Core Principle: Involve PALS in Every Decision
PALS can describe familiar patterns and what feels different. Listen to their communication and non-verbal cues while assessing breathing and arranging help.
Always ask PALS:
- How are you feeling right now?
- Is ventilator pressure feeling OK?
- Any cough stuck? Where - chest or balloon area?
- Feeling dry cough or wet secretions?
- Balloon feeling too tight or too loose?
- Any other discomfort?
Key Insight: The more you involve PALS in daily decisions, the more they understand what helps them. Their feedback is valuable, but apparent comfort or a reassuring monitor reading must not delay emergency help when warning signs are present.
Knowing PALS well can help you recognize problems early. It cannot prevent every emergency. Caregivers and family members must learn to quickly interpret non-verbal cues, including facial expression, eye movements and lip reading, to identify important words or understand what is being pointed at. By immediately recognizing these subtle signs of discomfort, you can take action before the situation worsens or vital parameters start showing concern.
What We Monitor
When PALS shows discomfort, check these parameters:
Changes in these parameters indicate something is wrong. But always combine parameter reading with PALS feedback - they often sense discomfort before numbers change significantly.
Two-Person Approach
Person 1: Immediate Care
- Stay with PALS and follow the individualized emergency plan
- Talk to PALS, get feedback
- Check external connections; suction or provide prescribed backup support only if trained
Person 2: Call and Coordinate
- Call 112 for emergency warning signs and contact the respiratory/ICU team immediately
- Prepare supplies
- Monitor parameters
- Give the address, tracheostomy/ventilator details, symptoms and actions already taken
Decision Flowchart
Use observations to explain the problem to the treating team. Emergency warning signs take priority over every branch below.
Severe distress, ineffective ventilation or suspected tube blockage/displacement? Call 112 and skilled airway help now.
Follow prescribed backup support only if trained; do not bag through a tube of uncertain patency.
• Wet or dry cough?
• Visible disconnection, kink or alarm?
• Any other discomfort?
- Suction only if indicated, prescribed and you have been trained.
- Use the taught technique; do not force the catheter or routinely instil saline.
- Unable to pass it, worsening distress or no prompt improvement: stop and escalate immediately.
- Follow the prescribed secretion/humidification plan.
- Do not select a new nebulized medicine yourself.
- Breathing distress needs urgent assessment; do not wait for nebulization to work.
- Contact a respiratory therapist, trained ICU nurse or doctor.
- Do not deflate, inflate or adjust the cuff based on sensation alone.
- Subglottic suction requires a suitable tube, specific training and a prescribed plan.
- Possible blocked or displaced TT tube. Call 112 and the respiratory/ICU team now.
- Do not force the catheter or attempt ventilation through a tube of uncertain patency.
- TT removal/replacement is a skilled airway intervention, not a trial-and-error next step for an untrained caregiver.
Call 112 if not already called; follow dispatcher and individual plan instructions.
Do not cancel emergency assessment after a serious episode without speaking to them.
Do not take an extra dose without advice.
Any fever?
They will decide which assessment or tests are needed.
Normal SpO2 does not rule out a ventilation problem. Do not use Ambu solely to lower pulse/BP.
Leak values normal?
Do not guess cuff inflation or change ventilator settings.
Contact the respiratory/ICU team; call 112 if ventilation is ineffective.
Understanding Each Situation
Situation A: SpO2 Dropping / Low Tidal Volume
Possible causes include secretions, a blocked or displaced tube, equipment problems or another illness. Breathlessness and ineffective ventilation need urgent assessment.
Sequence
1Call 112 now for severe distress, ineffective ventilation or suspected tube blockage/displacement.
2Stay with PALS; ask about symptoms while another person contacts the respiratory/ICU team.
3Check external power, visible connections and kinks as trained.
4Suction only as prescribed and trained. Do not force the catheter or routinely instil saline.
5If breathing does not promptly improve, stop repeated attempts and get urgent skilled help.
6Continue only trained emergency support while help arrives; report changes and actions already taken.
Path Selection
- Wet/gurgling: prescribed suction by a trained person; escalate if ineffective.
- Dry cough: follow the prescribed secretion plan; do not delay emergency help for nebulization.
- Cuff-area concern: trained respiratory/ICU review; no improvised cuff manipulation.
- Suction catheter will not pass: possible blocked or displaced TT tube. Call 112 and a respiratory therapist, trained ICU nurse or doctor immediately. Do not force the catheter or bag through a tube of uncertain patency. Tube replacement requires specific airway training and authorization.
Situation B: High Pulse / High BP with Normal SpO2
Important: A high pulse or BP is not a diagnosis of retained secretions. Normal SpO2 does not rule out inadequate ventilation. Severe breathlessness, chest pain, collapse or reduced responsiveness require emergency help immediately.
Common Causes
- Fever or illness: report symptoms and temperature to the doctor.
- Possible secretions: use only the trained, prescribed plan; do not assume this is the cause.
- Discomfort: check positioning and ask about pain. Pressure changes need clinical advice.
What To Do
- Check temperature and repeat readings if practical, without delaying care.
- Ask about pain, breathlessness and other new symptoms.
- Contact the treating doctor for persistent changes. Do not increase BP medicine or ventilator pressure yourself.
- Call 112 for emergency warning signs; do not wait for tests or a lower SpO2.
Situation C: PALS Says "Pressure Feels Insufficient"
When PALS reports ventilator pressure feeling low or inadequate:
Checklist
- Settings unchanged?
- Circuit properly connected?
- Leak values normal?
- New leak or cuff concern? Report it to the respiratory team.
Actions
- Call 112 if ventilation is ineffective or there is severe distress
- Check for high leak
- Use only the backup support prescribed and taught for this person; do not change settings yourself
- Contact the respiratory therapist, trained ICU nurse or doctor for airway/ventilation decisions, and the technician for equipment faults
When Home Troubleshooting Must Stop
Suction catheter will not pass: call for skilled airway help now
A tracheostomy tube may be blocked or displaced. Do not force the catheter or squeeze an Ambu bag harder to push through an obstruction. Do not wait to complete a suction/nebulization cycle before calling for help.
- Call 112 and the treating respiratory/ICU team immediately. Explain that the person has a tracheostomy and the suction catheter will not pass. Do not wait for the equipment technician to arrive before calling emergency services.
- Stop repeated attempts. Do not attempt ventilation through a tube whose patency and position are uncertain. Stay with PALS and follow the dispatcher’s instructions and the person’s written airway emergency plan.
- Get the right trained responder. A doctor, respiratory therapist or ICU nurse competent and authorized in emergency tracheostomy care must assess whether the tube needs removal/replacement or another airway intervention. A caregiver should perform such an action only if specifically trained and authorized in that person’s written emergency plan; general experience or an online guide is insufficient.
- Prepare for handover while help is coming. Bring the airway plan, tube details, prescribed spare tubes and equipment. Report alarms, breathing changes, SpO2 trend, catheter resistance and what has already been tried. Continue only the emergency support you are trained and instructed to provide.
Cuff concerns and subglottic suction need specific training
Do not deflate or inflate the cuff to investigate a sensation of trapped secretions. Cuff changes can affect ventilation and airway protection. Contact the respiratory therapist, trained ICU nurse or doctor for assessment.
Subglottic suction is only possible with a suitable tube and must follow the prescribed technique taught for that device. It is not a substitute for managing a blocked airway. A ventilator technician’s equipment skills alone do not qualify them to change a TT tube or manipulate its cuff.
If the prescribed immediate actions fail to promptly restore effective breathing, or the person worsens at any point, escalate immediately. Do not keep trying different methods or wait for the person to say they feel better.
Quick Reference
Equipment Checklist
Always Ready
- Ambu bag
- Suction machine
- Suction catheters
- Normal saline only for prescribed uses; not routine instillation into the tracheostomy
- Syringes (5ml, 10ml)
Backup
- Spare TT tubes in the sizes prescribed by the airway team
- Nebulizer + medicines
- Oxygen concentrator
- Backup ventilator (if available)
Emergency Contacts
Keep these numbers beside the written emergency plan. Call emergency services immediately for airway compromise; contact the treating team in parallel:
Remember: Listen to PALS, call early, and use the individualized plan. Low-risk checks and trained support can happen while skilled help is on the way. This page does not teach emergency airway procedures.