Ear, Nose & Throat
A 2 year old girl is brought to the Emergency Department with a 2 day history of cough and fever. Her parents describe a harsh, productive cough. On examination the patient has a stridor and signs of respiratory distress. You give a stat dose of dexamethasone and nebulised adrenaline but see no improvement. What diagnosis should now be considered?
Answer:
Bacterial tracheitis may occur at any age. In the early phase, patients may present similarly to croup however there is a failure to respond or only transient response to steroids/nebulised adrenaline and the condition worsens.Bacterial Tracheitis
Ear, Nose & Throat
Last Updated: 12th February 2021
Bacterial tracheitis may occur at any age. In the early phase, patients may present similarly to croup however there is a failure to respond or only transient response to steroids/nebulised adrenaline and the condition worsens.
In this condition, the larynx, trachea and bronchi can become obstructed with purulent debris. There is an adherent pseudomembrane that forms over the tracheal mucosa that can slough off causing an obstruction. There is normally a preceding upper respiratory tract infection for a couple of days, followed by a rapid deterioration with a pyrexia and respiratory distress. There is a cough producing copious secretions and retrosternal pain. There is no dysphagia or drooling – unlike epiglottitis.
Causative organisms
The most common causative organisms are:
- Staphylococcus aureus (41%)
- Haemophilus influenzae (18%)
- Streptococcus pneumoniae (15%)
- Moraxella catarrhalis (13%)
- Streptococcus pyogenes (9%).
Management
Treatment is with intravenous antibiotics.
Endotracheal intubation is often needed for airway control, management of respiratory failure and pulmonary toilet.
Young children can deteriorate quickly due to the smaller size of the airway. Full recovery with no long-term morbidity is expected in the vast majority of children.
The mean length of stay in hospital varies with reports between 3 and 12 days.
Complications
The most frequent complication associated with the acute phase of illness is pneumonia.
Less common complications include:
- Acute respiratory distress syndrome
- Septic shock
- Pulmonary oedema
- Pneumothorax
- Cardiorespiratory arrest (rarely)
Long-term morbidity associated with bacterial tracheitis is minimal. As treatment in the acute phase of the illness frequently requires insertion of an endotracheal tube into an inflamed airway, the potential for the subsequent development of subglottic stenosis is well recognised.
Croup vs Epiglottitis vs Tracheitis
| Comparison | Croup | Epiglottitis | Tracheitis |
|---|---|---|---|
| Incidence | Common | Rare | Rare |
| Age | 6 months to 3 years | 2 - 5 years (and adults) | 6 months - 14 years |
| Aetiology | Viral | Bacterial | Bacterial |
| Speed of onset | Slow | Very rapid | Rapid |
| Fever | Rarely > 39°C | Normally > 39°C | Normally > 39°C |
| Cough | Barking | Suppressed | Productive |
| Voice | Hoarse | Muffled (+ dysphagia and drooling) | Hoarse |
| Position | Supine | Sitting forward, neck extended | Supine |
| Neck x -ray | Steeple sign on AP view, normal lateral view | Normal AP view, thumbprint on lateral view | Steeple sign on AP view, hazy lateral view |
| Response to adrenaline | Very good | No response | Partial or no response |
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
