Paeds · respiratory-sleep-and-airway
Epiglottitis and bacterial tracheitis
Also known as Acute epiglottitis · Supraglottitis · Bacterial tracheitis · Membranous laryngotracheobronchitis · Pseudomembranous croup · Acute infective upper airway obstruction
Fellowship guide to paediatric epiglottitis and bacterial tracheitis: recognising the toxic child with a threatened airway, distinguishing supraglottic from subglottic and tracheal disease, the changing microbiology after Haemophilus influenzae type b vaccination, the do-no-harm rule of not distressing the child, controlled airway management in theatre, and empiric antibiotic selection including anti-staphylococcal cover for tracheitis.
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Target exams
Red flags
- A toxic-looking child who is drooling, sitting forward in the tripod position, and will not lie down
- Muffled hot-potato voice with soft stridor and no barking cough, suggesting epiglottitis
- A child with a croup illness who suddenly becomes toxic with high fever and worsening stridor, suggesting bacterial tracheitis
- Stridor that persists or worsens despite nebulised adrenaline and corticosteroid
- Any child with acute upper airway obstruction who is agitated, exhausted, cyanosed, or has a falling conscious level
- Attempting to examine the throat with a tongue depressor in a child with suspected epiglottitis
- Silent chest, bradycardia, or reduced respiratory effort signalling imminent complete obstruction
Life stages
Care settings
Clinical exam formats
Board mappings
- Recognises the toxic child with a threatened airway and does not distress them
- Distinguishes epiglottitis, bacterial tracheitis, and croup at the bedside
- Knows that airway control precedes investigation in suspected epiglottitis
- Coordinates controlled airway management with anaesthesia, ENT, and intensive care
- Selects empiric antibiotics including anti-staphylococcal cover for tracheitis
- Understands the changing microbiology of epiglottitis after Hib vaccination
- Initial management of a child with suspected acute epiglottitis
- Recognition of bacterial tracheitis complicating a croup illness
- Counselling families about airway emergencies and the reason for theatre
- Bedside assessment of a child with acute upper airway obstruction
- Decision-making around timing and setting of definitive airway control
- Communication of an airway emergency and the plan to intubate
- Level 1: Recognises the child with stridor and airway compromise
- Level 2: Initial stabilisation and escalation of an infective airway
- Level 3: Leads coordinated airway management and intensive care
- Microbiology and empiric antibiotics for epiglottitis and tracheitis
- Clinical features distinguishing supraglottic from subglottic infection
- Epidemiological effect of Hib vaccination on epiglottitis
- History and examination of a child with acute airway obstruction
- Communication of the airway plan and safety-netting advice
- Structured assessment of a toxic child with stridor
- Recognition and stabilisation of paediatric epiglottitis and tracheitis
- Empiric antibiotic selection with MRSA cover for bacterial tracheitis
- Indications for definitive airway control and intensive care
- Recognition and resuscitation of the child with a threatened airway
- Appropriate use of antibiotics, imaging, and airway intervention
- Coordination of a multidisciplinary airway emergency response
- Canadian approach to paediatric infective upper airway obstruction
- Post-Hib epidemiology and evolving pathogens of epiglottitis
- Anaesthesia and intensive care coordination for airway control
Overview & Definition
A previously well child who suddenly looks toxic, sits bolt upright drooling, and refuses to lie flat is describing an airway emergency long before any test is ordered. Epiglottitis and bacterial tracheitis are the two bacterial infections that can close a child's airway within hours, and both demand that the clinician resist the reflex to examine, cannula, and investigate before the airway is safe. The single most important early action in each is to keep the child calm and summon senior airway help, because a distressed child with a critically narrowed airway can obstruct completely and die. [1]
Epiglottitis, more accurately called supraglottitis, is a rapidly progressive bacterial cellulitis of the epiglottis and the surrounding supraglottic structures. The swollen, cherry-red epiglottis folds down over the laryngeal inlet and threatens sudden total obstruction. It was once the classic paediatric emergency caused by Haemophilus influenzae type b, but widespread conjugate vaccination has transformed both its frequency and its microbiology. [8]
Bacterial tracheitis is a bacterial infection of the trachea, usually superimposed on a preceding viral illness, that produces thick purulent exudate and sloughed mucosal pseudomembrane in the subglottis and trachea. A child looks like croup at first, then becomes toxic, febrile, and progressively obstructed, and crucially fails to respond to the nebulised adrenaline and steroid that would settle true croup. Because it does not spare the vaccinated, bacterial tracheitis is now a more common cause of life-threatening infective airway obstruction in children than epiglottitis in many centres. [2]
References12ShowHide
- [1]Sutton AE Epiglottitis. StatPearls [Internet], 2026.PMID 28613691
- [2]Casazza G Pediatric Bacterial Tracheitis-A Variable Entity: Case Series with Literature Review. Otolaryngol Head Neck Surg, 2019.PMID 30348058
- [3]Huang YL Bacterial tracheitis in pediatrics: 12 year experience at a medical center in Taiwan. Pediatr Int, 2009.PMID 19371289
- [4]Miranda AD Bacterial tracheitis: a varied entity. Pediatr Emerg Care, 2011.PMID 21975496
- [5]McVernon J Changes in the epidemiology of epiglottitis following introduction of Haemophilus influenzae type b (Hib) conjugate vaccines in England: a comparison of two data sources. Epidemiol Infect, 2006.PMID 16288684
- [6]Midwinter KI Paediatric epiglottitis: the influence of the Haemophilus influenzae b vaccine, a ten-year review in the Sheffield region. Clin Otolaryngol Allied Sci, 1999.PMID 10542929
- [7]Allen M Acute epiglottitis: Analysis of U.S. mortality trends from 1979 to 2017. Am J Otolaryngol, 2021.PMID 33429180
- [8]Guardiani E Supraglottitis in the era following widespread immunization against Haemophilus influenzae type B: evolving principles in diagnosis and management. Laryngoscope, 2010.PMID 20925091
- [9]Heath PT Non-type b Haemophilus influenzae disease: clinical and epidemiologic characteristics in the Haemophilus influenzae type b vaccine era. Pediatr Infect Dis J, 2001.PMID 11303834
- [10]Moreira M Bacterial Tracheitis: A New Presentation of a Well-Known Disease. Cureus, 2024.PMID 39092363
- [11]Kadam SJ Croup. StatPearls [Internet], 2026.PMID 28613724
- [12]Tamma PD Ventilator-associated tracheitis in children: does antibiotic duration matter? Clin Infect Dis, 2011.PMID 21540205