What is Bacterial Tracheitis (Croup)?
Bacterial tracheitis, also known as bacterial croup or laryngotracheobronchitis, is a dangerous infection that affects the trachea. The term was first used in the 1970s, but this condition was identified in the medical world as early as the 1920s. It usually targets children under six years old, and it’s often a secondary infection, meaning it follows a viral infection. The infection can also rarely occur spontaneously in adults, and in patients dependent on a tracheostomy, which is a surgically created hole in the windpipe that helps them to breathe.
The primary concern of treatment is to protect patients’ airways. This is because the thick, mucus-filled secretions caused by this illness can narrow and block the airway. When a patient comes in with symptoms, doctors need to quickly rule out other causes of airway blockage so they can start treatment quickly. Treatment mainly focuses on safeguarding the airway, deciding whether the condition requires diagnostic or therapeutic endoscopy, which is a procedure that allows doctors to look inside your body, and using drugs to kill or stop the growth of bacteria.
What Causes Bacterial Tracheitis (Croup)?
Bacterial tracheitis is an infection in the windpipe (trachea) often following a viral infection in the upper respiratory tract. The usual viruses involved include Influenza A and B, respiratory syncytial virus, parainfluenza, measles, and enterovirus. These viruses can damage the lining of the windpipe through our body’s immune response, making it easier for bacteria to take hold.
Patients with this condition are generally healthy before the infection, and the majority of them recover with the right diagnosis and treatment. Nonetheless, those with weakened immune systems can experience severe complications. The bacteria involved are most commonly Staphylococcus aureus, Streptococcus pneumoniae, and Streptococcus pyogenes. Other less common bacteria include Pseudomonas aeruginosa, Escherichia coli, and Klebsiella pneumonia.
People with long-term tracheostomies (a tube placed into the windpipe to help breathing) are at increased risk for bacterial tracheitis. This could be due to the buildup of bacteria in the tracheostomy tube. In 95% of tracheostomy-related cases, a single bacterial species is present, and in 83%, multiple species are found. The most common bacteria found in these patients are Staphylococcus aureus, Pseudomonas aeruginosa, and Streptococcus pneumoniae.
Meticulous care of the tracheostomy, including regular cleaning and replacing parts of the tube, is crucial to lessen the risk of bacterial tracheitis in this specific group of people.
Risk Factors and Frequency for Bacterial Tracheitis (Croup)
Bacterial tracheitis is a condition that varies in frequency from country to country, with an estimated 0.1 to 1 case(s) per 100,000 children. Generally, it affects children between the ages of three to eight. However, it can also occur in babies and adults. Recently, doctors have noticed more cases in an older age group, specifically children aged five to ten. Males seem to be slightly more susceptible to this condition than females. The incidence of this infection increases during the fall and winter, which is when common viral infections like the flu and RSV also spread.
Interestingly, according to a study on 33 children who had undergone tracheostomy at a major care center, bacterial tracheitis seemed to be associated with higher socioeconomic status. However, there is a speculation that patients from lower socioeconomic backgrounds might not seek treatment as often.
- The yearly number of bacterial tracheitis cases per 100,000 children varies, with numbers between 0.1 to 1.
- It’s most common in children aged 3-8, but can also impact babies and adults.
- Nowadays, more cases are being seen in an older age group, specifically children between 5-10 years old.
- Males are a little bit more likely to have this condition than females.
- This bacterial infection is more common during fall and winter, which coincides with the flu and RSV season.
- Higher socioeconomic status might be associated with the occurrence of bacterial tracheitis, but it’s also possible that those from a lower socioeconomic background are not seeking treatment as often.
Signs and Symptoms of Bacterial Tracheitis (Croup)
Bacterial tracheitis is a throat infection that can affect both adults and children. The symptoms can vary quite a bit depending on the person’s age and whether they have a medical device called a tracheostomy. In people who don’t have a tracheostomy, bacterial tracheitis often looks like a viral infection at first. They may have symptoms like a runny nose, a cough, a fever, body aches, and a sore throat for about a week before their symptoms get significantly worse.
Following this, they may experience a sharp deterioration in breathing, higher fevers, voice changes, appearing sick and weakened and increased mucus owing to the bacterial infection. Some people may have intense breathing distress with less than a day of symptoms.
The symptoms can include:
- Loud breathing
- Fever
- A productive and painful cough
- Thick secretions
- Tracheal tenderness
However, symptoms like excessive saliva and posturing suggest a different diagnosis, like epiglottitis, as children dealing with bacterial tracheitis usually do not face major difficulty in swallowing saliva. With severe throat blockages, they might have bluish skin due to oxygen deficit, appear slothful or can seem combative, signalling low oxygen or high carbon dioxide levels.
People with tracheostomies and bacterial tracheitis might display symptoms that include:
- High fevers
- Chills
- A productive cough
- Thick, pus-like secretions
- Bloody phlegm
- Breakdown of the skin around the tracheostomy or skin infection
- High ventilation pressures
- Blockage of the tracheostomy
Testing for Bacterial Tracheitis (Croup)
If a doctor suspects bacterial tracheitis, they will diagnose you based on a physical examination and your medical history. You might have symptoms like a fever, breathlessness, hoarseness in your voice, and even appear sickly or severely unwell. Preliminary treatments like using nebulisers with epinephrine and glucocorticoid medications generally don’t improve a patient’s condition in this case.
Lab tests might not be very specific in diagnosing this condition. While an increased white blood cell count or a slightly lowered count can be seen, it doesn’t confirm bacterial tracheitis. Similarly, while an elevated Erythrocyte Sedimentation Rate (ESR) and C-Reactive protein (CRP) can be seen in almost 68% of patients, these are not definitive indicators. Even though blood cultures are hardly ever positive, they might still be done if there is suspicion of sepsis or if the patient has a compromised immune system.
X-ray images of your neck can show narrowing in the area below your vocal cords or trachea, which is typically seen in croup (a childhood condition that affects the windpipe, the airways to the lungs and the voice box). Alternatively, X-rays may show a condition known as the “candle dripping” sign, an irregular or hazy appearance on the trachea’s inside surface. Meanwhile, your epiglottis (the flap at the base of your tongue that keeps food from going into the windpipe) should appear normal. Chest X-rays might not be very helpful for diagnosis, but can sometimes show signs of a simultaneous pneumonia infection, which is seen in roughly half of the cases and can make the disease more severe. Computed tomography (CT) scans are not typically used for diagnosis unless there is stability in the patient’s respiratory condition, and there is a suspicion of narrowing of the trachea or recurrent tracheitis.
The definitive way to diagnose bacterial tracheitis is by directly seeing the infected airway using a laryngoscope or bronchoscope. These tools can show a normal or mildly red and swollen epiglottis and a red, swollen trachea with thick pus-like discharge. The bronchoscope can also be used to vacuum off the discharge for tempory relief from airway blockage and to collect samples for testing.
Bacterial tracheitis is a rare illness that can be hard to diagnose because its symptoms are similar to many other conditions. These include epiglottitis, which shows symptoms such as fever, blockage of the upper airway, and a sickly appearance. Croup, a childhood condition that inflames the windpipe, voice box, and airways, can also show similar symptoms. Other conditions that might mimic bacterial tracheitis include throat or deep neck infections, allergies causing swelling, foreign objects stuck in the airway, intake of harmful substances, throat cancers, diphtheria, and severe bacterial pneumonia, among others.
Treatment Options for Bacterial Tracheitis (Croup)
Treating bacterial tracheitis, a bacterial infection of the windpipe, begins by promptly checking for breathing issues. Intubation, inserting a tube down the throat to help breathing, is a common need for these patients. However, this procedure can be challenging due to inflammation, and it should be performed by experienced teams in a critical care setting with surgical tools ready in case the standard intubation fails. Signs of potential breathing failure include low oxygen levels, strained breathing, tiredness, confused thinking, and weak breath sounds. Young children, who have smaller windpipes, are more likely to need breathing support.
If intubation is required, doctors choose breathing tubes a size or two smaller than usual due to narrowing in the windpipe. The patient will be admitted to intensive care after intubation to provide close monitoring and frequent cleaning of the inserted tube. If the patient shows improvement, with fewer secretions from the windpipe and the development of a small air leak around the tube, the tube may be removed. Other treatments for less severe cases can include extra humidified oxygen, a trial of racemic epinephrine (a medication to help breathing), heliox (a combination of helium and oxygen), and calming the patient who may be agitated, making breathing more difficult.
Quick antibiotic treatment is crucial and should cover a wide range of bacteria, including MRSA, a type of hard-to-treat bacteria. The antibiotic choice can be refined based on the results of a stain test, but broad coverage is preferred initially until bacteria culture results become available. Current recommendations suggest a course of antibiotics for 10-14 days. The top-choice medications include amoxicillin-clavulanic acid, ceftriaxone+nafcillin or vancomycin, clindamycin+a third-generation cephalosporin, or ampicillin-sulbactam. For patients with a severe allergy to specific antibiotics (beta-lactam), the combo of vancomycin or clindamycin plus levofloxacin or ciprofloxacin is recommended.
Corticosteroids, a type of steroids, haven’t shown any benefit in altering the course of the disease or patient outcomes. Antiviral therapy may be beneficial if the infection is preceded by influenza and symptoms have been present for less than 48 hours. However, routine, blanket use of antiviral treatment has not proven effective.
What else can Bacterial Tracheitis (Croup) be?
Bacterial tracheitis, an infection of the trachea, can resemble a lot of other medical conditions, which makes accurately diagnosing it a little tricky. Here’s a list of conditions that can look a lot like bacterial tracheitis:
- Amyloidosis
- Angioedema, which involves swelling beneath the skin
- Candidiasis, a fungal infection that can affect the larynx (voice box) or trachea
- Damage caused by swallowing a harmful substance
- Deep neck infections
- Diphtheria, a serious bacterial illness
- Epiglottitis, inflammation of part of the windpipe
- Foreign body in the windpipe or digestive tract
- Disease of the larynx or trachea caused by other types of fungi
- Granulomatosis with polyangiitis – previously known as Wegener’s granulomatosis
- Bruising of the voice box
- Trauma or injury to the voice box
- Abnormal shape of the voice box, known as laryngomalacia
- Reflux affecting the larynx and pharynx
- Croup, a childhood condition
- Leukoplakia, white patches on the mouth and tongue
- Cancer affecting the oesophagus, larynx, thyroid, or trachea. Subtypes can include adenocarcinoma, several types of thyroid cancer, lymphoma, melanoma, metastasis, squamous cell carcinoma, or thymoma.
- Necrotizing sialometaplasia, a condition affecting the salivary glands
- Peritonsillar abscess, a collection of pus behind the tonsils
- Pseudoepitheliomatous hyperplasia, a skin condition
- Retropharyngeal abscess, an abscess behind the throat
- Sarcoidosis, an inflammatory disease
- Subglottic stenosis, a narrowing of the airway below the vocal cords
- Pressure on the trachea
- Narrowing of the trachea
- Granulation caused by a tracheostomy
- Obstruction or misplacement of a tracheostomy tube
- Weakening of the tracheal walls, known as tracheomalacia
- Tuberculosis, a severe lung disease
- Viral infection of the larynx or trachea
- Paralysis or weakness of the vocal cords
Each of these conditions requires different treatment, so it’s important for healthcare professionals to distinguish them from bacterial tracheitis.
What to expect with Bacterial Tracheitis (Croup)
Bacterial tracheitis is a severe disease that can become life-threatening. However, it is quite treatable if it is identified and addressed early on. A 2018 review of 36 patients from a specialized medical center showed that 69% of children diagnosed with bacterial tracheitis had to be admitted to the pediatric intensive care unit (PICU). Additionally, 43% of these children needed a procedure called intubation to assist their breathing, and one child unfortunately died due to an airway blockage.
As for patients who relied on a ventilator due to respiratory issues, those with bacterial tracheitis showed a longer period of time relying on mechanical ventilation and a lengthier stay in the ICU in comparison to patients without lower respiratory infections.
In another observation, children who had a tracheostomy – a procedure that opens up the windpipe for breathing, and were diagnosed with bacterial tracheitis, had higher rates of return visits to the hospital within 30 days, compared to children without a tracheostomy.
Possible Complications When Diagnosed with Bacterial Tracheitis (Croup)
If bacterial tracheitis isn’t treated, it can lead to several complications. These may include:
- Acute respiratory distress syndrome (a severe lung condition)
- Acute ventilatory dependent respiratory failure (a type of breathing failure)
- Airway obstruction (blockage in the airway)
- Anoxic encephalopathy (brain damage caused by lack of oxygen)
- Aspiration pneumonia (pneumonia caused by inhalation of foreign material)
- Cardiopulmonary arrest (a sudden stop in effective blood flow)
- Cellulitis (a skin infection)
- Death
- Disseminated intravascular coagulation (a condition affecting the blood’s ability to clot)
- Hypoxia (lack of oxygen)
- Intubation (the procedure of inserting a tube)
- Pneumonia (lung inflammation)
- Pulmonary edema (fluid accumulation in the lung)
- Systemic inflammatory response syndrome (SIRS), sepsis, septic shock (body-wide inflammatory state)
- Tracheostomy (surgical opening in the windpipe)
- Tracheal stenosis (narrowing of the windpipe)
- Toxic shock syndrome (a severe bacterial infection)
Recovery from Bacterial Tracheitis (Croup)
If a patient requires a tracheostomy, which could be performed by ear, nose, and throat surgeons, oral and maxillofacial surgeons, or general surgery teams, they need a group of therapists for their care. These include respiratory therapy, speech therapy, physical therapy, and occupational therapy. Moreover, the surgery teams should regularly check on patients with a tracheostomy, take care of the wound and tracheostomy, and watch out for any changes in condition or potential complications. They are also responsible for conducting trials for capping and planning for the removal of the tracheostomy tube when the infection gets better and the patient’s airway is stable.
Furthermore, the teams of respiratory therapists and nursing staff have a significant role in the daily care of the tracheostomy. The speech-language pathologists are there to help the patient improve their ability to swallow and try a Passy Muir speaking valve, which assists in speech. Case management and social work teams also play an essential part in providing the patient with tracheostomy supplies and deciding whether the patient would be discharged to their home or a rehabilitation facility. Their role is critical in deciding the patient’s discharge status and addressing any safety concerns the patient or their family may have.
Preventing Bacterial Tracheitis (Croup)
Preventing bacterial tracheitis, an infection in the windpipe, is particularly important for both children and adults reliant on a tracheostomy—a medical procedure that creates an opening in the neck for breathing. Generally, good hygiene like correct hand washing or wearing a facial mask can help impede acquiring bacterial tracheitis, although total avoidance is impossible in people without tracheostomies. Vaccines against bacterial and viral pathogens such as Haemophilus Influenzae B, Streptococcus Pneumoniae, and Diphtheria can diminish the chance of windpipe infections and swelling.
Prompt medical attention should be sought for any signs of shortness of breath or concerns about a blockage in the airway. It is advisable to visit a primary care doctor, an urgent care center, or a local emergency department in such scenarios.
For people with tracheostomies, education for both patient and caregiver is key to avoid bacterial tracheitis. Multidisciplinary teams—consisting of surgeons, ear, nose and throat specialists, respiratory therapists, nurses, speech therapists, social workers and case managers—have a role in instructing patients dependent on a tracheostomy how to properly clean and maintain their tracheostomy sites and devices.
Part of this care includes cleaning the tracheostomy tube with hydrogen peroxide, saline solution, and using suction frequently daily to ward off mucous clogging or trapping of skin or respiratory bacteria. It is also crucial to keep these areas moist to prevent crusting and blockage. Other protective measures include using barrier ointments and dressings, removing any crust, and daily skincare around the tracheostomy area, all aimed to prevent skin breakdown and contamination of external infectious agents into the trachea.
