A 4-year-old girl is brought to the Emergency Department for fever and cough.
You saw her 3 days ago for a Seal-like, barky cough and low-grade fever. You diagnosed her with mild croup, gave a dose of steroids, and the patient improved in the ED and was discharged home. The child’s parents say she was doing better at home, but then last night, she developed a high fever, sore throat, and a worsening cough productive of yellow sputum.
Currently, the patient has temp 102.2 F, HR 125/min, RR 22/min, POx 96% on RA. She is toxic appearing and exhibits inspiratory and expiratory stridor, but she is alert and speaking in full sentences with no muffled voice. You suspect bacterial tracheitis based on her history and exam.
What is bacterial tracheitis?
Also known as bacterial croup it is a rare bacterial superinfection of the tracheal mucosa, most commonly caused by Staphylococcus Aureus. Streptococcus Pneumoniae and polymicrobial infections are etiologies as well. The thick, mucopurulent secretions from infection of the tracheal lining result in airway narrowing. Pseudo-membranes may develop which can slough off and cause sudden airway obstruction.
When should I be suspicious for bacterial tracheitis?
Bacterial tracheitis is rare, with an estimated incidence of 0.1 per 100,000 children per year. Patients will typically present with an initial of fever, barky cough and stridor, appearing much like typical croup. However, in bacterial tracheitis symptoms progress rapidly to high fevers, productive cough, and toxic-appearance with inspiratory and expiratory stridor. Patients may also complain of sore throat and have tenderness of the trachea which may help distinguish tracheitis from croup. In addition, bacterial tracheitis will not improve with typical treatments for croup (steroids or nebulized epinephrine).
How do we diagnose bacterial tracheitis?
In the stable patient, lateral neck radiographs can assist in the diagnosis. They may show subglottic narrowing and irregular edges to the usually smooth tracheal wall.
What are the keys to managing this patient?
The definitive diagnosis and treatment for bacterial tracheitis is with bronchoscopy, and most of these patients will need definitive airway management during their course. However, like epiglottitis, this is preferably done in the operating room. Removal of the purulent layer during bronchoscopy is therapeutic. Patients will also need IV fluid resuscitation and antibiotics. Recommendations are for MRSA coverage with vancomycin or clindamycin and a third-generation cephalosporin (such as ceftriaxone).
Mapelli E, Sabhaney V. Stridor and Drooling in Infants and Children. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016.
Rose, Email. Pediatric Upper Respiratory Emergencies: Upper Airway Obstruction and Infections. In: Walls R, Hockberger R, Gausche-Hill M. Rosen’s Emergency Medicine: Concepts and Clinical Practice, Ninth Edition Philadelphia, PA: Elsivier Inc; 2018.