118(4):1418-21. PMID: 17015531. [PubMed] [Read by QxMD]

Graf J1, Stein F. Tracheitis in pediatric patients. Semin Pediatr Infect Dis. 2006 Jan;17(1):11-3. PMID: 16522500. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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1 Response

  1. December 10, 2018

    […] that kid have “recurrent croup?” Or is it something more sinister? This is an outstanding Pediatric EM Morsel on tracheitis in children. […]

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