Rosen & Barkin's 5-Minute Emergency Medicine Consult (92 page)

DIAGNOSIS

Usually preceding viral infection with acute deterioration in course of illness

• Fever
  
• Cough
  
• Retractions
  
• Inspiratory/expiratory stridor
  
• Toxic appearance
  
• Hoarseness
  
• Cyanosis
  
• Nasal flaring
  
• Sore throat/neck pain
  
• Dysphonia (drooling uncommon)
  
• Complications:
  
  • Respiratory:
    
    • Airway obstruction
      
    • Subglottic stenosis
      
    • Pulmonary edema
      
    • Pneumothorax
      
    • ARDS
      
    • Endotracheal tube (ETT) plugging
      
  • Infection:
    
    • Septic shock
      
    • Toxic shock syndrome (TSS)
      
    • Pneumonia
      
    • Retropharyngeal cellulitis
      
  • Cardiopulmonary arrest
    
  • Renal failure
    

• Clinical assessment and management of airway takes priority over diagnostic workup; secure airway, optimally in operating room under controlled conditions.
  
• Ensure adequate oxygenation before proceeding:
  
  • Pulse oximetry
    

• WBC variably elevated
  
• Blood cultures usually negative
  
• Request tracheal cultures from endoscopist/surgeon.
  

Radiographs of neck soft tissue:

• If done, perform in ED; accompany and monitor at all times.
  
• Tracheal margin irregularities
  
• Subglottic narrowing
  
• Clouding of tracheal air column
  
• Irregular intratracheal densities
  
• Normal epiglottis
  

• Flexible fiberoptic laryngoscopy:
  
  • Permits direct visualization of epiglottis
    
  • Mucosal edema
    
  • Subglottic edema, secretions, membrane
    
• Bronchoscopy:
  
  • Direct visualization of trachea
    
  • Laryngotracheal inflammation and erosions
    
  • Mucopurulent secretions
    
  • Membranes
    
  • Therapeutic stripping of membranes
    
  • Enables direct culture of material
    

• Infection:
  
  • Croup (failure to respond to treatment, older age, rapid deterioration or toxic appearance should raise suspicion for bacterial tracheitis rather than croup.)
    
  • Epiglottitis
    
  • Peritonsillar abscess
    
  • Retropharyngeal abscess
    
  • Uvulitis
    
  • Laryngeal diphtheria
    
• Angioedema
  
• Intraluminal obstruction:
  
  • Foreign body aspiration
    
• Caustic ingestion
  
• Trauma
  

TREATMENT

• Assess airway/breathing:
  
  • Supplemental oxygen
    
  • Racemic epinephrine aerosol if easily tolerated
    
  • Reassurance; avoid agitating child
    
• Bag-valve-mask (BVM) ventilation if in respiratory failure
  
• Intubate if unable to maintain airway with BVM and other measures.
  
• Immediate transport
  
• Notify receiving ED of airway status.
  

Airway management:

• Anticipate difficult airway
  
• Intubation required in ∼75% (40–100%) of patients. More frequently required in younger patients. Active airway management ensures stable airway and facilitates suctioning.
  
• Intubation should ideally be performed in the operating room with surgical airway backup.
  
• Select an ETT 1–2 sizes smaller than usual for age/size.
  
• Meticulous ETT care and suctioning
  
• If BVM ventilation needed, use appropriately sized mask with 2-hand seal.
  
• Supplemental humidified oxygen
  

• Continue monitoring of ventilation and oxygenation.
  
• IV fluids, bolus, as necessary
  
• Bronchoscopy if not rapidly deteriorating:
  
  • Assess need for intubation
    
  • Therapeutic stripping of membranes
    
• IV antibiotics to cover typical pathogens:
  
  • Ceftriaxone and nafcillin or vancomycin
    
  • Vancomycin or clindamycin for penicillin-allergic patients
    
  • Consider corticosteroid therapy
    

• Ceftriaxone: 50 mg/kg IV, max. 2 g
  
• Nafcillin: 50 mg/kg IV; max. 2 g
  
• Ampicillin/sulbactam: 50 mg/kg IV; max. 3 g
  
• Vancomycin: 15 mg/kg IV; max. 1 g
  
• Clindamycin: 10 mg/kg IV; max. 1 g
  
• Racemic epinephrine: 2.25% solution diluted 1:8 with water in doses of 2–4 mL via aerosol
  
• Dexamethasone: 0.6 mg/kg IV
  

Ceftriaxone plus nafcillin

Vancomycin or clindamycin:

• Consider if penicillin allergic, and in areas of high prevalence of MRSA
  

FOLLOW-UP

All patients with suspected or documented bacterial tracheitis:

• Admit to PICU.
  
• PICU length of stay varies from 3–9 days.
  

None

Critical care, otolaryngologist, or pulmonologist should be consulted.

Few long-term complications

• Consider in patients with croup-like illness who rapidly deteriorate.
  
• May be more severe in younger patients due to narrower tracheal diameters.
  

• Hopkins BS, Johnson KE, Ksiazek JM, et al. H1N1 influenza presenting as bacterial tracheitis.
  Otolaryngol Head Neck Surg.
  2010;142:612–614.
  
• Hopkins A, Lahiri T, Salerno R, et al. Changing epidemiology of life-threatening upper airway infections: The re-emergence of bacterial tracheitis.
  Pediatrics
  . 2006;118:1418–1421.
  
• Huang YL, Peng CC, Chiu NC, et al. Bacterial tracheitis in pediatrics: 12 year experience at a medical center in Taiwan.
  Pediatr Int
  . 2009;51:110–113.
  
• Salamone FN, Bobbitt DB, Myer CM, et al. Bacterial tracheitis reexamined: Is there a less severe manifestation?
  Otolaryngol Head Neck Surg
  . 2004;131:871–876.
  
• Tebruegge M, Pantadazidou A, Thorburn K, et al. Bacterial tracheitis: A multi-centre perspective.
  Scand J Infect Dis
  . 2009;41:548–557.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Epiglottitis, pediatric
  
• Epiglottitis, adult
  
• Croup
  

CODES

• 464.4 Croup
  
• 464.11 Acute tracheitis with obstruction
  
• 464.21 Acute laryngotracheitis with obstruction
  

BASICS