Tracheitis overview

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Tracheitis is a bacterial infection of the trachea. It results in airway inflammation with mucosal edema, tracheal ulceration and thick membranous exudates. It is most commonly caused by a superimposed bacterial infection following a viral upper respiratory tract infection. Common bacterial pathogens include Staphylococcus Aureus, Haemophilus Influenza, Streptococcus Viridans and Moraxella Catarrhalis. It is a disease most commonly encountered in pediatric age group, between 2-10 years of age. However, mechanical ventilation can also cause tracheitis as it allows colonization of the trachea through endotracheal tube. Clinical features include cough, hoarseness, stridor which can rapidly progress into respiratory distress within 36 to 72 hours. Acute airway obstruction can also develop due to rapid formation of tracheal exudates. Securing airway by endotracheal intubation is therefore crucial in management of tracheitis along with early initiation of empiric antibiotics. Rigid endoscopy is performed to remove thick membranous exudates, known to cause significant tracheal lumen obstruction. Complications of tracheitis include airway obstruction, acute respiratory distress syndrome, toxic shock syndrome, septic shock and multi organ failure.

Causes

Bacterial tracheitis is most often caused by the bacteria Staphylococcus aureus. It frequently follows a recent viral upper respiratory infection. Common causes include Staphylococcus Aureus Streptococcus Pyogenes, Haemophilus Influenza, Moraxella Catarrhalis, Mycoplasma Pneumonia, Echoviruses, Klebsiella Pneumonia, Adenovirus, Rhinovirus, Coxsakievirus and Influenza virus.

Risk Factors

Common risk factors in the development of tracheitis include pediatric age group, viral upper respiratory tract infection, mechanical ventilation and immunocompromised state. The individuals most likely to be affected are between 2-10 years of age. Staphylococcus Aureus is the most commonly cultured organism on tracheal aspirate. Mechanical ventilation allows easy colonization of the trachea by bacteria and cause tracheitis. Invasive fungal infections commonly develop among immunocompromised individuals and can cause tracheitis.

Diagnosis

Physical Examination

Physical examination of patients with tracheitis is usually remarkable for stridor, tracheal tenderness, and intercostal retractions. The may appear toxic, lethargic and in respiratory distress. Coarse crackles can be heard on auscultation of the chest, signifying underlying pneumonia.

Treatment

Medical Therapy

Treatment of tracheitis involves prompt intiation 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 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 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.