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 tracheopulmonary infections. Tracheobronchitis in this setting is generally characterized by clinical signs of respiratory tract infection (eg, fever, cough, increased and/or purulent sputum production, increased need for tracheal suctioning) without radiographic evidence of pneumonia.

Tracheal infections associated with tracheostomy tubes and endotracheal intubation in children will be discussed here. Bacterial tracheitis in children without artificial airways and ventilator-associated pneumonia (VAP), are discussed separately:

●Bacterial tracheitis in children without artificial airways (see "Bacterial tracheitis in children: Clinical features and diagnosis" and "Bacterial tracheitis in children: Treatment and prevention")

●VAP (see "Clinical presentation and diagnostic evaluation of ventilator-associated pneumonia" and "Treatment of hospital-acquired and ventilator-associated pneumonia in adults" and "Risk factors and prevention of hospital-acquired and ventilator-associated pneumonia in adults")

TERMINOLOGY

●Terms describing the scope of this topic – 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) [1,2]. VAT is generally characterized by clinical signs of respiratory tract infection (eg, fever, cough, increased sputum production, increased need for tracheal suctioning) 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. VAT applies to patients receiving mechanical ventilation via an endotracheal tube or tracheostomy. (See "Complications of the endotracheal tube following initial placement: Prevention and management in adult intensive care unit patients", section on 'Tracheobronchitis'.)

•Tracheostomy-associated tracheobronchitis – Tracheobronchitis also can occur in children who have tracheostomy tubes for airway support but who are not receiving mechanical ventilation. The term "tracheostomy-associated tracheobronchitis" is a more appropriate descriptor for this category of infection, with VAT representing a substantial subset of this.

•"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."

●Terms used to describe clinical entities that are discussed separately – The following conditions are not the focus of this topic and are discussed separately:

•Bacterial tracheitis – This term generally refers to an invasive exudative bacterial infection of the soft tissues of the trachea that occurs in previously healthy children most commonly in the setting of a preceding 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".)

•Ventilator-associated pneumonia (VAP) – VAP is a type of hospital-acquired infection that develops after more than 48 hours of invasive mechanical ventilation. VAP is an important problem in the intensive care unit setting, and it is associated with an increased risk of mortality. Diagnostic criteria for "probable" VAP are summarized in the figure (algorithm 1) and discussed in greater detail separately. (See "Clinical presentation and diagnostic evaluation of ventilator-associated pneumonia".)

MICROBIOLOGY

●Bacteria

•Colonization – Artificial airways rapidly become colonized with potentially pathogenic bacteria [3,4]. Colonizing bacteria may arise from the upper airway, ventilator tubing or reservoirs, or humidification circuits [5]. In children who are chronically tracheostomy-dependent, bacterial biofilms likely play an important role [6].

The frequency of bacterial colonization among intubated children managed in the intensive care unit setting was described in a prospective study of 61 endotracheally-intubated children who had routine surveillance cultures performed in the absence of evidence of infection [7]. By four to six days after intubation, approximately 50 percent of tracheal aspirate cultures yielded moderate to heavy growth (≥10⁴ cfu/mL) of pathogenic bacteria.

Similarly, in a study of 68 children who underwent tracheostomy at a single institution, 53 percent were noted to have positive tracheal cultures within 30 days of surgery [8]. 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 Pseudomonas aeruginosa during the first two years [9].

•Bacterial pathogens – The bacterial pathogens that cause respiratory tract infections in children with artificial airways are generally those that colonize the airway, including S. aureus, P. aeruginosa, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Acinetobacter species, Klebsiella pneumoniae, Escherichia coli, Serratia marcescens, Enterobacter species, Stenotrophomonas maltophilia, and other gram-negative enteric organisms [3,4,7,8,10-16].

Most cases of artificial airway-associated tracheobronchitis are associated with a single bacterial pathogen in culture, though a substantial minority are polymicrobial [12,13,15]. In a study of 164 children with tracheostomies diagnosed with tracheobronchitis, a single pathogen was isolated in 72 percent, two pathogens in 24 percent, and three in 4 percent [13]. The most commonly isolated organisms in this study were P. aeruginosa, S. marcescens, and S. aureus; patients who had been hospitalized for >7 days before onset had a higher likelihood of growing E. coli or K. pneumoniae.

In a prospective multicenter study of 237 episodes of tracheostomy-associated infections (including either tracheobronchitis or pneumonia) in hospitalized children, 35 percent of respiratory cultures grew P. aeruginosa plus ≥1 other pathogen, 10 percent grew P. aeruginosa alone, 32 percent grew nonpseudomonal pathogens alone, and 23 percent were negative or grew normal respiratory flora [15].

●Viruses – Viral lower respiratory tract infections in children with artificial airways are caused by the same respiratory viruses that affect children without artificial airways (eg, influenza, respiratory syncytial virus, rhinovirus, parainfluenza, human metapneumovirus, SARS-CoV-2). (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".)

●Fungi – Fungal pathogens (eg, Candida, Aspergillus) generally do not play a role in VAT, though they are occasionally detected in cultures from children with artificial airways [8,12].

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 [12,17-19]. 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) [12].

●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) [20,21]. 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 [5]:

●New fever or a change from baseline body temperature, including elevated or decreased body temperature

●New onset of cough, respiratory distress, or increased work of breathing

●Change in the color, thickness, and/or odor of tracheal secretions (ie, more purulent secretions as opposed to thin clear secretions)

●Increased need for airway suctioning

●Increased need for supplemental oxygen or ventilatory support; however, a marked increase in ventilatory requirement is more suggestive of VAP

In a prospective multicenter study of 237 episodes of tracheostomy-associated infections (including either tracheobronchitis or pneumonia) in hospitalized children, the relative frequency of these findings was as follows [15]:

●Fever – 44 percent

●Hypothermia – 6 percent

●Breathing difficulty or respiratory distress – 58 percent

●Change in quantity or quality of tracheal secretions – 68 percent

●Hypoxemia or increased oxygen requirement – 66 percent

●Requirement for increased ventilator settings – 18 percent

The above clinical findings are also seen in patients with VAP; however, the clinical course tends to be less severe in tracheobronchitis compared with VAP. The distinction between ventilator-associated tracheobronchitis (VAT) and VAP is made with chest imaging, as discussed below. (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). Absence of a new infiltrate on chest radiograph generally excludes VAP. However, if the child does not improve as expected, a follow-up chest radiograph may be warranted since radiographs obtained early in the course of VAP may be nondiagnostic.

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 pediatric 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 [22,23]. 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 [5]. 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 [7].

The number of polymorphonuclear neutrophils (PMNs) on the Gram stain is also useful in determining the likelihood of infection. PMNs can be measured quantitatively (ie, ≥25 per low power field) or semiquantitatively (ie, none, few [1+], moderate [2+], many [3+], or abundant [4+]). If PMNs are absent or present only in low numbers, bacterial infection is unlikely. However, many PMNs on Gram stain, even when exceeding the 25 per low power field threshold, may occur in the absence of infection [7].

In a prospective multicenter study of 289 tracheostomy-dependent children with 440 encounters for suspected respiratory tract infection, those with moderate/many PMNs on Gram stain were three times more likely to be diagnosed with tracheobronchitis or pneumonia compared with those who had no or few PMNs on Gram stain [15].

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, this finding in isolation is insufficient to establish the diagnosis. In the absence of other clinical evidence of infection, positive culture results even in this quantity often represent airway colonization [7,22]. In a study evaluating 552 cultures from 62 children with tracheostomies, colony counts among children without infection were similar to those of children diagnosed with tracheobronchitis [24].

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 [25]. 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 [9].

Viral testing — In children who are chronically tracheostomy-dependent, viral lower respiratory tract infections (LRTI) 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 LRTI 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.

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 LRTI. However, if both the bacterial culture and viral testing are positive, this may represent either viral LRTI complicated by bacterial superinfection or viral LRTI 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 [5]. 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 [22,26-28]. No single test confirms the diagnosis.

●Clinical diagnosis of tracheobronchitis in chronically tracheostomy-dependent children – For children who are chronically tracheostomy-dependent, tracheobronchitis is typically diagnosed clinically on the basis of fever, cough, and new onset purulent tracheal secretions in the absence of other causes for these findings such as a viral infection. Sputum/tracheal aspirate cultures are helpful in the management; however, positive cultures alone are insufficient to make the diagnosis since most patients with tracheostomies are chronically colonized.

●Diagnostic criteria for ventilator-associated tracheobronchitis (VAT) in intubated patients – The most commonly used diagnostic criteria for VAT are those of the Centers for Disease Control and Prevention (CDC)/National Healthcare Safety Network (NHSN) surveillance definition [29]. The definition requires all of the following criteria (table 1):

•Patient has been intubated for at least 48 hours

•New onset of signs of respiratory tract infection, including ≥2 of the following with no other recognized cause:

-Fever >38°C or hypothermia <36°C

-Cough

-New or increased sputum production/increased need for endotracheal suctioning

-Rhonchi and/or wheezing

-Respiratory distress (or apnea and/or bradycardia in neonates)

•No radiographic evidence of pneumonia

•A positive culture obtained by deep tracheal aspirate or bronchoscopy

These surveillance criteria have limitations, and they therefore lack precision. The determination of increased sputum production at the bedside can be somewhat subjective [26]. 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 [22,26]. Chest radiographs lack specificity and sensitivity in detecting pulmonary infiltrates such that episodes defined clinically as VAT could truly be early ventilator-associated pneumonia (VAP) [26]. 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 [7].

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 [11,12,17,18,28,30].

In practice, clinicians should be aware that VAT lies on a continuum between colonization and VAP; determining when the patient reaches the threshold for treatment requires clinical judgment.

DIFFERENTIAL DIAGNOSIS — 

The differential diagnosis of bacterial tracheobronchitis in children with artificial airways includes [5]:

●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, reduce duration of mechanical ventilation and length of stay [LOS] and prevent progression to a more serious 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

●Decision to administer empiric antibiotics – For patients with a presumptive diagnosis of bacterial tracheobronchitis based upon the above criteria (see 'Diagnosis' above), the decision to administer empiric antibiotic therapy while awaiting culture results depends on illness severity:

•Mild symptoms: Defer until culture results are available – For patients with mild symptoms (low-grade fever and slightly increased sputum production or need for suctioning) who are otherwise well-appearing, we usually defer treatment until culture results are available. (See 'Definitive therapy' below.)

•Moderate to severe symptoms: Start upfront empiric therapy – For patients with considerable symptomatology (eg, high fevers, respiratory distress, need for increased ventilator settings), upfront empiric therapy is usually warranted pending culture results.

●Factors determining choice of empiric therapy – When the decision is made to administer empiric antibiotics, the choice of therapy is aimed at providing coverage for the most likely pathogens (see 'Microbiology' above) and is influenced by the following factors [5]:

•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 [25].

•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.

●Empiric therapy for tracheostomy-dependent children who are not systemically ill – For treatment of tracheobronchitis in chronically tracheostomy-dependent children who do not appear systemically ill, oral/enteral antimicrobial therapy is appropriate. 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, or

•A fluoroquinolone (eg, ciprofloxacin or levofloxacin) [14], or

•Clindamycin

●Empiric therapy for intubated children or tracheostomy-dependent children who are systemically ill – 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). The choice of therapy in these patients is similar to the approach for hospital-acquired pneumonia, as discussed separately. (See "Pneumonia in children: Inpatient treatment", section on 'Hospital-acquired pneumonia'.)

●Additional considerations based upon Gram stain results – 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" and "Carbapenem-resistant E. coli, K. pneumoniae, and other Enterobacterales (CRE)", section on 'Approach to treatment'.)

Reevaluation — After initiating treatment for artificial airway-associated tracheobronchitis, we suggest re-evaluating the diagnosis within 24 to 48 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 nonpathogenic microbe, or polymicrobial growth suggesting 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 uncomplicated artificial-airway-associated bacterial tracheobronchitis [28,30]. Many antimicrobial stewardship programs favor a three-day treatment course for VAT [28].

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) [30]. 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 [11,12,17,18]. While the lack of association suggests that VAT is not a serious illness in most cases, the studies 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) [11,12,17,18]. 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) [31]. There were no deaths attributable to tracheobronchitis.

PREVENTION — 

Measures that may help prevent respiratory tract infections in children with artificial airways include the following [17,32]:

●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 [8].

Several studies in the PICU setting have shown that implementing care bundles incorporating many of the measures listed above is associated with lower rates of VAT and VAP [12,17,33]. Additional 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'.)

SUMMARY AND RECOMMENDATIONS

●Pathogenesis – Children who require artificial airways (eg, children who are chronically tracheostomy-dependent and those who require acute endotracheal intubation) are at risk for bacterial tracheobronchitis 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/increased need for endotracheal suctioning) 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 (see 'Diagnostic evaluation' above):

•Chest radiograph (see 'Chest imaging' above)

•Complete blood count with differential (see 'Complete blood count' above)

•Gram stain and culture of tracheal aspirate (see 'Gram stain' above and 'Culture' above)

•Viral testing (see 'Viral testing' above)

●Diagnosis

•Clinical diagnosis of tracheobronchitis in chronically tracheostomy-dependent children – For children who are chronically tracheostomy-dependent, tracheobronchitis is typically diagnosed clinically on the basis of fever, cough, and new onset purulent tracheal secretions in the absence of another explanation for these findings such as a viral infection. (See 'Diagnosis' above.)

•Diagnostic criteria for ventilator-associated tracheobronchitis (VAT) in intubated patients – The diagnostic criteria for VAT in this setting are summarized in the table (table 1).

●Treatment – For children diagnosed with bacterial tracheobronchitis (according to the criteria above), we suggest antibiotic therapy (Grade 2C). For patients with mild symptoms (low-grade fever, slightly increased sputum production or need for suctioning) who are otherwise well-appearing, treatment can be deferred until culture results are available. Upfront empiric therapy pending culture results is appropriate if the patient has considerable symptomatology (eg, high fevers, respiratory distress, need for increased ventilator settings). (See 'Treatment' above.)

Initial empiric antimicrobial therapy is aimed at providing coverage for the most likely pathogens (see 'Microbiology' 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), 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.)