Epiglottitis and Bacterial Tracheitis

Epiglottitis and bacterial tracheitis are pediatric airway infections that can deteriorate quickly and are easy to confuse with croup. In the post-Hib vaccine era, Staphylococcus aureus now leads epiglottitis, and the bedside distinction often hinges on toxicity, cough, stridor, and a few classic radiographic signs.

Epiglottitis and Bacterial Tracheitis

• Post-Hib microbiology shift: Staphylococcus aureus is now the most common cause of epiglottitis, while Hib is uncommon except in unvaccinated or immunocompromised patients.
• Croup versus tracheitis clues: Children with bacterial tracheitis usually look toxic and often lack a cough, a useful contrast with croup when upper-airway symptoms seem out of proportion.
• Stridor and drooling patterns: Tracheitis more often presents with stridor, while epiglottitis may not; in older children with epiglottitis, drooling and tripoding can be absent.
• Classic neck film findings: A lateral neck radiograph may show the thumbprint sign in epiglottitis, while an AP film can show a steeple sign with tracheitis. We get into when imaging helps versus harms in the episode.
• Airway-first management stance: Keep the patient upright in a position of comfort and involve ENT or anesthesia early, because airway obstruction can progress rapidly and a surgical airway backup may be needed.
• Empiric antimicrobial coverage: Initial therapy should cover typical upper-airway bacteria with a third-generation cephalosporin or ampicillin-sulbactam, adding antistaphylococcal coverage when MRSA risk is present.

Tracheitis With Tracheostomy

• Secretion change warning signs: In children with a tracheostomy, changes in secretion color, odor, or volume can be an early clue to developing bacterial tracheitis.
• Prior culture guided antibiotics: With an artificial airway, empiric treatment should include antipseudomonal activity and be tailored to pathogens recovered on prior tracheal cultures.
• Plugging and bleeding risk: Tracheostomy-associated tracheitis raises the risk of mucus plugging and bleeding, making airway toileting as important as antimicrobial choice. We walk through the practical bedside priorities in the chapter.
• Supportive airway clearance: Humidified air, saline, and deep suctioning can materially improve secretion management while definitive treatment is started.