7.3 Ventilator-Associated Complications, Extubation Readiness & Tracheostomy Emergencies

Ventilator complications, liberation and tracheostomy emergencies

Prevent injury and reassess deterioration

With an abrupt change, assess the child, airway and circuit at once. Consider displacement, obstruction, pneumothorax and equipment problems (DOPE). Also consider breath stacking, bronchospasm, derecruitment and circulatory deterioration. Review capnography, pressure and flow with chest movement and perfusion. Experimental volutrauma study · Cyclic collapse study · Inflammation study · PALICC-2 · AARC patient–ventilator assessment

Prevent and evaluate ventilator-associated infection

The CDC's pediatric ventilator-associated event (PedVAE) definition is for surveillance. It uses sustained rises in daily minimum inspired oxygen fraction or mean airway pressure after stability or improvement. A qualifying event may reflect infection or another cause. At the bedside, suspect ventilator-associated pneumonia (VAP) when new pulmonary findings and worsening support requirements occur with evidence of infection. Assess for mimics such as atelectasis or pulmonary edema. An endotracheal aspirate may help guide antibiotics when the clinical findings support bacterial infection. A positive culture alone can reflect colonization.

Use head-of-bed elevation when appropriate, regular oral care with brushing or gauze according to dentition, safe handling of condensate, and circuit changes for soilage or malfunction or per manufacturer instructions. Routine oral chlorhexidine for pediatric VAP prevention is generally discouraged. Avoid unnecessary sedation and use readiness screening to shorten exposure. The SCCM pediatric PANDEM guideline suggests against routinely adding daily interruption to protocolized sedation. Suction when indicated using an appropriately sized catheter. Avoid routine saline instillation and reserve deep suction for inadequate shallow clearance. Subglottic drainage tubes can be considered in selected larger children expected to need prolonged ventilation. Pediatric evidence is limited.

For likely bacterial VAP, consider prior cultures and antibiotic exposure, illness severity and the local antibiogram. Obtain a lower airway specimen if feasible, without delaying urgent treatment. Reassess when culture and clinical data return, narrow therapy and tailor duration to response, organism and complications. UCSF uses 7 days in its pediatric pathway. UC Davis uses 5 days and extends to 7 for a slow response. A 2025 pediatric retrospective study found a median of 6 days. These data support reassessment and short courses when appropriate, with the optimal duration for all children still uncertain. SHEA pediatric prevention recommendations · SCCM pediatric PANDEM guideline · CDC 2026 surveillance · AARC suction guideline · BrighT STAR pediatric culture consensus · UCSF pediatric pathway · UC Davis 2026 pathway · Pediatric duration cohort

Assess readiness and plan extubation

For acutely hospitalized children ventilated conventionally for more than 24 hours, PALISI suggests protocolized screening and an extubation readiness bundle that includes a spontaneous breathing trial (SBT). Check whether the illness is improving, support is modest and stable, the child can breathe spontaneously, and perfusion and gas exchange are adequate for that child's baseline. Assess sedation, cough, secretions and ability to protect the airway. A successful SBT addresses breathing capacity. The team still needs an airway and postextubation support plan.

During the trial, watch work of breathing, air entry, respiratory rate, gas exchange, mental status and circulation. Return to supportive settings and investigate deterioration if the child tires or gas exchange or perfusion worsens. Use baseline and age to interpret findings. The adult rapid shallow breathing index cutoff of 105 cannot be applied to infants. For example, 35 breaths/min divided by 0.035 L yields 1,000 breaths/min/L. The number alone cannot decide readiness.

For a cuffed endotracheal tube, use a standardized leak assessment with the cuff deflated as one component of upper-airway risk assessment. An air leak pressure above 25 cm H₂O is one risk marker, along with traumatic or repeated intubation, an oversized tube or known airway disease. Neither the presence nor absence of leak determines readiness on its own. Leak testing has limited predictive value with uncuffed tubes.

PALISI suggests dexamethasone at least 6 hours before planned extubation in children at high risk of postextubation upper-airway obstruction. Regimens vary and the benefit for preventing reintubation is uncertain. One pediatric trial used 0.25 mg/kg IV per dose (maximum 8 mg) every 6 hours for four doses, starting 6–12 hours before extubation. The trial found no significant reduction in moderate-to-severe obstruction overall. Follow the local high-risk airway plan and avoid delaying a standard-risk extubation solely to complete steroids. For children at high risk of extubation failure, plan immediate noninvasive respiratory support as appropriate. For infants younger than 1 year who need this support, PALISI conditionally favors CPAP over HFNC.

If stridor develops, assess air movement, retractions, oxygenation and fatigue. Nebulized epinephrine may provide temporary relief for suspected edema while the airway team evaluates the child. Worsening oxygenation, poor air entry or fatigue requires prompt preparation for reintubation. Consider other causes such as vocal fold dysfunction or fixed narrowing, especially if symptoms persist. PALISI pediatric liberation guideline · Cuffed-tube risk study · Dexamethasone trial · Pediatric SBT trial · FIRST-ABC postextubation trial · Postextubation epinephrine trial

Prepare for tracheostomy emergencies

A tracheostomy may bypass upper-airway obstruction, provide long-term ventilation or facilitate clearance. Know the child's upper-airway patency, date of placement and whether the surgical team has cleared routine changes. Record tube model, diameter, length, cuff status and suction size and depth. Cuffed tubes can facilitate ventilation. Use the lowest pressure that provides the prescribed seal and measure it with a manometer according to the tube and local plan. Continue aspiration-risk assessment because the cuff sits below the vocal folds. Choose active heated humidification or an appropriate heat and moisture exchanger based on ventilation, secretions and the child's plan. Keep the same-size and smaller tubes with obturators, suction, ties, manual ventilation equipment and face/stoma interfaces at hand.

For acute distress, call the resuscitation and airway teams, assess breathing and circulation, and apply oxygen to the face and tracheostomy or stoma when the upper-airway route is uncertain. Remove any speaking valve, cap, exchanger or removable inner cannula. Use a soft suction catheter to the prescribed depth to check patency before attempting positive-pressure ventilation through a possibly displaced tube. A catheter that passes permits suction and reassessment. If assisted ventilation remains necessary, check chest rise, exhaled CO₂ when available and the clinical response. Evaluate other DOPE causes if gas exchange remains poor.

If the catheter cannot pass and the child is deteriorating, treat the tube as blocked or displaced. Avoid forcing breaths through it. Deflate the cuff before removing a nonfunctional tube. For an established tract, a trained responder can try the same-size tube, then the designated smaller tube if needed. Remove the obturator, recheck catheter passage and confirm effective ventilation before securing it. In a fresh tract or before the first planned change, call the surgical airway and anesthesia teams immediately and follow the postoperative rescue plan. Blind reinsertion risks a false passage. While the team secures the airway, ventilate by the effective route: face mask with the stoma covered when the upper airway is patent, or a small mask over the stoma when the upper airway is obstructed. Begin CPR per PALS if heart rate stays below 60/min with cardiopulmonary compromise despite effective ventilation with oxygen, or if pulseless.

AARC pediatric tracheostomy guideline · ATS pediatric tracheostomy guideline · NTSP pediatric emergency guideline · Johns Hopkins All Children's fresh-tracheostomy pathway · 2025 AHA/AAP PALS