Breathing Experts Lead New Pediatric Tracheostomy Guidelines

Over the past two decades, pediatric tracheostomy care has evolved significantly. However, the guidelines from the American Thoracic Society (ATS) had not been updated since 2000. Christopher Baker, MD, along with many other experts in tracheostomy care from around the world, recognized the need for revision. So, he applied to the ATS to change them, co-chairing an international panel. Together, they published “Care of Infants and Children with Tracheostomies."

These clinical guidelines focus on topics that haven’t been addressed by prior consensus statements. The multidisciplinary team of panelists included pulmonologists, pediatric and adult otolaryngologists, critical care doctors, respiratory therapists, speech pathologists, nurses, developmental pediatricians, and others.

“There was a lot of expertise. We focused on pediatrics and really tried to emphasize best practices,” Dr. Baker says. “We addressed topics that are interesting and relevant, some potentially controversial. We didn’t want to just recommend what everyone already does.” 

New ATS tracheostomy guidelines 

The ATS uses the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. GRADE is a common framework used for evaluating evidence and the strength of recommendation. The new tracheostomy guidelines address the following six questions: 

1. Should ethical principles be applied to conversations with families about tracheostomy tube placement for their infants and children? 
2. Should a standardized process for initial discharge be used for infants and children with tracheostomy tubes? 
3. Should infants and children with tracheostomies always have an awake and attentive trained caregiver presents? 
4. Should tracheal aspirate cultures be obtained for infants and children with tracheostomies during routine clinic visits and acute respiratory illnesses? 
5. When should infants and children who have tracheostomy tubes undergo evaluation and bronchoscopy (rigid and/or flexible) to evaluate the airway? 
6. Should all infants and children with tracheostomies undergo a capped polysomnogram before decannulation? 

In the guidelines, each question includes background information, analyzes the evidence, 
outlines benefits and harms, and ultimately leads to a final recommendation.

Recommendations are classified as strong or conditional based on the certainty and quality of evidence. 

“Sometimes low-quality evidence results in a conditional recommendation. But sometimes, even with weak evidence, we make a strong recommendation because patient safety is on the line,” Dr. Baker says.

As they decided on recommendations, the group consulted families of children with tracheostomies. Their opinions, Dr. Baker says, were invaluable. 

“We’re not just making recommendations from the medical perspective — we practice reality-based medicine,” Dr. Baker says. “It doesn’t matter what a research paper or a medical textbook says. The real world is where families are trying to actually deliver the care. To do it without the families would be a huge mistake.”

Health equity in tracheostomy care 

The new guidelines also address health equity — a topic not covered in the previous guidelines — by considering barriers to accessing care. For example, these recommendations may be easy for larger hospitals with sizable home ventilator programs. But what about a doctor in a small town where there’s only one pulmonologist? Care needs to be adapted to fit the varied economic, cultural, and structural context of different health systems.

“Unfortunately, our health care system is not equitable. This is one of the first ATS guidelines to include health equity. I’m proud of that. I really think it matters. It’s not about politics. It’s about patient care. Hopefully our recommendations help.” 

Together, the new guidelines tackle tough questions with transparency, equity, and patient-centered care at the forefront.