The term tracheitis literally means inflammation (-itis) of the trachea. The trachea, or windpipe, is the large breathing tube that extends from the voice box (larynx) down to the point where it splits into the two main airways of the lungs (the bronchi). While viruses can cause mild inflammation of this tube (as part of bronchitis), bacterial tracheitis is a specific and severe invasive infection of the tracheal lining.

In bacterial tracheitis, a bacterial infection becomes superimposed on an initial viral infection. This leads to a powerful inflammatory response within the trachea. The lining of the windpipe becomes intensely swollen, and it begins to produce thick, pus-filled mucus and debris. This material can form thick plaques or “pseudomembranes” that coat the inside of the airway.

To understand the danger, it is helpful to use an analogy. Think of your child’s trachea as the main, rigid air hose leading to their lungs.

• In viral croup, the area above this hose (the larynx) becomes swollen, making the opening narrower and causing a noisy sound when breathing in (stridor).
• In bacterial tracheitis, it is as if a thick, sticky, and messy glue has been poured inside the main air hose itself. This “glue” (the infected mucus and pseudomembranes) narrows the hose dramatically and can break off in clumps, suddenly and completely plugging the airway. This is why it is a true airway emergency.

This condition is sometimes referred to as “bacterial croup” or “pseudomembranous croup” because it shares some features with croup but is a much more severe bacterial process.

In children especially, tracheitis can escalate quickly. I’ve seen cases where what looked like a regular cold turned into a breathing emergency within hours.

Bacterial tracheitis is caused by almost always a secondary bacterial infection that occurs after the airway has already been inflamed and damaged by a primary viral infection. The initial viral illness damages the lining of the trachea, stripping away its normal protective mechanisms and creating a vulnerable surface where bacteria can invade and multiply.

The Initial Viral Infection

The viruses that typically set the stage for bacterial tracheitis are the same ones that cause common childhood respiratory illnesses:

• Parainfluenza virus (the most common cause of croup)
• Influenza A or B virus (the flu)
• Respiratory Syncytial Virus (RSV)
• Measles virus (in unimmunized children)

The Secondary Bacterial Invaders

Once the trachea is damaged by the virus, bacteria that may normally live harmlessly in the upper airway can invade the tissue and cause a severe infection.

• The most common bacterium responsible for tracheitis is Staphylococcus aureus, including methicillin-resistant strains (MRSA).
• Other common culprits include Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae. The incidence of tracheitis caused by Haemophilus influenzae type b has dramatically decreased thanks to the routine childhood Hib vaccine (NORD, 2020).

I’ve seen many kids come in with tracheitis after the flu, it’s not the virus itself but the bacterial  follow-up that causes most of the damage.

A child does not get bacterial tracheitis from another person in the traditional sense. The process is internal.

1. First, the child contracts a common, contagious respiratory virus from another person through respiratory droplets from a cough or sneeze.
2. The child develops symptoms of a typical upper respiratory infection, such as a runny nose, cough, and fever.
3. Then, as they seem to be recovering or suddenly worsen, bacteria from the child’s own upper airway take advantage of the weakened defenses and damaged tracheal lining. They invade the trachea, leading to the severe secondary infection.

Therefore, bacterial tracheitis itself is not contagious, but the initial virus that triggers it is.

Risk Factors

The condition is most common in young children, typically between the ages of 6 months and 8 years. This is because their airways are much smaller in diameter, so even a small amount of swelling and mucus can cause a critical obstruction. The primary risk factor is having a recent or current viral upper respiratory tract infection, especially croup or influenza.

Tracheitis often sneaks in after a virus. A child seems to be recovering, then suddenly worsens, hoarse voice, loud breathing, high fever. That sudden change is the red flag.

The key to recognizing bacterial tracheitis is understanding its typical two-phase presentation. It often begins by mimicking a simple case of viral croup, only to take a sudden and dramatic turn for the worse.

Initial Croup-like Phase

The illness may start with symptoms that are classic for croup:

• A harsh, “barking” cough.
• A hoarse voice.
• A high-pitched, noisy sound when breathing in, known as inspiratory stridor.
• A low-grade fever.

The Turn for the Worse: “Red Flag” Symptoms

Unlike simple viral croup, which usually starts to improve after a few days, a child with bacterial tracheitis will suddenly become much sicker. Parents should seek immediate emergency medical care if a child with a croup-like illness develops any of the following warning signs:

• High Fever: The fever often spikes to a high level (e.g., above 102°F or 39°C).
• “Toxic” Appearance: The child looks very ill, anxious, pale, and is struggling.
• Rapidly Worsening Respiratory Distress: The stridor becomes constant, not just when crying.
• Failure to Respond to Standard Croup Treatment (like nebulized epinephrine or steroids).
• A productive cough with thick, pus-like sputum (though young children often can’t cough this up effectively).

One of the most alarming signs is stridor that doesn’t improve with typical croup treatments. In those moments, tracheitis is a top differential, and quick airway management is critical.

Diagnosis involves clinical evaluation and imaging, especially when airway obstruction is suspected. The goal is to confirm inflammation, rule out similar conditions (like croup or epiglottitis), and monitor for respiratory distress.

• Clinical Suspicion: The diagnosis is strongly suspected based on the clinical picture of a child who appears toxic, has a high fever, and is in severe respiratory distress that is not responding to standard croup therapy.
• X-ray: An X-ray of the neck may show a narrowing of the subglottic trachea (the “steeple sign” of croup), but may also show a “shaggy” or irregular appearance of the tracheal wall, hinting at tracheitis.
• Direct Visualization (Definitive Diagnosis): The gold standard for diagnosing bacterial tracheitis is the direct visualization of the airway. This is typically done in the controlled setting of an operating room or an intensive care unit. An otolaryngologist (ENT surgeon) or a critical care physician will perform a laryngoscopy or bronchoscopy. This involves using a thin, flexible or rigid tube with a camera (an endoscope) to look directly at the voice box and into the trachea. The definitive finding is the presence of thick, pus-filled secretions and adherent pseudomembranes lining the tracheal wall.

When symptoms escalate quickly and don’t respond to common viral treatments, bronchoscopy gives us a definitive answer, and helps guide immediate care.

Tracheitis is a medical emergency, especially in children, and often requires hospitalization. The goals of treatment are to secure the airway, remove the infected secretions, and eradicate the bacterial infection with antibiotics.

1. Airway Management

This is the number one priority. Many children will require endotracheal intubation (placing a breathing tube) to secure the airway and allow for suctioning. Frequent, deep suctioning is required to remove the thick, glue-like secretions and pseudomembranes.

2. Intravenous (IV) Antibiotics

High-dose IV antibiotics are started immediately to target the likely bacterial culprits (Staphylococcus and Streptococcus).

3. Supportive Care

• Humidified oxygen.
• IV fluids.

Potential Complications

If not recognized and treated rapidly, bacterial tracheitis can lead to:

• Complete airway obstruction and respiratory arrest.
• Toxic shock syndrome.
• Acute Respiratory Distress Syndrome (ARDS).
• In rare cases, subglottic stenosis (scarring and narrowing of the airway below the vocal cords).

With prompt diagnosis and aggressive treatment, the prognosis for bacterial tracheitis is good, and most children recover completely.

Time is everything with tracheitis. I’ve seen kids bounce back within days with prompt antibiotics, but delay even a few hours, and they might need intensive airway support.

Bacterial tracheitis is a rare but life-threatening secondary bacterial infection of the windpipe that typically follows a viral illness in young children. It is the very definition of a “wolf in sheep’s clothing,” often mimicking viral croup initially before rapidly progressing to a much more severe illness with high fever and respiratory distress. For parents, the key message is to trust your instincts.In infectious conditions like tracheitis, early detection is life-saving. I always tell parents, if your child’s breathing sounds different, or if their voice changes suddenly, seek care fast. Prompt recognition and aggressive hospital treatment are essential for a good outcome.

American Academy of Pediatrics (AAP). (n.d.). Croup and Your Young Child. Retrieved from https://www.healthychildren.org/English/health-issues/conditions/chest-lungs/Pages/Croup-and-Your-Young-Child.aspx (Note: Discusses croup, the common precursor).

The Merck Manual Professional Version. (2023). Tracheitis. Retrieved from https://www.merckmanuals.com/professional/pulmonary-disorders/tracheitis/tracheitis

National Organization for Rare Disorders (NORD). (2020). Bacterial Tracheitis. Retrieved from https://rarediseases.org/rare-diseases/bacterial-tracheitis/