Gastrostomy, tracheostomy and central-line troubleshooting — formative SAQs

SAQ 1 (10)

A 4-year-old child with cerebral palsy and a tracheostomy for chronic lung disease desaturates to 80 per cent on the ward. The nurse cannot pass the suction catheter. The tracheostomy was inserted four months ago. [4]

1. Recite the National Tracheostomy Safety Project paediatric emergency algorithm you would run, in order. (5) [4]
2. The tube has fallen out entirely. How does your response differ from a tube that is merely obstructed, and how does tract maturity change what you do? (3) [3]
3. Forty minutes later the child stabilises. Four weeks after this event the family report a small amount of bright red blood at the stoma. What is your concern and your immediate action? (2) [5]

Model answer

National Tracheostomy Safety Project algorithm. The child comes before the device, so I assess airway and breathing first, then run the algorithm in order: I suction via the tracheostomy; if the suction catheter will not pass I remove the inner cannula and clean or replace it; if the child is still not oxygenating I deflate the cuff; if the obstruction persists I remove the tracheostomy tube and ventilate — by a bag-valve-mask over the face if the upper airway is patent and the stoma is covered, or by a mask held over the stoma if the upper airway is not patent. I call for senior airway help early. The cardinal error is to persist with a non-functioning tube while the child deteriorates. [4]

Decannulation and tract maturity. If the tube has fallen out entirely, my priority is oxygenation while I decide on replacement. The response turns on tract maturity. This child's tract is mature — the tracheostomy was inserted four months ago, well beyond the seven-to-ten-day immature threshold — so I reinsert a tracheostomy tube of the same size with the obturator in place, gently and without force; if I meet resistance I use a tube one size smaller; if neither passes I ventilate and call for help. I do not apply this logic to an immature tract: within the first seven to ten days the tract is not established and blind instrumentation can create a false passage in the pretracheal tissues, so in that period I ventilate by face mask, cover the stoma, and call the surgeon or anaesthetist. [3]

Late bleed. Bright red blood at the stoma in the weeks after tracheostomy raises a tracheoinnominate artery fistula until proven otherwise. This is a surgical emergency. The immediate actions are to hyperinflate the cuff to tamponade, to withdraw the tube to reposition the cuff against the erosion, to apply firm digital pressure against the sternum compressing the innominate artery, and to call the surgical and anaesthetic teams while I secure the airway and large-bore access. I do not assume a late bleed is trivial granulation. [5]