This document reviews the literature on tracheobronchitis and summarizes key findings from studies. It was found that microbiological colonization in trached patients is dynamic and often different from initial hospitalization. Surveillance cultures are not helpful in guiding treatment. The standard of care for managing episodes varies. A prospective study was proposed to document the frequency and risk factors for tracheobronchitis episodes in home tracheostomy patients.

1. TRACHEOBRONCHITIS:
Review of the Literature and the
PHS TBS Outcomes
January 19, 2012
Roy C. Maynard, M.D.
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2. Tracheobronchitis
• Definition: Inflammation of the trachea and bronchi
• Causes:
- Viruses (influenza, parainfluenza, RSV, measles,
rubella, adenovirus, Echovirus, coxsackie, herpes and
others)
- Bacteria (haemophilus influenzae, streptococcus
pneumoniae, streptococcus, staphylococcus, nocardia,
diptheria, mycoplasma and others)
- Miscellaneous (asthma, COPD, allergies, cystic
fibrosis, ciliary dyskinesia, tracheostomy)
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3. Tracheobronchitis
• Symptoms:
- Cough
- Sputum
- Hemoptysis
- Fever
- Difficulty breathing
- Stridor, wheeze, rhonchi
- Chest pain
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4. Review of the Literature
• Bacterial colonization, tracheobronchitis and pneumonia
following tracheostomy and long-term intubation in pediatric
patients. (Chest 1979;76;420-424).
– 27 patients with CNS diagnosis and artificial airways
– 100% had airway colonization
– TB defined as purulent secretions without clinical or radiographic evidence for
pneumonia
– 16.5 trach cultures/patient/year
– Bacteria profile changed 50% of the time with pneumonia
– 24 (89%) had recurrent chronic TB and 68 episodes of pneumonia (2.8 episodes per
patient)
– Antibiotic treatment changed bacteria profile
– Pseudomonas, serratia, strep pneumoniae, alpha-strep, E coli, staph, anaerobes (2
patients had positive blood cultures)
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5. Review of the Literature
• Suspected Respiratory Tract Infection in the Tracheostomized
Child: The Pediatric Pulmonologist’s Approach. (Chest
1998;113;1549-1554).
– Goal to determine standard of care for differentiating colonization from infection in trached
children (multiple diagnoses) by survey of practitioners in academic setting (34/46 responded)
– Average 48.5 +/- 77 patients (50% vented)
– 91% get trach culture if change in trach secretions (regardless clinical status)
– Most frequent change (green sputum, then foul smelling, then fever)
– Most frequent indication for Abx Tx – (WBC’s in sputum, then resp illness, then green or foul
smelling secretions)
– 79% managed over telephone
– No formal protocol
– Most centers will not treat with Abx in presence of purulence if patient well
– Most common Abx – Bactrim and Augmentin outweighed nebulized tobi/gent
– No waiting for culture to prescribe (base on previous), no f/u cultures
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6. Review of the Literature
• Oropharyngeal carriage and lower airway colonization/infection
in 45 tracheotomized children. (Thorax 2002;57;1015-1020).
– 5-year prospective study of 45 children (neuro and airway obstruction) initially intubated then
trached in a PICU before transfer to chronic ward
– Infection treated with Abx for fever>38.5C, leukocytosis, increased CRP, purulent secretions
(>106 CFU/ml)
– Pneumonia only diagnosed if + CXR
– Compared potential pathogens in mouth with lower airway
– 6/45 had sterile lower airways (these patients had normal mouth flora)
– 39/45 (86%) had colonized/infected lower airways post trach
– Community “flora” more common following trach (S pneumoniae, M catarrhalis, H influenzae,
S aureus, E coli)
– Hospital “flora” more common intubated (pseudomonas, acintobacter, klebsiella, S
maltophilia)
– 33% post trach with pseudomonas (no change) but increased S aureus
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7. Review of the Literature
• Surveillance tracheal aspirate cultures do not reliably predict
bacteria cultured at the time of an acute respiratory infection in
children with tracheostomy tubes. (Chest 2011;DOI 10.1378/
Chest 10-2539).
– Study designed to characterize practice of obtaining and using info from trach cultures to
guide treatment of lower resp tract infections
– Records retrospectively reviewed from 170 children over 4 years
– Survey of pediatric pulmonologists and otolarygologists (ENT)
– 54% of pulmonologists and 15% of ENT obtain routine tracheal aspirates, among physicians
who obtain cultures, 80% of ENT and 97% of pulmonologists use info to guide therapy
– In children with surveillance cultures, common for recovered pathogenic bacteria (when
patient ill) to be different than from previous surveillance culture
– Potentially ineffective antibiotic coverage would have been chosen in 56% of cases if
previous trach culture had been used to guide therapy
– Limited value using previous trach cultures to guide therapy
– Probably little value obtaining routine trach cultures
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8. Review of the Literature
• A pediatric home health infection control surveillance
program: Implementation to outcomes. (Caring 2005, Sept.
26-33).
– Children’s Homecare of Columbus, Ohio
– Monitored respiratory infections in home-bound trach dependent
children
– Clinical; fever>99 axillary, new or increased secretions, purulence,
cough, SOB, RR, new chest findings
– Diagnostic criteria; trach culture and or CXR
– Needed one clinical and one diagnostic or 3 clinical and Abx prescribed
– 6 to 12 respiratory infections per 1,000 trach days
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9. Tracheobronchitis Episodes/1,000 trach days
14
12
10
8
Columbus
6 Columbus
4
2
0
2000 2001 2002 2003 2004
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10. What We Know!
• Microbiological colonization well described
• May be different from when first hospitalized
to steady state
• Microbiological colonization is dynamic, often
changes over time and after antibiotic
treatment
• Should not base treatment on cystic fibrosis
model
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11. What We Know!
• Surveillance cultures probably not helpful
• Role of anaerobes unclear
• Different prescribing patterns for “threshold” of
tracheobronchitis
• Oral antibiotics most common treatment in the past
• Most managed over the phone
• Little data on frequency of respiratory infections or
tracheobronchitis in trached patients at home
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12. What We Don’t Know!
• Standard of care in the PHS community:
- Telephone or office visit to manage episodes
- Prescribing patterns of antibiotics; neb vs.
oral vs. IV vs. combination
- Duration of treatment
- Cultures obtained?
- Other interventions implemented?
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13. What We Don’t Know!
• Episodes of TB per patient per year
• Episodes of TB per 1,000 trach days
• Failed treatment for TB episodes resulting in
hospitalization (still in review)
• Incidence of fever with TB episodes
• Difference in TB episodes related to:
- Suction technique
- Vent or no vent
- Patient ability to cough or not cough
- Diagnosis
- Age
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14. PHS Tracheobronchitis Study
• Objective:
- Document standard of care in community
- Frequency of TB episodes
- Most common presenting clinical symptoms
- Identify risk factors associated with
development of TB in trached home care
patients
- Episodes of home treatment failure resulting
in a “respiratory” hospitalization
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15. PHS Tracheobronchitis Study
• Study Design:
- Prospective surveillance study 12-month duration
- Final 225 trached patients (started 238; 13 patients
dropped out, ended up with 140 vent, 85 humidity)
- Patient ages (0-40 years)
- Surveyed monthly by PHS respiratory therapists for Abx
treated TB episodes
- Tracheobronchitis episode defined as respiratory
symptoms and illness in a tracheostomized patient
felt to warrant antibiotic treatment by a health care
provider
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16. Pneumonia
• New crackles
• CXR findings
• Health care provider diagnosed
• (Still in review of hospital records)
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17. Patients Greater/Less Than 18 Years of Age
Patients Min Max Mean Std Median Mode
All
225 0 40 10.08 9.1086 7.0 0
< 18 years
175 0 17 6.22 5.5043 4.0 0
>= 18 years
50 18 40 23.60 5.6460 22.0 18
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18. Age Subcategories
Patients Min Max Mean Std Median Mode
All 225 0 40 10.08 9.1086 7.0 0
<2 42 0 1 0.33 0.4771 0.0 0
2-5 55 2 5 3.16 1.1016 3.0 2
6-9 26 6 9 7.19 1.1668 7.0 6
10-12 15 10 12 10.93 0.9612 11.0 10
13-17 37 13 17 14.84 1.4436 15.0 13
18-24 34 18 24 20.50 2.1356 21.0 18
25-40 16 25 40 30.19 5.1019 28.0 26
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19. Diagnosis Categories
At Least One Tracheobronchitis
No Tracheobronchitis Episodes Episode
N Row % Col % N Row % Col %
All Diagnosis Categories
91 40.4 100.0 134 59.6 100.0
Unknown 4 100.0 4.4 . . .
Brain Injury or CNS
33 34.4 36.3 63 65.6 47.0
Hypotonia or Neuromuscular
10 47.6 11.0 11 52.4 8.2
Airway Obstruction 11 45.8 12.1 13 54.2 9.7
Primary Lung Disorder 5 23.8 5.5 16 76.2 11.9
Congenital Heart Disease 1 14.3 1.1 6 85.7 4.5
Congenital Syndrome 19 48.7 20.9 20 51.3 14.9
Inborn Error of Metabolism 5 71.4 5.5 2 28.6 1.5
Other 3 50.0 3.3 3 50.0 2.2
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20. Vent vs. Humidity
N %
All
225 100.00
Vent
140 56.00
Humid
85 33.33
Vent/Humid
0 5.33
No Record
0 1.33
No Record/Humid
0 3.11
No Record/Humid/Vent
0 0.89
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21. Symptoms of Tracheobronchitis
100
90
80 I secretions
d secretions
70
breath sounds
60 O2 sat
50 heart rate
cough
40
fever
30 tachypnea
20 dyspnea
10 chest pain
0
Symptoms
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22. Interventions
100
90
80
70 inc nebs
60 inc O2
50 inc BD's
40 trach culture
30 end tidal CO2
20 antibiotics
10
0
interventions

23. Antibiotic Administration
Trach Culture Trach Culture
All Not Sent Sent
N N % N %
All
287 199 69.34 88 30.66
Combo
171 102 59.65 69 40.35
Neb
65 58 89.23 7 10.77
Oral
48 39 81.25 9 18.75
IV
3 . . 3 100.00
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24. Antibiotic Treatment
50
45
40
35 neb/oral
30 neb
oral
25
neb/IV/oral
20 oral/IV
neb/IV
15
IV
10
5
0
Antibiotic Administration Routes
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25. Number of Antibiotic Episodes and Antibiotic Episode Days by Route
Antibiotic Episode Days
% of
Episodes Episodes Min Max Mean Std Median Mode
All Routes
287 100.00 2 70 14.74 9.3343 11.0 11
Combo
171 59.58 3 70 16.87 10.686 14.0 11
Neb
65 22.65 2 42 12.29 6.2192 11.0 11
Oral
48 16.72 5 27 10.77 4.6915 10.0 10
IV
3 1.05 8 11 10.00 1.7321 11.0 11
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26. Episodes by Trach Days
All Patients
Patients Total Min Max Mean Std Median Mode
Trach Days
225 69515 3.0000 365.00 308.96 102.06 365.00 365.00
Antibiotic Episodes
225 287 0.0000 8.0000 1.2756 1.5014 1.0000 0.0000
Total Episode Days
225 4231 0.0000 144.00 18.804 25.272 10.000 0.0000
Episodes per Trach Day
225 1 0.0000 0.0294 0.0043 0.0054 0.0027 0.0000
Episode Days per Trach Day
225 15 0.0000 0.7097 0.0655 0.1003 0.0301 0.0000
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27. Tracheobronchitis Episodes/1,000 trach days
14
12
10
8 Columbus
Columbus
6 PHS
4
2
0
2000 2001 2002 2003 2004 2010
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28. Hospital Stays Associated with Antibiotic Episode
Total Days in Hospital
Hospital Stays
Total Hospital
Patients Days Min Max Mean Std Median Mode
All 225 323 0 41 1.44 5.2624 0.0 0.0
0 188 0 0 0 0.00 0.0000 0.0 0.0
1 32 190 2 35 5.94 5.8802 4.0 3.0
2 3 61 9 40 20.33 17.098 12.0 .
3 2 72 31 41 36.00 7.0711 36.0 .
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29. Sterile Suction Technique by Tracheobronchitis Episode
The FREQ Procedure
Table of bRST by abEpisodes
bRST(Binary Routine Suction
Techniques) abEpisodes
Frequency
Expected
Percent
Row Pct At least one Tracheobronchitis
Col Pct No Tracheobronchitis Episodes Episode Total
Sterile 90 131 221
89.382 131.62
40.00 58.22 98.22
40.72 59.28
98.90 97.76
Non-Sterile 1 3 4
1.6178 2.3822
0.44 1.33 1.78
25.00 75.00
1.10 2.24
Total 91 134 225
40.44 59.56 100.00
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30. What Did We Learn?
• Of the 225 patients enrolled in the study, 175
(77.7%) were less than 18 years of age and 50
(23.3%) were older than 18 years of age
• 287 episodes of tracheobronchitis in 225 patients
(1.27 episodes per patient/year)
• 4.1 episodes/1,000 trach days
• 40% of patients did not have an episode of
tracheobronchitis
• 60% of patients had one or more episodes
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31. What Did We Learn?
• Episodes of tracheobronchitis trended to be
common the younger the patient
• Episodes of tracheobronchitis trended to be more
common in ventilator-dependent patients
(p=0.0525)
• Higher risk for tracheobronchitis associated with
CNS injury or disease, primary lung disorder and
congenital heart disease
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32. What Did We Learn?
• Trach cultures are obtained only 30% of the time
• Most common symptoms are increased and
discolored secretions, change in breath sounds
and oxygen saturations
• Fever is noted 50% of the time, and 76% of fevers
are less than 102
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33. What Did We Learn?
• Other Interventions:
– 75% receive increased neb treatments
– 52% receive additional oxygen
– 35% receive additional bronchiodrainage
– 17% have end-tidal CO2 checked
• Effective cough had no effect on incidence of
tracheobronchitis
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34. What Did We Learn?
• 23% of episodes treated with nebulized antibiotics
(Abx) alone
• 60% receive combination antibiotic therapy
• 17% receive oral Abx only
– 32% were fluoroquinilones
– 20% were cephalosporins
– 17% were penicillins
– 14% were macrolides
• Mean duration of antibiotic therapy was 18.8 days,
median 10 days
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35. What Did We Learn?
• 84% initially managed with telephone
• 37% had office visit or ED visit
• 18.6% of patients ended up with a hospitalization
• 8 patients (8/42 or 19% of hospitalized patients)
had 2 or more hospitalizations
• 81% of enrolled patients had no hospitalization for
respiratory illness
• Mean duration of hospitalization for patients with a
single episode was 8.2 days but mode was 3 days
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36. Conclusions
• PHS has established a benchmark for the
incidence and standard of care for episodes of
tracheobronchitis in tracheostomized home care
patients
• Still need to review hospitalizations for justification
and incidence of pneumonia
• Possible presentation at the Chest conference in
Atlanta this year
• Publication in Chest or Pediatric Pulmonology
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37. Q&A
Questions?
Thank you for attending!
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