Tracheostomy care and emergencies: Viva

Branch 1: The emergency approach to the distressed child

The candidate should recognise this as a tracheostomy emergency and state that a child with a tracheostomy who is acutely distressed has a blocked or displaced tube until proven otherwise. They should describe the algorithm: call for help, give high-flow oxygen to both the face and the stoma, remove any speaking valve or cap and the inner cannula if present, then pass a suction catheter to test patency. A catheter that passes indicates a patent tube to suction and reassess, while a catheter that will not pass indicates a blocked or displaced tube. [1]

The candidate should then explain that if the tube cannot be cleared, the correct step is to deflate the cuff if present and remove the tracheostomy tube, because a tube that cannot be cleared only occupies the airway. After removal they should oxygenate via the intact upper airway with the stoma covered, or via the stoma, and only then attempt controlled re-cannulation with the same size and then a smaller tube. A strong candidate emphasises that a visible tube is never proof of a patent airway and that patency must be confirmed by air movement and capnography. [1]

Branch 2: Tube types and why they matter in the crisis

The examiner may ask the candidate to describe the tube this child might have and why it matters. The candidate should classify tubes by the features that change bedside behaviour: cuffed versus uncuffed, single versus double lumen with a removable inner cannula, and fenestrated versus non-fenestrated. They should explain that most young children have small uncuffed single-lumen tubes because their airway is narrow, and that a removable inner cannula, when present, allows a blocked tube to be cleared in seconds. [2]

The candidate should stress the practical preparation this implies: the emergency plan and go-bag at the bedside must name the exact tube, its size, and whether it has an inner cannula or a cuff, with a same-size tube and a smaller tube ready. If the examiner probes speech and humidification, the candidate should link them to physiology, explaining that the bypassed upper airway no longer warms and humidifies air, so humidification prevents the mucus plugs that block tubes, and that speech requires airflow to reach the cords through a leak, a fenestration, or a speaking valve. [2]

Branch 3: The false passage risk and decannulation

If the examiner pivots to the child being only a few days post-tracheostomy instead of 6 months, the candidate must recognise the changed danger. They should explain stoma tract maturation: a fresh tract has not healed into a stable channel, so displacement allows the tissue planes to collapse and blind reinsertion risks a false passage into pretracheal tissue. The safe response to an early accidental decannulation is to oxygenate from above using the intact upper airway, call the surgical team, and use the stay sutures to reopen the tract under vision rather than force a tube blindly. [1]

Because this real child is now well 6 months on, the examiner may finish by exploring decannulation. The candidate should describe a stepwise pathway: confirm the original indication has resolved and the child no longer needs ventilation, assess the airway with endoscopy to exclude obstruction and granulation, and use downsizing and capping trials to confirm the child tolerates the natural airway. They should acknowledge the genuine debate about whether a sleep study is mandatory before decannulation, and that final tube removal is followed by a monitored observation period before discharge. [3]