TRACHEOSTOMY CARE

TRACHEOSTOMY CARE
By Rommel Luis C. Israel III

LEARNING OBJECTIVES
At the end of the lecture, the students will be able to:
1. Define tracheostomy
2. State two reasons why tracheostomy tubes are inserted
3. Discuss types of tracheostomy tubes
4. Discuss the procedure for cleaning a tracheostomy tube
a. Single
b. Double
5. Discuss the procedure for suctioning an established tracheostomy

WHAT IS TRACHEOSTOMY?
 It is a medical procedure (temporary or permanent) that involves creating an opening in the neck
in order to place a tube into a person’s windpipe
 The tube is inserted through a cut in the neck below the vocal cords
 It allows air to enter the lungs.
- Breathing is then done through the tube, bypassing the mouth, nose, and throat.
 It is commonly known as a stoma (hole in the neck that the tube passes through)
Source:
Krans, B 2012, Tracheostomy, Healthline, Healthline Media, viewed 25 February 2022, https://www.healthline.com/health/tracheostomy .

TRACHEOSTOMY HISTORY
 First recorded in 1649
 The practice had been in use long before this, however, previously known as pharyngotomy,
laryngotomy, or bronchotomy.
 It is one of the oldest operations known, with ancient Egyptian artifacts engraved with depictions
of tracheostomy that date back to 3600BC.
 Written references to a surgical procedure of an incision in the trachea also appeared in a Hindu
text written circa 2000BC.
 Alexander the Great was reported to save a soldier’s life from suffocation in circa 1000BC, by way
of an incision of the trachea using his sword tip.
Source:
Smith, Y 2011, Tracheotomy History, News-Medical.net, viewed 25 February 2022, https://www.news-
medical.net/health/Tracheotomy-History.aspx .

From the 16th century to the 19th century
 it was generally regarded by surgeons as dangerous with a low chance of success
 Tracheotomies were reserved as an option for emergency treatment for obstruction of the upper
airways, although the success rate of the procedure was not favorable.
In 1546
 Antonio Musa Brasavola (Italian Physician) performed a successful tracheotomy on a patient
suffering from obstruction of the tonsils
 The first successful documented case.
Source:

In 1630
 Habicot performed the first documented pediatric tracheotomy, on a teenaged boy that had
swallowed gold that became lodged in his esophagus and caused an obstruction of the airway.
In 1718
 Lorenz Heister (German surgeon) introduced the term tracheotomy to common practice and it
remains the most widely used term today.
Source:

In the 19th century
 Tracheotomies became a surgical procedure that was performed more commonly, despite the
continued high mortality and morbidity rates associated with the procedure.
 Chevalier Jackson standardized the surgical procedure in the early 1900s by showing that lower
mortality rates were evident when proper techniques and adequate postoperative care were
employed. The technique he advocated involved a low tracheal incision to the second or third
tracheal rings.
Source:

WHY IS TRACHEOSTOMY PERFORMED?
Purposes of tracheostomy tubes
1. Removal of secretions
- A tracheostomy is performed for several reasons, all involving restricted airways
- It may be done during an emergency when your airway is blocked.
2. Facilitate breathing
- it could be used when a disease or other problem makes normal breathing impossible.
Source:

Conditions that may require a tracheostomy
include:
 Anaphylaxis
 birth defects of the airway
 burns of the airway from inhalation of
corrosive material
 cancer in the neck
 chronic lung disease
 coma
 diaphragm dysfunction
 facial burns or surgery
 infection
 injury to the larynx or laryngectomy
 injury to the chest wall
 need for prolonged respiratory or ventilator
support
Source:

Conditions that may require a tracheostomy
include:
 obstruction of the airway by a foreign body
 obstructive sleep apnea
 paralysis of the muscles used in swallowing
 severe neck or mouth injuries
 tumors
 vocal cord paralysis
Source:

COMPONENTS OF TRACHEOSTOMY TUBE
 The tracheostomy tube is used to hold the tracheal stoma (hole) open.
 Standard components of the tracheostomy tube include the:
- hub
- flange
- outer cannula
- inner cannula
- cuff
- pilot balloon
- inflation line

COMPONENTS OF TRACHEOSTOMY TUBE

THE HUB
• is the part that protrudes from the
patient’s neck.
• It has a universal 15mm diameter so that it
can connect to the ventilator circuit,
rescucitation bags, speaking valves, and
caps.
• the inner and outer diameters of the
tracheostomy tube have different sizes that
correspond to the patient’s
unique anatomy.

TUBE
SHAFT
• The outer cannula, makes up the main
component of the tracheostomy tube and
is the part that is inserted into the trachea.
• It can either be fenestrated or non-
fenestrated, cuffed or cuffless.
• The size of the outer cannula be shown on
the flange as the outer diameter (OD). The
outer diameter is the distance between the
outside walls of the outer cannula, and is
measured in millimeters.

INNER
CANNULA
• Dual cannula (DC) tracheostomy tubes have an
inner cannula.
• It is placed inside the outer cannula.
• It can be easily removed or replaced for cleaning
and therefore can help to prevent obstruction
such as from mucous plugs.
• There are different sizes of inner cannulas that
must be matched to the corresponding outer
cannula or it will not fit appropriately. The
appropriate size comes packaged with the
tracheostomy tube. Additional inner cannulas can
be purchased separately as needed.
Portex DIC tracheostomy tubes have a color coded
inner cannula, which corresponds to the
matching hub of the Portex tracheostomy tube,
allowing for quick identification of the correct tube.

INNER
CANNULA
There are four ways to secure inside the outer
cannula:
- prong clip
- luer lock
- ring clip
- telephone jack style.
*Single lumen airways do not use an inner
cannula.
Inner cannulas can be disposable or non-
disposable, fenestrated or non-fenestrated.
If the inner cannula is fenestrated, the outer
cannula should also be fenestrated or it would not
function as intended.

INNER
CANNULA
• The inner diameter (ID) refers to the distance
between the inside walls of the inner cannula,
and is measured in millimeters.
• Using an inner cannula decreases the usable
airway diameter, increases airway resistance,
and may increase the work of breathing (Carter,
A. et al, 2013; Cowan, T. et al, 2001).
• Pediatric tubes do not offer inner cannulas,
because the tube itself is already very small.

FLANGE
(Neck Plate)
• It is the part of the tracheostomy tube that
extends from the outer part of the
tracheostomy tube and has holes to attach the
tracheostomy tube tie.
• It should lie flat against the skin on the neck.
• The flange has important information about the
tracheostomy tube including the tracheostomy
tube size, the size of the outer diameter (mm),
the size of the inner diameter (mm), the brand
and cuff type.

FLANGE
(Neck Plate)
Tracheostomy tube abbreviations on the flange:
Shiley:
• DCT- Disposable Cannula Cuffed Tracheostomy
• DCFS- Disposable Cannula Cuffless
• CFN- Cuffless Fenestrated (non-disposable)
• LPC- Low Pressure Cuffed
• FEN- Fenestrated
Portex:
• DIC- Disposable Inner Cannula

TRACHEOSTOMY
TUBE TIE
• It is used to keep the tracheostomy tube in
place to prevent accidental decannulation.
• It attaches to the flange and wraps around the
patient’s neck.
• Tracheostomy tube ties should be used unless
the patient recently underwent local or free flap
reconstructive surgery or other major neck
surgery (Mitchell, 2013). This is to avoid neck
pressure from the ties.
• A patient should not be discharged from the
hospital with a tracheostomy tube sutured in
place. (Mitchell, 2013).

TRACHEOSTOMY
TUBE TIE
• One finger should be used to ensure that
the tracheostomy tie is tight enough to
prevent dislodgement.
- The edges of the tracheostomy
flange may cause small ulcerations if
the collar/ties that hold the
tracheostomy tube in place are too
tight.

TRACHEOSTOMY
TUBE TIE
• There are a few different materials
used for tracheostomy ties:
- twill
- Velcro ties (most commonly
used)
- stainless steel metal chain.

Obturator
• It is sometimes called a pilot
• Purpose:
- to assist with the insertion of the
tracheostomy tube.
• The inner cannula is removed and the
obturator inserted which extends slightly
beyond the tracheostomy tube. The
obturator has a blunt tip and cushions the
placement of the tube in the trachea to
avoid tissue damage. Immediately
following placement, the obturator is
removed and replaced with the inner
cannula.

Cuffed and Cuffless
Tracheostomy Tubes
Cuffed Tracheostomy Tube
- it is a balloon-like feature
located around the outer
cannula, near the bottom of
the tracheostomy tube.
- it has a pilot line and pilot
balloon as an indicator for cuff
status.

Cuffed and Cuffless
Tracheostomy Tubes
Cuffeless Tracheostomy Tube
- It does not have the balloon-
like feature
- Most pediatric tubes are
cuffless, even if the individual
requires mechanical
ventilation

Cuffed and Cuffless
Tracheostomy Tubes
Purpose of the Tracheostomy Cuff
- to maintain the air is delivered
from the mechanical ventilator to
the lungs.
- it fills the tracheal space around
the tracheostomy tube to prevent
airflow from escaping around the
tube and through the upper
airway. Therefore, positive
pressure ventilation can be
applied more effectively when the
cuff is inflated.
There is a common misconception in the
medical field that the cuff prevents
aspiration.

Cuffed and Cuffless
Tracheostomy Tubes
The cuff DOES NOT prevent
aspiration
- material can still pass around
the cuff since there is not a
complete seal against the
tracheal wall.

Pilot line
• It is the inflation line
• leads from the cuff to the pilot
balloon.
• It is a pathway for air to flow into
and out of the cuff.

Pilot
Balloon
• It is a balloon-like feature located
at the end of the pilot line.
• The bottom of the pilot balloon
contains a spring loaded valve,
called a luer valve, which prevents
air from leaking out of the pilot
balloon.
• A syringe attaches to the luer valve
to either inflate or deflate the cuff
of the tracheostomy tube.

Pilot
Balloon
• When the pilot balloon is inflated,
this indicates that the cuff is
inflated.
• When the pilot balloon is deflated,
this indicates that the cuff is
deflated.

PILOT BALLOON INFLATED OR DEFLATED
Source:
Tracheostomy Education 2019, Tracheostomy cuff inflated and deflated, www.youtube.com, viewed 25 February 2022,
https://youtu.be/RvdGRDLvB8w .
Click the picture to
watch the video
Copy-paste
the link
below to
watch the
video online

Fenestrated
Tracheostomy
Tubes
• A fenestration is a hole in the
curvature of the posterior wall of the
tracheostomy tube.
• Fenestrated tubes have various shaped
openings along the shaft of the inner
and outer cannulas that were
designed to allow airflow through the
fenestration for better voicing.
• They also provide less work of
breathing when the cuff is deflated
(Hussey, MJ & Bishop, JD, 1996) .

Fenestrated
Tracheostomy
Tubes
• Some tubes offer both fenestrated
and non fenestrated inner
cannulas.
• The use of the fenestrated inner
cannula is indicated in order to
achieve the benefits of the
fenestration.
• Use of the standard inner cannula
will block the fenestration and
therefore block airflow through the
fenestration.
NOTE: It is not a
requirement for the
patient to have a
fenestrated
tracheostomy tube
during speaking valve
use.

Tracheostomy
cap
• It is a small plastic piece that is placed on
the 15mm hub of the tracheostomy tube.
• The cap blocks all airflow through the
tracheostomy tube and the patient must
therefore inhale and exhale around the
tracheostomy tube and through the upper
airway.
• Capping is frequently used as a tool
during decannulation trials.

PILOT BALLOON INFLATED OR DEFLATED
Source:
Craig Hospital 2020, Capping a Tracheostomy Tube, www.youtube.com, Craig Hospital, viewed 25 February 2022,
https://youtu.be/S4NIO_DEJks .
watch the video
Copy-paste
the link
below to
watch the
video online

MANUFACTURER
VARIATION
• Tracheostomy tubes are available in a variety of sizes and styles from several
manufacturers.
• Some examples of manufacturers of tracheostomy tubes include Shiley™, Portex™,
Bivona™, Traco®, and Blom®.
• It is imperative that clinicians are able to identify the patient has a tracheotomy tube,
the brand, type, size, composition, material of the tube and cuff, whether or not the
tube is fenestrated, or if it is a custom tube.
• The tracheostomy tube should be selected based on the individual patient’s anatomy
and clinical needs.

Tracheostomy
Materials
• Tracheostomy tubes are made of a variety of medical grade materials:
- plastic (Single use/Disposable)
- silicone (commonly used in pediatric airways, single patient use, but maybe
sterilized and reused for the same patient
- sterling silver and stainless steel ( referred to as Jackson tubes, are
constructed of silver or stainless steel, typically cuffless)
• Two types of plastics commonly used are:
- (PVC) polyvinyl chloride (Shiley™ and Portex™)
- polyurethane (Tracoe®).

Tracheostomy
Tube Length
•Extra proximal length tubes are for patients with
thicker necks (obese patients).
•Standard tracheostomy tubes are too short and too
curved for proper positioning due to the distance
between the skin and the trachea.
- Therefore, standard tracheostomy tubes are
more likely to be dislodged in patients with
thick necks.

Single Lumen
Tracheostomy
Tubes
• It consists of the outer cannula only (there is
not an inner cannula).
• Most pediatric tracheostomy tubes are single
lumen tubes, because their diameters are
too small to accommodate an inner
cannula.
• It is important to check the patency of single
lumen tubes regularly.
- AIrway patency can be checked by
passing the suction catheter.
- If the suction catheter is unable to pass,
this indicates an obstruction.
•

Double Lumen
Tracheostomy
Tubes
• Tracheostomy tubes with an inner cannula
are called dual-cannula or double lumen
tubes.
• Double lumen tubes are the most
commonly used tracheostomy tube.
• Use of an inner cannula increases airway
resistance (Cowan et al, 2001), but lends a
safety factor in that it can be quickly
changed in the event of a mucus plug,
leaving the outer cannula intact.

Pediatric
Tracheostomy
Tubes
• They are single lumen tubes
due to the small inner
diameter.
• Most pediatric tubes are
cuffless.

TYPES OF TRACHEOSTOMY TUBE
Types of tracheostomy tubes
1. Disposable/non-disposable
2.Single cannula
3.Double cannula

EARLY COMPLICATIONS
Early Complications that may arise during
the tracheostomy procedure or soon thereafter
include:
 Bleeding
 Air trapped around the lungs
(pneumothorax)
Source:
Molnar, H n.d., Complications and Risks of Tracheostomy, www.hopkinsmedicine.org, viewed 25 February 2022,
https://www.hopkinsmedicine.org/tracheostomy/about/complications.html .
Image:
St. Vincent's Hospital Lung Center n.d., Pneumothorax, viewed 25 February 2022, https://www.svhlunghealth.com.au/conditions/pneumothorax .

EARLY COMPLICATIONS
Early Complications that may arise during the tracheostomy procedure or soon thereafter include:
 Air trapped in the deeper layers of the chest(pneumomediastinum)
 Air trapped underneath the skin around the tracheostomy (subcutaneous emphysema)
 Damage to the swallowing tube (esophagus)
 Injury to the nerve that moves the vocal cords (recurrent laryngeal nerve)
 Tracheostomy tube can be blocked by blood clots, mucus or pressure of the airway
walls. Blockages can be prevented by suctioning, humidifying the air, and selecting the
appropriate tracheostomy tube.
Source:

LATER COMPLICATIONS
Later Complications that may occur while the tracheostomy tube is in place include:
 Accidental removal of the tracheostomy tube (accidental decannulation)
 Infection in the trachea and around the tracheostomy tube
 Windpipe itself may become damaged for a number of reasons, including pressure from the
tube; bacteria that cause infections and form scar tissue; or friction from a tube that moves too
much
 These complications can usually be prevented or quickly dealt with if the caregiver has proper
knowledge of how to care for the tracheostomy site.
Source:

DELAYED COMPLICATIONS
Complications that may result after longer-term
presence of a tracheostomy include:
 Thinning (erosion) of the trachea from the
tube rubbing against it (tracheomalacia –
pathological softening)
 Development of a small connection from the
trachea (windpipe) to the esophagus
(swallowing tube) which is called a tracheo-
esophageal fistula
Source:

DELAYED COMPLICATIONS
Complications that may result after longer-term presence of a tracheostomy include:
 Development of bumps (granulation tissue) that may need to be surgically removed before
decannulation (removal of trach tube) can occur
 Narrowing or collapse of the airway above the site of the tracheostomy, possibly requiring an
additional surgical procedure to repair it
 Once the tracheostomy tube is removed, the opening may not close on its own. Tubes
remaining in place for 16 weeks or longer are more at risk for needing surgical closure
Source:

HIGH-RISK GROUP
The risks associated with tracheostomies are higher in the following groups of patients:
 children, especially newborns and infants
 smokers
 alcohol abusers
 diabetics
 immunocompromised patients
 persons with chronic diseases or respiratory infections
 persons taking steroids or cortisone
Source:

CLEANING A TRACHEOSTOMY TUBE
 Plastic and metal tubes may be cleaned with mild soap and clean tap
water.
 Hydrogen peroxide may be used to clean plastic or stainless steel tubes.
 Do not use hydrogen peroxide with sterling-silver tracheostomy tubes.
 If the tracheostomy tube is cuffed, clean the cuff using the
manufacturer’s instructions found in the package. The cuff should not
come in contact with any cleaning detergents or chemicals.
Source:
University of Iowa Hospitals & Clinics 2019, How to clean a tracheostomy tube, University of Iowa Hospitals & Clinics, viewed 25 February 2022,
https://uihc.org/health-topics/how-clean-%C2%A0tracheostomy-
tube#:~:text=Steps%20to%20clean%20a%20tracheostomy%20tube&text=Soak%20them%20for%20a%20few .

Supplies you will need
 Clean tap water
 Mild soap
 Hydrogen peroxide (do not use this with sterling-silver tracheostomy
tubes)
Source:

Steps to clean a tracheostomy tube
1. Place the dirty tracheostomy tube, obturator, and strap in a clean container.
2. Add clean tap water and mild soap. Be sure the tube, obturator, and strap are covered
by water.
3. Soak them for a few minutes to loosen any secretions.
4. Clean the tube and other parts using pipe cleaners and gauze sponges. Pass the pipe
cleaner through the tube to remove all of the secretions.
5. Rinse well with clean tap water to remove all the soap.
Source:

Steps to clean a tracheostomy tube
6. Make sure the secretions and lint from the pipe cleaners are removed.
7. Place the tracheostomy tube parts on a clean towel in a safe place. Let them air
dry all the way. It will take about 2 to 3 hours. Note: Have an extra tracheostomy
tube ready for use while the newly-cleaned tube dries.
8. When the tracheostomy tube is dry, look for cracks, a change in color of the tube,
or any foul odor. The tube will need to be replaced if you find any of these.
9. Get the tube ready to be used again by adding ties and putting the obturator in
the tube.
10. Place all of the tracheostomy tube parts in a closed, clean container. Keep this
with you at all times.
Source:

Cleaning the inner cannula
To clean the inner cannula so it does not become plugged:
1. Unlock it by turning it until the notch is reached and then slide it out.
2. Use a small brush or pipe cleaners to clean it.
3. Rinse it under cool running water.
4. Look through the inner cannula to make sure it is clean.
5. Shake it or use dry pipe cleaners to remove moisture.
6. Put it back in and lock it into place.
Source:

CLEANING THE TRACHEOSTOMY TUBE
Source:
Parkland Heralth 2018, Cleaning your tracheostomy tube, www.youtube.com, viewed 25 February 2022, https://youtu.be/ETdyNAkRBXY
.
watch the video
Copy-paste
the link
below to
watch the
video online

PROCEDURE FOR SUCTIONING THE
TRACHEOSTOMY

INDICATION FOR SUCTIONING
 Audible or visual signs of secretions in the tube
 Signs of respiratory distress
 Suspicion of a blocked or partially blocked tube
 Inability by the patient to clear the tube by coughing out the secretions
 Vomiting
 Desaturation on pulse oximetry
 Changes in ventilation pressures (in ventilated children)
 Request by the patient for suction
Source:
The Royal Children's Hospital Melbourne 2014, Clinical Guidelines (Nursing) : Tracheostomy management, Rch.org.au, viewed 25 February 2022,
https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Tracheostomy_management/ .
.

EQUIPMENT
 Suction apparatus (wall attachment or portable unit)
 Suction canister
 Tubing
 Suction catheter
 Sterile water
Source:
.

RECOMMENDED SUCTION CATHETER SIZES
FOR CHILDREN
Tracheostomy tube size (in
mm)
3.0mm 3.5mm 4.0mm 4.5mm 5.0mm 6.0mm 7.0 mm
and >
Recommended suction
catheter size (Fr)
7 8 8 10 10 10-12 12
Source:
.

RECOMMENDED SUCTION CATHETER SIZES
FOR ADULT
 The size of the suction catheter should be less than half the internal diameter of the tracheal tube (A
way to calculate this is to multiply the tube size by three and divide that number by two)
 The total suction procedure (from insertion to removal of catheter) should take a maximum of 15
seconds with negative pressure applied continuously as the catheter is being withdrawn from the
tracheal tube.
 The catheter should be introduced to a depth no more than the tip of the artificial airway to prevent
trauma and bleeding from airway mucosa.
 In patients not considered at high risk of adverse events, the suction catheter may be passed until
either a point of resistance is felt or a cough is stimulated, then the catheter should be withdrawn 1-2
cm prior to continuous suction.
Source:
.

Supplies needed
 Suction catheter (keep the package)
 Connection tubing
 Suction machine
 Clean tap water
Source:
University of Iowa Hospitals & Clinics 2019, Suctioning a tracheostomy, University
of Iowa Hospitals & Clinics, viewed 25 February 2022, https://uihc.org/health-
topics/suctioning-
tracheostomy#:~:text=Steps%20to%20suction%20a%20tracheostomy&text=Conn
ect%20the%20suction%20catheter%20to .

Steps to suction a tracheostomy
1. Turn on the suction machine with the
pressure set on the low-to -medium setting.
2. Connect the suction catheter to the tubing on
the suction machine.
3. Dip the suction catheter tip into the clean tap
water.
4. Take 4 to 5 deep breaths.
5. Gently put the suction catheter into the
tracheostomy tube as far as you can without
forcing it. Do not cover the suction control vent
with your thumb while putting the catheter into
your tracheostomy tube.
Put the suction catheter into the
trachestomy tube
Source:
topics/suctioning-

Steps to suction a tracheostomy
6. Pull the suction catheter back out a little bit
before you start to suction.
7. Cover the suction control vent with your
thumb to start suctioning. Do not suction for
more than 10 seconds each time. Turn or twist
the suction catheter as it is taken out.
8. Remove your thumb from the suction control
vent if you feel the catheter pull during
suctioning.
9. Wait 20 to 30 seconds between each suction
try. After 3 tries, wait 5 to 10 minutes before
suctioning again.
Cover the suction control vent with
your thumb to start suctioning.
Source:
topics/suctioning-

Tracheostomy Suctioning- Nursing Skills
Source:
NURSINGcom 2021, Tracheostomy Suctioning- Nursing Skills, www.youtube.com, viewed 25 February 2022,
https://youtu.be/jHp4AhBXsJU .
watch the video
Copy-paste
the link
below to
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video online

RESOURCES
 Carter, A., Fletcher, SJ., Tuffin, R., The effect of inner tube placement on resistance and work of breathing through tracheostomy tubes:
a bench test. Anaesthesia. 2013 Mar;68(3):276-82. doi: 10.1111/anae.12094. Epub 2012 Dec 20.
 Cowan T, Op’T Holt TB, Gegenheimer C, Izenberg S, Kulkarni P
. Effect of inner cannula removal on the work of breathing imposed by
tracheostomy tubes: A bench study. Respiratory Care, 2001;46(5): 460–465.
 Hernández G, Ortiz R, Pedrosa A et al. The indication of tracheotomy conditions the predictors of time to decannulation in critical
patients. Med Intensiva. 2012;36(08):531–539. [PubMed] [Google Scholar]
 Hussey JD, Bishop MJ. Pressures required to move gas through the native airway in the presence of a fenestrated vs a nonfenestrated
tracheostomy tube. Chest. 1996;110(2):494-497.
 Khoo K, Arnot-Smith J. Complications with the use of Bivona adjustable flange tracheostomy tube. J Intensive Care Soc. 2015;16(1):81–
82. doi:10.1177/1751143714552991
 Mitchell, RB, Hussey, HM, Setzen, G, Jacobs, IN, Nussenbaum, B, Dawson, C., Brown, CA, Brandt, C., Deakins, K., Hartnick, C., Merati, A.
Clinical consensus statement: tracheostomy care. Otolaryngology Head Neck Surgery, 2013;Jan;148(1):6-20.
 Rumbak, M. et al. Significant Tracheal Obstruction Causing Failure to Wean in Patients Requiring Prolonged Mechanical Ventilation: A
forgotten Complication of Long Term Mechanical Ventilation. Chest, 1999.
 Shrivastava DK, Kapre S, Gray R. Weaning is facilitated by use of nonfenestrated tracheostomy tubes in chronically ill tracheostomized
subacute care patients. Chest. 2003;124(4_MeetingAbstracts):205S

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