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Bacterial tracheitis in children: Treatment and prevention

Bacterial tracheitis in children: Treatment and prevention
Literature review current through: Jan 2024.
This topic last updated: Jan 12, 2023.

INTRODUCTION — The treatment and prevention of bacterial tracheitis in children will be reviewed here. The clinical features and diagnosis of bacterial tracheitis and tracheal infections associated with tracheostomy tubes and endotracheal intubation in children are discussed separately. (See "Bacterial tracheitis in children: Clinical features and diagnosis" and "Tracheobronchitis associated with tracheostomy tubes and endotracheal intubation in children".)

DEFINITION — Bacterial tracheitis is an invasive exudative bacterial infection of the soft tissues of the trachea (picture 1) [1]. In some cases, there is involvement of the subglottic laryngeal structures, extension into the upper bronchial tree, or associated pneumonia [2-5]. Thus, "acute bacterial laryngotracheobronchitis" may be a more accurate clinical and anatomic description of this entity, but "bacterial tracheitis" is the preferred terminology in most publications.

Other terms that have been used to describe bacterial tracheitis include "exudative tracheitis," "bacterial croup," "membranous croup," "pseudomembranous croup," "acute laryngotracheobronchitis," and "membranous laryngotracheobronchitis" [6].

The discussion below addresses bacterial tracheitis that develops in children without an artificial airway in place. Tracheal infections associated with tracheostomy and endotracheal tubes are discussed separately. (See "Tracheobronchitis associated with tracheostomy tubes and endotracheal intubation in children".)

INITIAL EMERGENCY DEPARTMENT MANAGEMENT — Key aspects of the initial management of the child with suspected bacterial tracheitis in the emergency department setting include the following:

Assess the need for intubation – Patients presenting with severe airway obstruction or impending respiratory failure (ie, marked retractions, poor air entry, fatigue, listlessness, depressed level of consciousness) require prompt intervention. While preparing to intubate, bag-valve-mask ventilation (BVM) should be provided with 100% oxygen. Most patients with bacterial tracheitis can be successfully oxygenated with BVM. Intubation may be challenging if the obstruction or narrowing of the subglottic airway is severe. Whenever possible, intubation should be performed with the assistance of a skilled provider (ie, an anesthesiologist or otolaryngologist). If time allows, the patient should be transported to the operating room where an artificial airway can be established, surgically if necessary. Operative bronchoscopy can be performed once the child is stabilized (see 'Bronchoscopy' below). Neuromuscular-blocking agents should be avoided unless the ability to provide BVM has been demonstrated. The approach to emergency endotracheal intubation and management of the difficult pediatric airway are discussed in greater detail separately. (See "Technique of emergency endotracheal intubation in children" and "The difficult pediatric airway for emergency medicine".)

Supportive respiratory care – For children not requiring immediate intubation, supportive respiratory care consists of providing supplemental oxygen and a trial of inhaled bronchodilator therapy (nebulized epinephrine if stridor is noted; albuterol if wheezing is noted). (See 'Supportive care' below and 'Respiratory treatments' below.)

Fluid resuscitation (if needed) – Patients with signs of hypovolemia or poor perfusion should receive intravenous (IV) fluid therapy (typically with 20 mL/kg of isotonic saline). Children with associated septic or toxic shock syndrome may require more aggressive fluid resuscitation and/or vasopressor support, whereas less aggressive fluid management may be sufficient in milder cases. (See "Treatment of hypovolemia (dehydration) in children in resource-abundant settings" and "Shock in children in resource-abundant settings: Initial management", section on 'Volume and rate'.)

Prompt administration of appropriate empiric antibiotic therapy – Appropriate empiric antibiotic regimens are summarized in the table and discussed in greater detail below (table 1). (See 'Antibiotic therapy' below.)

ONGOING INPATIENT MANAGEMENT

Setting — In general, children with bacterial tracheitis are best managed in a pediatric intensive care unit setting even if endotracheal intubation is not required. Intubated patients require close monitoring and attentive respiratory and nursing care. Patients who are not intubated have potential to deteriorate rapidly and may require prompt intervention with advanced respiratory support.

Specialist consultation — Appropriate specialists should be consulted early in the hospital course. For most children, this includes an infectious disease specialist and a specialist with expertise in managing the pediatric airway and performing laryngoscopy and bronchoscopy in young children (depending on the expertise at the particular center, this may be a pediatric otolaryngologist, surgeon, or pulmonologist or other specialist with the necessary training and experience).

Supportive care — Supportive care for children hospitalized with bacterial tracheitis includes:

Supplemental oxygen – For patients with hypoxia and respiratory distress, supplemental oxygen should be provided to maintain oxygen saturation (SpO2) in an acceptable range. There are no data to support a specific target SpO2 in bacterial tracheitis. It is reasonable to use the same target as is used for pneumonia (ie, SpO2 ≥94 percent). (See "Pneumonia in children: Inpatient treatment", section on 'Respiratory support'.)

Fever control – High fever can contribute to tachypnea and respiratory distress in children with tracheitis, and treatment with antipyretics can improve work of breathing and insensible fluid losses.

Fluids and nutrition – Children without an artificial airway in place are initially made nil per os, given the risk of deterioration and potential need for intubation. Maintenance intravenous (IV) fluids should be provided, and intake and output should be assessed regularly. Fever and tachypnea may increase fluid requirements. For intubated children, enteral feeds can be initiated via an orogastric or nasogastric feeding tube once the child's clinical status has stabilized. (See "Maintenance intravenous fluid therapy in children" and "Overview of enteral nutrition in infants and children".)

Comfort – Agitation or anxiety can worsen the degree of respiratory distress and airway obstruction. Children with symptomatic airway obstruction should be approached cautiously, and unnecessary invasive interventions should be avoided. For patients who are not intubated, the use of sedatives or anxiolytics to reduce agitation is discouraged as this may cause respiratory depression. Intubated patients generally require sedative and analgesic medications to maintain comfort and safety. This is discussed separately. (See "Initiating mechanical ventilation in children", section on 'Sedation and analgesia'.)

Ongoing assessment of the airway

Intubation — Close respiratory monitoring is critical to all children admitted for management of bacterial tracheitis given the risk for acute airway compromise from the tracheal exudate and pseudomembranes. This is especially true if endotracheal intubation was not performed in the course of the initial presentation. For children with progressive respiratory failure, the need for intubation should be anticipated so that the procedure can be performed in a controlled setting if possible. Intubation can be challenging due to the narrowed and/or obstructed subglottic airway and should be performed with the assistance of a skilled provider (ie, an anesthesiologist or otolaryngologist). Neuromuscular-blocking agents should be avoided unless the ability to provide bag-valve-mask ventilation (BVM) has been demonstrated. The approach to emergency endotracheal intubation and management of the difficult pediatric airway are discussed in greater detail separately. (See "Technique of emergency endotracheal intubation in children" and "The difficult pediatric airway for emergency medicine".)

Patients who are intubated during treatment for bacterial tracheitis require meticulous respiratory care. Frequent suctioning is necessary to prevent obstruction of the endotracheal tube, which can be fatal [7]. Post-intubation care is discussed separately. (See "Technique of emergency endotracheal intubation in children", section on 'Post-intubation care'.)

Endotracheal intubation is often necessary, though some children with bacterial tracheitis can be successfully managed without intubation [4,5,8-10]. In a systematic review of 300 cases, intubation was performed in 72 percent [11]. In older case series, nearly all patients were intubated; however, in case series from the contemporary era, intubation was required in only 40 to 50 percent of patients [4,8,11,12]. This may reflect changes in the epidemiology and microbiology over time, changes in respiratory care practices over time (with a trend toward greater use of noninvasive ventilatory support), or increased awareness of the entity and earlier diagnosis.

Tracheostomy usually is not necessary during initial management but may be necessary for residual subglottic stenosis [1,4,5,10]. (See 'Complications' below.)

Bronchoscopy — Direct visualization of the airway with laryngoscopy and tracheobronchoscopy is an important diagnostic and therapeutic intervention in the management of the child with bacterial tracheitis [4,6,12-14]. Findings on the airway examination can confirm the diagnosis, and the procedure may be necessary to remove adherent or copious pseudomembranous exudates causing airway obstruction. However, not all affected children require bronchoscopy. Our approach to determining the need for bronchoscopy is as follows [6,12]:

Impending respiratory failure – For children presenting with signs of severe airway obstruction and impending respiratory failure (ie, marked retractions, poor air entry, fatigue, listlessness, depressed level of consciousness), airway control precedes diagnostic evaluation. If time allows, the patient should be transported to the operating room, where an artificial airway can be established. Operative bronchoscopy is performed once the child is stabilized. Additional details of airway management are summarized above and are discussed in greater detail separately. (See 'Intubation' above and "Emergency evaluation of acute upper airway obstruction in children".)

High clinical suspicion – For children without respiratory failure but with a high level of clinical suspicion for bacterial tracheitis (eg, a child with acute onset of airway obstruction [stridor and/or dyspnea] in the setting of preceding viral upper respiratory infection, with poor response to inhaled epinephrine, and with airway radiograph demonstrating tracheal irregularity), we proceed with bronchoscopy in the operating room setting. Debridement of tracheal exudates via rigid bronchoscopy may produce sufficient improvement to permit further management without intubation [4,6].

Less severe presentation – For children with a less severe presentation (eg, cough, stridor, odynophagia, and fever without significant respiratory distress), we perform bedside flexible laryngoscopy as the initial evaluation. We proceed to operative bronchoscopy only if flexible laryngoscopy reveals purulent secretions that do not clear with suctioning or if the child subsequently develops more severe airway obstruction. (See 'Ongoing assessment of the airway' above.)

In the available case series, practice varied regarding the use of bronchoscopy. In some reports, bronchoscopy was performed routinely [4,6,13], whereas in others, children with milder symptoms were managed without bronchoscopy [5,12].

Serial bronchoscopic debridement is generally unnecessary but may be required in some cases to clear secretions that cause endotracheal tube plugging or recurrent episodes of respiratory distress in children not initially intubated [4,15]. It is not necessary to perform serial bronchoscopy merely to document resolution of local inflammatory signs in the trachea.

The typical bronchoscopic findings of bacterial tracheitis are discussed separately. (See "Bacterial tracheitis in children: Clinical features and diagnosis", section on 'Findings'.)

Extubation — Extubation generally can be accomplished when systemic signs are improved, ventilator requirements are minimal, tracheal secretions have become minimal, and a "cuff leak" is detectable around the endotracheal tube. The "cuff leak" refers to detection of airflow around the endotracheal tube with the cuff deflated. Details of the cuff leak test are provided separately. (See "Extubation management in the adult intensive care unit", section on 'Cuff leak'.)

Most patients are able to be extubated by day 2 to 4 of treatment. (See 'Expected course' below.)

Use of glucocorticoid therapy to facilitate extubation is discussed below. (See 'Glucocorticoids' below.)

Respiratory treatments — There are no clinical trials of bronchodilator therapy (eg, epinephrine, albuterol) or inhaled airway clearance agents (eg, nebulized hypertonic saline) in the treatment of bacterial tracheitis. Use of these drugs is largely extrapolated from their use in other settings (eg, viral croup, bronchiolitis). (See "Bronchiolitis in infants and children: Treatment, outcome, and prevention".)

Nebulized epinephrine – For most children presenting with acute respiratory distress and stridor, we suggest a trial of nebulized epinephrine. Dosing is the same as for croup, as follows:

Racemic epinephrine is administered as 0.05 mL/kg per dose (maximum of 0.5 mL) of a 2.25% solution diluted to 3 mL total volume with normal saline. It is given via nebulizer over 15 minutes.

L-epinephrine (parenteral product) is administered as 0.5 mL/kg per dose (maximum of 5 mL) using the 1 mg/mL strength (may also be referred to as a 1:1000 dilution). It is given via nebulizer over 15 minutes.

Nebulized epinephrine acts by reducing subglottic airway edema, though it likely has no effect on clearing airway secretions. Some children with bacterial tracheitis may respond to nebulized epinephrine, though the response is usually not complete. Others may have little or no response, likely because their airway obstruction is caused by secretions and debris within the airway rather than airway edema. Indeed, lack of response to nebulized epinephrine may prompt the clinician to consider a diagnosis of bacterial tracheitis in a child initially suspected to have viral croup [13].

In one case series of 36 children with bacterial tracheitis, 24 received initial treatment with nebulized racemic epinephrine, of whom 60 percent had a partial response and 40 percent had no response [12].

Albuterol (salbutamol) – Inhaled albuterol (salbutamol) is not a routine part of the respiratory care for children with bacterial tracheitis. However, in patients with wheezing, nebulized albuterol may be trialed. If no clinical response is seen within one hour of treatment, ongoing treatments should not be given. If there is a clinical response to albuterol, repeated doses can be administered with ongoing assessment after each treatment. (See "Bronchiolitis in infants and children: Treatment, outcome, and prevention".)

Wheezing can be associated with bacterial tracheitis as a result of: (1) narrowing of the large airways from purulent secretions or sloughed, necrotic mucous membranes, or (2) the effects of a preceding viral bronchiolitis infection. Wheezing may or may not improve after nebulized albuterol therapy [7].

Nebulized hypertonic saline – Nebulized hypertonic (3%) saline is not a routine part of the respiratory care for children with bacterial tracheitis. However, hypertonic saline may be a useful adjunctive treatment to promote clearance of airway secretions in select intubated patients when poor airway clearance is impacting gas exchange and/or lung expansion.

There are no available data on the use of nebulized hypertonic saline in bacterial tracheitis. Nevertheless, nebulized hypertonic saline is used in many centers to promote airway clearance in children requiring mechanical ventilation for other acute respiratory infections (eg, pneumonia, bronchiolitis). The evidence to support this practice is scant [16-18]. (See "Bronchiolitis in infants and children: Treatment, outcome, and prevention".)

Glucocorticoids — Children with bacterial tracheitis are commonly treated with glucocorticoids, though evidence to support the practice is limited.

Initial treatment – We suggest not using glucocorticoids as a specific therapy for management of bacterial tracheitis. However, since there is considerable overlap between the presentation of bacterial tracheitis and viral croup, it is reasonable to treat with dexamethasone initially if there is clinical concern for croup. (See "Management of croup", section on 'Initial treatment'.)

In two case series including a total of 70 children with bacterial tracheitis, 87 percent received glucocorticoids (chiefly dexamethasone) in the emergency department [12,14].

Prior to extubation – In children requiring intubation, treatment with a short course of glucocorticoid (eg, single dose of dexamethasone 0.6 mg/kg, maximum 16 mg) to facilitate extubation can be considered once the child otherwise appears ready for extubation (ie, when systemic signs are improved and the need for suctioning of airway secretions is minimal) [4,19,20]. The endotracheal cuff leak test (ie, airflow detected around the endotracheal tube with the cuff deflated) is often used in guiding the decision to treat with glucocorticoids. If no leak is detected, we typically provide a single dose of dexamethasone. It is important to recognize that the cuff leak test has not been validated in this setting [21]. Nevertheless, given the known risk of post-extubation stridor with potential need for reintubation in these children, we feel the potential benefits outweigh the downsides. (See "Extubation management in the adult intensive care unit", section on 'Glucocorticoids'.)

Antibiotic therapy — All patients with suspected bacterial tracheitis should receive prompt treatment with broad-spectrum IV antibiotics. Once culture and susceptibility results are available, the regimen should be tailored appropriately.

Choice of therapy — Initial empiric antimicrobial therapy for bacterial tracheitis should include broad coverage for the most frequently isolated pathogens, which include Staphylococcus aureus (including methicillin-resistant S. aureus [MRSA]), group A Streptococcus, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis [14]. (See "Bacterial tracheitis in children: Clinical features and diagnosis", section on 'Microbiology'.)

We suggest an initial empiric treatment with a parenteral antibiotic regimen that consists of (table 1):

Vancomycin, plus

Either a third-generation cephalosporin (eg, ceftriaxone, cefotaxime [if available]) or ampicillin-sulbactam

Monotherapy with ceftaroline is a reasonable alternative to the combination regimen described above. Ceftaroline is a fifth-generation cephalosporin with in vitro activity similar to ceftriaxone but with improved coverage for gram-positives, including MRSA. However, there are no published data on the use of ceftaroline in this setting.

We generally prefer a regimen that includes vancomycin when MRSA is suspected, given that there is greater clinical experience using vancomycin to treat invasive infections in children. (See "Staphylococcus aureus in children: Overview of treatment of invasive infections", section on 'Empiric antimicrobial therapy'.)

Other alternatives and options for patients with penicillin or cephalosporin allergies are provided in the table (table 1).

Gram stain results should be reviewed since a specific pathogen may be suggested before culture results are available. However, broad-spectrum antimicrobial therapy should be continued until culture results are available.

Once culture and susceptibility results are available, the regimen can be tailored appropriately.

Duration — The optimal duration of antibiotic therapy for bacterial tracheitis is unknown. The available case series provide little meaningful guidance, but a 10-day course appears to be sufficient. Longer courses may be warranted for children with associated extratracheal sites of infection or persistence of tracheal inflammation beyond 7 to 10 days.

Completion of the course with oral antibiotics may be an option depending upon the availability of oral agents effective against the documented or presumed pathogen(s) and the appropriateness of such agents for treatment of any extratracheal sites of infection, if present. Conversion to an oral agent or agents may be done when the patient is able to resume and tolerate oral feedings and/or at the time of discharge from the hospital if the course of therapy is to be completed as an outpatient. This should generally occur only after systemic signs of illness (eg, fever, respiratory distress) have resolved or improved substantially.

Antiviral therapy — For children in whom influenza is the suspected or confirmed predisposing viral etiology, antiviral therapy should be started as soon as possible after symptom onset, ideally within 48 hours. Treatment of influenza is discussed separately. (See "Seasonal influenza in children: Management", section on 'Antiviral therapy'.)

CLINICAL COURSE

Expected course — Most children with bacterial tracheitis demonstrate substantial clinical improvement within 48 to 72 hours of initiation of appropriate antimicrobial therapy and other supportive measures. Some children require prolonged mechanical ventilation, intensive care unit stay, and hospitalization, particularly if there is associated septic shock or acute respiratory distress syndrome. In a systematic review of eight case series with a total of 217 patients, 75 percent required intubation [14]. The average duration of mechanical ventilation ranged from 48 to 182 hours, and length of hospital stay ranged from 5 to 12 days.

Clinical deterioration — For patients who clinically deteriorate (eg, worsening hypoxemia or progression from sepsis toward septic shock) or do not improve within 48 to 72 hours, it is reasonable to broaden the spectrum of coverage of antimicrobial therapy. This may consist of adding vancomycin if it was not initially included in the regimen and, depending on the level of concern, adding an antipseudomonal agent and/or coverage for multidrug-resistant gram-negative organisms, especially if gram-negative bacilli are abundant on Gram stain of tracheal secretions. Such decisions should be made in consultation with an infectious disease specialist.

Complications — Complications occur in a minority of patients and may be due to consequences of acute airway obstruction, spread of infection to other parts of the respiratory tract, systemic effects of the infection, and/or consequences of tracheal intubation and mechanical ventilation. In the available case series, the reported frequency of these complications was as follows [11,12,14]:

Cardiorespiratory arrest (due to acute airway obstruction) – 2 to 3 percent

Septic shock or toxic shock syndrome – 2 to 3 percent

Acute respiratory distress syndrome – 1 to 3 percent

Pneumothorax – 1 to 2 percent

Postobstructive pulmonary edema – 0.5 to 1 percent

Subglottic stenosis – 1 percent

OUTCOME — Most children with bacterial tracheitis recover without sequelae. The tracheal mucosa usually heals without scarring, though residual subglottic stenosis has been described [5,7,10,11]. In the available case series, the overall case fatality rate is approximately 2 to 3 percent [11,12,14,19]. Most deaths are due to acute airway obstruction.

PREVENTION — The primary means of prevention consists of vaccination against pneumococcus and viruses (eg, measles, influenza) that may predispose children to bacterial tracheitis. (See "Pneumococcal vaccination in children" and "Seasonal influenza in children: Prevention with vaccines" and "Measles, mumps, and rubella immunization in infants, children, and adolescents".)

Other measures to prevent viral upper respiratory tract infections are discussed separately. (See "The common cold in children: Management and prevention", section on 'Prevention'.)

SUMMARY AND RECOMMENDATIONS

Initial stabilization – The initial emergency department management of the child with suspected bacterial tracheitis focuses on assessing the need for intubation, providing supportive respiratory care, administering intravenous (IV) fluid therapy, and promptly administering IV antibiotic therapy (table 1). (See 'Initial emergency department management' above.)

Setting of care – Children with bacterial tracheitis are best managed in a pediatric intensive care unit setting. Appropriate specialists should be consulted early in the hospital course. For most children, this includes an infectious disease specialist and a specialist with expertise in managing the pediatric airway and performing laryngoscopy and bronchoscopy in young children (eg, an otolaryngologist). (See 'Setting' above and 'Specialist consultation' above.)

Airway management – Children presenting with severe airway obstruction or impending respiratory failure (ie, marked retractions, poor air entry, fatigue, listlessness, depressed level of consciousness) require prompt intervention. Intubation can be challenging due to the narrowed and/or obstructed subglottic airway and should be performed with the assistance of a skilled provider (ie, an anesthesiologist or otolaryngologist). Neuromuscular-blocking agents should be avoided unless the ability to provide bag-valve-mask ventilation (BVM) has been demonstrated. The approach to emergency endotracheal intubation and management of the difficult pediatric airway are discussed in greater detail separately. (See "Technique of emergency endotracheal intubation in children" and "The difficult pediatric airway for emergency medicine".)

Role of bronchoscopy – For children who require intubation based on the severity of their symptoms and for children without respiratory failure but with a high level of clinical suspicion for bacterial tracheitis (eg, a child with acute onset of airway obstruction in the setting of preceding viral upper respiratory infection, poor response to inhaled epinephrine, and tracheal irregularity on airway radiograph), we suggest rigid bronchoscopy to remove tracheal exudates (Grade 2C). (See 'Bronchoscopy' above.)

Children with a less severe presentation (eg, cough, mild stridor, odynophagia, and fever without significant respiratory distress) can be managed without bronchoscopy, though they should be monitored closely for worsening airway obstruction.

Supportive care – Supportive care for children hospitalized with bacterial tracheitis consists of supplemental oxygen as needed, fever control, maintenance IV fluids, and measures to reduce anxiety and discomfort. (See 'Supportive care' above.)

Inhaled respiratory treatments – Inhaled bronchodilators (eg, epinephrine, albuterol [salbutamol]) do not play a major role in the management of children with bacterial tracheitis, but a trial of these medications may be appropriate for some patients (see 'Respiratory treatments' above):

For most children presenting with acute respiratory distress and stridor, we suggest a trial of nebulized epinephrine (Grade 2C). Some children with bacterial tracheitis may respond to nebulized epinephrine, though the response is usually not complete. Others may have little or no response, likely because their airway obstruction is caused by secretions and debris within the airway rather than airway edema.

In patients with wheezing, we suggest a trial of nebulized albuterol (salbutamol) (Grade 2C). If no clinical response is seen within one hour of treatment, ongoing treatments should not be given.

Role of glucocorticoid therapy

Initial treatment – Since there is considerable overlap between the presentation of bacterial tracheitis and viral croup, most affected children receive glucocorticoids initially as treatment for presumed croup. Once the diagnosis of bacterial tracheitis is established, we suggest against ongoing glucocorticoid therapy as a specific treatment for bacterial tracheitis. (See 'Glucocorticoids' above and "Management of croup", section on 'Initial treatment'.)

Prior to extubation – For intubated patients whose clinical status has improved and who otherwise appear ready for extubation but do not have a detectable endotracheal "cuff leak," we suggest glucocorticoid therapy (eg, single dose of dexamethasone 0.6 mg/kg, maximum 16 mg) prior to extubation (Grade 2C). (See "Extubation management in the adult intensive care unit", section on 'Glucocorticoids'.)

Antibiotics – All patients with suspected bacterial tracheitis should receive prompt treatment with broad-spectrum IV antibiotics (see 'Antibiotic therapy' above):

We suggest initial empiric treatment with a parenteral antibiotic regimen that consists of vancomycin plus either a third-generation cephalosporin (eg, ceftriaxone, cefotaxime) or ampicillin-sulbactam (Grade 2C). Monotherapy with ceftaroline is a reasonable alternative. Other alternative regimens and options for patients with penicillin or cephalosporin allergies are provided in the table (table 1). (See 'Choice of therapy' above.)

Once culture and susceptibility results are available, the regimen should be tailored appropriately. The usual duration of antibiotic therapy is 10 days. (See 'Duration' above.)

For patients who clinically deteriorate (eg, worsening hypoxemia or progression from sepsis toward septic shock) or do not improve within 48 to 72 hours, it is reasonable to broaden the spectrum of coverage of antimicrobial therapy. (See 'Clinical deterioration' above.)

Outcome – Most children with bacterial tracheitis demonstrate substantial clinical improvement within 48 to 72 hours of initiation of appropriate antimicrobial therapy and other supportive measures. Complications occur in a minority of patients and may be due to consequences of acute airway obstruction, spread of infection to other parts of the respiratory tract, systemic effects of the infection, and/or consequences of tracheal intubation and mechanical ventilation. The mortality rate is approximately 2 to 3 percent. (See 'Complications' above and 'Outcome' above.)

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