includes a stationary humidification system that is used when the child is connected to the circuit Similarly, a heat–moisture exchanger is attached to the end of the tracheostomy tube in patients who not require the ventilator The device is composed of a hydrophilic material that captures the patient’s own heat and humidity on exhalation so that it can be inspired on inhalation Clinical Findings/Management The approach to the ill patient with an artificial airway is the same as that for any patient who comes to the ED The initial evaluation consists of an assessment of the patient’s ABCDs (airway, breathing, circulation, and disability), with particular attention to the airway and breathing An emergency physician who knows how to anticipate common problems and to recognize them early is able to institute appropriate therapy without delay Obstruction and Decannulation The most life-threatening complication in a patient with an artificial airway is cannula obstruction or dislodgment Younger children are more likely to experience accidental decannulation because of the short length of the trachea and tracheostomy tube Some infant tubes are as short as to cm H2 O In addition, the small lumen is more easily occluded by a mucous plug or by an accumulation of secretions Infants with less-developed intercostal muscles and children with neuromuscular disorders may be unable to generate an adequate cough to keep the airway clear of debris The presentation is similar to that of other children with airway obstruction The child may appear distressed with tachypnea, cyanosis, accessory muscle use, and/or nasal flaring Alternatively, the child may be lethargic or obtunded as a result of prolonged respiratory effort or an elevated carbon dioxide level Any child with an artificial airway and respiratory distress is assumed to have an obstruction The patient should be placed immediately on high-flow humidified oxygen The physician should determine whether the tracheostomy tube appears to be in place, recognizing that a tube in the stoma does not necessarily indicate a tube in the trachea If a cannula change was attempted before the child’s arrival in the ED, a false passage into the paratracheal soft tissues may have occurred Auscultation for the presence and symmetry of bilateral breath sounds should be performed and the quality of the patient’s respiratory effort should be assessed Immediate suctioning is appropriate in an attempt to assess tube patency and to clear the airway of secretions