Tracheobronchitis associated with tracheostomy tubes and endotracheal intubation in children

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©2022 UpToDate®

Tracheobronchitis associated with

tracheostomy tubes and endotracheal
intubation in children
Author: Charles R Woods, MD, MS
Section Editors: Glenn C Isaacson, MD, FAAP, Sheldon L Kaplan, MD
Deputy Editor: Carrie Armsby, MD, MPH

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.

Literature review current through: Oct 2022. | This topic last updated: Sep 27, 2022.

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,
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Tracheobronchitis associated with tracheostomy tubes and endotracheal intubation in children

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 "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

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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
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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

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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

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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)

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● 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.
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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
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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
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metapneumovirus). (See "Seasonal influenza in children: Clinical features and

diagnosis" and "Respiratory syncytial virus infection: Clinical features and
diagnosis" 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
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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

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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")

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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.)

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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".)
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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
"Overview of carbapenemase-producing gram-negative bacilli", section on
'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

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● 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
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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]:

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● 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'.)
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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.)

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● 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'
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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.)

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Topic 6045 Version 15.0

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