Tracheitis medical therapy

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

=Overview

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.

Medical Therapy

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.

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). 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 are available , antibiotics regimen should be changed accordingly. Antibiotics are used for 10-14 days.

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.

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. 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.

• Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
• Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
• Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
• Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].

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 name10 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. '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) '(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 '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)