🧠 Acute bacterial (exudative) tracheitis is a rare but potentially life-threatening airway infection of the subglottic trachea that typically follows a viral URTI. It can rapidly progress to airway obstruction — prompt recognition and expert airway management are essential. ⚠️ It must be distinguished from croup and epiglottitis.

📘 About

Severe bacterial infection of the trachea, often following a viral illness.
Most common in children aged 3–8 years, but may occur in adolescents or adults.
Mortality is now low with modern ICU care but it remains a paediatric emergency.

🦠 Microbiology

Common bacteria: Staphylococcus aureus (MSSA/MRSA), Streptococcus pneumoniae, Streptococcus pyogenes, Haemophilus influenzae type B.
Less common: Moraxella catarrhalis, Pseudomonas, Gram-negative bacilli, anaerobes.
Viral trigger: Influenza, parainfluenza, or RSV often precedes bacterial invasion.

⚠️ Risk Factors

Recent viral respiratory infection (especially influenza).
Immunocompromised or chronically ill children.
Tracheostomy or prior airway instrumentation.

🩺 Clinical Features

Prodromal URTI (cough, coryza) → sudden deterioration.
High fever and toxic appearance.
Harsh, painful cough with thick purulent sputum.
Stridor (often biphasic) and marked hoarseness.
Tracheal tenderness and respiratory distress.
Cyanosis, lethargy, and use of accessory muscles indicate impending airway failure.

💡 Clue: Drooling and tripod posture are uncommon in tracheitis — if present, think epiglottitis.

🔍 Differentiating Airway Infections

Feature	Mild Croup	Bacterial Tracheitis	Epiglottitis
Onset	Gradual over 1–2 days	Viral prodrome → sudden worsening	Very sudden
Stridor	Inspiratory, mild	Continuous (often biphasic)	Soft, continuous
Voice	Hoarse	Very hoarse	Muffled (“hot potato” voice)
Secretions	Swallows saliva	Thick purulent secretions	Drooling (unable to swallow)
Systemic features	Mild or afebrile	Toxic, high fever	Toxic, high fever (>39 °C)

🧪 Investigations

Blood tests: raised WCC, CRP.
Microbiology: Blood cultures; tracheal aspirates if intubated.
Imaging: Neck X-ray may show “candle-wax dripping” sign (irregular tracheal mucosa). ⚠️ Do not delay airway intervention for imaging.
Bronchoscopy: diagnostic — reveals inflamed trachea with thick exudate or pseudomembrane.

💊 Management

Airway first: Secure by experienced anaesthetist ± ENT surgeon in theatre or ICU. 💨 40–100% of children require intubation.
Supportive: Humidified oxygen, suctioning of secretions, IV fluids.
Racemic adrenaline: may provide temporary relief but less effective than in croup.
Empirical IV antibiotics:
- Cefotaxime or ceftriaxone PLUS flucloxacillin (or vancomycin if MRSA suspected).
- Clindamycin if toxin-producing staphylococci suspected.
Steroids: Generally not effective (contrast with croup).
Antivirals: Consider oseltamivir if influenza-associated.

⚡ Complications

Acute airway obstruction
Pneumonia or aspiration
ARDS and respiratory failure
Septic shock and cardiac arrest (late)

📚 References

🧠 Teaching tip: Think of bacterial tracheitis when a “croup-like” child becomes rapidly worse or fails to respond to nebulised adrenaline. It’s toxic, exudative, and dangerous — airway control saves lives.

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Acute Tracheitis