Brief
in
Tracheitis
Dominick DeBlasio, MD, MEd,*† F. Joseph Real, MD, MEd*†
*Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
†
University of Cincinnati College of Medicine, Cincinnati, OH
AUTHOR DISCLOSURE Drs DeBlasio and Real
have disclosed no financial relationships
relevant to this article. This commentary does
not contain a discussion of an unapproved/
investigative use of a commercial product/
device.
Pediatric Bacterial Tracheitis—A Variable
Entity: Case Series with Literature Review.
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Sandweiss D, Meier J. Otolaryngol Head Neck
Surg. 2019;160(3):546–549
Tracheitis in Pediatric Patients. Graf J, Stein
F. Semin Pediatr Infect Dis. 2006;17(1):11–
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Bacterial Tracheitis—Tremendously Rare,
but Truly Important: A Systematic Review.
Tebruegge M, Pantazidou A, Yau C, Christi MJ,
Curtis N. J Pediatr Infect Dis. 2009;4(3):199–209
Bacterial Tracheitis in Children: Clinical
Features and Diagnosis. Woods CR.
UpToDate website. https://www.uptodate.com/
contents/bacterial-tracheitis-in-children-clinical-
features-and-diagnosis. Updated May 3, 2019.
Accessed June 22, 2019
Bacterial Tracheitis in Children: Treatment
and Prevention. Woods CR. UpToDate
website. https://www.uptodate.com/
contents/bacterial-tracheitis-in-children-
treatment-and-prevention. Updated June 10,
2019. Accessed June 22, 2019
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The disease process of tracheitis is characterized by purulent tracheal secretions
and pseudomembranes, which can lead to airway obstruction and subsequent
respiratory failure. Although it is relatively rare (with an estimated incidence of
0.1 cases per 100,000 children), tracheitis remains a life-threatening condition
that typically requires emergency evaluation and intervention. This In Brief
addresses the process in both previously healthy children and those with
artificial airways.
TRACHEITIS IN PREVIOUSLY HEALTHY CHILDREN
Tracheitis, also referred to as bacterial tracheitis, exudative tracheitis, or acute
bacterial laryngotracheobronchitis, is typically seen in younger children, with
most cases occurring in children 6 years or younger. Tracheitis is particularly
perilous for young pediatric patients given their small-caliber airways, which are
more easily obstructed. The rates of tracheitis are slightly higher in males (male to
female ratio is 1.3:1), with most cases occurring during the late fall and winter
months, which corresponds with the seasonal pathogens during that time frame.
Tracheitis in previously healthy children most often results from a bacterial
superinfection of the trachea after a viral respiratory illness. The most common
preceding viral illnesses are influenza and parainfluenza. These viruses cause a
mild mucosal injury to the trachea, which provides an entry for bacteria leading to
a secondary infection. Common bacteria associated with tracheitis include
Staphylococcus aureus (the most common), Streptococcus pyogenes, a-hemolytic
streptococci, Moraxella catarrhalis, and Haemophilus influenzae.
Clinically, most patients will have a viral prodromal period (characterized by
cough, coryza, and, sometimes, fever) for a few days before the onset of signs and
symptoms typically associated with the bacterial infection. A typical presentation
for tracheitis includes sudden onset of stridor (possibly biphasic), worsening
cough, and respiratory distress characterized by retractions and tachypnea. Other
signs and symptoms may include fever and hoarseness. Based on the degree of
airway obstruction and resultant respiratory distress, a child may also present with
mental status changes such as somnolence or combativeness resulting from
hypoxia or hypercarbia.
Airway radiographs (both anterior-posterior and lateral) can be useful to aid in
the diagnosis of tracheitis but may be of limited value. These radiographs may
show the narrowing of the subglottic trachea (the classic “steeple sign,” which is
seen in croup as well) and may demonstrate lower tracheal wall irregularities and
the presence of pseudomembranes in the trachea. Airway films are often not
definitive and may not help to differentiate between croup and tracheitis because
only 40% to 85% of patients with tracheitis will show the tracheal irregularity or
Vol. 41 No. 9 S E P T E M B E R 2 0 2 0 495
 presence of pseudomembranes. Additional laboratory eval-
uation with complete blood cell counts and blood cultures is
rarely useful and not recommended.
A presumptive diagnosis of tracheitis may be made based
on history, clinical examination, and radiographic findings
and should be differentiated from croup and epiglottitis.
Children with croup are typically well appearing with a
barking cough, hoarse voice, and stridor. The child with
epiglottitis typically presents as toxic appearing, drooling,
and sitting upright with neck extension and refusal to speak.
The definitive diagnosis of tracheitis requires direct exam-
ination of the airway. This diagnostic step also allows for
removal of tracheal exudates, an important component of
therapy. Patients with significant respiratory distress should
undergo bronchoscopy (and possible intubation) performed
in the operating room. Bronchoscopy typically reveals puru-
lent exudates and the presence of pseudomembranes in
the trachea. Patients with a less severe presentation may
undergo flexible laryngoscopy as the initial form of airway
examination.
The most critical aspect of care for a child with tracheitis
is management of the airway. Bacterial tracheitis tends to
progress rapidly, which underscores the importance of
urgent evaluation of the airway. If a patient with suspected
tracheitis presents in an outpatient setting, it is important to
urgently transfer the patient to a higher-acuity setting for
further evaluation and management. It is imperative to
assess the need for intubation expeditiously. Approximately
75% of children with tracheitis will require intubation at
some point during the disease course. Moreover, intubation
may also be challenging given that the trachea itself is
inflamed and lined with exudate and pseudomembranes,
which significantly decreases the caliber of the airway. Thus,
all patients with tracheitis should ideally be managed in an
intensive care setting, and the typical length of intubation is
2 to 5 days.
In addition to helping establish the diagnosis of trache-
itis, bronchoscopy is an important part of treatment because
it can be used to remove the exudate and pseudomem-
branes, which are causing the airway obstruction. The
exudates that are removed can then be sent for culture
and Gram-stain to direct the antibiotic drug treatment
regimen. Repeated bronchoscopy procedures are typically
not required, and children with very mild cases may not
require bronchoscopy. Children with mild tracheitis
(patients with stridor, cough, and fever but without sig-
nificant respiratory distress) who do not require initial
496 Pediatrics in Review
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bronchoscopy require very close monitoring in a pediatric
emergency department or PICU given the potential to
worsen quickly.
Systemic antibiotic drugs are also a crucial component of
tracheitis treatment. Initial antibiotic drug treatment should
be broad spectrum and should include an antimicrobial
agent that covers S aureus given that this bacterium is the
most common cause of tracheitis. Although there are sev-
eral effective treatment options, one of the most preferred
initial regimens is the use of vancomycin plus either a third-
generation cephalosporin or ampicillin-sulbactam. This
broad spectrum therapy should be continued until culture
results and antibiotic sensitivities from the tracheal exudates
are available to help narrow the antibiotic drug regimen. The
typical duration of antibiotic drug treatment is 10 days, with
patients typically being transitioned from intravenous to
oral therapy at same point in the treatment course.
Several other treatment modalities that are often used in
the management of tracheitis include glucocorticoids and
nebulized epinephrine and albuterol. The use of these
therapies varies across institutions and does not have the
substantial supporting evidence to make these treatments
part of standard care for tracheitis.
With appropriate antimicrobial drug therapy and airway
management, most children with tracheitis typically show
significant improvement within 72 to 96 hours. Although
most children recover fully, tracheitis is fatal in approxi-
mately 2% to 3% of patients, most commonly due to airway
obstruction with subsequent cardiopulmonary arrest. Fur-
thermore, complications such as pneumothorax, pulmonary
edema, and subglottic stenosis occur in an additional 2% to
3% of patients.
TRACHEITIS IN CHILDREN WITH ARTIFICIAL AIRWAYS
It is important for the clinician to be aware of the possibility
of tracheitis in patients with artificial airways and to recog-
nize the different presentation in patients with a tracheos-
tomy or endotracheal tube. These tubes serve as potential
points of entry for bacteria and also disrupt normal tracheal
mucosa, creating a condition that predisposes to tracheitis.
Patients typically present with changes in mechanical set-
tings and oxygen saturations (if applicable) and increased
secretions that may demonstrate alterations in viscosity
and/or odor, leading to an increased need for suctioning
and changes in other clinical features (development or
elevation of fever, increased work of breathing). In this
situation, it is important to obtain a Gram-stain and culture
of a tracheal aspirate and compare it with a previous (if
applicable) culture. This comparison will determine
whether there is a new, active infection or continued colo-
nization with previously identified bacteria. Direct visuali-
zation of the trachea is also helpful to make an accurate and
timely diagnosis of tracheitis, especially in children who
appear systemically ill. In addition, chest radiography may
be useful to rule out pneumonia because it may be difficult
to distinguish pneumonia from tracheitis in a child with an
artificial airway. Antibiotic drug therapy should be tailored to
the results of the culture and Gram-stain. It is important to
note that the presence of polymorphonuclear neutrophils is
not the best indicator of infection, and antibiotic agents
should not be started empirically based solely on their
presence. If patients are overall well-appearing, it is appro-
priate to treat with oral/enteral antibiotic drugs, with typical
choices being amoxicillin-clavulanate or clindamycin.
Patients who appear systemically ill typically require intra-
venous antibiotics. If patients are treated as outpatients,
close follow-up is essential.
In conclusion, tracheitis is a rare but very important
clinical entity that can be life-threatening to children both
with and without artificial airways. It is imperative for
clinicians to recognize the clinical signs and symptoms
associated with tracheitis to perform a timely evaluation.
The outcome for children with tracheitis is significantly
improved in patients with early diagnosis and treatment.
COMMENTS: Respiratory compromise of any kind is a
concerning presentation for pediatric patients, and this In
Brief reinforces the need to identify bacterial tracheitis as
early as possible and take expeditious action when con-
cerned, and the importance of close follow-up. Prevention
through immunizations has helped decrease the develop-
ment of bacterial tracheitis: the influenza vaccine by pre-
venting a major preceding viral infection that can alter the
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tracheal mucosa, but also the Haemophilus and pneumo-
coccal vaccines, which help prevent some of the bacterial
pathogens involved. Patients with artificial airways, espe-
cially those with tracheostomy tubes, present commonly to
their general pediatricians with noted changes in tracheal
secretions observed through routine suctioning. One of the
clinical challenges is distinguishing a viral infection from
bacterial tracheitis because the latter would benefit from
antibiotic treatment. Having a tracheostomy tube may pre-
dispose patients to tracheitis because the anatomical loca-
tion of the tracheostomy bypasses the upper airway
protection of the nose and mouth to filter out bacteria. Even
with the most careful caretaker, frequent suctioning can lead
to minimal “trauma” and disruption of the epithelial lining
of the trachea. We were unable to find any guidelines about
the approach to identifying suspected tracheitis in patients
with artificial airways. A change in tracheal secretions may
be observed in viral infections, so obtaining a Gram-stain
and culture is imperative. Noting polymorphonuclear neu-
trophils on the Gram-stain has not been found to be the best
predictor of a bacterial infection because viral infections
can cause similar inflammatory processes. Yet, obtaining a
Gram-stain and culture, followed by prospective observation
of the clinically stable outpatient without airway compro-
mise over the next few days, is prudent. If the patient
remains symptomatic and the culture reveals a true bacterial
pathogen, then treatment with antibiotic agents may be
warranted. This approach may avoid overuse of antibiotic
agents while providing antibiotics for patients who will truly
benefit. Obtaining a tracheal culture when the patient is well
allows the clinician to identify what organisms a patient may
be colonized with and can also help to sort out true path-
ogens. Evidence-based clinical guidelines are needed for
this important group of patients.
– Janet R. Serwint, MD
Associate Editor, In Brief
Vol. 41 No. 9 S E P T E M B E R 2 0 2 0 497
 Tracheitis
Dominick DeBlasio and F. Joseph Real
Pediatrics in Review 2020;41;495
DOI: 10.1542/pir.2019-0181

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 Tracheitis
Dominick DeBlasio and F. Joseph Real
Pediatrics in Review 2020;41;495
DOI: 10.1542/pir.2019-0181

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pedsinreview.aappublications.org/content/41/9/495

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