01Approach to the Critical Patient/attcp33

Immediate airway priorities

›Airway threat recognition

›Rapidly progressive stridor in toxic-appearing child

›Failure to respond to nebulized epinephrine cardinal red flag

›Biphasic stridor suggesting critical subglottic narrowing

›Impending respiratory failure signs

›Hypoxia SpO2 < 92% on room air

›Inability to handle secretions

›Altered mental status or cyanosis

›If impending respiratory arrest, immediate controlled intubation in OR or by most experienced provider

›Avoid sedatives that compromise airway protective reflexes

›RSI with video laryngoscopy preferred

Stabilization and monitoring

›Initial resuscitation targets

›Oxygen titration to SpO2 92% to 96%

›High-flow oxygen via non-rebreather mask initially

›Escalate to intubation if worsening

›IV access and fluid resuscitation

›20 ml/kg isotonic fluid bolus for shock physiology

›NPO if airway intervention anticipated

›Continuous monitoring bundle

›Pulse oximetry continuous

›Cardiac monitor for arrhythmias from hypoxia or sepsis

›Respiratory rate trend every 15 minutes

Escalation triggers and consults

›Immediate consultation indications

›Pediatric intensive care unit activation

›All confirmed or suspected bacterial tracheitis

02History/hx44

Prodrome and symptom timeline

›Classic prodromal pattern

›Viral upper respiratory illness preceding bacterial deterioration

›Duration 2 to 7 days in approximately 55% of cases

›Rhinorrhea and low-grade fever as initial symptoms

›Acute deterioration phase

›High fever with rapid progression

›Barking or brassy cough in 85% of cases

›Stridor in 77% of cases

›Hoarseness or voice changes in 67% of cases

›Key distinguishing historical features

›Failure to respond to nebulized racemic epinephrine

›Key differentiating feature from viral croup

›Lack of improvement after two to three doses

›Toxic appearance despite croup-like symptoms

›High fever >39 degrees Celsius persisting

›Copious purulent or mucopurulent secretions

Risk factors and exposures

›Patient risk profile

›Age distribution

›Mean age approximately 5 to 6 years historically

›Children under 4 years more likely to require intubation

›Preceding viral infection

›Influenza A identified in 72% of viral cultures in large case series

›Seasonal predominance October through March

›Host susceptibility factors

›Down syndrome associated with increased susceptibility

›Immunodeficiency states

03Physical Exam/exam49

Vital signs and general appearance

›Vital sign pattern

›Fever typically high grade above 39 degrees Celsius

›Persists despite antipyretics

›Differentiates from viral croup where fever milder

›Tachycardia and tachypnea proportional to severity

›Hypoxia-driven tachycardia

›Respiratory rate trend as fatigue marker

›Oxygen saturation on room air baseline

›SpO2 below 92% as immediate intervention trigger

›Continuous monitoring required

›General appearance

›Toxic-appearing child in majority of presentations

›Some patients present non-toxically requiring high clinical suspicion

›Agitation may indicate hypoxia

›Increased work of breathing

›Suprasternal retractions

›Subcostal and intercostal retractions

›Nasal flaring and accessory muscle use

Airway and respiratory exam

›Upper airway findings

›Stridor character

›Inspiratory stridor typical

›Biphasic stridor if severe suggesting critical narrowing

›Cough quality

›Barking or brassy cough quality

›May be productive of purulent secretions

›Oropharyngeal examination

04Differential Diagnosis/ddx38

Life-threatening mimics

›Critical upper airway emergencies

›Epiglottitis

›ICD-10 J05.1 acute epiglottitis

›Drooling, dysphagia, tripoding, sniffing position

›Swollen epiglottis on direct visualization or imaging

›No barking cough typically

›Retropharyngeal abscess

›ICD-10 J39.0 retropharyngeal and parapharyngeal abscess

›Neck stiffness, dysphagia, unilateral cervical adenopathy

›Widened prevertebral space on lateral neck film

›Foreign body aspiration

›ICD-10 T17.9 foreign body in respiratory tract

›Sudden onset without fever or prodrome

›History of choking event

›Focal wheeze or air trapping on imaging

Common mimics

›Non-life-threatening differentials

›Viral croup laryngotracheobronchitis

›ICD-10 J05.0 acute obstructive laryngitis croup

›Responds to nebulized epinephrine and dexamethasone

›Less toxic appearance and lower fever

›No purulent tracheal secretions

›Peritonsillar abscess

›Trismus and hot potato voice

›Uvular deviation

›Older age group typically

›Angioedema

05Laboratory Tests/lt38

Infection and inflammation markers

›Core infection labs

›Complete blood count with differential

›Leukocytosis with left shift common but not universal

›Some patients have normal white cell count

›Thrombocytopenia as severe illness marker

›C-reactive protein

›Typically elevated

›Helps distinguish bacterial from viral process

›Procalcitonin

›Elevated in bacterial infection

›Not a standalone rule-out test

›Useful adjunct when diagnosis uncertain

Microbiologic studies

›Culture and identification

›Blood cultures before antibiotics

›Bacteremia may be present

›Guides antibiotic de-escalation

›Tracheal aspirate culture

›Gold standard for organism identification

›Most commonly Staphylococcus aureus including MSSA and potentially MRSA

›Also Group A Streptococcus, Moraxella catarrhalis, Streptococcus pneumoniae, Haemophilus influenzae

›Gram stain of tracheal secretions

›Abundant polymorphonuclear cells with organisms

›Guides empiric therapy while cultures pending

›Viral respiratory panel

›Identifies concurrent viral infection

›Influenza A most commonly identified in 72% of viral cultures

06Diagnostic Tests/dt65

Scoring Systems

›Clinical severity assessment tools

›Westley Croup Score

›Stridor at rest 0 to 2 points

›Retractions 0 to 3 points

›Air entry 0 to 2 points

›Cyanosis 0 to 4 points

›Level of consciousness 0 to 5 points

›Score >= 6 severe croup or bacterial tracheitis concern

›Does not differentiate bacterial tracheitis from viral croup

›Epinephrine response assessment

›No improvement after two to three doses of nebulized racemic epinephrine

›Consider bacterial etiology if no response

›ACEP Level C recommendation for clinical reassessment after epinephrine

›Limitations of scoring systems

›No validated scoring system specific to bacterial tracheitis

›Clinical trajectory and epinephrine response more informative than score alone

›High clinical suspicion must override reassuring scores

MRI

›MRI role in bacterial tracheitis

›Limited acute utility

›Availability constraints in emergency setting

›Motion artifact risk with agitated child

›Airway instability precludes scanner time

›Potential applications

›Subglottic and tracheal mucosal detail if diagnosis uncertain after CT

›Retropharyngeal extension characterization

›Complex soft tissue neck infection delineation

07Disposition/dispo36

Admission indications

›Level of care determination

›PICU admission criteria

›All confirmed or high-suspicion bacterial tracheitis cases

›PICU required in approximately 69% of cases from case series

›Intubated patients require PICU-level monitoring

›Intubation criteria

›Intubation required in approximately 43% of cases

›Younger children under 4 years more likely to require intubation

›Deteriorating despite high-flow oxygen and initial management

›General ward admission if PICU not required

›Responding to therapy with improving stridor

›Stable oxygen saturation on supplemental oxygen

›Tolerating secretions and oral intake beginning

Transfer criteria

›Transfer indications

›Facility without pediatric PICU capability

›Transfer after airway secured when possible

›Do not transfer unstable patient with uncontrolled airway

›Transfer preparation

›Intubate before transfer if impending respiratory failure

›Experienced transport team with pediatric airway capability

›Antibiotics initiated before transfer

Discharge criteria

›Criteria for safe discharge

›Clinical resolution requirements

›Afebrile for minimum 24 to 48 hours

›SpO2 >= 92% on room air without support

08Treatment/t69

Immediate airway management

›Controlled airway intervention

›Orotracheal intubation strategy

›Preferred setting: operating room under general anesthesia

›Video laryngoscopy preferred for best visualization

›Uncuffed endotracheal tube 0.5 to 1 size smaller than predicted due to subglottic edema

›Expect copious secretions requiring immediate suctioning

›Preparation essentials

›Difficult airway equipment immediately available

›Surgical airway backup plan

›Anesthesia and ENT at bedside

›Rigid tracheobronchoscopy

›Definitive diagnostic and therapeutic procedure

›Performed under general anesthesia

›Debridement of pseudomembranes and collection of cultures simultaneously

›ACEP Level C consensus recommendation for surgical airway evaluation

Oxygen and supportive care

›Respiratory support

›Supplemental oxygen

›High-flow oxygen 100% non-rebreather mask initially

›Target SpO2 92% to 96%

›Secretion management

›Frequent endotracheal suctioning when intubated

›Heated humidified circuit to prevent mucus plugging

›Chest physiotherapy adjunct when tolerated

›Sedation when intubated

›Midazolam 0.05 to 0.1 mg/kg IV for procedural sedation

›Avoid excessive sedation compromising respiratory drive when not intubated

Empiric antibiotic therapy

›First-line empiric regimen

›Third-generation cephalosporin plus anti-staphylococcal agent

›Ceftriaxone 50 mg/kg IV every 24 hours maximum 2 g per dose

›Plus nafcillin or oxacillin 150 to 200 mg/kg/day IV divided every 4 to 6 hours for MSSA

›MRSA coverage when local prevalence warrants

›Vancomycin 15 mg/kg IV every 6 hours

›Trough or AUC-guided monitoring per institutional protocol

›Maximum 60 mg/kg/day

›Clindamycin 10 mg/kg IV every 6 to 8 hours as alternative for non-severe MRSA

›Maximum 40 mg/kg/day

›Check local D-zone test results before use

›Alternative broad-spectrum regimens

›Ampicillin-sulbactam 200 mg/kg/day of ampicillin component IV divided every 6 hours

›Piperacillin-tazobactam 300 mg/kg/day of piperacillin component IV divided every 6 to 8 hours for severe illness

Culture-directed de-escalation

›Antibiotic stewardship principles

›Narrow based on tracheal aspirate and blood culture results

›MSSA identified: nafcillin or oxacillin preferred over vancomycin

›MRSA identified: continue vancomycin or clindamycin based on susceptibility

›GAS identified: penicillin G 250,000 units/kg/day divided every 4 to 6 hours

›Transition to oral antibiotics

›After clinical improvement and tolerating oral intake

›Total course 10 to 14 days

›Oral agent guided by culture sensitivities

Antiviral and adjunct therapy

›Antiviral therapy

›Oseltamivir when concurrent influenza identified

›Weight-based dosing for children under 40 kg

›Less than 15 kg: 30 mg twice daily for 5 days

›15 to 23 kg: 45 mg twice daily for 5 days

›23 to 40 kg: 60 mg twice daily for 5 days

›Greater than 40 kg: 75 mg twice daily for 5 days

›Influenza coinfection identified in large case series

›Treat concurrently with antibiotics when diagnosed

›Ineffective treatments

›Nebulized racemic epinephrine

›Not effective as definitive treatment

›May provide temporary symptomatic relief

›Failure to respond is diagnostic clue

›Corticosteroids

›Not effective for bacterial tracheitis unlike viral croup

›May be given empirically before diagnosis established

›Nebulized epinephrine and dexamethasone empiric trial

›Appropriate before diagnosis clear

›Failure triggers bacterial tracheitis workup

09Special Populations/sp47

Pregnancy

›Bacterial tracheitis in pregnancy

›General considerations

›Extremely rare in adults including pregnant women

›Case reports exist in immunocompromised pregnant patients

›Physiologic upper airway edema of pregnancy may worsen obstruction

›Antibiotic selection in pregnancy

›Ceftriaxone 2 g IV every 24 hours generally safe in pregnancy category B

›Vancomycin use with caution and monitoring

›Avoid tetracyclines in pregnancy

›Clindamycin 900 mg IV every 8 hours acceptable when indicated

›Airway and imaging approach

›Early multidisciplinary team including obstetrics and anesthesia

›Chest radiograph with abdominal shielding when indicated

›Fetal monitoring when viable gestation

›Maternal SpO2 target >= 95% for fetal oxygen delivery

Geriatric

›Bacterial tracheitis in older adults

›Epidemiologic context

›Predominantly a pediatric disease

›Adult cases reported with immunodeficiency or comorbidity

›MRSA more prevalent in older adults with healthcare exposure

›Presentation differences

›May present without classic toxic appearance

›Baseline comorbidities complicate severity assessment

›Immunosuppression may mask fever

›Management modifications

›Antibiotic dosing adjusted for renal function

10Background/b66

Epidemiology

›Incidence and demographics

›Uncommon but dangerous cause of upper airway obstruction

›Rarer than viral croup but more severe

›Can occur at any age but predominantly affects children

›Age distribution

›Mean age historically 5 to 6 years

›Cases in infants and adults reported

›No significant sex predominance

›Seasonal pattern

›Predominantly cold months October through March

›Correlates with influenza and viral respiratory illness season

›Hospitalization burden

›PICU admission in approximately 69% of cases

›Mechanical ventilation in approximately 43% of cases

›Respiratory arrest in 2.7% of cases in one large series

›Recurrence

›Documented recurrence in subset of patients at 4 to 12 months

›Mechanisms not fully understood

›Comorbid associations

›Down syndrome overrepresented

›Immunodeficiency states increase susceptibility

Pathophysiology

›Mechanism of disease

›Viral-bacterial coinfection model

›Viral upper respiratory illness damages tracheal epithelium

›Bacterial superinfection of disrupted mucosal barrier follows

›Influenza A most commonly implicated viral trigger in 72% of viral cultures

11Patient Discharge Instructions/pdi27

copy discharge instructions

›Bacterial tracheitis recovery instructions

›Antibiotic course completion

›Take all prescribed antibiotics as directed even if feeling better

›Total course typically 10 to 14 days

›Activity and recovery

›Rest at home until fully recovered

›Avoid daycare or school until fever-free for 24 hours and breathing normal

›Hydration and nutrition

›Encourage oral fluids once tolerated

›Soft diet initially if throat soreness persists

›Warning signs requiring immediate return to emergency department

›Breathing changes

›Any new stridor or noisy breathing

›Increased work of breathing or retractions

›Lips or fingertips turning blue

›Fever and systemic signs

›Fever returning after initial improvement

›Appearing toxic or very unwell

›Unusual sleepiness or difficulty waking

›Other urgent symptoms

›Inability to swallow or handle secretions

›Inability to maintain oral intake

›Parents or caregivers with concern about child's condition

›Follow-up plan

›Pediatrician or family physician follow up within 1 to 2 days of discharge

›ENT follow up if recommended by hospital team

›Return for any worsening before scheduled appointment

12References/r14

Guidelines and key sources

›Clinical guideline sources

›Pediatric Infectious Diseases Society and IDSA antimicrobial therapy guidance

›American Academy of Pediatrics croup and upper airway infection resources

›Surviving Sepsis Campaign pediatric guidelines

›Key literature

›Hopkins A et al case series characterizing bacterial tracheitis demographics intubation rates and microbiology

›Donaldson JD and Maltby CC series reporting epinephrine failure as cardinal diagnostic feature

›Bernstein T et al series reporting influenza A in 72% of viral cultures and younger age intubation risk

›Case series reporting PICU admission in 69% and intubation in 43% and respiratory arrest in 2.7%

›Coding references

›ICD-10 J04.1 acute tracheitis

›ICD-10 J04.10 acute tracheitis without obstruction

›ICD-10 J04.11 acute tracheitis with obstruction

›SNOMED CT bacterial tracheitis disorder concept

Evidence & Review

Evidence & Review