Bacterial tracheitis, diagnosis and treatment

During a 22-month period, 5 children, 6-13 months of age, presented with an acute obstructive upper airway infection which resembled both croup and epiglottitis. All 5 failed to respond to standard treatment for croup, including aerosolized racemic epinephrine. In all patients, direct laryngoscopy revealed minimal or no change in the epiglottis and aryepiglottic folds but severe subglottic swelling and copious purulent tracheal secretions. Gram stains of the purulent secretions revealed many polymorphonuclear leukocytes with gram-positive cocci (3 patients) and small gram-negative rods (2 patients). Cultures subsequently confirmed the presence of S. Aureus and H. Influenzae. Initial therapy for all patients included endotracheal intubation, antibiotic therapy for both S. Aureus and H. Influenzae and frequent tracheal suctioning. Hospitalization varied from one to 3 weeks. We reported findings in these patients because: the initial diagnosis was unclear due to confusion caused by clinical features common to both croup and epiglottitis and bacterial tracheitis requires a prompt accurate diagnosis and aggressive antibiotic and airway management in order to prevent unnecessary morbidity and mortality.

Diagnosis and therapy of necrotizing tracheobronchitis in ventilated neonates

From January 1983 to September 1984 our neonatal ICU (NICU) treated eight endotracheally intubated infants who had suspected airway obstruction characterized by hypercarbia dissonant with severity of lung disease and difficulty in ventilation with lack of chest movement, both on conventional intermittent mandatory ventilation and high-frequency oscillation. Bronchoscopic removal of necrotic tissue was possible in six infants, two of whom survived. Bronchoscopy showed desquamation of epithelial surfaces, leaving encrusted exudations considered to be characteristic of necrotizing tracheobronchitis (NTB). The four nonsurvivors of bronchoscopy and one of the infants not submitted to bronchoscopy had NTB confirmed at autopsy. NTB was not associated with any specific lung disease, humidifier, or ventilator. The autopsy frequency of NTB during this period was 5 per 160 NICU admissions. A separate chart review of unselected autopsied cases in 1981 and 1982 showed that 12 of 284 neonates admitted to the NICU had NTB. NTB appears to be a rediscovered condition related to endotracheal intubation and mechanical ventilation using high mean airway pressures.

Herpetic tracheobronchitis detected at bronchoscopy: cytologic diagnosis by the immunoperoxidase method

Herpes simplex virus (HSV) infection of the respiratory tract requires rapid specific diagnosis to avoid late complications and maximize the efficacy of available drug therapy. We report a method of accomplishing this that was tested in 33 cytologic specimens derived from sputum, washings, or brushings from 25 debilitated elderly males suffering from a variety of underlying neoplastic and nonneoplastic chronic diseases. All specimens had shown either single cells (54%), multinucleated groups (8%), or both (38%); they displayed the ground-glass appearance (86%), discrete nuclear inclusions (4%), or both (10%), as appreciated by the Papanicolaou stain. The specimens were processed by the peroxidase-antiperoxidase technique utilizing anti-HSV-1 antibody and 3,3'-diaminobenzidine (DAB) as the chromogen. In six cases, aminoethylcarbazol (AEC) was used for comparison. Twenty-nine of the 33 specimens (88%) stained positively for HSV-1 as did control sections of herpetic encephalitis and esophagitis; there were no false positives with appropriate negative controls. All 12 bronchoscopic specimens revealed virocytes with HSV immunopositivity; in contrast, 17 of 21 (80%) sputum specimens were positive for HSV. The strongest positivity was noted in bronchial brushings and washings whereas the only four negative smears were from sputum specimens. The DAB immunostain was coarser and stronger at the periphery of the cytoplasm, and the hematoxylin counterstain permitted a clear identification of nuclear viral changes. With AEC, the immunostain was more vivid and evenly distributed, but counterstaining was impaired due to the greater solubility of the chromogen. The technique is sensitive, reproducible, and less expensive and time-consuming than electron microscopy (EM) or viral cultures.

Adverse effects of racemic epinephrine in epiglottitis

Acute epiglottitis, a potentially fatal disease, may be difficult to diagnose if the presentation is atypical. We present three such patients who were initially diagnosed as acute laryngotracheitis. They deteriorated rapidly after administration of racemic epinephrine via nebulizer. We caution that: diagnosis of acute epiglottitis should be considered in similar patients; and appropriate precautions must be taken prior to visualization of the airway.

Bacterial tracheitis--two-year experience

Inflammatory illnesses of the pediatric airway cause significant morbidity and mortality. Bacterial tracheitis is a distinct entity with features common to both croup and epiglottitis. Ten patients between the ages of 3 months and 12 years were treated at Children's Hospital, Boston, MA., for bacterial tracheitis. The clinical presentation and medical management is discussed. Seven of the patients required both direct laryngoscopy and bronchoscopy; one patient required urgent intubation; and one patient required indirect laryngoscopy. In one patient the diagnosis was based on clinical and radiographic findings in conjunction with tracheal aspirates. Seven of the 10 patients did well with aggressive medical management. Three patients required endotracheal intubation. No patient required tracheotomy, and there were no cardiopulmonary arrests. It is of particular interest that although the patients in this series presented in a manner similar to that of patients in other published series, the management is significantly different and the overall outcome is significantly better.

Stridor in childhood

The acute onset of stridor in a young child usually represents viral croup, particularly during the fall and early winter. If the clinical picture is entirely consistent with this diagnosis and gas exchange is maintained, management with cool mist at home is appropriate. Rapid deterioration is unusual in viral croup; however, if obstruction is prolonged or becomes unusually severe, racemic epinephrine aerosols, hospitalization for careful observation, a brief course of corticosteroid therapy, and, rarely, endotracheal intubation may be required. Many of the other causes of acute stridor in childhood represent true pediatric emergencies: epiglottitis, foreign body aspiration, bacterial tracheitis, allergic airway edema, and retropharyngeal abscess, all requiring management with a consultant. Chronic stridor in infancy most often represents laryngomalacia, a developmental abnormality of the laryngeal cartilage which usually resolves by the second year of life and rarely requires specific treatment. Other causes of chronic stridor in childhood include subglottic hemangioma, vocal cord paralysis, and a long list of abnormalities. In the older child with chronic stridor or in the infant whose clinical picture is unusual for laryngomalacia, airway roentgenograms, barium studies, or laryngoscopy/bronchoscopy should be obtained to establish the definitive diagnosis.

Laryngeal cancer: long-term follow-up of respiratory functions after laryngectomy

Pulmonary function of 31 heavy smokers with laryngeal cancer was evaluated before and during the 1st year after total (n = 21) and conservative (n = 10) laryngectomy. 2 of them died because of recurrences, 1 for bronchopulmonary complications. Long-lasting hoarseness was the only presenting symptom in all patients. Preoperative lung function data and mucociliary clearance were consistent with a coexisting chronic obstructive lung disease in most subjects and was probably due to smoking. No differences were observed comparing pre- and postoperative data in the 10 conservative laryngectomy patients. On the contrary, the total-laryngectomy patients showed a progressive impairment of bronchial obstruction and bacteriological infection of the trachea during the 1st year after the operation. An impressive increase in mucociliary clearance rates has been observed 2 months after total laryngectomy during the postoperative hypersecretory phase. the obtained data allow us to hypothesize that when clinical conditions of laryngectomized patients in whom local or distant recurrences have been excluded deteriorate, this is related to a progressive bronchial obstruction at any level of the bronchial tree due to descending bacterial infection of the airways. To our knowledge this is the only work demonstrating that total laryngectomized patients need a complete pre- and postoperative evaluation of lung function, airway dynamics, mucociliary function and tracheal bacteriology for long-term prognosis and treatment.

Epiglottitis and laryngotracheobronchitis

Epiglottis and laryngotracheobronchitis are potentially life-threatening infections in the pediatric population. Unlike epiglottitis, laryngotracheobronchitis is very common. While both diseases may present with stridor and signs of respiratory obstruction, it is important to distinguish between them because the management strategies differ. Laryngotracheobronchitis usually responds to humidification. Epiglottitis requires an artificial airway and intensive antibiotics. The use of steroids remains controversial.

Bacterial tracheitis

Bacterial tracheitis is a recently described clinical entity characterized by high fever, stridor, and airway obstruction. Laryngoscopy shows membraneous inflammation with notable subglottic edema and copious mucopus in the trachea. Staphylococcus aureus is the most common bacterium to be cultured. Subglottic narrowing can be seen on lateral soft-tissue roentgenograms of the neck. Bacterial tracheitis should be treated by establishing a controlled airway by endotracheal intubation or tracheotomy, rather than by usual modalities used for the treatment of croup. Bacterial tracheitis seems to be similar to croup but is more likely to be fatal. Two of the five patients described herein died.

[Diagnosis and therapy of sternostomiasis in canaries]

Fifteen canaries were tested for the possibility of objective intravital diagnostics by smears from the trachea, by transparent tracheoscopy, X-ray examination, and coprological examination. All the results were negative. A positive outcome of the tests is the method of the fixing of the birds for X-ray examination, also applicable for other purposes. Thirty canaries were used for testing the results of therapy by a preparation based on DTHP-Hypocide. Twelve of them were killed before therapy for post-mortal diagnosis, twelve were killed two days, and six were killed nine days from the termination of the therapy. The post-mortem examination of the treated birds demonstrated the effectiveness of the therapy; however, the dosage, application intervals and application sites were found to be unsuitable.

Invasive Hemophilus infections: epiglottitis and cellulitis

Epiglottitis, along with other infectious croup syndromes (laryngotracheitis and spasmodic croup), are illnesses which cause acute upper airway obstruction. They are discussed in terms of etiology, symptoms, diagnosis and treatment. Cellulitis and the role of Hemophilus influenzae and antibiotic therapy are also described.

Etiology of stridor in the neonate, infant and child

Of 219 patients whose primary presenting symptom was stridor, 150 were males, 69 were females. All were under 2 1/2 years of age; more than half were four months of age or younger. Congenital anomalies caused stridor in 191 (87.2%). Congenital laryngeal anomalies accounted for the stridor in 132 (60.3%); there were 35 (16.0%) patients with congenital tracheal anomalies, 11 (5.0%) with congenital bronchial anomalies, 12 (5.5%) with infectious conditions, 12 (5.5%) with internal laryngeal trauma and 15 (6.8%) patients with other conditions. The cause of stridor was undetermined in two patients. Sixteen vascular anomalies were diagnosed and classified according to the part of the tracheobronchial tree which was involved. Twenty-six patients required tracheotomy. Fifty-eight (26.5%) were referred with an erroneous presumptive diagnosis for which they were being treated. The mean length of time from onset of symptoms to determination of the correct diagnosis by endoscopy was four months; it varied from one day to 16 months. The importance of early endoscopy for the diagnosis of conditions causing stridor cannot be overemphasized. The occurrence of more than 1 anomaly in 99 (45.2%) of the 219 patients demonstrates the importance of complete endoscopic examination of all patients with stridor.

Bacterial tracheitis

During a 14-month period, eight infants and children were observed with an acute, infectious, upper airway obstructive disease with features common to both croup and epiglottitis. We have termed this distinct entity "bacterial tracheitis." All patients failed to respond to treatment for croup, including racemic epinephrine delivered by intermittent positive-pressure breathing. Direct laryngoscopy consistently revealed a normal epiglottis and aryepiglottic folds but marked subglottic mucosal edema. Tracheal suctioning yielded copius mucopus below the subglottic swelling. Gram stain of this material corroborated subsequent cultures: Staphylococcus aureus, six; group A Streptococcus, one; and Haemophilus influenzae (not typed), one. All patients required periodic tracheal suctioning for relief of upper airway obstruction. Six patients required endotracheal intubation; one required a tracheostomy. Bacterial tracheitis should be considered in the differential diagnosis of a young child with a croup-like illness that is refractory to conventional therapy.

[Diagnostic and therapeutic applications of bronchoscopy (author's transl)]

The development of therapeutic bronchoscopy into diagnostic bronchoscopy is described. Based on a personal experience of more than 35,000 bronchoscopies, attention is given to some important points in diagnosis and therapy. In diagnosis, these factors include: 1) color of mucosa, 2) structure of cartilage, 3) minimal tissue changes (nodules, vessels, folds), 4) tonus, 5) secretion, 6) miscellaneous peculiarities. Therapeutic studies involve: 1) recanalisation (from secretion to foreign body and tumor), 2) scrubbing (in treatment of fibrinous bronchitis and tracheitis, 3) bougies, 4) irrigation, 5) washing (for status asthmaticus, aspiration of gastric contents, etc.), 6) tamponade for persistent hemoptysis.

Diagnosis of gastric aspiration by fiberoptic bronchoscopy

At the time of bronchoscopic observation, 28 of 31 patients proved to have aspirated gastric contents by the presence of gastric contents in the trachea or by direct observation of gastric aspiration followed by respiratory distress and erythema of subsegmental bronchi. Since gastric aspiration is a difficult diagnosis to make and few objective data are available to make the diagnosis, the present study would indicate that early fiberoptic bronchoscopic observation of the tracheobronchial tree is a useful procedure to establish a definitive diagnosis and to allow proper planning for clinical management.

Acute epiglottitis in infants and children

Sixty-one cases of acute epiglottitis at the Royal Alexandra Hospital for Children, Sydney, from July 1968 to December 1974 are reviewed. The average age of 2.7 years is lower than previously reported. The average time from the initial symptom to arrival at the hospital was 14 hours. The average time from arrival to performance of tracheotomy was two hours. The diagnosis was made when first seen and assessed in 50 of the 61 cases. There were eight respiratory arrests in the Casualty and five of these were successfully resuscitated. We believe that an artificial airway is necessary in most cases, and in this series, tracheotomy was performed, with minimal complications. Particular emphasis is given to diagnosis from the history, and a detailed description is given of physical examination of the oropharynx. Although x-ray examination is usually unnecessary when the diagnosis is in doubt, a plain lateral x-ray may be useful, with due precaution not to increase the respiratory obstruction. We consider that a patient with acute epiglottitis should be transferred immediately to a major pediatric hospital, and that in almost every case an artificial airway should be established.

Herpetic tracheobronchitis. Cytologic and virologic detection

Tracheobronchitis due to herpes simplex virus is a well-recognized finding in cases of burns, debilitation, or immunosuppression. Nearly all reported cases have been diagnosed at necropsy despite the possibility for clinical detection of such infections by exfoliative cytological studies, virus isolation and identification, or both. The present report details the cytologic and virologic diagnosis of herpetic tracheobronchitis in a patient with carcinoma of the lung and alcoholic fatty liver. Respiratory cells with herpetic infection cytologically showed less tendency to multinucleation than the characteristic herpes-infected cells of squamous epithelium, which may be a source of diagnostic confusion.

Respiratory syncytial and other viruses associated with respiratory disease in infants

Diagnosis by virus isolation and serology was attempted in 377 cases of respiratory-tract infection in infants under one year of age admitted to hospital during two winters. A diagnosis of infection with respiratory syncytial (R.S.) virus was made in 40%, rhinovirus in 6·1%, adenovirus in 3·7%, parainfluenza in 2·1%, enterovirus in 1·9%, and influenza in 1·3%. R.S.-virus infections were more severe than others and occurred mostly in the first five months of life, with a peak at two months. Rhinovirus infections occurred at all ages, and often involved the lower respiratory tract. Of the 12 deaths, only 1 (due to R.S. virus) was not associated with a contributory cause. Maternal antibody to R.S. virus did not notably affect the incidence or severity of R.S.-virus infections.

Detection of infectious bovine rhinotracheitis (IBR) by immunofluorescence

Infectious bovine rhinotracheitis can be readily and accurately diagnosed by direct fluorescent antibody techniques on infected bovine embryo kidney monolayers. Non-specific fluorescence was encountered in direct observation of bovine nasal secretions and cotyledon impressions.