Tracheitis

Overview

Tracheitis is an inflammation of the trachea, the windpipe that connects the larynx (voice box) to the bronchi in the lungs. This condition can affect people of all ages but is most common and potentially serious in young children. The inflammation can cause swelling that narrows the airway, leading to breathing difficulties and a characteristic harsh, barking cough.

There are several types of tracheitis, with bacterial tracheitis being the most severe form. This condition often follows a viral upper respiratory infection and can rapidly progress to airway obstruction if not treated promptly. Viral tracheitis is more common but generally less severe, while allergic or irritant-induced tracheitis can occur from exposure to smoke, chemicals, or allergens.

The importance of recognizing tracheitis lies in its potential to cause serious breathing problems, especially in children whose airways are naturally smaller. While mild cases may resolve with supportive care, bacterial tracheitis is a medical emergency requiring immediate attention. Understanding the signs and symptoms of tracheitis can help ensure timely medical intervention when needed, potentially preventing life-threatening complications.

Symptoms

The symptoms of tracheitis can vary depending on the cause and severity of the inflammation. They typically develop over hours to days and may initially resemble a common cold or croup before progressing to more distinctive signs:

• Cough - Often harsh, barking, and painful
• Shortness of breath - May worsen with activity or when lying down
• Hoarse voice - Due to inflammation near the vocal cords
• Fever - Often high in bacterial tracheitis
• Sore throat - Pain may extend down into the chest
• Nasal congestion - Common with viral causes
• Sneezing - May occur with allergic tracheitis

Primary Symptoms

The hallmark symptom of tracheitis is a harsh, barking cough that sounds different from a typical cough. This cough is often described as "brassy" or "seal-like" and may be painful. Stridor, a high-pitched sound heard during breathing, particularly when inhaling, is another characteristic sign. This occurs due to narrowing of the trachea from inflammation and swelling.

Respiratory Distress Signs

As tracheitis progresses, signs of respiratory distress may develop. These include rapid breathing, use of accessory muscles (visible contractions of neck and chest muscles with breathing), retractions (pulling in of the skin between ribs or above the collarbone with breathing), and cyanosis (bluish discoloration of lips or fingernails). Children may prefer to sit upright or lean forward to ease breathing.

Systemic Symptoms

Bacterial tracheitis often presents with high fever, sometimes exceeding 104°F (40°C), along with chills and general malaise. Patients may appear toxic or very ill, distinguishing bacterial from viral causes. Difficulty swallowing, drooling, and voice changes may occur if inflammation extends to surrounding structures. Some patients report chest pain, particularly with coughing or deep breathing.

Age-Related Variations

In infants and young children, symptoms may include irritability, poor feeding, and lethargy in addition to respiratory signs. Older children and adults may better articulate symptoms like throat pain extending into the chest or a feeling of airway tightness. The progression of symptoms tends to be more rapid in younger children due to their smaller airway diameter.

Causes

Tracheitis can result from various causes, with infections being the most common. Understanding the different causes helps guide appropriate treatment and management strategies.

Bacterial Causes

Bacterial tracheitis is often caused by Staphylococcus aureus, including methicillin-resistant strains (MRSA). Other bacteria include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. This typically occurs as a secondary infection following viral respiratory illness, when damaged tracheal tissue becomes susceptible to bacterial invasion. The bacteria produce thick, purulent secretions that can obstruct the airway.

Viral Causes

Viral tracheitis is more common and usually less severe than bacterial forms. Common viral culprits include parainfluenza viruses (which also cause croup), influenza viruses, respiratory syncytial virus (RSV), adenovirus, and coronaviruses. These viruses directly infect the tracheal epithelium, causing inflammation and swelling. Viral tracheitis may occur alone or as part of a broader upper respiratory infection.

Non-Infectious Causes

Allergic tracheitis can result from exposure to allergens such as pollen, dust mites, or pet dander. Irritant-induced tracheitis may follow inhalation of smoke, chemical fumes, or other environmental pollutants. Gastroesophageal reflux disease (GERD) can cause chronic irritation of the trachea from stomach acid. Prolonged intubation or tracheostomy can lead to mechanical irritation and subsequent inflammation.

Risk Factors for Development

Several factors increase the likelihood of developing tracheitis. Recent viral upper respiratory infection is the most significant risk factor for bacterial tracheitis. Young age, particularly between 6 months and 3 years, increases susceptibility due to smaller airways and developing immune systems. Immunocompromised states, whether from disease or medications, heighten infection risk. Environmental factors like exposure to cigarette smoke or air pollution can predispose to both infectious and non-infectious tracheitis.

Risk Factors

Certain factors increase the likelihood of developing tracheitis or experiencing more severe disease:

• Age: Children under 6 years, especially those between 6 months and 3 years
• Season: Fall and winter months when respiratory infections are more common
• Recent illness: Viral upper respiratory infection within the past week
• Immunosuppression: HIV, cancer treatment, immunosuppressive medications
• Chronic conditions: Asthma, cystic fibrosis, or other lung diseases
• Environmental exposure: Cigarette smoke, air pollution, occupational irritants
• Anatomical abnormalities: Tracheal anomalies or previous airway surgery
• Intubation history: Recent or prolonged mechanical ventilation
• Allergies: Severe allergic rhinitis or multiple environmental allergies
• Daycare attendance: Increased exposure to respiratory pathogens

Diagnosis

Diagnosing tracheitis requires careful clinical evaluation and may involve various tests to confirm the diagnosis and identify the causative agent.

Clinical Evaluation

The diagnosis often begins with a thorough history and physical examination. Key clinical features include the characteristic barking cough, stridor, and signs of respiratory distress. The physician will assess breathing pattern, oxygen saturation, and overall appearance. Distinguishing tracheitis from croup is important, as bacterial tracheitis patients often appear more ill and may not respond to standard croup treatments.

Laboratory Tests

Blood tests typically show elevated white blood cell count in bacterial tracheitis, with increased neutrophils. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are often elevated. Blood cultures may identify the causative organism in some cases. Viral studies, including rapid antigen tests or PCR, can help identify viral causes.

Imaging Studies

Lateral neck X-rays may show subglottic narrowing and irregular tracheal margins, distinguishing tracheitis from croup's smooth "steeple sign." Chest X-rays can reveal concurrent pneumonia or other complications. CT scans are rarely needed but may be used in complex cases to evaluate airway anatomy and rule out other conditions.

Direct Visualization

Flexible laryngoscopy or bronchoscopy may be performed in stable patients to directly visualize the trachea. This can confirm inflammation, assess severity, and obtain cultures of tracheal secretions. In bacterial tracheitis, thick, purulent secretions and pseudomembrane formation may be seen. However, this procedure must be done cautiously as it can precipitate airway obstruction.

Differential Diagnosis

Important conditions to distinguish from tracheitis include croup (usually has gradual onset and responds to steroids), epiglottitis (drooling, muffled voice, prefers sitting position), foreign body aspiration (sudden onset, unilateral findings), and retropharyngeal abscess (neck pain, difficulty swallowing). Careful evaluation helps differentiate these conditions.

Treatment Options

Treatment of tracheitis depends on the underlying cause and severity of symptoms. Prompt recognition and appropriate management are crucial, especially for bacterial tracheitis.

Emergency Management

Severe tracheitis with respiratory distress requires immediate attention. Supplemental oxygen is provided to maintain adequate oxygenation. Continuous monitoring of vital signs and oxygen saturation is essential. Preparations for potential intubation should be made, as airway obstruction can develop rapidly. Heliox (helium-oxygen mixture) may temporarily improve airflow in some cases.

Antibiotic Therapy

Bacterial tracheitis requires prompt antibiotic treatment. Initial empiric therapy typically includes broad-spectrum antibiotics covering Staphylococcus aureus and other common pathogens. Common choices include nafcillin or oxacillin plus a third-generation cephalosporin, or vancomycin if MRSA is suspected. Treatment duration is usually 10-14 days, with initial intravenous therapy followed by oral antibiotics once improvement occurs.

Supportive Care

Humidified air or oxygen helps soothe inflamed airways and loosen secretions. Adequate hydration is important to thin secretions. Fever and pain management with acetaminophen or ibuprofen provides comfort. Rest and avoiding irritants like smoke are recommended. For viral tracheitis, supportive care is the mainstay of treatment.

Airway Management

Some patients with bacterial tracheitis require intubation for airway protection and secretion management. Frequent suctioning may be needed to clear thick secretions. Bronchoscopy can be both diagnostic and therapeutic, allowing removal of secretions and pseudomembranes. The duration of intubation varies but is typically 3-7 days.

Additional Therapies

Corticosteroids are controversial in bacterial tracheitis but may be beneficial in viral cases or those with significant edema. Nebulized epinephrine may provide temporary relief of stridor but doesn't treat the underlying infection. For allergic tracheitis, antihistamines and avoiding triggers are important. Reflux management may be needed if GERD contributes to symptoms.

Prevention

While not all cases of tracheitis can be prevented, several measures can reduce the risk of developing this condition:

Infection Prevention

Good hand hygiene is crucial in preventing respiratory infections that can lead to tracheitis. Wash hands frequently with soap and water for at least 20 seconds, especially after coughing, sneezing, or being in public spaces. Avoid touching the face with unwashed hands. During respiratory illness seasons, minimize close contact with sick individuals when possible.

Vaccination

Staying up-to-date with vaccinations helps prevent infections that can lead to tracheitis. Important vaccines include annual influenza vaccination, pneumococcal vaccines as recommended, Haemophilus influenzae type b (Hib) vaccine for children, and COVID-19 vaccination. These vaccines reduce the risk of primary infections and secondary bacterial complications.

Environmental Measures

Avoid exposure to cigarette smoke and other respiratory irritants. Maintain good indoor air quality with proper ventilation and humidity control. Use air purifiers in homes with allergies or high pollution. During high pollution days or wildfire seasons, limit outdoor activities. For those with occupational exposures, proper protective equipment is essential.

Managing Underlying Conditions

Proper management of conditions that increase tracheitis risk is important. This includes controlling asthma with appropriate medications, treating allergies to reduce airway inflammation, managing GERD to prevent acid irritation of airways, and maintaining good overall health to support immune function. Regular medical follow-up ensures optimal management of chronic conditions.

Early Treatment

Prompt treatment of upper respiratory infections may prevent progression to tracheitis. Seek medical attention for persistent or worsening respiratory symptoms, high fever with respiratory symptoms, or any signs of breathing difficulty. Early intervention can prevent complications and reduce the severity of illness.

When to See a Doctor

Recognizing when to seek medical attention for suspected tracheitis is crucial, as the condition can rapidly worsen, especially in children. Immediate medical evaluation is needed for:

• Stridor (high-pitched breathing sound) at rest
• Significant difficulty breathing or shortness of breath
• Retractions (skin pulling in around ribs when breathing)
• Cyanosis (blue color of lips, face, or fingernails)
• Drooling or inability to swallow
• High fever (over 103°F/39.4°C) with respiratory symptoms
• Severe cough with inability to speak in sentences
• Rapid deterioration despite initial treatment
• Signs of dehydration from poor fluid intake
• Altered mental status or extreme lethargy

Non-emergency medical evaluation is appropriate for persistent cough lasting more than a week, hoarseness not improving after a few days, recurrent episodes of croup-like symptoms, mild breathing difficulties that don't improve with rest, or any concerns about your child's breathing pattern.

Complications

While most cases of tracheitis resolve without long-term problems, serious complications can occur, particularly with bacterial tracheitis:

Airway Obstruction

The most serious immediate complication is complete airway obstruction from severe swelling and secretions. This is a medical emergency requiring immediate intubation. Even partial obstruction can be life-threatening, especially in young children. Signs include severe stridor, extreme respiratory distress, and altered consciousness.

Respiratory Failure

Severe tracheitis can lead to respiratory failure requiring mechanical ventilation. This occurs when inflammation and secretions prevent adequate gas exchange. Children may require several days of ventilatory support while inflammation resolves and secretions clear.

Secondary Infections

Bacterial tracheitis can spread to adjacent structures, causing pneumonia, which occurs in up to 50% of cases. Less commonly, infection can spread to cause mediastinitis, sepsis, or toxic shock syndrome. These complications significantly increase morbidity and length of hospitalization.

Subglottic Stenosis

Repeated or severe inflammation can lead to scarring and narrowing of the airway below the vocal cords. This may cause chronic stridor, exercise intolerance, and recurrent respiratory infections. Some cases require surgical intervention to widen the airway.

Pulmonary Complications

Thick secretions can cause atelectasis (lung collapse) or mucus plugging of smaller airways. Aspiration of secretions may lead to chemical pneumonitis. Some patients develop reactive airway disease following severe tracheitis, with increased susceptibility to future respiratory infections.

Prognosis

The prognosis for tracheitis varies significantly based on the cause, severity, and timeliness of treatment.

Viral Tracheitis

Most cases of viral tracheitis have an excellent prognosis. Symptoms typically improve within 3-7 days with supportive care. Complete recovery is expected without long-term sequelae. Rarely, viral tracheitis may predispose to secondary bacterial infection, requiring vigilant monitoring.

Bacterial Tracheitis

With prompt recognition and appropriate treatment, most children with bacterial tracheitis recover completely. The acute phase typically lasts 3-7 days, with gradual improvement over 2-3 weeks. Mortality rates have decreased significantly with modern intensive care, now less than 2-4% in most series. Factors associated with better outcomes include early diagnosis, appropriate antibiotic therapy, and access to pediatric intensive care.

Long-term Outcomes

Most children have no long-term respiratory problems following tracheitis. However, some may experience increased susceptibility to respiratory infections for several months. Subglottic stenosis occurs in less than 5% of cases, usually those requiring prolonged intubation. Regular follow-up is important to monitor for late complications.

Recurrence

Recurrent tracheitis is uncommon but may occur in children with underlying airway abnormalities or immunodeficiency. Recurrent episodes warrant investigation for predisposing factors. Some children may have recurrent viral croup-like episodes that don't progress to true tracheitis.

Living with Tracheitis

Recovery from tracheitis requires patience and appropriate care to ensure complete healing and prevent complications.

During Acute Illness

Rest is essential during the acute phase. Keep the head elevated to ease breathing. Use a cool-mist humidifier to add moisture to the air. Encourage fluid intake to keep secretions thin and maintain hydration. Monitor for signs of worsening respiratory distress. Give medications as prescribed and complete the full course of antibiotics if prescribed.

Recovery Phase

Gradual return to normal activities is important. Avoid strenuous exercise until breathing is completely normal. Continue to avoid irritants like smoke or strong fumes. Some hoarseness or mild cough may persist for several weeks. Follow-up appointments are important to ensure complete recovery and check for complications.

School and Activities

Children can return to school once fever has resolved and breathing is comfortable. Inform teachers about recent illness and any ongoing symptoms. Physical education and sports should be resumed gradually. Some children may need brief rest periods during the day initially.

Preventing Recurrence

Maintain good hand hygiene practices. Ensure vaccinations are up-to-date. Avoid exposure to respiratory irritants. Treat underlying conditions like allergies or reflux. Seek prompt medical attention for respiratory symptoms that don't improve. Consider evaluation by a specialist if episodes recur.

Special Considerations

In Infants

Infants under 6 months are at highest risk for severe disease due to smaller airways and immature immune systems. They may present with apnea or poor feeding rather than classic symptoms. Lower threshold for hospitalization and monitoring is appropriate. Careful attention to hydration is crucial as infants dehydrate quickly.

In Immunocompromised Patients

These patients may have atypical presentations and unusual pathogens. Broader antibiotic coverage may be needed initially. Recovery may be prolonged with higher risk of complications. Close monitoring and longer treatment courses are often necessary. Prophylactic measures may be considered in high-risk individuals.

Allergic Tracheitis

Identification and avoidance of triggers is paramount. Allergy testing may help identify specific allergens. Treatment includes antihistamines and possibly inhaled corticosteroids. Environmental control measures at home and school are important. Some patients benefit from immunotherapy for severe allergies.

Recurrent Episodes

Children with recurrent tracheitis-like episodes need thorough evaluation. Consider anatomical abnormalities like subglottic stenosis. Evaluate for immunodeficiency or chronic aspiration. Gastroesophageal reflux should be investigated and treated. Some children benefit from prophylactic measures during high-risk seasons.

Related Conditions

Several conditions may present similarly to or occur alongside tracheitis:

• Croup - Viral infection affecting the larynx and trachea
• Epiglottitis - Inflammation of the epiglottis
• Bronchitis - Inflammation of the bronchial tubes
• Pneumonia - Common complication of bacterial tracheitis
• Whooping cough - Can cause similar coughing symptoms
• Asthma - May predispose to tracheitis

Frequently Asked Questions

References

1. Hopkins A, Lahiri T, Salerno R, Heath B. Changing epidemiology of life-threatening upper airway infections: the reemergence of bacterial tracheitis. Pediatrics. 2006;118(4):1418-1421.
2. Tebruegge M, Pantazidou A, Thorburn K, et al. Bacterial tracheitis: a multi-centre perspective. Scand J Infect Dis. 2009;41(8):548-557.
3. Bjornson CL, Johnson DW. Croup in children. CMAJ. 2013;185(15):1317-1323.
4. Graf J, Stein F. Tracheitis in pediatric patients. Semin Pediatr Infect Dis. 2006;17(1):11-13.
5. Salamone FN, Bobbitt DB, Myer CM, et al. Bacterial tracheitis reexamined: is there a less severe manifestation? Otolaryngol Head Neck Surg. 2004;131(6):871-876.
6. Miranda AD, Valdez TA, Pereira KD. Bacterial tracheitis: a varied entity. Pediatr Emerg Care. 2011;27(10):950-953.
7. Casazza G, Graham ME, Nelson D, et al. Pediatric Bacterial Tracheitis: A Variable Entity. Case Rep Emerg Med. 2019;2019:5938517.
8. Al-Mutairi B, Kirk V. Bacterial tracheitis in children: Approach to diagnosis and treatment. Paediatr Child Health. 2004;9(1):25-30.