Bacterial croup and toxic shock syndrome

An 8-year-old boy with bacterial tracheitis, treated by endotracheal intubation, humidification, airway toilet and antibiotics, experienced a toxic shock syndrome on the day after his admission. The course was favourable. Staphylococcus aureus was isolated from tracheal secretions. Bacterial tracheitis is an infrequent cause of non-menstrual toxic shock syndrome. The diagnosis of bacterial tracheitis should be suspected in a child with toxicity and croup who is not responding to the usual therapy. Endoscopy should be performed allowing for removal of the secretions. The maintenance of a clear airway is the main purpose of the treatment.Abbreviations TSS toxic shock syndrome - CNS central nervous system - CRP C-reactive protein - ICU intensive care unit     

Severe upper airway obstruction in the tropics requiring intensive care

BACKGROUND: The clinical profile of severe upper airway obstruction, a challenging acute pediatric emergency, has not been extensively documented in the developing nations of the tropics. METHODS: The diagnostic categories, severity of illness and outcome from 63 episodes of severe upper airway obstruction in 56 children admitted to the Pediatric Intensive Care Unit between January 1994 and December 1999 were reviewed. Outcome variables studied included requirement for ventilation, mortality and complications. Severity of illness was determined with the Pediatric Risk of Mortality (PRISM) II score. RESULTS: Viral croup (29%) was the most common diagnosis, followed by mediastinal malignancy (13%), bacterial tracheitis (11%) and Pierre Robin syndrome (11%). There were no admissions for acute epiglottitis. Thirty episodes (48%) required ventilation for a median duration of 4.0 days. Bacterial tracheitis (100%) and subglottic stenosis (100%) were the most likely diagnoses requiring ventilation. Difficulty in intubation was encountered in 13 episodes (43%) involving, in particular, patients with bacterial tracheitis (83%; P = 0.006). Only two patients required a tracheostomy. The overall mortality was 11%. The PRISM score for all categories was generally low (mean 10.3 +/- 1.0; median 9.0). Non-survivors had a significantly higher PRISM II score than survivors (27.4 +/- 9.7 vs 8.1 +/- 4.9, respectively; P = 0.002) and were more likely to include children with bacterial tracheitis and mediastinal malignancy. CONCLUSIONS: There is marked heterogeneity in the causes of upper airway obstruction in the tropics with viral croup remaining the most common. A significant proportion required ventilation, but outcome is generally favorable, except in those with bacterial tracheitis and mediastinal malignancy.     

Fulminant Branhamella catarrhalis tracheitis.

Branhamella catarrhalis, a well known commensal of the normal respiratory flora, is being increasingly implicated as an aetiological agent in various acute respiratory and non-respiratory infections. B. catarrhalis has demonstrated a particular predilection for turning pathogenic in the immunocompromised host. Bacterial tracheitis, presenting as an acute airway obstruction, is commonly caused by Staphylococcus aureus and Haemophilus influenzae. The unusual occurrence of a fulminant B. catarrhalis bacterial tracheitis in a previously normal and healthy Indian child is the subject of this communication.     

Acute laryngitis in children]

Acute laryngitis is the most common form of upper airway obstruction in young children. Laryngeal obstruction requiring hospitalization and sometimes intubation may be due to viral infection or occasionally to allergic reaction. The natural course of the disease is impossible to predict; therefore, repeated clinical assessments are needed. Continuous worsening of dyspnea may suggest a diagnosis of bacterial tracheitis. High doses of corticosteroids combined with aerosolized racemic epinephrine can relieve the respiratory difficulties.     

Acute Upper Airway Obstruction

Upper airway obstruction is defined as blockage of any portion of the airway above the thoracic inlet. Stridor, suprasternal retractions, and change of voice are the sentinel signs of upper airway obstruction. Most of the common causes among children presenting to emergency department are of acute infectious etiology. Among these, croup is the commonest while diphteria remains the most serious life-threatening cause. Recent reports indicate that bacterial tracheitis has become increasingly common. In ER evaluation the key clinical data in determining the cause and the site of obstruction are the onset, presence of fever, character of the stridor, retractions, the voice and the ability to handle secretions. After assessment of the severity of respiratory distress and resuscitative or supportive therapy including oxygen and emergent airway, specific treatment is directed at underlying etiology. All patients with audible stridor require early endotracheal intubation/tracheostomy. In croup the mainstay of treatment are cold humidified oxygen, budesonide nebulization ( in mild cases), Dexamethasone 0.6 mg/kg iv or im (in moderate and severe cases), and Adrenaline 5 ml 1:1000 (5 mg) solution as nebulization ( in severe cases). In diphtheria, early tracheostomy, anti-diphtheric serum and injectable penicillin are critical. Bacterial Tracheitis and Retropharyngeal abscess need early administration of injectable Cloxacillin, Amikacin and Clindamycin. ENT consultation should be obtained for early surgical drainage of retropharyngeal abscess. Angioneurotic edema is treated with subcutaneous adrenaline (1:1000, 0.01 ml/kg); hydrocortisone 10 mg/kg IV and antihistamines. Patients with severe obstruction and those with endotracheal tube/ trachesotomy should be transferred to PICU.     

Acute upper airway obstruction

Acute upper airway obstruction continues to challenge medical practitioners who care for children. Whilst usually straightforward, management can be complicated by incorrect diagnosis, unexpected deterioration, difficulty in assessing the need for intubation, difficulty in providing optimal intubation skills and confusion over the value of various therapies.The highest priority is preventing death or hypoxic injury in those few children who progress to profound obstruction.In this overview, the term laryngotracheitis is used as a synonym for croup and laryngotracheobronchitis, epiglottitis is used as a synonym for supraglottitis, and bacterial tracheitis is used as a synonym for pseudomembranous croup. The term ‘intubation’ is used as an abbreviation for mechanical relief of airway obstruction.     

Bacterial tracheitis in pediatrics: 12 year experience at a medical center in Taiwan

Background:  Bacterial tracheitis may cause life-threatening airway obstruction.
Methods:  Records of patients admitted to the pediatric wards of Mackay Memorial Hospital between 1994 and 2005 with a diagnosis of bacterial tracheitis made on bronchoscopic visualization of thick membranous tracheal secretions were retrospectively reviewed.
Results:  A total of 40 patients (aged 1 month–8 years, 29 [73%] under 3 years old) were included. Cough, fever, dyspnea, and hoarseness were the commonest symptoms. Fourteen patients (21%) required intubation. The most frequently isolated bacteriae were α-hemolytic streptococcus (in 11, 38%), pseudomonas (5, 17%), and Staphylococcus aureus (4, 14%). Intubation was more frequent in patients seen between 1994 and 1999 compared with those seen later (8/12 early vs 9/28 late). In the early period α-hemolytic streptococcus (55%) and pseudomonas (36%) were isolated. In the later period the most frequently isolated bacteria was α-hemolytic streptococcus (28%), followed by S. aureus (22%). No patients died, but those with pseudomonas infection had more severe complications, including tracheal stenosis. The average hospital stay in the early period was 26.2 ± 20.5 days versus 9.1 ± 4.8 days in the late period. The corresponding lengths of stay in the intensive care unit were 10.5 ± 11.5 days and 2.0 ± 2.2 days.
Conclusions:  Bacterial tracheitis requiring hospitalization of children appeared to be milder in the second half of the study period. Pseudomonas tracheitis tends to have a severe course.     

Generalized granuloma annulare. Report of two cases

We present a case of bacterial tracheitis in a 6.5 year old girl. Clinical signs and symptoms consisted of severe croup with high grade fever, which were preceded by upper respiratory tract prodrome. Initial treatment with steroids and nebulized epinephrine was unsuccessful. The patient was intubated a few hours after admission. Thick purulent secretions emerging from the trachea and the normal appearance of the epiglottis suggested the diagnosis of bacterial tracheitis, which was confirmed by isolation of Haemophilus influenzae in the culture of the tracheal secretions. The patient was administered a 14 day course of endovenous ceftriaxone and was kept on mechanical ventilation for 7 days. Fever and purulent tracheal secretions continued for the next 5 days. After 48 hours without these signs, laryngotracheobronchoscopy ruled out residual obstruction. Extubation was successfully performed. Fourteen days later physical examination showed no abnormalities and the patient was discharged. No complications were found during followup. The clinical, diagnostic and therapeutic aspects of this potentially life threatening entity that should taken into account in the differential diagnosis of severe croup are discussed.     

Tracheitis in pediatric patients

Despite the advances that have been achieved in supportive pediatric intensive care, tracheitis remains a significant cause of reversible upper-airway obstruction in pediatric patients. This discussion highlights the epidemiology and clinical presentation of tracheitis in the twenty-first century and reviews diagnostic and therapeutic modalities. The gold standard for therapy remains supportive airway management in conjunction with appropriate antibiotic therapy. Finally, the unique challenges of diagnosis and treatment of tracheitis in the technology dependent child with an existing artificial airway (endotracheal tube or tracheostomy) are addressed.     

Bilateral idiopathic vocal cord palsy

We present 3 cases of bilateral vocal cord palsy who presented with acute respiratory distress with features of upper airway obstruction requiring tracheostomy. No cause could be found despite clinical evaluation and laboratory investigations. This diagnosis should be considered when child presents with upper airway obstruction emergency after ruling out other important causes of stridor and laryngoscopic examination is warranted in such cases for diagnosis.     

Clinical practice

Stridor is the sound caused by abnormal air passage during breathing. The cause of stridor can be located anywhere in extrathoracic airway (nose, pharynx, larynx, and trachea) or the intrathoracic airway (tracheobronchial tree). Stridor may be acute (caused by inflammation/infection or foreign body inhalation) or chronic. It may be congenital or acquired. Stridor is a sign from which the underlying cause must be sought; it is not a diagnosis. The role of the pediatrician faced with a child or infant with noisy breathing is: (1) to determine the severity or respiratory compromise and the need for immediate intervention (to prevent respiratory failure); (2) to decide based upon history and clinical examination whether a significant lesion is suspected and, in the latter situation, to refer the child to an ENT surgeon for an upper and lower airway endoscopy; (3) to understand the consequences and management strategies of the underlying lesion and to collaborate with colleagues from related disciplines for follow-up and subsequent management of the child.     

Acquired upper airway obstruction

Acquired upper airway obstruction is a common cause of respiratory emergencies in children. Most pathologic processes that result in upper airway compromise are a consequence of infection, trauma or aspiration. Today, many of the infectious causes of upper airway obstruction have lost their threat as a result of the progress made in preventing and treating these infections. Prompt recognition and appropriate management of the child presenting with upper airway obstruction remains critical, because certain causes can progress rapidly from a mild to a potentially life-threatening disease state. A correct diagnosis can often be made by history and physical examination, but additional studies may be useful in selected cases. The child's clinical appearance is the most reliable indicator of severity, and measurable signs are of less value. If respiratory failure is imminent, airway protection and endoscopy for definitive diagnosis may have priority over any other therapeutic or diagnostic procedure.     

An alternate approach to the management of tracheal perforation in a child

Tracheal perforation can be difficult to manage when standard approaches are not feasible. We present a case report of a 2-year-old child who sustained a traumatic laceration of the intrathoracic trachea in the face of tracheitis and bronchitis. Accepted management techniques could not be employed because the child developed mediastinitis and respiratory distress syndrome. The use of extracorporeal membrane oxygenation (ECMO) facilitated ventilation and oxygenation when standard modes of ventilation failed. ECMO also provided a compliant low-pressure environment that allowed primary tracheal repair by wrapping the tracheal tear with a pedicle of intercostal muscle. A brief overview of the management of intrathoracic tracheal disruption is presented.     

Clinical management of upper airway obstruction: epiglottitis and laryngotracheobronchitis

OBJECTIVE: To present current concepts on diagnosis and treatment of upper airway obstruction, mainly related to differential diagnosis between acute viral laryngotracheobronchitis and epiglottitis.METHODS: Bibliographic review covering the last ten years, using both Medline system and direct research. The most relevant articles published about the subject were selected.RESULTS: Viral laryngotracheobronchitis is an acute self-limited disease of the upper airway in a child, clinically characterized by barking cough, stridor, hoarse voice, and upper respiratory symptoms. The disease is diagnosed by clinical signs and symptoms. Rarely, if no immediate airway management is needed, radiography of the neck may help to exclude other entities that cause laryngeal obstruction. In contrast to viral laryngotracheobronchitis, epiglottitis is characterized by inflammation of the supraglottic tissues and is caused mainly by Haemophilus influenzae type b. A previously healthy child suddenly develops a sore throat and fever. Within hours after the onset of symptoms the patient looks toxic, swallowing is painful and breathing is difficult. Drooling and cervical hyperextension are frequently present. Lateral neck radiograph is rarely required to the diagnosis and may delay appropriate management of the airway. Moderate viral laryngotracheobronchitis with stridor at rest and retractions should be treated with steroids (systemic or nebulized) and nebulized epinephrine. Severe viral laryngotracheobronchitis should be treated aggressively while arregements are made for endotracheal intubation. The diagnosis of epiglottitis requires immediate endotracheal intubation in the appropriate unit (emergency department, intensive care unit or surgical unit) and antimicrobial therapy. Alternatively at some medical centers children with severe upper airway obstruction have been treated with a mixture of helium and oxygen (70 to 80% concentration of helium) instead of room air or pure oxygen to avoid intubation.CONCLUSIONS: There are different levels of care for patients with upper airway obstruction, depending on their clinical presentation. The clinical manifestations of viral laryngotracheobronchitis may be confused with the presentation of epiglottitis. Despite this observation we believe that differential diagnosis between viral laryngotracheobronchitis and epiglottitis rests on clinical grounds.     

Laryngitis revealing bacterial tracheitis in a five-year-old child]

CASE REPORT: We report the case of a five-year-old boy with clinical features of croup and left lower lobe pneumonia. Response to inhaled adrenaline and dexamethasone was incomplete and he developed respiratory distress. Direct laryngoscopy performed in the operating room showed mild glottic and subglottic inflammation. On bronchoscopy, there was thick pus coming from the left lower lobe. He was intubated for three days and regular toilet brought back thick pus. Tracheal fluid culture grew Haemophilius influenzae. COMMENTS: We suggest that he had bacterial tracheitis but that the tracheal involvement was not prominent at the time of diagnosis. CONCLUSION: Laryngoscopy and bronchoscopy in specialized surroundings should be considered for each child with croup unresponsive to conventional treatment, especially in case of lower respiratory tract involvement.     

Innominate artery compression of trachea

Innominate artery may cross the trachea and cause airway obstruction is a rare cause of vascular obstruction of airway. We describe a child with stridor, inability to extubate in whom the diagnosis was suspected on fluoroscopy and confirmed by angiography. Reimplantation of the innominate artery resulted in excellent results with longterm follow up. Variantions of this condition and modalities for confirmation of diagnosis are discussed.     

Fourteen cases of imposed upper airway obstruction.

Imposed upper airway obstruction was diagnosed as the cause of recurrent and severe cyanotic episodes in 14 patients. Episodes started between 0.8 and 33 months of age (median 1.4) and occurred over a period of 0.8 to 20 months (median 3.5). Diagnosis was made by covert video surveillance, instituted after either (a) the observation that episodes began only in the presence of one person, or (b) characteristic findings on physiological recordings, lasting between 12 hours and three weeks, performed in hospital or at home. Surveillance was undertaken for between 15 minutes and 12 days (median 24 hours) and resulted in safety for the patient and psychiatric assessment of the parent: mother (n = 12), father (n = 1), and grandmother (n = 1). These revealed histories of sexual, physical, or emotional abuse (n = 11), self harm (n = 9), factitious illness (n = 7), eating disorder (n = 10), and previous involvement with a psychiatrist (n = 7). Management of the abusing parents is complex, but recognition of their psychosocial characteristics may allow earlier diagnosis. Imposed upper airway obstruction should be considered and excluded by physiological recordings in any infant or young child with recurrent cyanotic episodes. If physiological recordings fail to substantiate a natural cause for episodes, covert video surveillance may be essential to protect the child from further injury or death.     

Bacterial tracheitis in Down's syndrome.

Four children with Down''s syndrome and bacterial tracheitis are described. In three the infection was due to Haemophilus influenza. In patients with Down''s syndrome presenting with stridor tracheitis should be considered and appropriate treatment started.     

Strongyloidiasis in childhood.

Strongyloides stercoralis is an intestinal nematode of man that is still regularly encountered in many parts of the United States. Strongyloidiasis should be considered in any child with unexplained eosinophilia, steatorrhea, protein-losing enteropathy, or chronic diarrhea, especially if associated with weight loss, growth failure, or recurrent upper abdominal pain. This parasite should be ruled out in any patient from an endemic region who is to be treated with corticosteroids of immunosuppressive agents. Microscopical examination of duodenal fluid, Baermann's fecal extraction technique, or the Haradi-Mori stool culture method may be required to make a diagnosis because the organism is not routinely found in concentrated feces even after multiple examinations in some infected individuals. A diagnosis of strongyloidiasis is important because the disease is curable.