Tracheitis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dushka Riaz, MD
Overview
Treatment of tracheitis involves prompt initiation of antibiotics and urgent clinical assessment of airway. [1]
Medical Therapy
Medical Therapy
Treatment of tracheitis involves prompt initiation of antibiotics and clinical assessment of airway. Signs of impending respiratory failure include intercostal retractions, cyanosis, lethargy and confusion. Endotracheal intubation is performed in impending respiratory failure to maintain airway, perform frequent pulmonary toilet and manage acute respiratory failure. Operative bronchoscopy can be performed for direct visualization of trachea, confirmation of the diagnosis and removal of pseudomembranes. Endotracheal intubation rate has been reported between 38% to 100% and the mean duration of intubation is 3.2 days. It is therefore a crucial part of management of tracheitis which requires judicious assessment of the airway patency and the urgent availability of skills and expertise required for immediate airway intubation. Empiric broad spectrum antibiotics are initially used to control the infection. As the tracheal culture result becomes available the antibiotics can be changed according to the organism isolated. Most commonly isolated organisms include Staphylococcus Aureus, Streptococcus Pneumonia and Moraxella Catarrhalis. Third generation cephalosporin combined with an anti staphylococcal antibiotic e.g Nafcillin, Vancomycin , Clindamycin are included in the initial antibiotic regimen. Current guidelines have outlined a total treatment duration of 10 to 14 days. Supportive respiratory care is provided in less severe clinical presentation. This includes supplemental oxygen ( Sp02=94%) and bronchodilators (Epinephrine or Albuterol). Anti-pyretics can be used for fever. Corticosteroids have not proven benefit but are still used nonetheless. [2]
Treatment of tracheitis is based on the clinical severity of respiratory distress. Most patients progress to develop acute respiratory failure due to rapid development of pseudomembranes which obstruct the trachea. Early identification of impending respiratory failure decreases the likelihood of emergency intubation and complications. [3]
Antibiotics
Intravenous antibiotics should be used without any delay. Empiric broad spectrum antibiotics should be used which typically include a third generation cephalosporin (Ceftriaxone, Cefotaxime) combined with anti staphylococcal antibiotic (Vancomycin, Nafcillin, Clindamycin).[3] This regimen provides adequate cover for Gram negative organisms and Staphylococcus Aureus which are commonly implicated as the causative pathogens. Anti pseudomonal antibiotics can be added if the patient develops sepsis or does not improve within 48-72 hours of intravenous antibiotics. Once the results of Gram stain and culture sensitivity are available, antibiotics regimen should be changed accordingly.. Antibiotics are used for 10-14 days.[4]
Airway Management
Tracheitis can cause airway obstruction due to edema and exudates. Children are particularly at higher risk for intubation due to narrower subglottic region.[4] The rate of intubation has been reported between 38% -100% in literature. [5][6][7] Signs of immediate respiratory failure include tachypnea, intercostal retractions, fatigue, cyanosis and altered mental status. Airway intubation should be performed immediately. Pulmonary toilet can be performed through operative bronchoscopy to clear the airway. This further ensures a clear airway to maintain oxygen flow.
Endoscopy
Endoscopy can be used for diagnosis and treatment of tracheitis.[4]Flexible endoscopy is performed in patients in whom tracheitis is suspected but are not in respiratory distress. This helps to visualize the trachea and confirm the diagnosis and proceed to rigid endoscopy if exudates are seen causing tracheal obstruction. Rigid endoscopy is performed in individuals who are not in respiratory distress at the time of presentation but clinical suspicion for tracheitis is high.[5] The diagnosis is confirmed by presence of tracheal wall ulceration, necrotic debris and pus. Samples for gram stain and culture sensitivity can be collected. Pseudomembranes adhering to the tracheal wall can be removed. The procedure is therefore both therapeutic and diagnostic.
Supportive
Epinephrine has no proven clinical benefit in treatment of bacterial tracheitis. Viral croup responds to inhaled epinephrine however there is no clinical improvement if bacterial tracheitis is suspected.[8][3] Albuterol can be used if wheeze is present. Corticosteroids are not routinely recommended.[3] There is no literature available to support its use in management of tracheitis.
References
- ↑ "StatPearls". 2021. PMID 29262085.
- ↑ Sofer S, Duncan P, Chernick V (1983). "Bacterial tracheitis--an old disease rediscovered". Clin Pediatr (Phila). 22 (6): 407–11. doi:10.1177/000992288302200602. PMID 6601559.
- ↑ 3.0 3.1 3.2 3.3 Al-Mutairi B, Kirk V (2004). "Bacterial tracheitis in children: Approach to diagnosis and treatment". Paediatr Child Health. 9 (1): 25–30. doi:10.1093/pch/9.1.25. PMC 2719512. PMID 19654977.
- ↑ 4.0 4.1 4.2 "Bacterial Tracheitis - StatPearls - NCBI Bookshelf".
- ↑ 5.0 5.1 Gallagher PG, Myer CM (December 1991). "An approach to the diagnosis and treatment of membranous laryngotracheobronchitis in infants and children". Pediatr Emerg Care. 7 (6): 337–42. doi:10.1097/00006565-199112000-00004. PMID 1788120.
- ↑ Bernstein T, Brilli R, Jacobs B (September 1998). "Is bacterial tracheitis changing? A 14-month experience in a pediatric intensive care unit". Clin. Infect. Dis. 27 (3): 458–62. doi:10.1086/514681. PMID 9770140.
- ↑ Stroud RH, Friedman NR (2001). "An update on inflammatory disorders of the pediatric airway: epiglottitis, croup, and tracheitis". Am J Otolaryngol. 22 (4): 268–75. doi:10.1053/ajot.2001.24825. PMID 11464324.
- ↑ Casazza G, Graham ME, Nelson D, Chaulk D, Sandweiss D, Meier J (March 2019). "Pediatric Bacterial Tracheitis-A Variable Entity: Case Series with Literature Review". Otolaryngol Head Neck Surg. 160 (3): 546–549. doi:10.1177/0194599818808774. PMID 30348058.