Acute Inflammatory Upper Airway ObstructionGenie E. RooseveltGeneral Considerations.Acute inflammation of the upper airway is of great importance in infants and small children. Airway resistance is inversely proportional to the fourth power of the radius; therefore, minor reductions in cross-sectional area due to mucosal edema or other inflammatory processes cause an exponential increase in airway resistance and a significant increase in the work of breathing. The larynx is composed of four major cartilages (epiglottic, arytenoid, thyroid, and cricoid cartilages, from superior to inferior, respectively) and the soft tissues that surround them. The cricoid cartilage encircles the airway just below the vocal cords and defines the narrowest portion of the upper airway in children younger than 10 yr of age.Inflammation involving the vocal cords and structures inferior to the cords is called laryngitis, laryngotracheitis, or laryngotracheobronchitis, and inflammation of the structures superior to the cords (i.e., arytenoids, aryepiglottic folds [false cords], epiglottis) is called supraglottitis. The term croup refers to a heterogeneous group of mainly acute and infectious processes that are characterized by a barklike or brassy cough and may be associated with hoarseness, inspiratory stridor, and respiratory distress. Stridor is a harsh, high-pitched respiratory sound, usually inspiratory but may be biphasic, produced by turbulent airflow; it is not a diagnosis but a sign of upper airway obstruction (also see Chapter 370 ). Croup usually affects to some degree the larynx, trachea, and bronchi. When the involvement of the larynx is sufficient to produce symptoms, they dominate the clinical picture over the tracheal and bronchial signs. Traditionally, a distinction has been made between spasmodic or recurrent croup and laryngotracheobronchitis. Some clinicians believe that spasmodic croup may have an allergic component and improves rapidly without treatment whereas laryngotracheobronchitis is always associated with a viral infection of the respiratory tract. Others believe that the signs and symptoms are similar enough to consider them within the spectrum of a single disease.Etiology and Epidemiology.Viral agents account for most acute infectious upper airway obstructions. The exceptions are diphtheria, bacterial tracheitis, and epiglottitis. The parainfluenza viruses (types 1, 2, and 3) account for approximately 75% of cases; other viruses associated with this disease include influenza A and B, adenovirus, respiratory syncytial virus (RSV), and measles. Influenza A has been associated with severe laryngotracheobronchitis. Mycoplasma pneumoniae rarely has been isolated from children with croup and causes mild disease. Most patients with croup are between the ages of 3 mo and 5 yr, with the peak in the second year of life. The incidence of croup is higher in males, and it occurs most commonly during the winter but may occur throughout the year. Recurrences are frequent from 36 yr of age and decrease with growth of the airway. Approximately 15% of patients have a strong family history of croup.In the past, Haemophilus influenzae type b was the most commonly identified etiology of acute epiglottitis. Since the widespread use of the HiB vaccine in the United States, invasive disease due to H. influenzae type b in pediatric patients has been reduced by 8090%. Therefore, other agents, such as Streptococcus pyogenes, S. pneumoniae, and Staphylococcus aureus, now represent a larger proportion of pediatric cases of epiglottitis. In the pre-vaccine era, the typical patient was 24 yr of age, although cases were seen in the first year of life and in patients as old as 7 yr of age. Currently, the typical patient with epiglottitis is an adult with a sore throat, although cases still do occur in underimmunized children.Clinical ManifestationsCROUP (LARYNGOTRACHEOBRONCHITIS).Primarily, viruses cause croup, the most common form of acute upper respiratory obstruction. The term laryngotracheobronchitis refers to this viral infection of the glottic and subglottic regions. However, some clinicians use the term laryngotracheitis for the most common and most typical form of croup and reserve the term laryngotracheobronchitis for the more severe form that is considered an extension of laryngotracheitis associated with bacterial superinfection that occurs 5 to 7 days into the clinical course.Most patients have an upper respiratory tract infection with some combination of rhinorrhea, pharyngitis, mild cough, and low-grade fever for 1 to 3 days before the signs and symptoms of upper airway obstruction become apparent. The child then develops the characteristic barking cough, hoarseness, and inspiratory stridor. The low-grade fever may persist, although temperatures may reach 3940C (102.2104F); some children are afebrile. Symptoms are characteristically worse at night and often recur with decreasing intensity for several days and resolve completely within a week. Agitation and crying greatly aggravate the symptoms and signs. The child may prefer to sit up in bed or be held upright. Older children usually are not seriously ill. Other family members may have mild respiratory illnesses. Most patients with croup progress only as far as stridor and slight dyspnea before they start to recover.Physical examination may reveal a hoarse voice, coryza, normal to moderately inflamed pharynx, and a slightly increased respiratory rate. Patients may vary substantially in their degree of respiratory distress. Rarely, the upper airway obstruction progresses and is accompanied by an increasing respiratory rate; nasal flaring; suprasternal, infrasternal, and intercostal retractions; and continuous stridor. Croup is a disease of the upper airway, and alveolar gas exchange is usually normal. Hypoxia and low oxygen saturation are seen only when complete airway obstruction is imminent. The child who is hypoxic, cyanotic, pale, or obtunded needs immediate airway management. Occasionally, the pattern of severe laryngotracheobronchitis may be difficult to differentiate from epiglottitis despite the usually more acute onset and rapid course of the latter.Croup is a clinical diagnosis and does not require a radiograph of the neck. Radiographs of the neck may show the typical subglottic narrowing or steeple sign of croup on the posteroanterior view ( Fig. 3711 ). However, the steeple sign may be absent in patients with croup, may be present in patients without croup as a normal variant, and may be present in patients with epiglottitis. In addition, the radiographs do not correlate well with disease severity. Radiographs should be considered only after airway stabilization in children who have an atypical presentation or clinical course. Radiographs may be helpful in distinguishing between severe laryngotracheobronchitis and epiglottitis, but airway management should always take priority.ACUTE EPIGLOTTITIS (SUPRAGLOTTITIS).This dramatic, potentially lethal condition is characterized by an acute fulminating course of high fever, sore throat, dyspnea, and rapidly progressing respiratory obstruction. The degree of respiratory distress at presentation is variable. The initial lack of respiratory distress may deceive the unwary clinician, although respiratory distress may be the first manifestation. Often the otherwise healthy child suddenly develops a sore throat and fever. Within a matter of hours, the patient appears toxic, swallowing is difficult, and breathing is labored. Drooling is usually present and the neck is hyperextended in an attempt to maintain the airway. The child may assume the tripod position sitting upright and leaning forward with the chin up and mouth open while bracing on the arms. A brief period of air hunger with restlessness may be followed by rapidly increasingcyanosis and coma. Stridor is a late finding and suggests near-complete airway obstruction. Complete obstruction of the airway and death may ensue unless adequate treatment is provided. The barking cough typical of croup is rare. Usually no other family members are ill with acute respiratory symptoms. The diagnosis requires visualization of a large, cherry-red swollen epiglottis by laryngoscopy. Occasionally, the other supraglottic structures, especially the aryepiglottic folds, may be more involved than the epiglottis itself. In a patient in whom the diagnosis is certain or probable based on clinical grounds, laryngoscopy should be performed expeditiously in a controlled environment such as an operating room or intensive care unit depending on the institution. Anxiety provoking interventions such as phlebotomy, intravenous line placement, placing the child supine, or direct inspection of the oral cavity should be avoided until the airway is secure. If epiglottitis is thought to be possible, although not probable, in a patient with acute upper airway obstruction, the patient may undergo lateral radiographs of the upper airway first. Classic radiographs of a child who has epiglottitis show the thumb sign ( Fig. 3712 ). If the concern for epiglottitis still exists after the radiographs, visualization should be performed as described previously. Regardless, a physician skilled in airway management and use of intubation equipment should accompany patients with suspected epiglottitis at all times. Occasionally, an older cooperative child may voluntarily open the mouth wide enough for a direct view of the inflamed epiglottis.Establishing an airway by nasotracheal intubation or, less often, by tracheostomy is indicated in patients with epiglottitis, regardless of the degree of apparent respiratory distress, because as many as 6% of children with epiglottitis without an artificial airway die, compared with less than 1% of those with an artificial airway. No clinical features have been recognized that predict mortality. Pulmonary edema may be associated with acute airway obstruction. The duration of intubation depends on the clinical course of the patient and the duration of epiglottic swelling, as determined by frequent examination using direct laryngoscopy or flexible fiberoptic laryngoscopy. In general, children with acute epiglottitis are intubated for 23 days, because the response to antibiotics is usually rapid (see later). Most patients have concomitant bacteremia; occasionally, other infections may be present, such as pneumonia, cervical adenopathy, or otitis media. Meningitis, arthritis, and other invasive infections with H. influenzae type b are rarely found in conjunction with epiglottitis.ACUTE INFECTIOUS LARYNGITIS.Laryngitis is a common illness; viruses cause most cases; diphtheria is an exception but is extremely rare in developed countries. The onset is usually characterized by an upper respiratory tract infection during which sore throat, cough, and hoarseness appear. The illness is generally mild; respiratory distress is unusual except in the young infant. Hoarseness and loss of voice may be out of proportion to systemic signs and symptoms. The physical examination is usually not remarkable except for evidence of pharyngeal inflammation. Inflammatory edema of the vocal cords and subglottic tissue may be demonstrated laryngoscopically. The principal site of obstruction is usually the subglottic area.SPASMODIC CROUP.Spasmodic croup occurs most often in children 13 yr of age and is clinically similar to acute laryngotracheobronchitis, except that the history of a viral prodrome and fever in the patient and family are frequently absent. The cause is viral in some cases, but allergic and psychological factors may be important in others. Laryngoscopy reveals pale, watery edema with preservation of the epithelium (unlike the erythematous edema and destruction of the epithelium of acute infectious laryngotracheobronchitis).Occurring most frequently in the evening or nighttime, spasmodic croup begins with a sudden onset that may be preceded by mild to moderate coryza and hoarseness. The child awakens with a characteristic barking, metallic cough, noisy inspiration, and respiratory distress and appears anxious and frightened. The patient is usually afebrile. Usually, the severity of the symptoms diminishes within several hours and, the following day, the patient often appears well except for slight hoarseness and cough. Similar, but usually less severe, attacks without extreme respiratory distress may occur for another night or two. Such episodes often recur several times. Spasmodic croup may represent more of an allergic reaction to viral antigens than direct infection, although the pathogenesis is unknown.Differential Diagnosis.These four syndromes must be differentiated from one another and from a variety of other entities that may present as upper airway obstruction. Bacterial tracheitis is the most important differential diagnostic consideration. Diphtheritic croup is extremely rare in North America, although a major epidemic of diphtheria occurred in countries of the former Soviet Union beginning in 1990 from the lack of routine immunization of adults (see Chapter 172 ). Early symptoms include malaise, sore throat, anorexia, and low-grade fever. Within 23 days, pharyngeal examination reveals the typical gray-white membrane, which may vary in size from covering a small patch on the tonsils to covering most of the soft palate. The membrane is adherent to the tissue, and forcible attempts to remove it cause bleeding. The course is usually insidious, but respiratory obstruction may occur suddenly. Measles croup almost always coincides with the full manifestations of systemic disease and the course may be fulminant (see Chapter 225 ).Sudden onset of respiratory obstruction may be caused by aspiration of a foreign body (see Chapter 373 ). The child is usually 6 mo to 2 yr of age. Choking and coughing occur suddenly, usually without prodromal signs of infection, although children with a viral infection can also aspirate a foreign body. A retropharyngeal or peritonsillar abscess may mimic respiratory obstruction (see Chapter 367 ). Radiographs of the upper airway and chest are essential in evaluating these possibilities. Other possible causes of upper airway obstruction include extrinsic compression of the airway (e.g., laryngeal web, vascular ring) and intraluminal obstruction from masses (e.g., laryngeal papilloma, subglottic hemangioma).Upper airway obstruction is occasionally associated with angioedema of the subglottic areas as part of anaphylaxis and generalized allergic reactions, edema after endotracheal intubation for general anesthesia or respiratory failure, hypocalcemic tetany, infectious mononucleosis, trauma, and tumors or malformations of the larynx. A croupy cough may be an early sign of asthma. Vocal cord dysfunction can also occur. Epiglottitis, with the characteristic manifestations of drooling or dysphagia and stridor, can also result from the accidental ingestion of very hot liquid.Complications.Complications occur in approximately 15% of patients with viral croup. The most common is extension of the infectious process to involve other regions of the respiratory tract, such as the middle ear, the terminal bronchioles, or the pulmonary parenchyma. Bacterial tracheitis may be a complication of viral croup rather than a distinct disease. Pneumonia, cervical lymphadenitis, otitis media, or, rarely, meningitis or septic arthritis may occur during the course of epiglottitis. Mediastinal emphysema and pneumothorax are the most common complications of tracheotomy.Treatment.The mainstay of treatment for children with croup is airway management. Treatment of the respiratory distress should take priority over any testing. However, most children with either acute spasmodic croup or infectious croup can be managed at home safely. Mist was first used in the 19th century when physicians anecdotally witnessed an improvement in the symptoms of croup with the steam from teapots and hot tubs. Given the risk of burns and the observation that cold night air is also beneficial led to the use of cool mist. The proposed mechanisms to explain the beneficial effect of cool mist are that it (1) moistens airway secretions to facilitate clearance, (2) soothes inflamed mucosa, and (3) provides comfort and reassurance to the child, lessening any anxiety. Two studies tested the efficacy of moist air in patients with croup. Neither study showed a beneficial effect, although the sample sizes were small. In a study comparing nebulized saline placebo to racemic epinephrine, croup scores significantly improved after the administration of the placebo, although there was no control group. Improvement may be explained by spontaneous recovery with time. Current recommendations are to provide cool mist through a tube held in front of the patient by the parent. Children with both wheezing and croup concomitantly may experience worsening of their bronchospasm with cool mist.The marked decrease in the need for tracheotomies in croup has been attributed to the use of nebulized epinephrine. Although initially used with intermittent positive pressure ventilation, subsequent studies showed effectiveness with simple nebulization. The mechanism of action is believed to be constriction of the precapillary arterioles through the a-adrenergic receptors causing fluid resorption from the interstitial space and a decrease in the laryngeal mucosal edema. Traditionally, racemic epinephrine, a 1:1 mixture of the d- and l-isomers of epinephrine, has been administered. A dose of 0.25 to 0.75?mL of 2.25% racemic epinephrine in 3?mL of normal saline can be used as often as every 20?min. Racemic epinephrine was initially chosen over the more active and more readily available l-epinephrine to minimize anticipated cardiovascular side effects such as tachycardia and hypertension. However, there is evidence that l-epinephrine (5?mL of 1:1,000 solution) is equally effective as racemic epinephrine and does not carry the risk of additional adverse effects. This information is both practical and important, because racemic epinephrine is not available outside the United States.The indications for the administration of nebulized epinephrine include moderate to severe stridor at rest, the need for intubation, respiratory distress, hypoxia, and when stridor does not respond to cool mist. The duration of activity of racemic epinephrine is less than 2?hr. The symptoms of croup may reappear, but racemic epinephrine does not cause rebound worsening of the obstruction. Therefore, observation is mandated. Patients may be safely discharged home after a 23?hr period of observation provided they have no stridor at rest, normal air entry, normal color, and normal level of consciousness and have receivedAfter several decades of debate about the effectiveness of corticosteroids in viral croup, there is now clear evidence of their benefit. Corticosteroids decrease the edema in the laryngeal mucosa through their anti-inflammatory action. Studies have demonstrated that steroids are beneficial, as measured by reduced hospitalization, shorter duration of hospitalization, and reduced need for subsequent interventions such as epinephrine administration. Most studies that demonstrated the efficacy of dexamethasone used a single dose of 0.6?mg/kg; however, there is some evidence that a dose as low as 0.15?mg/kg may be just as effective. Intramuscular dexamethasone and nebulized budesonide have an equivalent clinical effect, and oral dosing of dexamethasone is as effective as intramuscular administration. The only adverse effect described in the treatment of croup with corticosteroids was the development of Candida albicans laryngotracheitis in a patient who received dexamethasone, 1?mg/kg/24?hr, for 8 days. Corticosteroids should not be administered to children with varicella or tuberculosis (unless the patient is receiving appropriate anti-tuberculosis therapy) because they worsen the clinical course.Antibiotics are not indicated in croup. Preliminary studies with a helium-oxygen mixture (Heliox) have shown similar clinical improvements in children with croup when compared with responses in children given racemic epinephrine.Children with croup should be hospitalized for any of the following: progressive stridor, severe stridor at rest, respiratory distress, hypoxia, cyanosis, depressed mental status, or the need for reliable observation.Epiglottitis is a medical emergency and warrants immediate treatment with an artificial airway placed under controlled conditions, either in an operating room or intensive care unit. All patients should receive oxygen en route unless the mask causes excessive agitation. Racemic epinephrine and corticosteroids are ineffective. Cultures of blood, epiglottic surface, and, in selected cases, cerebrospinal fluid, should be collected at the time of airway stabilization. Ceftriaxone, cefotaxime, or a combination of ampicillin and sulbactam should be given parenterally pending culture and susceptibility reports because from 1040% of H. influenzae type b cases are resistant to ampicillin. After insertion of the artificial airway, the patient should improve immediately, and respiratory distress and cyanosis should disappear. Epiglottitis resolves after a few days of antibiotics, and the patient may be extubated; antibiotics should be continued for 710 days. Chemoprophylaxis is not recommended for household contacts of patients with invasive H. influenzae type b infections unless there is a child younger than 48 mo in the home who has not completed the HiB immunization series. Rifampin prophylaxis (20?mg/kg orally once a day for 4 days; maximum dose, 600?mg) should be given to all household members if there is one contact younger than 48 mo of age who is incompletely immunized or if there is an immunocompromised child in the household.Acute laryngeal swelling on an allergic basis responds to epinephrine (1:1,000 dilution in dosage of 0.01?mL/kg to a maximum of 0.5?mL/dose) administered subcutaneously or racemic epinephrine (dose of 0.250.75?mL of 2.25% racemic epinephrine in 3?mL of normal saline). Corticosteroids are frequently required (24?mg/kg/24?hr of prednisone. After recovery, the patient and parents should be discharged with a preloaded syringe of epinephrine to be used in emergencies. Reactive mucosal swelling, severe stridor, and respiratory distress unresponsive to mist therapy may follow endotracheal intubation for general anesthesia in children. Racemic epinephrine and corticosteroids are helpful.TRACHEOTOMY AND ENDOTRACHEAL INTUBATION(see Chapter 57.1 ). With the introduction of routine nasotracheal intubation or tracheotomy for epiglottitis, the mortality rate has dropped to almost zero. Both procedures should always be performed in an operating room or intensive care unit if time permits; prior intubation and general anesthesia greatly facilitate performing a tracheotomy without complications. The use of a nasotracheal tube that is 0.51.0?mm smaller than estimated by age is recommended to facilitate intubation and reduce long-term sequelae. The choice of procedure should be based on the local expertise and experience with the procedure and the postoperative care involved with each.Endotracheal intubation or tracheotomy is required for all patients with epiglottitis, but for patients with laryngotracheobronchitis, spasmodic croup, or laryngitis, it is rarely required. Severe forms of laryngotracheobronchitis that require tracheotomy in a high proportion of patients have been reported during severe measles and influenza A virus epidemics. Assessing the need for these procedures requires experience and judgment because they should not be delayed until cyanosis and extreme restlessness have developed (see Chapter 55 , Chapter 57.3 , and Chapter 58 ).The endotracheal tube or tracheostomy must remain in place until edema and spasm have subsided and the patient is able to handle secretions satisfactorily. It should be removed as soon as possible, usually within a few days. Adequate resolution of epiglottic inflammation that has been accurately confirmed by fiberoptic laryngoscopy, permitting much more rapid extubation, often occurs within 24?hr. Racemic epinephrine and dexamethasone (0.5?mg/kg/dose every 6?hr as needed) may be useful in the treatment of croup associated with extubation.Prognosis.In general, the length of hospitalization and the mortality rate for cases of acute infectious upper airway obstruction increase as the infection extends to involve a greater portion of the respiratory tract, except in epiglottitis, in which the localized infection itself may prove to be fatal. Most deaths from croup are caused by a laryngeal obstruction or by the complications of tracheotomy. Untreated epiglottitis has a mortality rate of 6% in some series, but if the diagnosis is made and appropriate treatment is initiated before the patient is moribund, the prognosis is excellent. The outcome of acute laryngotracheobronchitis, laryngitis, and spasmodic croup is also excellent. As a group, children who need to be hospitalized for croup have somewhat increased bronchial reactivity compared with normal children when tested several years later but the significance is uncertain.REFERENCES LaryngotracheobronchitisFogel JM, Berg IJ, Gerber MA, et al: Racemic epinephrine in the treatment of croup: Nebulization alone versus nebulization with intermittent positive pressure breathing. J Pediatr 1982;101:102831. Geelhoed GC, Turner J, MacDonald WB: Efficacy of a small single dose of oral dexamethasone for outpatient croup: A double blind placebo controlled trial. BMJ 1996;313:14042. Johnson DW, Jacobson S, Edney PC, et al: A comparison of nebulized budesonide, intramuscular dexamethasone, and placebo for moderately severe croup. N Engl J Med 1998;339:498503. Klassen TP, Craig WR, Moher D, et al: Nebulized budesonide and oral dexamethasone for treatment of croup: A randomized controlled trial. JAMA 1998;279: 162932. Kristjansson S, Berg-Kelly K, Winso E: Inhalation of racemic adrenaline in the treatment of mild and moderately severe croup: Clinical symptom score and oxygen saturation measurements for evaluation of treatment effects. Acta Pediatr 1994;83:115660. Ledwith CA, Shea LM, Mauro RD: Safety and efficacy of nebulized racemic epinephrine in conjunction with oral dexamethasone and mist in the outpatient treatment of croup. Ann Emerg Med 1995;25:331337. Luria JW, Gonzalez-del-Rey JA, DiBiulio GA, et al: Effectiveness of oral or nebulized dexamethasone for children with mild croup. Pediatr Adolesc Med 2001;155:134045.

Rittichier KK, Ledwith CA: Outpatient treatment of moderate croup with dexamethasone: Intramuscular versus oral dosing. Pediatrics 2000;106:134448. Waisman Y, Klein BL, Boenning DA, et al: Prospective randomized double-blind study comparing L-epinephrine and racemic epinephrine aerosols in the treatment of laryngotracheitis. Pediatrics 1992;89:3026. Walner DL, Ouanounou S, Donnelly LF, et al: Utility of radiographs in the evaluation of pediatric upper airway obstruction. Ann Otol Rhinol Laryngol 1999;108:37883. Weber JE, Chudnofsky CR, Younger JG, et al: A randomized comparison of helium-oxygen mixture (Heliox) and racemic epinephrine for the treatment of moderate to severe croup. Pediatrics 2001;107:E96. EpiglottitisAdams WG, Deaver KA, Cochi SL, et al: Decline in childhood Haemophilus influenzae type b (HiB) in the HiB vaccine era. JAMA 1993;269:22126. Frantz TD, Rasgon BM: Acute epiglottitis: Changing epidemiologic patterns. Otolaryngol Head Neck Surg 1993;109:45760. Gorelick MH, Baker MD: Epiglottitis in children, 1979 through 1992: Effects of Haemophilus influenzae type b immunization. Arch Pediatr Adolesc Med 1994;148:4750. Hickerson SL, Kirby RS, Wheeler JG, et al: Epiglottitis: A 9-year case review. South Med J 1996;89:48790. Kulick RM, Selbst SM, Baker MD, et al: Thermal epiglottitis after swallowing hot beverages. Pediatrics 1988;81:44144. Murrage KJ, Janzen VD, Ruby RR: Epiglottitis: Adult and pediatric comparisons. J Otolaryngol 1988;17:19498. Schuller DE, Birck HG: The safety of intubation in croup and epiglottitis: An eight-year follow-up. Laryngoscope 1975;85:3346. Senior BA, Radkowski D, MacArthur C, et al: Changing patterns in pediatric epiglottis: A multi-institutional review, 1980 to 1992. Laryngoscope 1994;104:131422. 371.2 Bacterial TracheitisBacterial tracheitis, an acute bacterial infection of the upper airway, does not involve the epiglottitis but, like epiglottitis and croup, is capable of causing life-threatening airway obstruction. Staphylococcus aureus is the most commonly isolated pathogen. Moraxella catarrhalis, nontypable H. influenzae, and anaerobic organisms have also been implicated. Most patients are younger than 3 yr of age, although older children may be affected. There are no clear sex differences in incidence or severity. Bacterial tracheitis often follows a viral respiratory infection (especially laryngotracheitis) so it may be considered a bacterial complication of a viral disease, rather than a primary bacterial illness. This life-threatening entity is now more common than epiglottitis.Clinical Manifestations.Typically, the child has a brassy cough, apparently as part of a viral laryngotracheobronchitis. High fever and toxicity with respiratory distress may occur immediately or after a few days of apparent improvement. The patient with bacterial tracheitis can lie flat, does not drool, and does not have the dysphagia associated with epiglottitis. The usual treatment for croup (e.g., mist, racemic epinephrine) is ineffective. Intubation or tracheostomy may be necessary. The major pathologic feature appears to be mucosal swelling at the level of the cricoid cartilage, complicated by copious thick, purulent secretions, sometimes causing pseudomembranes. Suctioning these secretions, although occasionally affording temporary relief, usually does not sufficiently obviate the need for an artificial airway.Diagnosis.The diagnosis is based on evidence of bacterial upper airway disease, which includes high fever, purulent airway secretions, and an absence of the classic findings of epiglottitis.Treatment.Appropriate antimicrobial therapy, which usually includes antistaphylococcal agents, should be instituted in any patient whose course suggests bacterial tracheitis. When bacterial tracheitis is diagnosed by direct laryngoscopy or is strongly suspected on clinical grounds, an artificial airway is indicated. Supplemental oxygen may be necessary.Complications.Chest radiographs often show patchy infiltrates and may show focal densities. Subglottic narrowing and a rough and ragged tracheal air column can often be demonstrated radiographically. If airway management is not optimal, cardiorespiratory arrest can occur. Toxic shock syndrome has been associated with tracheitis (see Chapter 166.2 ).Prognosis.The prognosis for most patients is excellent. Patients usually become afebrile within 23 days of the institution of appropriate antimicrobial therapy, but prolonged hospitalization may be necessary. With a decrease in mucosal edema and purulent secretions, extubation can be accomplished safely, and the patient should be observed carefully while antibiotics and oxygen therapy are continued.REFERENCES Berstein T, Brilli R, Jacobs B: Is bacterial tracheitis changing? A 14-month experience in a pediatric intensive care unit. Clin Infect Dis 1998;27:45862. Brook I: Aerobic and anerobic microbiology of bacterial tracheitis in children. Pediatr Emerg Care 1997;13:1618. Eckel HE, Widemann B, Damm M, et al: Airway endoscopy in the diagnosis and treatment of bacterial tracheitis in children. Int J Pediatr Otorhinolaryngol 1993;27:14757. Dikutip dari:Kliegman, R.M., Bonita, Stanton, Geme, J., Schor, N., Berhrman, R.E. 2011. Nelson Textbook of Pediatrics 19th Edition. Saunders.