From PICU to home: a longitudinal airway safety framework for children with tracheostomies

As survival improves among children with chronic lung disease, severe neurologic impairment, neuromuscular disorders, congenital airway anomalies, and long-term ventilator dependence, pediatric tracheostomy care has shifted from a procedure-centered issue to a sustained respiratory care challenge. Post-tracheostomy adverse events are still frequently framed as isolated complications rather than as part of a continuous airway-safety and home-transition pathway.

This article synthesizes post-tracheostomy risk across four connected domains: acute airway-threatening events, chronic cannulation-related morbidity, hospital-to-home transition, and decannulation-related functional outcomes, and develops a pediatric longitudinal airway safety framework.

We conducted a structured narrative search and qualitative synthesis drawing primarily on recent pediatric guidelines, systematic and scoping reviews, multicenter studies, national database analyses, and qualitative investigations, with priority given to publications from 2010 onward.

Major topics addressed include hemorrhage, false passage, accidental decannulation, tube obstruction, air leak syndromes, peristomal skin injury, respiratory infection, granulation tissue, airway stenosis or malacia, persistent tracheocutaneous fistula, dysphagia, impaired phonation, and caregiver burden. The framework differs from existing guidance and reviews by using phase of care and changing dominant risk as its organizing logic, linking each phase to the care setting, surveillance priorities, responsible teams, escalation thresholds, caregiver capability, and child- and family-centered outcomes.

A risk-stratified pathway connecting PICU care with community-based respiratory management may improve safety, reduce avoidable healthcare utilization, and better align clinical practice with the realities faced by children and families across the full trajectory of tracheostomy dependence.