What is the best treatment approach for an adult patient with a chronic tracheostomy (trach) on a ventilator (vent) who develops tracheitis?

Treatment of Tracheitis in Adults with Chronic Tracheostomy on Mechanical Ventilation

Initiate broad-spectrum antibiotics immediately targeting Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA) while collecting lower respiratory tract cultures, then narrow therapy based on culture results and clinical response by 48-72 hours. 1

Immediate Diagnostic and Therapeutic Actions

Obtain Respiratory Cultures Before Antibiotic Changes

• Collect endotracheal aspirate or bronchoalveolar lavage specimens for quantitative or semiquantitative cultures with Gram stain before initiating or changing antibiotics 1
• A negative tracheal aspirate (absence of bacteria or inflammatory cells) in patients without antibiotic changes in the past 72 hours has 94% negative predictive value for bacterial infection and should prompt search for alternative diagnoses 1
• Blood cultures should be obtained to rule out bacteremia or extrapulmonary infection 1

Initial Empiric Antibiotic Selection

For patients with chronic tracheostomy on ventilators, assume high risk for multidrug-resistant organisms and initiate combination therapy:

• Use piperacillin/tazobactam PLUS ciprofloxacin, OR
• Use amikacin PLUS imipenem, meropenem, or antipseudomonal cephalosporin 2
• Add vancomycin or linezolid for MRSA coverage in ICUs with endemic MRSA or patients with recent antibiotic exposure 2
• If Acinetobacter baumannii risk exists (prolonged hospitalization, endemic ICU), ensure one agent is a carbapenem 2

The rationale for aggressive initial coverage is that delayed or inadequate antibiotic therapy in ventilator-associated respiratory infections significantly increases mortality 1, 2

Reassessment at 48-72 Hours

Clinical Response Evaluation

Monitor for resolution of:

• Fever and leukocytosis 1
• Purulent secretions 1
• Hypoxemia 2
• Hemodynamic instability 1

Antibiotic De-escalation Strategy

• Narrow antibiotics based on culture results and sensitivities to the most specific effective agent 1, 2
• If cultures are negative and clinical improvement occurs, consider stopping antibiotics and searching for non-infectious causes (atelectasis, pulmonary edema, pulmonary embolism) 1
• If cultures grow organisms, tailor therapy to the specific pathogen and continue for 7 days total in patients showing clinical improvement 2

Distinguishing Tracheitis from Ventilator-Associated Pneumonia

Tracheobronchitis Criteria

Purulent tracheobronchitis presents with purulent secretions, fever, and leukocytosis without new or progressive pulmonary infiltrates on chest radiograph 1, 3, 4

Treatment Considerations for Tracheobronchitis

• While controversial, treating ventilator-associated tracheobronchitis (VAT) with antibiotics may prevent progression to pneumonia (10-30% of VAT cases progress to VAP) 3, 4
• Antibiotic treatment for VAT reduces duration of mechanical ventilation and ICU length of stay 3, 4
• However, balance this against promoting antimicrobial resistance 4

Practical approach: In chronic tracheostomy patients with purulent secretions and systemic signs of infection, initiate antibiotics as described above, as the distinction between tracheobronchitis and early pneumonia is often unclear and delayed treatment worsens outcomes 1, 2, 3

Critical Airway Management Considerations

Secretion Management

• Ensure adequate humidification (inspired gas temperature 32-34°C with humidity 36-40 mg/L) to prevent mucus plugging 5, 6
• Perform regular suctioning with appropriately sized catheters 5, 6
• Avoid routine saline instillation, as it decreases oxygen saturation and may contaminate lower airways 6

Emergency Obstruction Protocol

If acute deterioration occurs with high-pitched wheezing over the trachea:

1. Remove all external attachments and inner cannula immediately 5, 6
2. Attempt aggressive suctioning 5, 6
3. Perform emergency tracheostomy tube change without delay if suctioning fails—this is life-saving and cannot be postponed 5, 6

Common Pitfalls to Avoid

• Do not use anticholinergic agents (e.g., scopolamine patches) in tracheostomy patients with increased secretions, as they thicken mucus and worsen clearance 6
• Do not delay antibiotics while awaiting culture results in patients with clinical signs of infection 1, 2
• Do not continue broad-spectrum antibiotics beyond 7 days in clinically improving patients, as this promotes resistance without improving outcomes 2
• Do not rely solely on clinical criteria without obtaining respiratory cultures, as tracheal colonization is common and does not always indicate infection requiring treatment 1