The physician should not hesitate to change the cannula Suctioning alone may not clear an obstruction caused by thick secretions All the necessary equipment for the change should be present, including a replacement tracheostomy tube, an endotracheal tube one-half size smaller, and a bag–valve–mask ventilation circuit with oxygen flow, scissors, and tracheostomy ties The change is best accomplished with the participation of two people: one secures the patient and removes the old tube, whereas the other inserts the new tube Remember to deflate the cuff prior to removal, if one exists Please see Chapter 130 Procedures for details on how to change a tracheostomy tube Infection Bacterial colonization of the trachea usually occurs in a child with a tracheostomy Common colonizing organisms include gram-positive cocci (Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae , α- and β-hemolytic streptococci), gram-negative bacilli (Klebsiella, Pseudomonas, Escherichia coli, Serratia marcescens, Haemophilus influenzae ), and anaerobes (Peptostreptococcus, Bacteroides ) These same organisms can become pathogenic, causing tracheitis or pneumonia Differentiating between bacterial colonization of the trachea and clinical infection can be difficult The physician should elicit a history of any changes in the quantity, thickness, or odor of the tracheal secretions, and any systemic signs of infection or respiratory distress Along with physical examination, there should be a determination of oxygenation by pulse oximetry A Gram stain and bacterial culture, and a rapid viral detection assay of the tracheal secretions, may be helpful in determining the presence and cause of an infection Leukocytosis in the tracheal secretions and a predominant organism by Gram stain may be suggestive of bacterial tracheitis; radiographic evidence of a new infiltrate indicates pneumonia If the child appears well and follow-up can be ensured, outpatient antibiotic therapy may be appropriate For children with increased oxygen or ventilatory requirements, hospitalization should be considered for intravenous (IV) antibiotic therapy, aggressive pulmonary toilet, and close monitoring Erythema of the peristomal skin is usually caused by irritation and should be managed by increasing the frequency of the tracheostomy care at home The additional findings of warmth, tenderness, purulent drainage, or fever may suggest the presence of a peristomal cellulitis Depending on its severity, this condition should be treated with oral or IV antibiotics