Tracheobronchitis associated with tracheostomy tubes and endotracheal intubation in children

INTRODUCTION — Children who require artificial airways (ie, tracheostomy for the management of chronic respiratory insufficiency or endotracheal intubation for an acute critical illness) are at increased risk for bacterial tracheopulmonary infections. Infections in these patients occur due to bacterial colonization of the artificial airway and mucosal injuries related to airway cannulation [1]. Tracheobronchitis in this setting is generally characterized by clinical signs of respiratory tract infection (eg, fever, cough, increased sputum production) without radiographic evidence of pneumonia.

Tracheal infections associated with tracheostomy tubes and endotracheal intubation in children will be discussed here. The clinical features, diagnosis, treatment, and prevention of bacterial tracheitis in children and the diagnosis of ventilator-associated pneumonia are discussed separately:

●(See "Bacterial tracheitis in children: Clinical features and diagnosis".)

●(See "Bacterial tracheitis in children: Treatment and prevention".)

●(See "Clinical presentation and diagnostic evaluation of ventilator-associated pneumonia".)

TERMINOLOGY — The following terms are used in this topic:

●Ventilator-associated tracheobronchitis – Ventilator-associated tracheobronchitis (VAT, also called nosocomial tracheobronchitis) has been proposed as a clinical entity distinct from, and possibly a precursor to, ventilator-associated pneumonia (VAP) [2,3]. VAT is generally characterized by clinical signs of respiratory tract infection (eg, fever, cough, increased sputum production) without radiographic evidence of pneumonia. VAT can occur in children ventilated via endotracheal intubation or tracheostomy tube placement. Though VAT is widely accepted as a distinct clinical entity in children and adults, its intermediary role in development of VAP and whether early treatment of VAT reduces risk of subsequent VAP remain uncertain. VAT in adult patients is discussed separately. (See "Complications of the endotracheal tube following initial placement: Prevention and management in adult intensive care unit patients", section on 'Tracheobronchitis'.)

●Artificial airway-associated tracheobronchitis – Tracheobronchitis also can occur in children who have tracheostomy tubes for airway support but who are not receiving mechanical ventilation. The term "artificial airway-associated tracheobronchitis" may be more appropriate for this category of infection, with VAT representing a substantial subset of this. Children with laryngeal diversion and tracheostoma without a tracheostomy tube also may develop bacterial tracheitis, but it is unclear if they have increased risk relative to children with intact airways.

●"Tracheobronchitis" versus "tracheitis" – The terms "tracheobronchitis" and "tracheitis" are often used interchangeably to describe infections associated with artificial airways. In this topic we will use the term "tracheobronchitis."

A separate term, "bacterial tracheitis" is used to describe the invasive exudative bacterial infection of the soft tissues of the trachea that occurs in previously healthy children most commonly in the setting of a viral respiratory tract infection (eg, croup or bronchiolitis). Bacterial tracheitis in children is discussed in greater detail separately. (See "Bacterial tracheitis in children: Clinical features and diagnosis".)

VAP is discussed separately. (See "Clinical presentation and diagnostic evaluation of ventilator-associated pneumonia".)

PATHOGENS — Artificial airways rapidly become colonized with potentially pathogenic microbes [4,5]. Common colonizing bacteria include Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Acinetobacter species, Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli, Serratia marcescens, Enterobacter species, Stenotrophomonas maltophilia, and other gram-negative enteric organisms [4-10]. Most cases of apparent ventilator-associated tracheobronchitis (VAT) are associated with a single organism in culture [9]. Candida and Aspergillus have been reported in cultures from children with artificial airways [9,10], but the role of fungal pathogens in artificial airway-associated tracheobronchitis is unclear.

Colonizing bacteria may arise from the upper airway, ventilator tubing or reservoirs, or humidification circuits [1]. In children who are chronically tracheostomy-dependent, bacterial biofilms play an important role [11].

In a prospective study of 61 endotracheally-intubated children, more than one-half of the cultures of tracheal secretions obtained four to six days after intubation yielded ≥10⁴ cfu/mL of pathogenic bacteria in the absence of other evidence of infection [6]. Three of 10 children cultured on the first day after intubation had pathogenic species isolated with colony counts ≥10⁴ cfu/mL.

In a study of 68 children who underwent tracheostomy at a single institution, 53 percent were noted to have positive tracheal cultures with 30 days of surgery [10]. Nearly one-half of the children with positive cultures did not require antibiotic therapy, since they lacked symptoms and the bacterial growth was attributed to colonization. Staphylococcus aureus was the most commonly isolated organism in this series.

In a retrospective study of 210 children who underwent tracheostomy at a single-center, 18 percent developed chronic colonization with P. aeruginosa during the first two years [12].

EPIDEMIOLOGY — Estimates of the incidence of tracheobronchitis in children depend on the setting:

●In the pediatric intensive care unit (PICU) setting – Estimates of the incidence of ventilator-associated tracheobronchitis (VAT) in the PICU setting range from 1.8 to 8.3 per 1000 ventilator days [9,13-15]. In one study of 73 children with VAT in a PICU setting, underlying conditions included airway surgery (23 percent), solid organ transplantation (20 percent), other major surgery (12 percent), malignancy (15 percent), trauma (8 percent), neurologic conditions (7 percent), and other critical illness (14 percent) [9].

●Children who are chronically tracheostomy-dependent – Tracheobronchitis is common among children who are chronically tracheostomy-dependent. In studies of children with newly placed tracheostomy tubes, approximately 30 to 40 percent were readmitted to the hospital within the first 12 months for lower respiratory tract infections (ie, tracheobronchitis and pneumonia) [16,17]. Pneumonia accounted for the majority of readmissions, but it is likely that many additional episodes of tracheobronchitis occurred that did not require hospital admission.

CLINICAL FEATURES — Tracheobronchitis in children with artificial airways may be difficult to distinguish from associated lung infection (eg, ventilator-associated pneumonia [VAP]) and viral infections involving the lower respiratory tract.

Aspects of the history and physical examination that suggest a possible tracheal infection include [1]:

●New fever or elevation of fever above the most recent baseline of daily maximum temperature elevation

●Change in the color, viscosity, and/or odor of tracheal secretions

●Increased need for airway suctioning (suggesting increased production or volume of airway secretions or exudate)

●Increased need for oxygen supplementation or ventilatory support (eg, monitored oxygen saturations have declined), although marked increases in ventilatory requirement is more suggestive of VAP

●Increased work of breathing

●New crackles, rhonchi, and/or wheezing on chest auscultation

These clinical findings can also be seen in patients with VAP; however, the clinical course tends to be more severe in patients with VAP. In many cases, the distinction between ventilator-associated tracheobronchitis (VAT) and VAP can only be made with chest imaging. (See 'Chest imaging' below.)

DIAGNOSTIC EVALUATION — The evaluation for suspected bacterial tracheobronchitis in children with artificial airways includes the following:

●Chest radiograph (see 'Chest imaging' below)

●Complete blood count with differential (see 'Complete blood count' below)

●Gram stain and culture of tracheal aspirate (see 'Gram stain' below and 'Culture' below)

●Respiratory viral testing, depending on the clinical circumstances (see 'Viral testing' below)

Chest imaging — Chest radiographs should be obtained to distinguish ventilator-associated tracheobronchitis (VAT) from ventilator-associated pneumonia (VAP). A normal chest radiograph generally excludes VAP; however, chest radiographs lack specificity and sensitivity in detecting pulmonary infiltrates, particularly early in the course of VAP. Hence, episodes defined clinically as VAT could actually be early VAP [18]. Follow-up chest radiographs may help make the distinction.

Computed tomography (CT) has greater sensitivity for VAP; however, concerns regarding exposure to radiation in children undergoing CT preclude routine use of this modality in the evaluation of VAP and VAT. (See "Clinical presentation and diagnostic evaluation of ventilator-associated pneumonia", section on 'Chest imaging'.)

Complete blood count — Peripheral blood white blood cell count (WBC) with differential is commonly obtained in patients with suspected bacterial tracheobronchitis as an indicator of infection. This test lacks sensitivity and specificity as it can be elevated or depressed in a number of other conditions (eg, VAP, viral infection) and may be normal in many children with VAT. Although it is not part of the diagnostic criteria for VAT, abnormal WBC (<4000 WBC/mm³ or ≥15,000 WBC/mm³) is included in the Centers for Disease Control and Prevention (CDC)/National Healthcare Safety Network (NHSN) surveillance definition of VAP and therefore it is generally obtained when this diagnosis is being considered.

Inflammatory biomarkers — Inflammatory biomarkers such as C-reactive protein (CRP) and procalcitonin have not been validated as adjuncts for the diagnosis of VAT in children or adults [19,20]. In a study of intubated adult patients, CRP and procalcitonin levels were higher at time of onset for VAP compared with VAT, but neither biomarker could reliably discriminate between these two entities [20]. Use of these tests in adult patients is discussed in greater detail separately. (See "Clinical presentation and diagnostic evaluation of ventilator-associated pneumonia", section on 'Tests of limited value'.)

Microbiology

Gram stain — The Gram stain of the tracheal aspirate should be compared with previous cultures if any are available. Presence of microbes with morphology different from those identified in recent specimens (eg, current gram-positive cocci versus past gram-negative rods, and vice versa) raises suspicion for new bacterial infection over simple colonization [1]. A negative Gram stain may be somewhat reassuring when there is otherwise low suspicion of airway infection. A positive Gram stain alone without other clinical data suggesting the presence of infection may reflect colonization [6].

Quantitation (ie, ≥25 per low power field) or semiquantitation (ie, few to many, 2+ to 4+) of polymorphonuclear neutrophils (PMNs) on the Gram stain also may have utility in some cases. If PMNs are absent or present only in low numbers, bacterial infection is unlikely. The presence of many PMNs, even when exceeding the 25 per low power field threshold, may occur in the absence of infection and does not help in differentiating between tracheobronchial and pulmonary infection [6].

Culture — Growth of pathogens in culture of tracheal secretions supports the diagnosis of bacterial tracheobronchitis. Quantitative cultures that yield ≥10⁴ cfu/mL of a single bacterial species have been suggested as indicative of infection rather than colonization. However, in the absence of other clinical evidence of infection, positive culture results even in this quantity may represent airway colonization [6,19]. Polymicrobial growth, low levels of growth, and/or growth of nonpathogenic bacteria are more suggestive of contamination or colonization rather than infection.

Review of prior tracheal aspirate cultures can be helpful, although they do not reliably predict the microbial etiology or antimicrobial susceptibility pattern of the current infection [21]. Current results are less likely to differ from those of past tracheal aspirate cultures obtained within the past 30 days than when longer periods of time have elapsed. Chronic colonization with P. aeruginosa is not uncommon [12].

Viral testing — In children who are chronically tracheostomy-dependent, viral lower respiratory tract infections (LRI) are common causes of purulent secretions and acute respiratory symptoms. Thus, viral testing of tracheal aspirates (eg, with multiplex polymerase chain reaction tests, rapid viral antigen tests, or viral culture) should be routinely performed as part of the initial evaluation of acute respiratory exacerbations in this population. In contrast, viral infections less commonly cause nosocomial VAT in children who are intubated in the pediatric intensive care unit (PICU). In this setting, viral testing is not routinely part of the initial evaluation, but may be useful if the initial evaluation is nondiagnostic or if there is known exposure to a viral pathogen.

Viral LRIs in children with artificial airways are generally caused by the same respiratory viruses that affect children without tracheostomies (eg, influenza, respiratory syncytial virus, rhinovirus, parainfluenza, human metapneumovirus). (See "Seasonal influenza in children: Clinical features and diagnosis" and "Respiratory syncytial virus infection: Clinical features and diagnosis in infants and children" and "Epidemiology, clinical manifestations, and pathogenesis of rhinovirus infections".)

Results of viral testing should be interpreted in conjunction with the clinical picture and results of the bacterial culture. Interpretation is fairly straightforward if the bacterial culture is negative and viral testing is positive, consistent with viral LRI. However, if both the bacterial culture and viral testing are positive, this may represent either viral LRI complicated by bacterial superinfection or viral LRI in the setting of chronic airway colonization. As previously described, quantitative culture results and review of prior tracheal cultures can be helpful in distinguishing between these (see 'Culture' above). The patient's clinical picture should also be taken into consideration. If the patient is acutely ill with considerable symptomatology (eg, high fevers, needing increased respiratory support), bacterial superinfection is more likely.

Bronchoscopy — Although rarely required in the routine evaluation of VAT in children with artificial airways, if bronchoscopy is performed for another reason, the findings may help confirm or exclude the diagnosis [1]. Bacterial tracheobronchitis is suggested if there is visual evidence of tracheal inflammation in clinical settings otherwise suggestive of infection.

If bronchoscopy is performed, bronchoalveolar lavage (BAL) specimens should be sent for culture. (See 'Culture' above and "Clinical presentation and diagnostic evaluation of ventilator-associated pneumonia", section on 'Invasive respiratory sampling'.)

DIAGNOSIS — Tracheobronchitis in children with artificial airways is a clinical diagnosis that is imperfectly defined [18,19,22,23]. No single test confirms the diagnosis. For children who are chronically tracheostomy-dependent, tracheobronchitis is typically diagnosed clinically on the basis of fever and new onset purulent tracheal secretions in the absence of other causes for these finding. Sputum cultures are helpful in the management, but positive sputum cultures alone are insufficient to make the diagnosis.

The most commonly used diagnostic criteria for diagnosing ventilator-associated tracheobronchitis (VAT) are those of the Centers for Disease Control and Prevention (CDC)/National Healthcare Safety Network (NHSN) surveillance definition [24]:

●Absence of clinical or radiographic evidence of pneumonia, AND

●A positive culture obtained by deep tracheal aspirate or bronchoscopy, AND

●≥2 of the following signs or symptoms with no other recognized cause:

•Fever >38°C (taken rectally in infants ≤1 year of age)

•Cough

•New or increased sputum production

•Rhonchi and/or wheezing

•In infants ≤1 year of age: respiratory distress, apnea, and/or bradycardia

These surveillance criteria have limitations and they therefore lack precision. The determination of increased sputum production at the bedside can be somewhat subjective [18]. Increased secretions also may occur from viral infections or other mechanisms unrelated to the presence of infection. Respiratory distress may be readily evident in some children but masked in others, especially when sedated while on mechanical ventilation [18,19]. Chest radiographs lack specificity and sensitivity in detecting pulmonary infiltrates such that episodes defined clinically as VAT could actually be early ventilator-associated pneumonia (VAP) [18]. Chest auscultation is often unreliable in ventilated patients (eg, audible crackles may not indicate infection, infection that is present may not generate crackles audible over ventilator-related noise). Similarly, fever and other adjunctive tests such as peripheral blood white blood cell count (WBC) are not specific to respiratory tract infections or bacterial versus viral respiratory tract infections. Even positive Gram stains and quantitative bacterial cultures of tracheal aspirates provide less certainty than previously thought [6].

Despite these limitations, most studies that have addressed the frequency and factors associated with VAT in children have generally used the CDC/NHSN or similar criteria as a proxy for the clinical definition of VAT [8,9,13,14,23,25].

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of bacterial tracheobronchitis in children with artificial airways includes [1]:

●Other bacterial infections of the upper or lower respiratory tract infection, including:

•Ventilator-associated pneumonia (see "Clinical presentation and diagnostic evaluation of ventilator-associated pneumonia")

•Sinusitis (see "Acute bacterial rhinosinusitis in children: Clinical features and diagnosis")

These can generally be distinguished from tracheobronchitis by the clinical course and radiographic findings.

●Viral respiratory tract infections, including:

•Respiratory syncytial virus, and other causes of viral bronchiolitis (see "Bronchiolitis in infants and children: Clinical features and diagnosis")

•Seasonal influenza (see "Seasonal influenza in children: Clinical features and diagnosis", section on 'Pneumonia and respiratory tract complications')

•Coronavirus disease 2019 (COVID-19) (see "COVID-19: Clinical manifestations and diagnosis in children")

These can be distinguished from a bacterial infection by performing appropriate virologic studies. (See 'Viral testing' above.)

●Bacterial colonization of the trachea, which is generally distinguished from an acute infection based upon lack of symptoms (eg, fever cough, increased secretions, increased oxygen requirement).

TREATMENT

Goals of treatment — The goals of treatment must balance the desire to treat episodes early in order to improve patient outcomes (ie, to reduce duration of mechanical ventilation and length of stay [LOS] and prevent ventilator-associated pneumonia [VAP] or systemic infection) against the desire to avoid overtreatment with antimicrobial agents, which promotes the emergence of antimicrobial-resistant microbes and increases the cost of medical care. (See 'Outcome' below.)

Empiric therapy — If, based upon the above criteria (see 'Diagnosis' above), a diagnosis of bacterial tracheobronchitis is considered likely in a child with an artificial airway, we suggest treating with antimicrobial therapy.

The choice of initial empiric antibiotic therapy is aimed at providing coverage for the most likely pathogens (see 'Pathogens' above) and is influenced by several factors [1]:

●The severity of illness (children with severe infections should generally be treated with broad-spectrum antibiotics).

●Results of the Gram stain of the tracheal aspirate.

●Susceptibilities of pathogens previously identified in the patient, with the caveat that results of past tracheal aspirate cultures do not reliably predict current results, though they are more likely to be consistent when obtained within the past 30 days [21].

●The child's likelihood of having multidrug-resistant flora (children with recent hospitalizations or residing in long-term care facilities are more likely to be colonized with multidrug-resistant organisms).

●Local resistance patterns.

If gram-positive cocci are identified on the Gram stain, empiric coverage for S. aureus should be provided. Empiric coverage for methicillin-resistant S. aureus (MRSA) may be warranted in patients who have a known history of MRSA based upon past culture results, frequent interaction with the health care system, severe infection, and/or high likelihood of MRSA due to local susceptibility patterns. (See "Staphylococcus aureus in children: Overview of treatment of invasive infections".)

Similarly, if gram-negative rods are identified, the likelihood of extended spectrum beta-lactamase (ESBL) or carbapenemase-producing organisms must be considered when choosing appropriate empiric therapy. (See "Extended-spectrum beta-lactamases", section on 'Treatment options' and "Carbapenem-resistant E. coli, K. pneumoniae, and other Enterobacterales (CRE)", section on 'Approach to treatment'.)

Oral/enteral antimicrobial therapy is appropriate for treatment of tracheobronchitis in chronically tracheostomy-dependent children who do not appear systemically ill. In the absence of previous cultures to guide decision-making, and in the absence of risk factors for multidrug resistant organisms, reasonable options for empiric therapy include amoxicillin-clavulanate, quinolones (eg, ciprofloxacin or levofloxacin), or clindamycin. There are little available data to inform management decisions in this setting other than the epidemiology and microbiology of these infections. (See 'Pathogens' above.)

Intravenous antibiotic therapy is generally indicated for patients with artificial airway-associated bacterial tracheobronchitis who appear systemically ill, including those who are intubated in the pediatric intensive care unit (PICU).

Reevaluation — After initiating treatment for artificial airway-associated tracheobronchitis, we suggest re-evaluating the diagnosis within 48 to 72 hours based upon the unfolding clinical course and available laboratory data. This may allow discontinuation of antimicrobial therapy in certain circumstances, particularly if any of the following occur:

●An alternate explanation for initial signs and symptoms becomes apparent, such as confirmation of a viral respiratory tract infection with a clinical course consistent with the identified viral etiology

●Culture of tracheal secretions shows no growth, growth of a microbe deemed likely to be a nonpathogen in the host, or polymicrobial results that suggest colonization and/or contamination

●Rapid symptom resolution (ie, within 12 to 24 hours) that is attributable to interventions other than antimicrobial therapy (eg, pulmonary toilet, changes in ventilator settings, re-expansion of an atelectatic lung segment)

Definitive therapy — When the culture and susceptibility results of the current tracheal aspirate become available, the antibiotic regimen should be tailored accordingly.

A treatment course of three to seven days is generally sufficient for an uncomplicated course of artificial-airway-associated bacterial tracheobronchitis [23,25]. Alternatively, antimicrobial therapy may be continued until a few days after resolution of respiratory tract symptoms. In a retrospective study of 118 intubated children with VAT, the likelihood of progressing to VAP was similar in those who were treated with a prolonged course of antibiotics (≥7 days) compared with shorter courses (hazard ratio [HR] 1.08, 95% CI 0.4-2.9) [25]. However, the risk of acquiring multidrug-resistant organisms was increased with prolonged antibiotic duration (HR 5.15, 95% CI 1.54-7.19).

OUTCOME — Based on the available studies, ventilator-associated tracheobronchitis (VAT) in children does not appear to be associated with increased risk of mortality [8,9,13,14]. While the lack of association suggest that VAT is not a serious illness in most cases, it is possible that these studies failed to detect an association because many had small sample sizes and may have been underpowered to detect an association. In addition, some studies likely included episodes that were not true bacterial VAT.

Several studies have demonstrated an association between VAT and both longer duration of mechanical ventilation and longer pediatric intensive care unit (PICU) length of stay (LOS) [8,9,13,14]. The directional causality of this association is unclear. It is possible that VAT prolongs the need for mechanical ventilation and thus longer PICU LOS. However, it is also likely that children with underlying conditions requiring longer durations of mechanical ventilation are at greater risk of developing VAT.

There are few published reports of outcomes following tracheobronchitis among children who are chronically tracheotomy-dependent. In our experience, most of these children recover from a single episode of tracheobronchitis without lasting sequelae. Frequent or recurrent respiratory tract infections likely contribute to morbidity and mortality in this population; however, recurrent pneumonias play a more important role than do tracheal infections. In a study from a single institution of 142 tracheostomy-dependent children followed for an average of 4.1 years, there were 29 episodes of tracheobronchitis among 25 patients (18 percent) [26]. There were no deaths attributable to tracheobronchitis.

PREVENTION — Measures that may help prevent respiratory tract infections in children with artificial airways include the following [13,27]:

●Avoiding intubation when possible (eg, using noninvasive ventilation)

●Extubation as soon as possible

●Minimizing sedation while intubated

●Elevation of the head of the bed to at least 30°

●Regular oral care

●Minimizing pooling of secretions above the endotracheal tube (ETT)

●Using separate catheters for oral and ETT suctioning

●Using closed suctioning systems for ETT suctioning

●Maintaining ventilator circuits (eg, changing circuit if visibly soiled or malfunctioning)

●Performing hand hygiene between patient contacts

These measures are appropriate for intubated patients in the pediatric intensive care unit (PICU) setting and generally do not apply to chronically tracheostomy-dependent children managed in the outpatient setting. However, some of these interventions (eg, practicing good hand hygiene, good oral hygiene, and minimizing pooling of oropharyngeal secretions) are likely to be effective in both settings. In addition, routine tracheotomy tube changes and local stoma care are important preventive measures in tracheotomy-dependent children since tracheotomy tubes may be a source for continuing bacterial contamination [10].

Data on the effectiveness of these measures for prevention of ventilator-associated tracheobronchitis (VAT) in children are limited, as described below. Indirect supporting evidence comes from studies in adult patients that have demonstrated reduced rates of ventilator-associated pneumonia (VAP) using some of these interventions. The approach in adult patients is discussed separately. (See "Risk factors and prevention of hospital-acquired and ventilator-associated pneumonia in adults", section on 'Prevention'.)

In one study in the PICU setting, implementation of a care bundle incorporating many of the measures listed above was associated with a decrease in VAT episodes in the pre-intervention to postintervention period from 3.9 to 1.8 cases per 1000 ventilator days [13]. However, another study using a similar care bundle aimed at reduction of VAP observed an increase in VAT rate from 2 to 3.2 episodes per 1000 ventilator days, while the VAP rate fell from 5.6 to 0.3 infections per 1000 ventilator days [9].

SUMMARY AND RECOMMENDATIONS

●Pathogenesis – Children who require artificial airways are at increased risk for bacterial tracheopulmonary infections because of bacterial colonization of the artificial airway and mucosal injuries related to airway cannulation. (See 'Introduction' above.)

●Clinical features – Tracheobronchitis in children with artificial airways is generally characterized by clinical signs of respiratory tract infection (eg, fever, cough, increased sputum production) without radiographic evidence of pneumonia. It may be difficult to distinguish from associated lung infection (eg, ventilator-associated pneumonia [VAP]) and viral infections involving the lower respiratory tract. (See 'Clinical features' above and 'Differential diagnosis' above.)

●Evaluation – The evaluation of suspected tracheobronchitis in a child with an artificial airway includes chest radiograph, complete blood count with differential, and Gram stain and culture of tracheal aspirate. Viral studies are helpful in some circumstances. (See 'Diagnostic evaluation' above.)

●Diagnosis – Tracheobronchitis in children with artificial airways is a clinical diagnosis. Commonly used diagnostic criteria include the following (see 'Diagnosis' above):

•Absence of clinical or radiographic evidence of pneumonia, AND

•A positive culture obtained by deep tracheal aspirate or bronchoscopy, AND

•≥2 of the following signs or symptoms with no other recognized cause:

-Fever >38°C (taken rectally in infants ≤1 year of age)

-Cough

-New or increased sputum production

-Rhonchi and/or wheezing

-In infants ≤1 year of age: respiratory distress, apnea, and/or bradycardia

●Treatment – For children diagnosed with bacterial tracheobronchitis (according to the criteria above), we suggest antibiotic therapy (Grade 2C). (See 'Treatment' above.)

Initial empiric antimicrobial therapy is aimed at providing coverage for the most likely pathogens (see 'Pathogens' above) and is individualized according to the severity of illness, previous culture results (if available), current Gram stain results, and local resistance patterns. (See 'Empiric therapy' above.)

The antibiotic regimen should be tailored when the culture and susceptibility results of the tracheal aspirate are available. The usual duration of treatment is three to seven days. (See 'Definitive therapy' above.)

●Outcome – Among children admitted to the pediatric intensive care unit (PICU), ventilator-associated tracheobronchitis (VAT) is associated with prolonged duration of mechanical ventilation and PICU length of stay. Studies have not identified an increased risk of mortality in children with VAT. Among chronically tracheotomy-dependent children, most patients recover from a single episode of tracheobronchitis without lasting sequelae. (See 'Outcome' above.)

●Prevention – Measures to prevent respiratory tract infections in children with artificial airways include elevating the head of bed at least 30°, providing regular oral care, and extubating as soon as possible. (See 'Prevention' above.)