It's 1:30 a.m. on a chilly January morning. With a busy day behind them and reports finally completed, ambulance crew members settle into their bunks and quickly fall asleep. Suddenly, their sleep is interrupted with a familiar request: "Medic 14, respond code 3 to difficulty breathing."
They alert dispatch that they're responding and take a quick look at the call information: "three-year-old child in severe respiratory distress." The 10-year-veteran crew member's normal nonchalance regarding "difficulty breathing" calls immediately disappears, and, driving just a little faster than normal, he reviews with his junior partner the differential diagnosis for acute respiratory distress in young children. Asthma and acute obstruction are considered, as well as conditions typically unique to the pediatric population: croup, epiglottitis and bronchiolitis among them.
On arrival, the crew finds the three-year-old male conscious, apparently alert to surroundings, non-verbal, with labored ventilations and audible inspiratory/expiratory stridor. Of particular note is a frequent barking, seal-like cough.
Trauma is immediately ruled out, and the patient is exposed to allow for assessment/treatment. Physical exam reveals hot, dry skin and bilateral wheezes to auscultation. Accessory muscle use does not appear to be significant, and there's no central or peripheral cyanosis noted.
Recent history includes upper respiratory symptoms for two weeks to include runny nose and productive cough. During the exposure and initial assessment, the parents tell the paramedics that they put the child to bed approximately four hours ago, and were awakened by coughing from the child's room about half an hour ago. They didn't note him as being in serious respiratory distress at the time; he was able to speak in a very hoarse voice and was complaining of a severe sore throat. They further report that the patient became febrile approximately 12 hours ago with a marked increase in temperature over the past six hours. On interview, the parents deny apparent dysphasia, muffled "hot potato" voice or marked drooling.
"Croup," says the senior paramedic. His partner, nodding in agreement, sits the patient up in a high Fowler's position. The veteran paramedic begins to administer treatment for suspected viral croup per local protocols: humidified oxygen followed by nebulized epinephrine. Confident that the child's condition will begin to improve shortly, he assumes care of the patient and brings a firefighter along to assist him.
Medic 14 begins code 2 transport to the nearest hospital, with base hospital contact made en route. The paramedic informs the base hospital that they're coming in with a pediatric patient exhibiting signs and symptoms consistent with croup, and that they've followed local protocols and have treatment in progress. The hospital is given an ETA of 20 minutes.
After establishing an IV of normal saline, the paramedic reassesses the patient, who's now exhibiting markedly increased work of breathing, increased stridor, decreased oxygen saturation and intercostal retractions. The patient is beginning to look tired and is exhibiting peripheral cyanosis. "Bump it up to code!" the attending paramedic shouts to his partner, then directs the firefighter to get ready to ventilate the patient with a bag-valve mask.
Three minutes later, the firefighter indicates that the patient is now taking only gasping breaths. Respiratory arrest appears imminent. The patient is laid supine, and the upper airway is visualized with a laryngoscope. Thick, mucosal secretions are suctioned, and the epiglottis comes into view. It doesn't appear to be swollen, and intubation is attempted with a 4.5 mm ID endotracheal (ET) tube, which is the indicated size for a three-year-old. Despite adequate glottic visualization, the paramedic is unable to pass the ET tube. He instructs the firefighter to place an oropharyngeal airway and begin bag-valve-mask ventilations.
He recontacts the base hospital to give an update. With the base hospital physician on the radio, the paramedic gives a detailed account of the patient's history, presenting signs and symptoms, the failure of standard treatment for croup to produce any improvement in patient condition, and the inability to intubate the patient.
Bacterial Tracheitis: Frequency & Causes
Bacterial tracheitis is a rare but serious infection of the upper airway characterized by an inflammation of the larynx, trachea and bronchi. Affecting only approximately one in 1,000,000 people a year, it strikes primarily children between three and eight years of age.(1) Bacterial tracheitis is caused by several different bacterial pathogenic infections of the respiratory tract, including Staphylococcus aureus, Streptococcus pyogenes, Streptococcus pneumoniae, Moraxella catarrhalis, Haemophilus influenzae type b, Klebsiella species, Pseudomonas species, Peptostreptococcus species, Bacteroides species and anaerobes.(2)
Typically, a child will develop bacterial tracheitis secondary to a prolonged acute respiratory viral infection, which leaves the immune system vulnerable to bacterial infection. With the bacterial invasion of the trachea, local and systemic inflammatory responses occur, including mucopurulent exudates, ulceration and sloughing of the tracheal mucosa. These processes in turn present a high potential for upper airway obstruction.Recognition & Assessment
Bacterial tracheitis typically occurs during the fall and winter months and presents with signs and symptoms very similar to viral croup, including inspiratory stridor and a cough often described as "barking," "brassy," or "seal-like." This presentation often leads to an initial misdiagnosis of croup. In addition to stridor and the classic cough, there's typically a history of prolonged upper respiratory infection symptoms, to include runny nose, productive cough, and fever. Marked drooling and dysphagia, commonly seen with epiglottitis, are typically absent.
Distinguishing bacterial tracheitis from croup based on signs and symptoms requires recognizing that croup typically progresses in a fairly slow fashion, whereas bacterial tracheitis symptoms are usually subclinical for a prolonged period and then suddenly become severe. Wheezing, not typically present with croup, may be a finding in bacterial tracheitis secondary to bronchial involvement. Fever, although present in both circumstances, is typically low-grade in croup and very high in bacterial tracheitis, often reaching 103Ï104_ F. The fever will also usually be reported as having become much worse over a period of several hours, whereas croup tends to produce a fever that, once present, is stable.
Interestingly, the sudden increase in fever is most often the reason for the 9-1-1 call -- not the significant deterioration in the patient's respiratory condition it typically correlates with. Of particular note is that standard croup treatment -- humidified oxygen and racemic epinephrine -- tend to produce no improvement, and there may even be a marked deterioration in patient condition.
Because of the risk of complete or near-complete airway obstruction, appropriate treatment must be started early and is based on aggressive assessment and reassessment. Pay particular attention to signs that would indicate deoxygenation, such as a markedly decreased pulse oximetry reading or peripheral cyanosis, as well as warning signs of impending respiratory collapse, such as sternal/intercostal retractions and suddenly severe work of breathing. If these conditions are not present, field treatment is mainly supportive and consists of positioning the patient in high Fowler's, providing blow-by non-humidified oxygen and rapid transport to a hospital. If respiratory failure is imminent, treatment involves immediate placement of an ET tube following methodologies prescribed by regional guidelines. Due to the inflammation of the airway and the presence of thick secretions, an ET tube 1 mm ID smaller than normally indicated is the correct choice.(2)
In the clinical setting, treatment involves aggressive, definitive respiratory management to include bronchoscopy and pulmonary toilet, as well as wide spectrum IV antibiotic therapy.Outcome
The detailed account presented by the paramedic allowed the base hospital physician to formulate a working diagnosis of bacterial tracheitis. The failure of the first intubation attempt was attributed to non-recognition of the need to use a smaller ET tube than would normally be indicated, and the second attempt, using a tube 1 mm ID smaller than the first, was successful. The patient was provided ET ventilations for the remainder of the transport. On arrival at the hospital, the patient's signs of perfusion were excellent: Peripheral cyanosis was resolved, and the patient's oxygen saturation was 100% with continuous ET ventilations. After emergency department evaluation, the patient was admitted to the intensive care unit, where a regimen of IV cephalosporin and cloxacillin was initiated. Pulmonary toilet was performed, and three days later, the patient was showing significant signs of clinical improvement. The patient was extubated and transferred to a tertiary care center. Two weeks later, the patient was discharged home without further complications.
Mark Rock,BA, NREMT-P, is a graduate of theUniversity ofOregon and did post-graduate work atPortland_s Neurological Sciences Institute. A member of the JEMS EMT and Paramedic Advisory Committee (EPAC), Rock practices as a paramedic inVentura,Calif. Contact him firstname.lastname@example.org.
- Bandar A, Kirk V: Bacterial tracheitis in children: Approach to diagnosis and treatment. Paediatr Child Health. 2004; 9:25Ï30.
- Ragan S, Emery KC,SnoodSK: Bacterial tracheitis. http://emedicine.medscape.com/article/961647-overview
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