AbstractWe hypothesised that long‐term tracheostomy in infants and children may perpetuate chronic airway inflammation and airway remodeling due to easier access to the lungs for microorganisms. Pulmonary surfactant represents an important part of the initial host defense, and in particular, the surfactant proteins (SP) A and D may directly interact with invading microorganisms and also modulate the activity of local immune cells. The goals of this study were to determine the presence and intensity of a peripheral airway inflammation and of potential deficiency states of surfactant proteins in nonsymptomatic children with tracheostomy. Bronchoalveolar lavage (BAL) cell pattern, bacteria and viruses recovered, and concentrations of SP‐A, SP‐B, SP‐C, and SP‐D were assessed in 46 children (4.3 years (1.6–6)) median (range) carrying a tracheostomy for 2.4 years (1.3–4.9), and were compared to 16 children with no lung disease. Children with tracheostomy had an increased total number of cells, increased neutrophils, and more frequently bacteria, but no viruses were recovered. SP‐D concentration was reduced by 50% on average (P = 0.0002). SP‐A, SP‐B, and SP‐C were not different between the two groups. SP‐D was inversely correlated to neutrophils, and high numbers of bacteria were associated with lower SP‐D concentrations. We suggest that bacteria and low SP‐D support neutrophilic inflammation in the lower respiratory tract of nonsymptomatic with children with tracheostomy. Pediatr Pulmonol. 2004; 37:356–361. © 2004 Wiely‐Liss, Inc.