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{{CMG}}; {{AE}} [[User:Dushka|Dushka Riaz, MD]]


{{CMG}}
=Overview=
==Overview=
Treatment of [[tracheitis]] involves prompt initiation of [[Antibiotic|antibiotics]] and urgent clinical assessment of [[airway]]. <ref name="pmid29262085">{{cite journal| author=| title=StatPearls | journal= | year= 2021 | volume=  | issue=  | pages=  | pmid=29262085 | doi= | pmc= | url= }} </ref>
Treatment of [[tracheitis]] involves prompt intiation of [[Antibiotic|antibiotics]] and clinical assessment of [[airway]]. Signs of impending [[respiratory failure]] include i[[Intercostal|ntercostal]] [[Retraction|retractions]], [[Cyanosis|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 visualisation 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 [[Antibiotic|antibiotics]] are initially used to control the [[Infection|infection.]] As the [[Trachea|tracheal]] [[Culture medium|culture]] result becomes available the [[Antibiotic|antibiotics]] can be changed according to the [[organism]] isolated. Most commonly isolated [[Organism|organisms]] include [[Staphylococcus aureus|Staphylococcus Aureus]], [[Streptococcus Penumoniae Infection|Streptococcus Pneumonia]] and [[Moraxella catarrhalis|Moraxella Catarrhalis]]. [[Cephalosporins|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 (patient information)|Epinephrine]] or [[Albuterol]]). [[Anti-pyretics]] can be used for [[Fever|fever.]] [[Corticosteroids]] have not proven benefit but are still used nonetheless.


==Medical Therapy==


===Medical Therapy===
Treatment of [[tracheitis]] involves prompt initiation of [[Antibiotic|antibiotics]] and clinical assessment of [[airway]]. Signs of impending [[respiratory failure]] include i[[Intercostal|ntercostal]] [[Retraction|retractions]], [[Cyanosis|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 [[Antibiotic|antibiotics]] are initially used to control the [[Infection|infection.]] As the [[Trachea|tracheal]] [[Culture medium|culture]] result becomes available the [[Antibiotic|antibiotics]] can be changed according to the [[organism]] isolated. Most commonly isolated [[Organism|organisms]] include [[Staphylococcus aureus|Staphylococcus Aureus]], [[Streptococcus Penumoniae Infection|Streptococcus Pneumonia]] and [[Moraxella catarrhalis|Moraxella Catarrhalis]]. [[Cephalosporins|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 (patient information)|Epinephrine]] or [[Albuterol]]). [[Anti-pyretics]] can be used for [[Fever|fever.]] [[Corticosteroids]] have not proven benefit but are still used nonetheless. <ref name="pmid6601559">{{cite journal| author=Sofer S, Duncan P, Chernick V| title=Bacterial tracheitis--an old disease rediscovered. | journal=Clin Pediatr (Phila) | year= 1983 | volume= 22 | issue= 6 | pages= 407-11 | pmid=6601559 | doi=10.1177/000992288302200602 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6601559  }} </ref>


==Medical Therapy==
Treatment of [[tracheitis]] is based on the clinical severity of [[respiratory distress]]. Most patients progress to develop [[Respiratory failure|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. <ref name="pmid19654977">{{cite journal| author=Al-Mutairi B, Kirk V| title=Bacterial tracheitis in children: Approach to diagnosis and treatment. | journal=Paediatr Child Health | year= 2004 | volume= 9 | issue= 1 | pages= 25-30 | pmid=19654977 | doi=10.1093/pch/9.1.25 | pmc=2719512 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19654977  }} </ref>
 
Treatment of [[tracheitis]] is based on the clinical severity of [[respiratory distress]]. Most patients progress to develop [[Respiratory failure|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.  


===Antibiotics===
===Antibiotics===
[[Intravenous]] [[Antibiotic|antibiotics]] should be used without any delay. Empiric [[Broad-spectrum antibiotic|broad spectrum antibiotics]] should be used which typically include a [[Cephalosporin|third generation cephalosporin]]                 ( [[Ceftriaxone|Ceftriaxone,]] [[Cefotaxime]]) combined with anti staphylococcal [[antibiotic]] ( [[Vancomycin|Vancomycin,]] [[Nafcillin]], [[Clindamycin]]). This regimen provides adequate cove for [[Gram-negative bacteria|Gram negative]] [[Organism|organisms]] and [[Staphylococcus aureus|Staphylococcus Aureus]] which are commonly implicated as the causative [[pathogens]]. Once the results of [[Gram stain]] and [[Culture medium|culture]] are available , [[Antibiotic|antibiotics]] regimen should be changed accordingly. [[Antibiotic|Antibiotics]] are used for 10-14 days.
[[Intravenous]] [[Antibiotic|antibiotics]] should be used without any delay. Empiric [[Broad-spectrum antibiotic|broad spectrum antibiotics]] should be used which typically include a [[Cephalosporin|third generation cephalosporin]] ([[Ceftriaxone|Ceftriaxone,]] [[Cefotaxime]]) combined with anti staphylococcal [[antibiotic]] ([[Vancomycin|Vancomycin,]] [[Nafcillin]], [[Clindamycin]]).<ref name="pmid19654977">{{cite journal |vauthors=Al-Mutairi B, Kirk V |title=Bacterial tracheitis in children: Approach to diagnosis and treatment |journal=Paediatr Child Health |volume=9 |issue=1 |pages=25–30 |date=January 2004 |pmid=19654977 |pmc=2719512 |doi=10.1093/pch/9.1.25 |url=}}</ref> This regimen provides adequate cover for [[Gram-negative bacteria|Gram negative]] [[Organism|organisms]] and [[Staphylococcus aureus|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 medium|culture]] sensitivity are available, [[Antibiotic|antibiotics]] regimen should be changed accordingly.[[Antibiotic|. Antibiotics]] are used for 10-14 days.<ref name="urlBacterial Tracheitis - StatPearls - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK470240/ |title=Bacterial Tracheitis - StatPearls - NCBI Bookshelf |format= |work= |accessdate=}}</ref>
 


===Airway Management===
===Airway Management===
Tracheitis can cause airway obstruction due to edema and exudates. Children are particularly at high risk due to narrower subglottic region. Intubation rate is therefore greater in this group. The reported rate of intubation has been reported between 50% -100% in literature. Signs of immediate respiratory failure include tachypnea, intercostal retractions, fatigue, cyanosis and altered mental status. Airway intubation should be performed immediately.  
[[Tracheitis (patient information)|Tracheitis]] can cause [[airway]] obstruction due to [[edema]] and [[Exudate|exudates]]. Children are particularly at higher risk for [[intubation]] due to narrower [[Subglottic airway|subglottic]] region.<ref name="urlBacterial Tracheitis - StatPearls - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK470240/ |title=Bacterial Tracheitis - StatPearls - NCBI Bookshelf |format= |work= |accessdate=}}</ref> The rate of [[intubation]] has been reported between 38% -100% in literature. <ref name="pmid1788120">{{cite journal |vauthors=Gallagher PG, Myer CM |title=An approach to the diagnosis and treatment of membranous laryngotracheobronchitis in infants and children |journal=Pediatr Emerg Care |volume=7 |issue=6 |pages=337–42 |date=December 1991 |pmid=1788120 |doi=10.1097/00006565-199112000-00004 |url=}}</ref><ref name="pmid9770140">{{cite journal |vauthors=Bernstein T, Brilli R, Jacobs B |title=Is bacterial tracheitis changing? A 14-month experience in a pediatric intensive care unit |journal=Clin. Infect. Dis. |volume=27 |issue=3 |pages=458–62 |date=September 1998 |pmid=9770140 |doi=10.1086/514681 |url=}}</ref><ref name="pmid11464324">{{cite journal |vauthors=Stroud RH, Friedman NR |title=An update on inflammatory disorders of the pediatric airway: epiglottitis, croup, and tracheitis |journal=Am J Otolaryngol |volume=22 |issue=4 |pages=268–75 |date=2001 |pmid=11464324 |doi=10.1053/ajot.2001.24825 |url=}}</ref> Signs of immediate respiratory failure include [[tachypnea]], [[intercostal]] retractions, [[Fatigue (medical)|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===
[[Endoscopy]] can be used for [[diagnosis]] and [[treatment]] of [[tracheitis]]. 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.
[[Endoscopy]] can be used for [[diagnosis]] and [[treatment]] of [[tracheitis]].<ref name="urlBacterial Tracheitis - StatPearls - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK470240/ |title=Bacterial Tracheitis - StatPearls - NCBI Bookshelf |format= |work= |accessdate=}}</ref>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 [[Exudate|exudates]] are seen causing [[Trachea|tracheal]] obstruction.
Rigid endoscopy is preferred in individuals who have respiratory distress and tracheitis is suspected. The diagnosis can be confirmed and pseudomembranes can be removed. The procedure is therefore helpful in management as it relieves respiratory distress.
Rigid [[endoscopy]] is performed in individuals who are not in [[respiratory distress]] at the time of presentation but clinical suspicion for [[tracheitis]] is high.<ref name="pmid1788120">{{cite journal |vauthors=Gallagher PG, Myer CM |title=An approach to the diagnosis and treatment of membranous laryngotracheobronchitis in infants and children |journal=Pediatr Emerg Care |volume=7 |issue=6 |pages=337–42 |date=December 1991 |pmid=1788120 |doi=10.1097/00006565-199112000-00004 |url=}}</ref> The diagnosis is confirmed by presence of tracheal wall [[ulceration]], [[Necrosis|necrotic debris]] and [[Pus|pus.]] Samples for [[Gram staining|gram stain]] and [[Culture medium|culture]] sensitivity can be collected. Pseudomembranes adhering to the tracheal wall can be removed. The procedure is therefore both [[therapeutic]] and [[Diagnostic|diagnostic.]]
 
 
 
 
 
 
 


*Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
===Supportive===
*Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
[[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.<ref name="pmid30348058">{{cite journal |vauthors=Casazza G, Graham ME, Nelson D, Chaulk D, Sandweiss D, Meier J |title=Pediatric Bacterial Tracheitis-A Variable Entity: Case Series with Literature Review |journal=Otolaryngol Head Neck Surg |volume=160 |issue=3 |pages=546–549 |date=March 2019 |pmid=30348058 |doi=10.1177/0194599818808774 |url=}}</ref><ref name="pmid19654977">{{cite journal |vauthors=Al-Mutairi B, Kirk V |title=Bacterial tracheitis in children: Approach to diagnosis and treatment |journal=Paediatr Child Health |volume=9 |issue=1 |pages=25–30 |date=January 2004 |pmid=19654977 |pmc=2719512 |doi=10.1093/pch/9.1.25 |url=}}</ref>
*Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
[[Albuterol]] can be used if [[wheezing|wheeze]] is present.
*Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
[[Corticosteroids]] are not routinely recommended.<ref name="pmid19654977">{{cite journal |vauthors=Al-Mutairi B, Kirk V |title=Bacterial tracheitis in children: Approach to diagnosis and treatment |journal=Paediatr Child Health |volume=9 |issue=1 |pages=25–30 |date=January 2004 |pmid=19654977 |pmc=2719512 |doi=10.1093/pch/9.1.25 |url=}}</ref> There is no literature available to support its use in management of [[tracheitis]].
 
===Disease Name===
 
* '''1 Stage 1 - Name of stage'''
** 1.1 '''Specific Organ system involved 1'''
*** 1.1.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 100 mg PO q12h for 10-21 days '''(Contraindications/specific instructions)''' 
**** Preferred regimen (2): [[drug name]] 500 mg PO q8h for 14-21 days
**** Preferred regimen (3): [[drug name]] 500 mg q12h for 14-21 days
**** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
**** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
**** Alternative regimen (3): [[drug name]] 500 mg PO q6h for 14–21 days
*** 1.1.2 '''Pediatric'''
**** 1.1.2.1 (Specific population e.g. '''children < 8 years of age''')
***** Preferred regimen (1): [[drug name]] 50 mg/kg PO per day q8h (maximum, 500 mg per dose) 
***** Preferred regimen (2): [[drug name]] 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
***** Alternative regimen (1): [[drug name]]10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
****1.1.2.2 (Specific population e.g. '<nowiki/>'''''children < 8 years of age'''''')
***** Preferred regimen (1): [[drug name]] 4 mg/kg/day PO q12h（maximum, 100 mg per dose）
***** Alternative regimen (1): [[drug name]] 10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose) 
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
** 1.2 '''Specific Organ system involved 2'''
*** 1.2.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 500 mg PO q8h
*** 1.2.2  '''Pediatric'''
**** Preferred regimen (1): [[drug name]] 50 mg/kg/day PO q8h (maximum, 500 mg per dose)
 
* 2 '''Stage 2 - Name of stage'''
** 2.1 '''Specific Organ system involved 1 '''
**: '''Note (1):'''
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.1.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.1.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day) '<nowiki/>'''''(Contraindications/specific instructions)''''''
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] '''(for children aged ≥ 8 years)''' 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)
** 2.2  '<nowiki/>'''''Other Organ system involved 2''''''
**: '''Note (1):'''
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.2.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.2.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day)
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)


==References==
==References==
{{reflist|2}}
{{reflist|2}}
{{WH}}
{{WS}}


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[[Category:Pulmonology]]
[[Category:Intensive care medicine]]
[[Category:Intensive care medicine]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Pediatrics]]
[[Category:Pediatrics]]
[[Category:Thorax]]
[[Category:Thorax]]
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Latest revision as of 07:41, 3 May 2021

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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

  1. ↑ "StatPearls". 2021. PMID 29262085.
  2. ↑ 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. ↑ 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. ↑ 4.0 4.1 4.2 "Bacterial Tracheitis - StatPearls - NCBI Bookshelf".
  5. ↑ 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.
  6. ↑ 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.
  7. ↑ 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.
  8. ↑ 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.

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