Tracheitis: Inflammation of the Windpipe

What tracheitis means

"Trache-" refers to the trachea and "-itis" means inflammation. The trachea is a tube about 10 to 12 cm (4 to 5 inches) long in adults, held open by C-shaped rings of cartilage. It runs from the larynx (voice box) in the neck down behind the breastbone, where it splits into the two main bronchi.

When the lining of the windpipe is inflamed, it becomes swollen, raw and sensitive. That causes the classic symptom: a harsh, painful cough with a burning or scraping feeling in the center of the chest. Inflammation rarely stays in one place, so doctors often use broader terms:

Tracheitis symptoms

Viral tracheitis

Viral tracheitis usually comes with or after a cold or flu:

• a dry, hacking or barking cough that is worse at night and on cold air
• a raw, burning or tight pain behind the breastbone, worse when you cough or breathe deeply
• a hoarse voice and sore throat
• low-grade fever, tiredness, runny nose
• later, a cough that brings up small amounts of clear or white mucus

Bacterial tracheitis

Bacterial tracheitis typically starts like a viral illness or croup, then gets much worse over hours to a day:

• high fever, often above 39 °C (102.2 °F)
• a child who looks toxic: pale, very unwell, exhausted
• a brassy or barking cough with thick, pus-like secretions
• loud stridor when breathing in, and sometimes when breathing out
• breathing difficulty that does not improve with the usual croup treatments

Unlike epiglottitis, children with bacterial tracheitis can usually lie flat and do not usually drool.

Causes and risk factors

Viral infection

Most tracheitis is caused by the viruses behind colds, flu, COVID-19 and croup: parainfluenza, influenza, RSV, adenovirus and rhinovirus.

Bacterial infection

Bacterial tracheitis is usually a secondary infection on top of a viral one. The virus damages the lining and bacteria take hold. The commonest bacterium is Staphylococcus aureus, including MRSA. Others are Streptococcus pyogenes, Streptococcus pneumoniae, Moraxella catarrhalis and Haemophilus influenzae. The infection produces thick pus and peeling membranes that can block the windpipe.

It mainly affects children aged about 3 to 8, but it can occur at any age, including in adults after flu. A child who has had a breathing tube or a tracheostomy is at higher risk.

Non-infectious causes

• smoke, chemical fumes, vaping and very hot or very cold dry air
• acid reflux reaching the airway
• irritation from a breathing tube or tracheostomy
• radiation therapy to the chest
• rarely, autoimmune diseases such as relapsing polychondritis or granulomatosis with polyangiitis

Tracheitis vs croup vs epiglottitis vs bronchitis

How tracheitis is diagnosed

Mild viral tracheitis is diagnosed from the symptoms and a normal chest exam. A doctor will listen to the lungs, check oxygen levels, and consider a flu or COVID-19 test. A chest X-ray may be done if pneumonia is suspected.

Bacterial tracheitis is diagnosed in hospital:

• a neck X-ray may show a ragged, narrowed windpipe
• bronchoscopy (a camera passed into the airway) confirms the diagnosis, shows thick pus and membranes, and lets the team remove them
• samples from the airway are sent for culture to guide antibiotics
• blood tests show signs of a bacterial infection

Treatment

Viral tracheitis

Viruses do not respond to antibiotics. The aim is to ease symptoms while the windpipe heals:

• Rest and fluids, including warm drinks that soothe the raw feeling
• Humid air: a cool-mist humidifier or sitting in a steamy bathroom can ease the cough
• Pain relief: acetaminophen (paracetamol) or ibuprofen for fever and chest soreness. Follow the label dose. Do not give aspirin to children or teenagers
• Honey in warm water for cough in adults and children over 1 year. Never give honey to babies under 12 months
• Avoid smoke and vaping, which keep the lining inflamed

Antiviral medicine may be prescribed for confirmed flu or COVID-19 in people at high risk of complications.

Bacterial tracheitis

This is a medical emergency:

• Securing the airway: many children need a breathing tube in intensive care for several days, because secretions can block the windpipe
• IV antibiotics that cover Staphylococcus aureus, including MRSA, adjusted when culture results return
• Suctioning and bronchoscopy to clear thick secretions and membranes
• oxygen and fluids

Most children recover fully with prompt treatment, usually going home within 1 to 2 weeks.

Complications

Viral tracheitis rarely causes problems, though it can lead to acute bronchitis or, less often, pneumonia. Bacterial tracheitis can cause airway blockage, respiratory failure, pneumonia, toxic shock syndrome and, rarely, cardiac arrest if not treated quickly.

Prevention

• Annual flu vaccine and staying up to date with COVID-19, Hib, pneumococcal, measles and pertussis (whooping cough) vaccines
• Handwashing and avoiding close contact with people who are ill
• Not smoking or vaping, and avoiding secondhand smoke

Frequently asked questions

What does tracheitis mean?

Tracheitis means inflammation of the trachea, or windpipe. It is usually caused by a viral infection such as a cold or flu and causes a dry, painful cough with a raw feeling behind the breastbone. A rarer bacterial form is serious and mostly affects children.

What are the symptoms of tracheitis?

The main symptoms are a harsh, dry or barking cough, burning pain behind the breastbone that worsens with coughing, a hoarse voice, sore throat and mild fever. Bacterial tracheitis adds high fever, thick secretions, noisy breathing (stridor) and difficulty breathing.

How long does tracheitis last?

Viral tracheitis usually improves within 1 to 2 weeks, though a dry cough can linger for 3 weeks. Bacterial tracheitis needs hospital treatment with antibiotics and often airway support, and recovery typically takes 1 to 2 weeks.

Is tracheitis contagious?

The viruses that cause tracheitis are contagious and spread by droplets and hands, like a cold or flu. The inflammation itself is not passed on, and someone you infect may just get a cold. Bacterial tracheitis is not considered highly contagious.

Do you need antibiotics for tracheitis?

Not for viral tracheitis, which is the common form. Antibiotics are essential for bacterial tracheitis, which is diagnosed in hospital in someone who is very unwell with high fever, thick secretions and breathing difficulty.

How is tracheitis different from bronchitis?

Tracheitis affects the windpipe, so the pain is felt behind the breastbone and the cough is often dry and raw. Bronchitis affects the airways inside the lungs and usually causes a productive cough. The two often occur together as tracheobronchitis.