Epiglottitis and bacterial tracheitis: Viva

Branch 1: Recognising that this is not simple croup

The candidate should recognise that this child began with a typical viral croup picture but has now changed character in a way that is characteristic of bacterial tracheitis. The high fever, toxic appearance, worsening biphasic stridor, brassy cough, and crucially the failure to respond to nebulised adrenaline and corticosteroid together point away from croup and toward a bacterial tracheal infection superimposed on the preceding viral illness. The absence of drooling helps separate this from epiglottitis. [1]

The candidate should state that the failure of adrenaline and steroid to help is the single most useful clue, because true croup would be expected to improve, at least temporarily, with adrenaline. Anchoring on croup while a bacterial tracheitis obstructs the trachea is a recurring and dangerous error, and the deterioration overnight should trigger a complete reassessment rather than repeated doses of adrenaline. [3]

Branch 2: Do-no-harm stabilisation and airway management

The candidate should describe a do-no-harm approach: keep the child calm and upright, avoid distressing procedures, give oxygen as tolerated, and call simultaneously for senior anaesthesia, ear, nose and throat surgery, and paediatric intensive care. They should recognise that this child has a threatened airway and may need intubation, both to secure the airway and to allow the repeated suctioning and bronchoscopic toilet that clears the tenacious purulent secretions and pseudomembrane characteristic of tracheitis. [2]

The examiner may probe the endoscopic findings. The candidate should know that bronchoscopy in bacterial tracheitis reveals purulent tracheal secretions, mucosal inflammation, and a sloughing pseudomembrane, and that clearing this debris is simultaneously diagnostic and therapeutic. They should also anticipate that the endotracheal tube can become occluded by exudate, so meticulous humidification, suctioning, and vigilance for tube blockage are essential during the intubated period. [2]

Branch 3: Antibiotics and the microbiology

The candidate must know that the empiric regimen for bacterial tracheitis has to include anti-staphylococcal cover, because Staphylococcus aureus, including meticillin-resistant strains, is the dominant pathogen. A common approach combines an anti-staphylococcal agent such as flucloxacillin with a third-generation cephalosporin, adding vancomycin where meticillin-resistant Staphylococcus aureus is prevalent, given intravenously and continued for around ten to fourteen days. Omitting anti-staphylococcal cover is a classic and dangerous error. [1]

If the examiner pivots to a preceding influenza illness, the candidate should recognise the particularly dangerous combination of influenza and staphylococcal tracheitis, including the risk of necrotising staphylococcal disease and concurrent pneumonia or toxic shock. A clear statement that corticosteroids and adrenaline treat the airway swelling of croup but not the bacterial process of tracheitis, and must not delay antibiotics or airway intervention, demonstrates the understanding examiners are testing. [2]