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Please wait while the page loadsNursing Process in Action · Children's Nursing
Year 2Airway adjuncts, why a child needs a tracheostomy, tube types, humidification, safe suctioning, and the blocked-vs-displaced-tube emergency that every tracheostomy nurse needs at their fingertips.
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Student note
A stoma is the surgically created opening into the trachea. The cannula is the tube sitting in the stoma. Flanges are the side wings that hold the securing tapes. The hub is the outer connector for oxygen, humidification, or ventilator tubing. HME stands for heat and moisture exchanger. NPA here means nasopharyngeal airway (not to be confused with a nasopharyngeal aspirate sample).
Airway rule
Small airway + swelling/secretions = disproportionately large rise in resistance in children.
Two emergencies
A tracheostomy fails in one of two ways: the tube is blocked, or the tube is displaced.
Humidification rule
The tracheostomy bypasses the body’s natural humidifying system – add it back or secretions thicken and block the tube.
Suction rule
Correct size, prescribed depth, suction only on withdrawal, max 5–10 seconds, ≤30 mmHg.
What is actually different about a child’s airway that makes a tracheostomy higher-stakes?
Structural differences
Why small changes matter
Positioning matters
The clinical shortcut
Clinical pearl
Children are not small adults when it comes to airway anatomy. A large head, large tongue, high anterior larynx, and floppy epiglottis all narrow the margin for error – which is exactly why airway adjuncts and tracheostomies need such careful, precise management in children.
When the airway needs help before or instead of a tracheostomy, what are the options?
Guedel (oropharyngeal) airway
Nasopharyngeal airway (NPA)
Sizing matters both ways
Paediatric lens
What actually leads to a tracheostomy, and what do the parts of the tube do?
Common indications
Where it sits
The three key parts
If something goes wrong
Clinical pearl
A tracheostomy gives direct access to the trachea, which can be lifesaving – but it also means there is no upper airway "backup" the way there is in a child breathing normally. That trade-off is why tube security and patency are such a constant nursing focus.
Why do different tube designs exist, and why is humidification described as a "hidden" safety intervention?
Cuffed vs uncuffed
Fenestrated & inner tube
Why humidification matters
Practical safety points
Red flags
Clinical pearl
Humidification sounds like a comfort measure, but it is a genuine safety intervention. Without it, secretions thicken, cilia stop clearing them properly, and the tube itself can block – the single most dangerous tracheostomy complication.
Suctioning helps, so why is it also risky – and what does safe technique actually look like?
Why suction is needed
Suction risks
Safe technique rules
Daily care essentials
Red flags
Clinical pearl
Suctioning removes secretions, but it also briefly interrupts airflow and stimulates the airway – which is exactly why it should never be routine. Only suction when there is a clear clinical indication, and reassess afterwards.
The tube stops working – what do you actually do, in order?
The two big emergencies
Emergency sequence
The critical safety question
What must be at the bedside
Red flags
Clinical pearl
With a tracheostomy child, always think "blocked tube vs displaced tube" first. Do not spend time describing the tube in detail – check whether air is moving, call for help, oxygenate, suction if appropriate, and prepare for an emergency tube change.
| Feature | Why it matters clinically |
|---|---|
| Large head, short neck, prominent occiput | Positioning can flex the neck and obstruct the airway; may need shoulder support rather than head support. |
| Large tongue | Can fall back and obstruct the airway, especially with reduced consciousness. |
| High larynx (C3–C4) | More anterior and higher than in adults, making visualisation and airway manoeuvres different. |
| U-shaped, posteriorly-falling epiglottis | More likely to obstruct and makes airway management technically harder. |
| Narrow nasal passages, obligate nose breathing (infants) | Secretions, swelling, or tubes can significantly affect breathing and feeding. |
| Funnel-shaped, narrow airway | Small amounts of swelling or mucus cause a disproportionately large rise in resistance. |
| Adjunct | What it does | Key caution |
|---|---|---|
| Guedel (oropharyngeal) airway | Sits in the mouth, holds space so the tongue cannot fall back. | Only for reduced consciousness – if the child is too awake it can trigger gagging, vomiting, or laryngospasm. Care after oral, dental, tonsil/adenoid, or cleft-palate surgery. |
| Nasopharyngeal airway (NPA) | Passes through the nostril into the nasopharynx, bypassing tongue/soft-palate obstruction. | Avoid if basal skull fracture suspected. Paediatric nasal passages are small – wrong size/force risks bleeding or pressure injury. |
| Indication | Why a tracheostomy helps |
|---|---|
| Airway stenosis | Airflow through the normal route is restricted, so bypassing the narrowed area can improve ventilation. |
| Airway malacia | The airway is floppy and collapses; the tracheostomy bypasses or supports the unstable section. |
| Long-term ventilation (>16 hrs/day) | Gives a more stable, secure route for ventilation than prolonged upper-airway tubes. |
| Burns / trauma | Secures breathing below damaged or swollen tissue if the upper airway is unsafe. |
| Cystic hygroma / haemangioma | Provides an alternate route for air if a mass narrows the normal airway. |
| Infection / foreign body | Protects ventilation if swelling or obstruction threatens the airway. |
| Tube type | Mechanism | Safety point |
|---|---|---|
| Cuffed tube | Inflatable cuff seals the trachea, supporting positive pressure ventilation and reducing aspiration risk. | Inflate to minimal occlusion volume – too high damages tracheal mucosa, too low allows leak/aspiration. |
| Uncuffed tube | No cuff seal; common in young children, lower pressure-injury risk. | No cuff seal means tube position and tapes are vital – easier to dislodge. |
| Fenestrated tube | Holes allow air through the vocal cords, supporting voice. | Insert a non-fenestrated inner tube before suctioning to avoid tissue damage. |
| Inner tube | Removable inner liner, cleared of secretion build-up while the outer tube keeps the stoma open. | Thick secretions may need cleaning every 2–4 hours; replacements must match exact type/size. |
| Age | Approx. tube size | Suction pressure (from lecture slides) |
|---|---|---|
| Preterm–1 month | 3.0 | 8–10 mmHg |
| 0–3 years | 3.5–5.0 | 10–12 mmHg |
| 3–10 years | 5.0–6.0 | 12–15 mmHg |
| 10–16 years | 6.0–7.0 | 15–30 mmHg |
Student note
These figures are transcribed from lecture slides for revision purposes. Always check your local trust protocol and the child's own care plan before any real suctioning — this page does not replace clinical teaching or competency sign-off.
| Item | Why it's there |
|---|---|
| Same-size tube | For a like-for-like planned or emergency change. |
| One-size-smaller tube | Used if the stoma is starting to close or the same size will not pass. |
| Scissors, tapes, dressing, gauze, saline | For securing, cleaning, and dressing the stoma during a change. |
| HME | Restores humidification immediately after a tube change. |
| Suction catheters | To clear the tube or assist guided reinsertion. |
| Disconnection wedge | Used to help disconnect ventilator tubing safely if needed. |
Clinical pearl
The suction machine is not part of the emergency box, but it must travel with the child everywhere — including the playroom. The box itself should be checked at the start of every shift and before the child leaves the ward, with that check documented.
Guedel vs NPA
Guedel = mouth, needs reduced consciousness. NPA = nose, better tolerated awake
Cuffed vs uncuffed
Cuffed seals for ventilation/aspiration protection. Uncuffed common in young children
Suction safety
Correct size → prescribed depth → suction on withdrawal only → 5–10 sec, ≤30 mmHg
Emergency order
Call for help → oxygen → suction → change the tube if suction fails
Sources & References
National Tracheostomy Safety Project (2025) — NTSP Manual and Paediatric Resuscitation AlgorithmMcQueen S, Bruce E & Gibson F (2012) — The Great Ormond Street Hospital Manual of Children’s Nursing PracticesCoyne I, Neill F & Timmins F (2010) — Clinical Skills in Children’s NursingWatters KF (2017) — Tracheostomy in infants and children, Respiratory Care 62(6)Also practise with
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