Different Flags
Like any assessment of the unwell child, you should always start with A for 'airway'. In the case of a child with a tracheostomy, there may be two airways to consider.
Any airway problem can cause the patient to become unwell and show signs of distress. Conversely, children with tracheostomies can become unwell with all the problems that other patients get too. It is easy to become fixated with the tracheostomy. The 'flags' can be divided up into different categories:
Airway red flags
These include:
- Child with a minimal leak previously - suddenly able to talk/audible air leaks/bubbles seen at mouth
- Suction catheter not passing through tracheostomy
- Grunting, snoring or stridor
Breathing red flags
These include:
- Not breathing (or apnoea)
- Increasing ventilator support
- Increasing oxygen requirements
- Respiratory distress:
- Accessory muscle use
- Increased respiratory rate
- Higher airway pressures
- Lower tidal volumes
- Noisy breathing
Specific tracheostomy flags
These include when the child:
- Has a visibly displaced tracheostomy tube
- Has blood or blood-stained secretions around the tube - a recently performed or changed tracheostomy bleeds a little, but if in doubt, you should get it assessed
- Reports increased discomfort or pain
General flags
Any physiological changes can be due to an airway problem. Specifically, changes in:
- Respiratory rate
- Heart rate
- Blood pressure
- Level of consciousness
- Anxiety, restlessness, agitation and confusion may also be due to an airway problem