The skin of the neck under the ties securing the tracheostomy tube can also become inflamed Generally, this situation can be treated by increasing the amount of padding and by keeping the area dry An erythematous rash with satellite lesions classic for a monilial dermatitis should be treated with topical antifungal creams Asthma The incidence of asthma is increased in children with chronic lung disease Many children are maintained at home on inhaled β-agonist and inhaled corticosteroid therapy The usual viral and environmental triggers, such as dust, pets, and smoke, precipitate exacerbations of asthma The presentation is similar to that of other asthmatic patients, with varying amounts of respiratory distress, wheezing, and hypoxemia As previously mentioned, the physician must consider the possibility of cannula obstruction or dislodgment in all cases Treatment with oxygen, bronchodilators, and steroids should be initiated promptly However, emergency clinicians should recognize that children with chronic lung disease have less pulmonary reserve, and patients with neurologic diseases may not be able to generate the necessary increase in work of breathing to overcome the poor lung compliance associated with acute asthma Chest radiography and blood gas analysis should be performed as clinically indicated Continuous monitoring of pulse oximetry and end-tidal CO2 are helpful in tracking the illness trajectory in the ED Increased ventilatory support or continuous positive airway pressure may be required to overcome fatigue and atelectasis Bleeding and Granuloma The tracheal mucosa located adjacent to the stoma, the cuff, and the distal tip of the tracheostomy tube is prone to bleeding and granuloma formation The most common reason for bleeding is inadequate humidification causing drying and friability of the tracheal mucosa Infection or granuloma formation can also result in small amounts of bleeding Large amounts of blood coming from the tracheostomy tube opening can signify erosion of the tube into the brachiocephalic artery The incidence of tracheoarterial fistula formation is rare (approximately 0.7%) but commonly results in death due to massive hemoptysis and blood loss The risk for development of this life-threatening complication is highest during the postoperative period (i.e., within weeks of tube placement) Small amounts of bleeding from the tracheal stoma usually resolve with increased humidification of the inspired air The persistence of minor bleeding