Membranous (Bacterial) Tracheitis

Clinical Summary
Membranous tracheitis is an acute bacterial infection (Staphylococcus aureus,
Haemophilus influenzae, streptococci, and pneumococci) of the upper airway
capable of causing life-threatening airway obstruction. It may present as a primary
infection or occur as a bacterial complication of a viral infection of the upper
respiratory tract. The infection produces marked swelling and thick, purulent
secretions of the tracheal mucosa below the vocal cords. The secretions can form a
thick plug that may ultimately lead to an acute tracheal obstruction. Patients appear
toxic, with high fever and a croup-like syndrome that can progress rapidly. The
usual treatment for croup is ineffective in these patients. The characteristic
"membranes" may be seen on x-rays of the airway as edema with an irregular
border of the subglottic tracheal mucosa. On direct laryngoscopy, copious purulent
secretions can be found in the presence of a normal epiglottis. The differential
diagnosis includes acute laryngotracheobronchitis, retropharyngeal abscess,
peritonsillar abscess, foreign-body aspiration, and acute diphtheric laryngitis.
Emergency Department Treatment and Disposition
Otolaryngologic consultation should be obtained as soon as the diagnosis is
considered. Direct visualization of the trachea is more important than a possible
radiologic diagnosis. Aggressive airway management, including endotracheal
intubation, may be needed to protect the airway and allow for repeated suctioning
to prevent acute airway obstruction. The patient should be admitted to the intensive
care unit for close monitoring and sedation needs. Appropriate antibiotic coverage
against suspected organisms should be instituted immediately.
FIGURE 14.65.

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Membranous Tracheitis. Lateral soft tissue x-ray of the neck in a 13-year-old girl with the acute
onset of stridor after 3 days of sore throat. Membranes (arrows) are visible in the subglottic
region. (Photo contributor: Matthew R. Mittiga, MD.)

Pearls

1. Bacterial tracheitis often presents with acute, severe airway obstruction after
a short prodrome. It should be suspected in all patients with an atypical
croup-like presentation: unusual age group, toxicity, not improving with
routine croup therapy, and unusual roentgenographic changes of the
trachea.
2. Up to 50% of soft tissue films may delineate a subglottic membrane.

AMA Citation
Mittiga MR, Gonzalez del Rey JA, Ruddy RM. Chapter 14. Pediatric
Conditions.In: Knoop KJ, Stack LB, Storrow AB, Thurman R. eds. The Atlas of
Emergency Medicine, 3e. New York, NY: McGraw-Hill; 2010

Bacterial Tracheitis
Bacterial tracheitis (pseudomembranous croup) is a severe, life-threatening form of
laryngotracheobronchitis. As the management of severe viral croup has been
improved with the use of dexamethasone and vaccination has decreased the
incidence of epiglottitis, tracheitis is a more common cause of a pediatric airway
emergency requiring admission to the pediatric intensive care unit. This diagnosis
must be high in the differential when a patient presents with severe upper airway
obstruction and fever. The organism most often isolated is Staphylococcus
aureus, but organisms such as H influenzae, group A Streptococcus pyogenes,
Neisseria species, Moraxella catarrhalis,and others have been reported. A viral
prodrome is common. Viral coinfections are described and should be treated
especially Influenza A and H1N1. The disease probably represents localized

mucosal invasion of bacteria in patients with primary viral croup, resulting in

inflammatory edema, purulent secretions, and pseudomembranes. Although
cultures of the tracheal secretions are frequently positive, blood cultures are almost
always negative.
Clinical Findings
SYMPTOMS AND SIGNS

The early clinical picture is similar to that of viral croup. However, instead of gradual
improvement, patients develop higher fever, toxicity, and progressive or intermittent
severe upper airway obstruction that is unresponsive to standard croup therapy.
The incidence of sudden respiratory arrest or progressive respiratory failure is high;
in such instances, airway intervention is required. Findings of toxic shock and the
acute respiratory distress syndrome may also be seen. Recently, subsets of
patients with tracheal membranes have been reported with a less severe initial
clinical presentation. Nevertheless, these patients are still at risk for life-threatening
airway obstruction. Aggressive medical treatment and debridement still must occur
in these patients.
LABORATORY FINDINGS AND IMAGING

The white cell count is usually elevated with a left shift. Cultures of tracheal
secretions usually demonstrate one of the causative organisms. Lateral neck
radiographs show a normal epiglottis but severe subglottic and tracheal narrowing.
Irregularity of the contour of the proximal tracheal mucosa can frequently be seen
radiographically and should elicit concern for tracheitis. Bronchoscopy showing a
normal epiglottis and the presence of copious purulent tracheal secretions and
membranes confirms the diagnosis.
Treatment

Patients with suspected bacterial tracheitis will require direct visualization of the
airway in a controlled environment and debridement of the airway. Most patients will
be intubated because the incidence of respiratory arrest or progressive respiratory
failure is high. Patients may also require further debridement, humidification,
frequent suctioning, and intensive care monitoring to prevent endotracheal tube
obstruction by purulent tracheal secretions. Intravenous antibiotics to cover S
aureus, H influenzae, and the other organisms are indicated. Thick secretions
persist for several days, usually resulting in longer periods of intubation for bacterial

tracheitis than for epiglottitis or croup. Despite the severity of this illness, the
reported mortality rate is very low if it is recognized and treated promptly.
Hopkins, Brandon S et al: H1N1 influenza A presenting as bacterial tracheitis.
OtolaryngologyHead and Neck Surgery 2010;142(4):612. [PubMed: 20304287]

Tebruegge M et al: Bacterial tracheitis: A multi-centre perspective. Scand J Infect

Dis 2009:110. [PubMed: 19401934]

AMA Citation
Federico MJ, Stillwell P, Deterding RR, Baker CD, Balasubramaniam V, Zemanick
ET, Sagel SD, Halbower A, Burg CJ, Kerby GS. Chapter 19. Respiratory Tract &
Mediastinum. In: Hay WW, Jr, Levin MJ, Deterding RR, Abzug MJ, Sondheimer
JM. eds. CURRENT Diagnosis & Treatment: Pediatrics, 21e. New York, NY:
McGraw-Hill; 2012

Bacterial Tracheitis
Principles of Disease.
Bacterial tracheitis (membranous croup, bacterial croup, pseudomembranous
croup) is a relatively rare but serious cause of stridor and airway obstruction in
children. The epidemiology of upper airway infections has changed since
widespread immunization for H. influenzae and use of steroids for croup. This has
increased the relative frequency of bacterial tracheitis as a cause of respiratory
failure from upper airway infection. A recent series of 35 pediatric ICU admissions
for life-threatening airway infections reported that 17 were for bacterial tracheitis,
16 for viral croup, and 2 for epiglottitis.[58] Bacterial tracheitisgenerally affects
younger children, with a peak incidence at approximately 3 to 4 years of age.
However, it is also reported in patients well beyond this age group, thus making it
a diagnosis seen in adolescence and young adulthood as well.
The pathogenesis of bacterial tracheitis is severe inflammation of the tracheal
epithelium and the production of thick mucopurulent secretions. The lining of the
trachea forms a loosely adherent membrane that sloughs into the lumen.
Traditionally, S. aureus has been the organism primarily responsible for
bacterialtracheitis. More recently, the microbiology of bacterial tracheitis has

been better defined. In a review of bacterial tracheitis in 14 children, Brook

reported that aerobic bacteria (43%), anaerobic bacteria (20%), and mixed
anaerobic and aerobic flora (36%) were cultured. The predominant organisms
recovered in tracheal secretions were S. aureus (5), H. influenzae type b
(4), Moraxella catarrhalis (2), Peptostreptococcus species
(4), Prevotella and Porphyromonas (4), andFusobacterium species (2).[59] Others
have reported S. pneumoniae, alpha-hemolytic and group A streptococci,
and Candida albicans.
Clinical Features.
The clinical features of bacterial tracheitis overlap the symptoms of both croup
and epiglottitis (Table 168-2). Patients experience a viral prodrome of fever, barky
cough, and stridor. These symptoms typically intensify. The child appears toxic,
and signs of airway obstruction and respiratory failure may develop acutely.
Differentiation of bacterial tracheitis from severe croup or epiglottitis on clinical
grounds alone can be difficult. In one report of 16 patients with bacterialtracheitis,
an initial diagnosis of croup was made in 7 and acute epiglottitis in 2.[60] Features
that suggest bacterial tracheitis include a viral prodrome followed by acute
decompensation, symptoms atypical for croup (high fever, cyanosis, and severe
distress), poor response to usual treatment of croup (steroids and aerosolized
epinephrine), and both inspiratory and expiratory stridor.
Table 168-2 -- Comparison of Croup, Epiglottitis, and Bacterial Tracheitis
CROUP
EPIGLOTTITIS
BACTERIAL TRACHEITIS
Peak age

6 months to 3
years

5-7 years, but can be seen

throughout childhood

3-5 years, but seen throughout

childhood

Pathologic
features

Subglottic
inflammation,
edema

Inflammation and edema of

the epiglottis, aryepiglottic
folds

Bacterial superinfection with

inflammation of the tracheal
mucosa, copious mucopurulent
secretions obstructing the
trachea

Organisms

Parainfluenza
virus, RSV,
adenovirus

Group A beta-hemolytic
streptococcus,Staphylococcus
aureus, Streptococcus
pneumoniae, Haemophilus
influenzae

Staphylococcus aureus or
mixed flora

Clinical
features

Onset follows
URI prodrome
consisting of
croupy cough, Rapid progression of high
hoarse voice, fever, toxicity, drooling,
low-grade
stridor
fever,
inspiratory
stridor

Several-day prodrome of
crouplike illness progressing to
toxicity, inspiratory and
expiratory stridor, marked
distress

Laboratory
and
radiographic
findings

Steeple sign on
PA view of the
neck, or
normal

Normal upper airway

structures, shaggy tracheal air
column

Management Steroids
uncommon,

Thumbprint sign on lateral

aspect of the neck, thickened
aryepiglottic folds, loss of air
in the vallecula
Intubation, antibiotics

Intubation common, antibiotics

rare, intubation

CROUP

EPIGLOTTITIS

BACTERIAL TRACHEITIS

aerosolized
epinephrine
PA, posteroanterior; RSV, respiratory syncytial virus; URI, upper respiratory infection.

Diagnostic Strategies.
Evaluation of a toxic-appearing child with bacterial tracheitis should be conducted
expeditiously. Laboratory tests are nondiagnostic. The white blood cell count is
normal or slightly elevated. Blood cultures are usually negative. Lateral and
anteroposterior views of the neck and chest may be helpful. Findings on plain
radiographs include subglottic narrowing, a ragged edge of the usually smooth
tracheal air column, and a hazy density within the tracheal lumen. The epiglottis
and supraglottic structures appear normal. In addition, the chest radiograph may
reveal coexisting pneumonia. Bronchoscopy is both diagnostic and therapeutic
and should be performed on an emergency basis. This procedure should allow
visualization of the supraglottic structures and larynx, exclusion of other disease,
suctioning of tracheal secretions and debris, and establishment of an artificial
airway.
Management.
In relatively few cases, severe distress requires immediate intubation and
suctioning in the ED. Airway management in the setting of the operating room is
preferred. These patients require hospital admission, intensive care, supplemental
oxygen, fluid resuscitation, and broad-spectrum antibiotics.
Endotracheal intubation is required in the majority of patients.[58,61] The duration of
intubation in patients with bacterial tracheitis is reported to be 4 or 5 days, as
opposed to 48 hours for croup and 54 hours for epiglottitis.[60] Complications that
have been reported in association with bacterial tracheitis include toxic shock
syndrome, septic shock, renal failure, postintubation pulmonary edema, acute
respiratory distress syndrome, and need for reintubation.[61]

Marx: Rosen's Emergency Medicine - Concepts

and Clinical Practice, 8th ed.
Copyright 2013 Saunders, An Imprint of Elsevier