Bacterial tracheitis – A life threatening cause of stridor: A case report

Prasanna Narayanan Raju; M Manu; Pradheep Subramanian Raju; C Ravikumar; Raju Subramanian

doi:10.4103/jpcc.jpcc_44_22

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CASE REPORT

Year : 2022 | Volume : 9 | Issue : 4 | Page : 139-141

Bacterial tracheitis – A life threatening cause of stridor: A case report

Prasanna Narayanan Raju¹, M Manu¹, Pradheep Subramanian Raju¹, C Ravikumar², Raju Subramanian¹
¹ Krishna Maternity Home and Pediatric Center Pvt Ltd, Tirunelveli, Tamil Nadu, India
² Department of ENT, Tirunelveli Medical College Hospital, Tirunelveli, Tamil Nadu, India

Date of Submission	25-May-2022
Date of Decision	04-Jun-2022
Date of Acceptance	06-Jun-2022
Date of Web Publication	20-Jul-2022

Correspondence Address:
Dr. Prasanna Narayanan Raju
Krishna Maternity Home and Pediatric Center Pvt Ltd, North Highground Road, Palayamkottai, Tirunelveli - 627 002, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpcc.jpcc_44_22

Abstract

Bacterial tracheitis is an invasive bacterial infection of the trachea. It is an uncommon cause of life-threatening airway obstruction in children without an artificial airway, with an incidence of 0.1 per 1 lakh children per year. The clinical presentation is similar to viral croup and disease progression can be rapid. We report a case of bacterial tracheitis in a previously well infant who presented with acute febrile illness followed by stridor and impending respiratory failure. Early intervention measures such as airway clearance with bronchoscopy, mechanical ventilation, and initiation of empirical broad-spectrum antibiotics along with other supportive measures resulted in good outcome.

Keywords: Bacterial croup, bacterial laryngotracheobronchitis, bacterial tracheitis, membranous croup, membranous laryngotracheobronchitis

How to cite this article:
Raju PN, Manu M, Raju PS, Ravikumar C, Subramanian R. Bacterial tracheitis – A life threatening cause of stridor: A case report. J Pediatr Crit Care 2022;9:139-41

How to cite this URL:
Raju PN, Manu M, Raju PS, Ravikumar C, Subramanian R. Bacterial tracheitis – A life threatening cause of stridor: A case report. J Pediatr Crit Care [serial online] 2022 [cited 2023 Feb 8];9:139-41. Available from: http://www.jpcc.org.in/text.asp?2022/9/4/139/351517

Introduction

Bacterial tracheitis is an invasive exudative infection of soft tissues of the trachea. It is an uncommon cause of upper airway obstruction in children and requires a high degree of clinical suspicion for the diagnosis.^[1] It commonly affects preschool, early preschool aged children and is less common in infants. Clinical features may be similar to viral croup but these children appear more toxic and clinical response to inhaled epinephrine or systemic corticosteroids is absent or inadequate.^[2] Bronchoscopic visualization of the trachea is an essential diagnostic modality in severe cases and also helps in tracheal toileting. Management includes airway protective measures, supportive respiratory care, and early initiation of broad-spectrum antibiotics. Delay in therapy can lead to respiratory arrest. Recovery is usually complete with early diagnosis and treatment.^[3]

Case Report

A 11-month-old, previously well female child presented with history high grade fever for 1 day followed by sudden onset difficulty in breathing. There was no history suggestive of foreign body aspiration. Child had received primary vaccinations as per the schedule. On admission, child was lethargic with suprasternal retractions and severe inspiratory stridor. She was febrile (103F), tachycardic (heart rate 180–190/min) with borderline saturations (Spo₂ 85%–89% in room air). Considering possibility of croup, she was started on epinephrine nebulizations and one dose intravenous steroid was administered. As child continued to be hypoxemic, she was transferred to pediatric intensive care unit (PICU) and started on high flow nasal cannula oxygen along with empirical antibiotic (ceftriaxone). Chest X-ray showed no significant abnormality and X-ray neck lateral view was also noncontributory. Her saturations improved, however stridor and work of breathing continued to worsen in spite of the above measures. Blood investigations revealed elevated inflammatory markers with polymorphonuclear leukocytosis [Table 1]. Investigations were suggestive of possible bacterial etiology, probably bacterial tracheitis.

Table 1: Laboratory investigations

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In view of worsening respiratory status, endotracheal intubation along with bronchoscopy under anesthesia was planned. Rigid bronchoscopy was done which showed thick purulent fibrinous strands in the supra-glottic area, causing partial airway obstruction with extensive purulent material in the main bronchus [Figure 1]. Lavage was done and material sent for culture sensitivity. Child was intubated in the operating room and was continued on mechanical ventilation in PICU. Antibiotics were escalated to Meropenem along with clindamycin for anaerobic cover in view of clinical worsening. HIV serology and COVID reverse transcription polymerase chain reaction (PCR) were negative. Bronchial lavage culture was negative for viral PCR and showed growth of Moraxella catarrhalis which was sensitive to cephalosporins. Antibiotic was then de-escalated to ceftriaxone. Fever gradually subsided and repeat sepsis markers showed decreasing trend. Child was mechanically ventilated for 72 h. Respiratory secretions reduced and child was extubated to high-flow nasal cannula. There was minimal postextubation stridor which responded to steroids and epinephrine nebulizations. Child was weaned off oxygen over the next 48 h and remained stable during further hospital stay. Antibiotics were continued for a total of 14 days (intravenous followed by oral) and child was asymptomatic on follow-up.

Figure 1: (a-c) bronchscopy images showing purulent fibrinous adhesions in supraglottis and glottis region. (d-f) Purulent exudates in the trachea extending upto carina and main bronchi

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Discussion

Bacterial tracheitis is characterized by production of mucopurulent exudates with ulceration and sloughing of mucosa. It may present as a secondary illness following a viral respiratory infection.^[4] Common causative bacteria include Group A Streptococcus, Staphylococcus aureus, and M. catarrhalis. The disease may also occur secondary to viral infections. M. catarrhalis has been reported to be associated with severe disease.^[5]

Although the clinical features of bacterial tracheitis resemble viral croup, it is important to differentiate these conditions as the former can have rapid disease progression. Absent or poor response to conventional management measures such as racemic epinephrine nebulizations and corticosteroids is characteristic of bacterial tracheitis. The affected children generally appear more toxic with higher body temperatures. Swallowing of oral secretions is usually preserved and therefore drooling may be absent in bacterial tracheitis, unlike in epiglottitis.^[6]

Diagnosis is mainly by history and physical examination along with laboratory investigations and bronchoscopy. Chest radiograph features of pneumonia may be present in 50% of cases.^[7]

Bronchoscopy is the definitive diagnostic modality and is also useful for airway clearance and for the exclusion of other diagnoses such as epiglottitis. Bronchoscopy in bacterial tracheitis shows subglottic narrowing, diffuse erythema, and mucopurulent exudates that may partially occlude the airway. Exudates may also extend into the main bronchi. Epiglottis usually appears normal or only slightly inflamed.^[8]

Percentage of children with bacterial tracheitis requiring mechanical ventilation may range from 38% to 100% as per the various reports.^[9] Intubation should be done in a controlled environment preferably with a smaller size cuffed endotracheal tube and difficult airway should be anticipated in view of extensive inflammation.^[10] Children ventilated for bacterial tracheitis require adequate supportive care such as frequent suctioning for clearing secretions and adequate sedation or paralysis to prevent further airway injury.

With appropriate antibiotic cover and supportive measures, clinical improvement can be seen in 48–72 h. Weaning from ventilation can be considered once systemic signs improve secretions are minimal, and in some cases, presence of leak around endotracheal tube cuff might be useful in predicting recovery. The complications of bacterial tracheitis are related to acute airway obstruction – cardiorespiratory arrest, pneumothorax, postobstruction pulmonary edema, subglottic stenosis have been reported in around 1%–2% of cases.^[11] Recommended first-line antibiotics in a suspected case include third-generation cephalosporin plus vancomycin or clindamycin. The role of corticosteroids early in the disease is controversial.^[12]

In the index child, airway examination was done early in view of rapid clinical worsening in spite of initial measures. Bronchoscopy was performed in the operating room along with endotracheal intubation with a smaller size cuffed tube. The child required 72 h of mechanical ventilation. There was no peri-tubal leak prior to extubation and steroids were started prior to extubation as per the protocol. Postextubation stridor was minimal and responded well to epinephrine nebulizations.

Bacterial tracheitis is a relatively rare but potentially life-threatening cause of airway obstruction in children. This case report highlights the importance of considering alternative diagnoses in children presenting with features of viral croup but do not respond to conventional therapy. Early aggressive airway clearance is necessary to prevent grave complications. Diagnostic and therapeutic bronchoscopy, appropriate antibiotics, and supportive care are the essential components for successful outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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