Tracheitis: symptoms, causes and treatment

The trachea is the firm tube running down the neck and into the chest. Air passes through it on the way to the lungs. When its lining becomes inflamed or infected, the condition is called tracheitis.

Doctors use the word in more than one way. A mild, viral irritation of the windpipe often goes unnamed and settles with a cold. Bacterial tracheitis is different. It is a distinct infection in which bacteria settle in the airway lining and produce thick secretions that can block the passage.

The NHS website has pages for neighbouring problems such as croup, laryngitis and bronchitis, but when this guide was written we could not find an NHS page devoted to tracheitis. The detail here comes mainly from a professional medical reference (the MSD Manual), which is US-based, together with NHS pages on related airway conditions. A children's doctor or ENT specialist is the right person to apply it to a particular child.

MSD says most children with bacterial tracheitis have the symptoms of a viral chest or throat infection for one to three days before the severe stage begins. In a smaller number, the illness starts suddenly. The picture can look like croup at first, which is why the diagnosis is sometimes missed early on.

The points that should make a parent or carer act at once are listed below. They are drawn from the MSD description of bacterial tracheitis and from the NHS croup advice on when to call 999.

• Noisy breathing, especially a harsh, high-pitched sound when the child breathes in (stridor).

• A cough, a high fever and thick secretions that can make a child choke.

• Struggling to breathe, with grunting, or the tummy sucking in under the ribs.

• Blue, grey, pale or blotchy skin, lips or tongue. On brown or black skin this can be easier to see on the palms and soles.

• A child who is unusually sleepy, floppy, hard to wake or very quiet and still.

• A child who looks very unwell and is getting worse quickly after a cold or flu.

MSD says bacterial tracheitis usually follows a viral upper respiratory infection, and it mentions influenza in particular. It can also develop as a complication of viral croup or after a breathing tube has been placed in the windpipe.

The bacteria involved most often are Staphylococcus aureus and group A streptococci. MSD adds that cases caused by Streptococcus pneumoniae or Haemophilus influenzae have become less common because of childhood vaccines that target those germs.

This is one reason the routine childhood vaccination schedule matters for airway infections. It is also why having a flu illness, and then suddenly getting worse, is the story clinicians listen for. Tracheitis is not caused by anything a parent did or failed to do.

Several airway illnesses sound alike, so a comparison helps. The table sets out what the NHS says about croup, laryngitis and bronchitis against what MSD says about bacterial tracheitis. It is a guide only, because a child can have more than one problem and only an examination can sort them out.

There is no home test. A doctor suspects bacterial tracheitis when a child has stridor, looks very unwell, and has become worse after a viral illness. MSD notes that a poor response to nebulised adrenaline, a medicine used for croup, should alert the doctor to the possibility.

The diagnosis can be confirmed by looking directly at the airway with a laryngoscope, which may show pus and inflammation below the voice box. A side-on X-ray of the neck can also show narrowing of the windpipe, with an irregular outline rather than the smooth taper seen in croup.

MSD stresses that direct laryngoscopy should be done where a breathing tube can be placed quickly if needed. For that reason the examination takes place in hospital, often in theatre or intensive care.

The first aim is a safe airway. MSD says severe cases are managed in the same way as epiglottitis, with a breathing tube placed in a controlled setting by a clinician skilled in children's airways. Heart and breathing monitoring may be needed for two to three days after diagnosis.

The second aim is to treat the infection. MSD says broad-spectrum antibiotics given into a vein are started first, chosen to cover Staphylococcus aureus (including MRSA) and streptococci. Once the exact germ is known, treatment is narrowed. MSD gives a course of at least 10 days, with oral antibiotics for 10 to 14 days after leaving hospital.

Doctors choose the medicines according to local resistance patterns, so a children's infection specialist often advises. Paracetamol or ibuprofen can ease fever and discomfort, but they are not a treatment for tracheitis.

MSD lists hypotension (low blood pressure), cardiorespiratory arrest, bronchopneumonia and sepsis as possible complications. Narrowing of the airway below the voice box after a long period with a breathing tube can happen, but MSD calls it uncommon.

It also reports that the picture has changed over time: children are older on average at diagnosis, and fewer are as severely ill as in older case series. Even so, intensive care admission is still frequent.

MSD says most children who are treated appropriately recover without lasting effects. Parents are usually told what to watch for at home after discharge, such as returning noisy breathing, and who to contact. A child who has had a breathing tube may be followed up by an ENT team.

Call 999 or go to A&E if a child is struggling to breathe, has blue, grey or blotchy skin, is very sleepy or limp, is unusually quiet and still, or is drooling and finding it hard to swallow. These are the signs given on the NHS croup page. The NHS says not to drive a child to A&E yourself: ask someone else to drive or call 999 and ask for an ambulance.

For a child with a cold who has a barking cough or noisy breathing but is otherwise comfortable, the NHS says to call 111 or ask for an urgent GP appointment. Calling 111 is also the advice for any child aged 4 years or under with a bronchitis-type illness.

Adults with a long cough, chest pain or breathlessness should follow the NHS bronchitis advice: urgent GP or 111 help if a cough lasts more than 3 weeks or brings up blood, and 999 for severe breathlessness or blue or grey lips.

Suspected bacterial tracheitis is an emergency, so the route is 999 and an NHS emergency department with children's facilities, not a private appointment. Airway control, intensive care and intravenous antibiotics are hospital services.

Private care becomes relevant afterwards or for repeat problems. A child with recurring noisy breathing, or who needed a breathing tube, may be seen by a paediatric ENT or respiratory specialist. Private and NHS routes lead to the same sort of assessments, such as airway endoscopy, so the difference is mainly in waiting time and choice of hospital.