Paeds · investigations-procedures-and-technology
Gastrostomy, tracheostomy and central-line troubleshooting
Also known as Paediatric enteral and airway device troubleshooting · Gastrostomy tube complications in children · Tracheostomy emergency management in children · Central venous catheter occlusion and breakage in children
A fellowship approach to troubleshooting the three devices a technology-dependent child lives with — the gastrostomy, the tracheostomy and the central venous catheter. Recognise and resolve the common failure modes: the leaking or buried gastrostomy and the dislodged tube in an immature tract; the obstructed or decannulated tracheostomy run through the National Tracheostomy Safety Project algorithm; and the occluded, broken or infected central line managed with the right lock — sterile water and warm flush, a thrombolytic dwell for a clot, and an immediate clamp-and-repair for a fracture.
On this page
Study tools
Your progress
Saved on this device.
Practise this topic
Target exams
Red flags
- A tracheostomy child who deteriorates or cannot be oxygenated — obstruction until proven otherwise; suction, remove the inner cannula, deflate the cuff, then remove the tube and ventilate, following the National Tracheostomy Safety Project algorithm
- A tracheostomy that has fallen out within the first 7 to 10 days — the tract is immature; do not force a tube blindly down the stoma, call ENT or anaesthetics, and ventilate by face mask if the upper airway is patent
- Bright red bleeding around or through a tracheostomy 2 to 6 weeks after insertion — a tracheoinnominate artery fistula until proven otherwise; hyperinflate the cuff, withdraw the tube, apply digital pressure against the sternum and call the surgical team
- A gastrostomy that has fallen out of a tract less than 6 to 8 weeks old — the tract will close within hours; replace it at the bedside without delay and do not feed until position is confirmed
- A central venous catheter that has fractured externally — clamp immediately between the child and the break to prevent air embolism and blood loss, then repair or replace
- Fever with no other source in a child with a central line — central line-associated bloodstream infection; take peripheral and line cultures before antibiotics and consider removal
Life stages
Care settings
Clinical exam formats
Board mappings
- Procedural skills and device safety
- Acute and emergency assessment of the technology-dependent child
- Safe use of therapies, fluids and enteral nutrition
- Current 2026 PREP curriculum — Learning Objective 2.2.1: Recognise, prioritise and manage an acutely ill infant, child or young person
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: Clinical management – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 15: Essential general paediatrics
- Clinical Applications
- Medical Sciences — device complications and emergency algorithms
- Emergency and critical care
- Short Cases
- Procedural and acute scenarios
- 4. Professional skills and knowledge: Patient management
- 7. Patient safety, including safe prescribing and procedural safety
- 9. Safe prescribing and procedural safety
- Foundation of Practice (FOP)
- Theory and Science (TAS) — applied device troubleshooting
- Applied Knowledge in Practice (AKP)
- Clinical
- Communication
- Video
- General Pediatrics Content Outline — patient safety and management of chronic devices
- General Pediatrics EPA 7: Recognizing a Severely Ill Patient, Providing Initial Management, and Mobilizing Resources Needed for Continued Care
- Patient Care 3: Procedural skills and device management
- Systems-Based Practice 1: Patient Safety
- Medical Knowledge 2: Emergency and critical care
- Medical Expert
- Pediatrics: Foundations EPA #1 — Recognizing deteriorating and/or critically ill patients and initiating stabilization and management
A 4-year-old with cerebral palsy, a gastrostomy button and a tracheostomy for chronic lung disease is admitted overnight with increased secretions and desaturation. The bedside nurse cannot pass the suction catheter. This child is exactly the patient this page is written for: the technology-dependent child whose safety lives in whether the team can recognise a mucus plug, a dislodged tube or an occluded line in the first minute. The decision in each case is the same — resuscitate the child, then read the device — and the algorithms are learnable, exact and examinable. This page teaches the three devices side by side, the failure modes of each, and the bedside responses that separate a controlled resolution from an arrested deterioration. [1] [4]
Displacement (tube out, migrated or malpositioned) · Obstruction (mucus plug, fibrin sheath, kink or blockage) · Pneumothorax or Pulmonary/Plumbing failure (airway disaster, effusion, drug precipitate) · Equipment failure (fractured line, balloon deflation, cuff leak). The DOPE framework, borrowed from the endotracheal tube, applies to every device a child depends on — work down the list in the deteriorating child before reaching for a cause outside the device. [4] [8]
Overview & Definition
Imagine you are called to a child who is attached to one or more of three devices — a gastrostomy for feeding, a tracheostomy for breathing, and a central venous catheter for intravenous therapy. Each device keeps the child alive or nourished, and each has a small, predictable set of ways in which it stops working. Device troubleshooting is the recognition of those failure modes and the bedside response to them. The gastrostomy fails by leaking, by growing granulation, by burying its internal bumper, by becoming infected, or by falling out. The tracheostomy fails by obstructing with secretions, by falling out, by bleeding, or by developing a cuff leak. The central line fails by occluding, by fracturing, by becoming infected, or by dislodging. [1] [4]
The defining principle of device troubleshooting is that the child comes before the hardware. In every device emergency the first action is to assess and support airway, breathing and circulation, and only then to read the device. The second principle is that each device has a learned algorithm, and the team that has rehearsed it resolves the emergency calmly while the team that has not improvises dangerously. The National Tracheostomy Safety Project algorithm, the gastrostomy replacement logic of tract maturity, and the central-line occlusion categorisation are the three algorithms a general paediatrician must be able to recite. [3] [8]
The key idea a candidate must hold is tract maturity. A gastrostomy tract takes roughly six to eight weeks to mature, and a tracheostomy tract takes about seven to ten days; before those thresholds the tract will close within hours, and blind instrumentation is both futile and dangerous. After the threshold, replacement at the bedside is expected and safe. That single distinction — mature versus immature tract — governs the entire emergency response to a dislodged tube, and inverting it is one of the most dangerous errors in paediatric device care. [1] [3]
References12ShowHide
- [1]Novak I Gastrostomy Tubes: Indications, Types, and Care. Pediatr Rev, 2024.PMID 38556513
- [2]Sutherland C Pediatric gastrostomy tubes and techniques: making safer and cleaner choices. J Surg Res, 2017.PMID 29180216
- [3]Wynings EM Accidental Tracheostomy Decannulations in Children: A Prospective Cohort Study of Inpatients. Laryngoscope, 2023.PMID 35712851
- [4]Willis LD Pediatric Tracheostomy Year in Review. Respir Care, 2024.PMID 38626953
- [5]Chauhan JC Tracheoinnominate Artery Fistula Formation in a Child with Long-Term Tracheostomy Dependence. J Pediatr Intensive Care, 2019.PMID 31093462
- [6]Chiaravalli J Management of an Obstructed Tracheostomy in a Limited-Resource Setting. Cureus, 2017.PMID 28616369
- [7]Espinel AG Tracheostomy manipulations: Impact on tracheostomy safety. Pediatr Investig, 2019.PMID 32851308
- [8]Giordano P Recommendations for the use of long-term central venous catheter (CVC) in children with hemato-oncological disorders: management of CVC-related occlusion and CVC-related thrombosis. Ann Hematol, 2015.PMID 26300457
- [9]Anderson DM Alteplase for the treatment of catheter occlusion in pediatric patients. Ann Pharmacother, 2013.PMID 23463740
- [10]Baskin JL Thrombolytic therapy for central venous catheter occlusion. Haematologica, 2012.PMID 22180420
- [11]Park CK Neonatal central venous catheter thrombosis: diagnosis, management and outcome. Blood Coagul Fibrinolysis, 2014.PMID 24477225
- [12]Buetti N Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol, 2022.PMID 35437133