What are the symptoms and treatment options for tracheitis?

Tracheitis: Symptoms and Treatment

Key Clinical Symptoms

Bacterial tracheitis presents with fever, cough, dyspnea, and stridor or wheezing caused by airway constriction, which can progress to life-threatening airway obstruction if untreated. 1

Cardinal Presenting Features

• Stridor and respiratory distress are now the predominant symptoms in bacterial tracheitis, representing a shift from historical presentations 2
• Fever is common, though notably 60% of patients may be afebrile at presentation 3
• Cough that is persistent and may be unresponsive to typical treatments 4
• Dyspnea with marked retractions and poor air entry 2
• Wheezing due to airway narrowing and turbulent airflow through the inflamed trachea 4
• Toxic appearance in severe cases, though many patients present without appearing systemically ill 3, 5

Progressive Warning Signs

• Worsening stridor unresponsive to corticosteroids or nebulized epinephrine is a key indicator requiring urgent intervention 2
• Airway obstruction can result from extensive pseudomembrane formation in the trachea 1
• Respiratory acidosis indicating impending respiratory failure 2
• Agitation or complaints of difficulty breathing should never be ignored, even if objective signs are absent 1

Treatment Approach

Immediate Management

Early disease identification with urgent surgical intervention via direct laryngoscopy and bronchoscopy for debridement of mucopurulent debris is essential, combined with broad-spectrum intravenous antibiotics. 6

• Initiate broad-spectrum IV antibiotics immediately (ceftriaxone is commonly used) before culture results 2, 6
• Perform urgent direct laryngoscopy and bronchoscopy for debridement and tissue culture 6
• Prepare for intubation if respiratory distress worsens, though not all patients require this intervention 6, 3
• Maintain acute cardiopulmonary monitoring for 48-72 hours 6

Antibiotic Therapy

• Staphylococcus aureus is the most commonly cultured organism, followed by Streptococcus pyogenes and Moraxella catarrhalis 2, 3, 5
• Transition to targeted antibiotics once culture results are available 2
• Continue oral antibiotics for 10-14 days after discharge 6

Follow-up Interventions

• Re-evaluate the airway by repeat direct laryngoscopy and bronchoscopy at 48-72 hours to confirm disease resolution 6
• Mean hospital length of stay is approximately 4.8 days with this aggressive approach 6

Critical Diagnostic Pitfalls

Common Misdiagnoses

• Do not misdiagnose tracheitis as asthma when wheezing is present, as this leads to inappropriate treatment delays 4, 7
• Poor response to typical asthma treatments (bronchodilators, corticosteroids) should raise immediate suspicion for tracheitis 4, 2
• Tracheopathia osteoplastica and tracheobronchial amyloidosis are frequently misdiagnosed as asthma due to chronic cough and wheezing 4

High-Risk Populations

• Immunocompromised patients (HIV with CD4+ <50 cells/µL, neutropenia, corticosteroid use) are at risk for fungal tracheitis, particularly Aspergillus 1
• Younger children are more likely to require intubation compared to older patients 3
• Isolation of Moraxella catarrhalis is associated with higher intubation rates 3

Special Considerations

Fungal Tracheitis (Aspergillosis)

• Semi-invasive pseudomembranous tracheitis in immunocompromised patients presents with fever, cough, dyspnea, stridor or wheezing, culminating in airway obstruction 1
• Endoscopic examination demonstrates confluent exudative pseudomembrane adherent to the tracheal wall 1
• Treatment requires voriconazole as first-line, with amphotericin B as an alternative 1

Inflammatory/Autoimmune Tracheitis

• Autoimmune tracheal inflammation may be refractory to surgical interventions alone 8
• TNF-α inhibitors (adalimumab) combined with methotrexate may achieve clinical improvement in inflammatory tracheitis 8

Monitoring Requirements

• Administer high-flow humidified oxygen and nurse patients upright 1
• Keep patients NPO as laryngeal competence may be impaired despite full consciousness 1
• Capnography monitoring aids early detection of airway obstruction 1
• Never rely solely on pulse oximetry as it is not designed to monitor ventilation and can give incorrect readings 1