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BACTERIAL TRACHEITIS
Background
Although bacterial tracheitis is an uncommon infectious cause of acute upper airway obstruction, it is currently more prevalent than acute epiglottitis. Patients may present with crouplike symptoms, such as barking cough, stridor, and fever; however, patients with bacterial tracheitis do not respond to standard croup therapy and may experience acute respiratorydecompensation.[1, 2]
Pathophysiology
Bacterial tracheitis is a diffuse inflammatory process of the larynx, trachea, and bronchi with adherent or semiadherent mucopurulent membranes within the trachea. The major site of disease is at the cricoid cartilage level, the narrowest part of the trachea. Acute airway obstruction may develop secondary to subglottic edema and sloughing of epithelial liningor accumulation of mucopurulent membrane within the trachea. Signs and symptoms are usually intermediate between those of epiglottitis and croup.
Bacterial tracheitis may be more common in the pediatric patient because of the size and shape of the subglottic airway. The subglottis is the narrowest portion of the pediatric airway, assuming a funnel-shaped internal dimension. In this smallerairway, relatively little edema can significantly reduce the diameter of the pediatric airway, increasing resistance to airflow and work of breathing. With appropriate airway support and antibiotics, most patients improve within 5 days.
Although the pathogenesis of bacterial tracheitis is unclear, mucosal damage or impairment of local immune mechanisms due to a preceding viral infection, an injury totrachea from recent intubation, or trauma may predispose the airway to invasive infection with common pyogenic organisms.
Epidemiology
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Frequency
United States
Tan and Manoukian reported that 500 children were hospitalized for croup at one pediatric hospital over a 32-month period.[3] Approximately 98% had viral croup, and 2% had bacterialtracheitis. Cases usually occur in the fall or winter months, mimicking the epidemiology of viral croup.
International
According to a recent study, bacterial tracheitis remains a rare condition, with an estimated incidence of approximately 0.1 cases per 100,000 children per year.[4]
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Mortality/Morbidity
The predominant morbidity and mortality isrelated to the potential for acute upper airway obstruction and induced hypoxic insults. The mortality rate has been estimated at 4-20%. In the acute phase, patients generally do well if the airway is adequately managed and if antibiotic therapy is promptly initiated.
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Sex
In most epidemiologic studies, male cases are preponderant. Gallagher et alreported a male-to-female predominance of 2:1.[5]
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Age
Bacterial tracheitis may occur in any pediatric age group. Gallagher et al reported 161 cases of patients younger than 16 years.[5] The age range was from 3 weeks to 16 years, with a mean age of 4 years. This is in contrast to viral laryngotracheobronchitis, which occurs in patients aged 6months to 3 years.

History
Symptoms of bacterial tracheitis may be intermediately between those of epiglottitis and croup. Presentation is either acute or subacute.
* In the classic presentation patients present acutely with fevers, toxic appearance, stridor, tachypnea, respiratory distress, and high WBC counts. Cough is frequent and not painful.
* In a study by Salamone et al, asignificant subset of older children (mean age, 8 y) did not have severe clinical symptoms.[6]
* The prodrome is usually an upper respiratory infection, followed by progression to higher fever, cough, inspiratory stridor, and a variable degree of respiratory distress.
* Patients may acutely decompensate with worsening respiratory distress due to airway obstruction from a purulent membrane that...