Implementing pediatric tracheostomy guidelines in low- and middle-income countries

To the Editor: The recently published American Thoracic Society (ATS) Clinical Practice Guideline on the Care of Infants and Children with Tracheostomies is the first ATS guideline on pediatric tracheostomy care.1 It offers evidence-based recommendations for managing medically complex children with tracheostomies. While developed with attention to health equity, including disparities in access, caregiver burden, and resource availability, the guideline does not explore the unique challenges of implementing these recommendations in low- and middle-income countries (LMICs). Recognizing this gap, 3 guideline panelists collaborated with 4 clinicians from Argentina, Pakistan, Malawi, and South Africa to share perspectives on practical considerations in LMICs. This jointly authored commentary examines the feasibility of implementing the guideline recommendations across diverse health systems with varying infrastructure and resources. Providing pediatric tracheostomy care in LMICs is challenging due to clinical, infrastructural, and social constraints. Studies from South Africa and Rwanda highlight barriers to safe home care, including limited access to suction equipment, replacement tracheostomy tubes, and supplemental oxygen, as well as caregiver fatigue and financial strain.2-5 Many families lack reliable electricity and clean water, making adherence to guideline recommendations difficult.4 Post-discharge follow-up is often fragmented or unavailable, and emergency response systems are limited.6 These realities underscore that implementing recommendations, such as ensuring an awake caregiver or access to bronchoscopy or polysomnography, may not be feasible. The guideline recommends applying ethical principles—beneficence, nonmaleficence, autonomy, and justice—to guide shared decision-making about tracheostomy placement. While these principles should be considered everywhere, their application may be constrained by local context. In Malawi, tracheostomy placement occurs only at a few tertiary referral centers, such as Kamuzu Central Hospital in Lilongwe, and even there it is relatively uncommon. Indications include prolonged mechanical ventilation and acute upper airway obstruction, often requiring emergent placement with little opportunity for multidisciplinary or family discussions. When possible, providers engage families in decision-making, but there is no standardized process. Information sharing and assessment of family understanding are often limited by high patient volumes and staffing constraints. A standardized discharge process to facilitate the safe transition of tracheostomy-dependent children from hospital to home is recommended. In many LMICs, discharge is often infeasible due to infrastructure and home support limitations. In Malawi, discharge is rare and decannulation is pursued before discharge, largely because of safety concerns at home, where home oxygen is unavailable. When discharge does occur, families may relocate to remain near tertiary urban hospitals, as seen in Pakistan. In rural Pakistan, children with chronic lung disease of prematurity or other common indications for tracheostomy often do not survive because advanced care is inaccessible. Families who reach urban centers for tracheostomy placement rarely return home. In Argentina, providers may collaborate with local governmental agencies to prepare the home or arrange transfer to a regional facility when needed. In contrast, Red Cross War Memorial Children’s Hospital in Cape Town, South Africa offers a structured model of discharge and home care for children requiring chronic ventilation via tracheostomy through its Breatheasy program, which integrates multidisciplinary collaboration from pediatric pulmonologists, otolaryngologists, social workers, and other specialists.5,7 Families receive comprehensive training and support, enabling safe discharge—even to informal settlements—with ongoing outpatient care. For example, when homes lack reliable electricity, caregivers are trained to use a manual handheld or foot-controlled pump for suctioning the tracheostomy tube. These experiences demonstrate that standardized discharge can be achieved while adapting to local resources. Another key recommendation is that an awake and alert trained caregiver always be present with children at risk of immediate decompensation due to tracheostomy-related complications. This reflects the high risk of morbidity and mortality associated with tracheostomy-related emergencies, particularly in children who are ventilator-dependent, have severe airway obstruction, or are very young. However, implementing this recommendation is challenging across settings. Families juggle caring for other children and working outside the home. In the United States, home nursing shortages are well documented, and in LMICs, home nursing is often unavailable altogether.6 Families with financial means may hire additional support, but this represents a small minority. Even in relatively well-resourced programs like Breatheasy in South Africa, where substantial local resources and community networks exist, children with tracheostomies often share a bed with their sole caregiver. These realities highlight the disconnect between guideline recommendations and the practical constraints faced by families.8 The guideline further recommends obtaining tracheal aspirate cultures during acute respiratory episodes to guide antibiotic therapy, performing endoscopic airway evaluations in children with new respiratory symptoms, conducting complete airway evaluations prior to decannulation, and using polysomnography or pulse oximetry under direct observation to assess readiness for decannulation. These diagnostic tools are inconsistently available in LMICs. In Malawi, obtaining tracheal cultures is difficult because many clinical staff are not trained to collect these samples and laboratory personnel with microbiology expertise are not always available. Airway evaluations are possible but constrained by limited specialist availability—Kamuzu Central Hospital currently has only one specialist otolaryngologist for both adult and pediatric patients and no pulmonologists. In Argentina, pulse oximetry studies are widely available, but access to polysomnography is limited outside major centers in Buenos Aires. In rural Pakistan, where living with a tracheostomy is nearly impossible, pulse oximetry studies are not typically available. These examples illustrate how variability in access to diagnostic tools across settings can make strict adherence to these recommendations challenging. As pediatric tracheostomy care expands globally, guidelines must be adaptable to the realities of diverse health systems. Future iterations could incorporate LMIC-specific considerations or tiered recommendations for context-sensitive implementation.9,10 Collaboration with clinicians in LMICs is essential to understanding local practices, resource constraints, and facilitators and barriers to safe care. Our team is planning a mixed-methods study to further explore global pediatric tracheostomy practices, with the goal of informing future guideline development. We welcome continued dialogue and collaboration with international providers and families to ensure recommendations are both applicable and adaptable across settings. Ultimately, global efforts to improve access to respiratory care for all children remain critical, regardless of location or financial resources. Supplementary material is available at American Journal of Respiratory and Critical Care Medicine online. Please see the ICMJE disclosure forms, which have been provided as supplementary material. The authors have no conflicts of interest to disclose.