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TABLE OF CONTENTS

Objectives: ..................................................................................................................................................................... 2

Introduction ................................................................................................................................................................... 2

Is it just a tracheostomy, or is there more? Laryngectomies. ....................................................................................... 4

Tracheostomy versus surgical cricothyroectomy .......................................................................................................... 7

Parts of the tracheostomy device ................................................................................................................................ 10

Tracheostomy enhancements ..................................................................................................................................... 13

Quick reference chart on tracheostomy devices ......................................................................................................... 17

Tracheostomy emergencies......................................................................................................................................... 19

First treatment steps ............................................................................................................................................... 19

Helpful tips ............................................................................................................................................................... 21

Video of outer cannula insertion ............................................................................................................................. 22

Procedure: Sterile suctioning ...................................................................................................................................... 23

About the person with a tracheostomy ....................................................................................................................... 25

Cardiac arrest considerations ...................................................................................................................................... 26

References ................................................................................................................................................................... 28

Image credits ............................................................................................................................................................... 29

Note: Commercial product names are mentioned in the education, but no financial benefit or endorsement was derived from

their use. They represent commonly-known devices that may be referred by these more familiar names in the healthcare

setting.

Prehospital Care of the

Patient with a Tracheostomy

Continuing Education:

2 hours Special Considerations (state) or

Medical: Special Healthcare Needs (NREMT)

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OBJECTIVES:

The objectives for this continuing education include:

• Compare the major types of surgical airways and what to expect as normal and abnormal findings

during your patient assessment.

• Explore a subset of patients with tracheostomies: Individuals with a laryngectomy.

• Describe the appropriate assessment of the patient with a tracheostomy for both spontaneously

breathing and mechanically-ventilated individuals.

• Examine treatment plans and procedures for respiratory emergencies involving a patient with a

tracheostomy and with or without a laryngectomy.

• Discuss the appropriate procedure for tracheal suction to reduce healthcare-associated infections.

INTRODUCTION

What is a tracheostomy? A tracheostomy is a surgically-created hole (stoma) to the anterior neck,

located just below the thyroid gland and usually between the second and fourth tracheal rings. Functionally,

it’s similar to our prehospital surgical cricothyrotomy, but the location of the incision is different along with

the intended use, as shown in the comparison table below.

Surgical Cricothyrotomy Tracheostomy

Usually used as a rapid, emergent airway. Usually a planned surgical procedure.

Used for adult patients since they usually have

a wider airway and identifiable tracheal

landmarks, such as the cricothyroid

membrane. Should be avoided in young

children and infants.

Procedure is used for all ages, including

neonates and pediatrics.

A temporary rescue airway. Usually a permanent functional airway.

When performed correctly, less risk of cutting

veins and arteries.

Several vessels lie across the tracheal rings and

can be easily cut; Usually reserved for the

operating room.

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A little history: Tracheostomies have been around for thousands of years. Fortunately, the procedure is

kinder and gentler today compared to the earlier years.

The first known depiction of tracheostomy is from 3600 BC,

which was discovered by historians on ancient Egyptian

tablets. According to legend, Alexander the Great allegedly

used his sword to open the airway of a soldier choking from

a bone lodged in his throat.1,2 In the second to third century

AD, Aretaeus and Galen wrote about tracheostomies that

were performed by the Greek physician Asklepiades several

hundred years earlier.3 Success rates were considered as

questionable though.

Skipping ahead to the early 20th century, tracheostomies

became much safer thanks to the work of Dr. Chevalier

Jackson, who is considered as a pioneer in modern

laryngology and endoscopy. During the U.S. polio epidemic

in the 40s and 50s, tracheostomies and ventilator use become more common because of the paralysis that

accompanied this potentially-fatal disease. This accelerated the development of modern positive-pressure

ventilators that greatly improved the mortality rate and eventually replaced the “iron lung”.

Today: From 1993 to 2012, over one million adults (1,352,432 to be more exact) underwent long-term

tracheostomy placement, per the U.S. Agency for Healthcare and Research Quality’s Healthcare Cost and

Utilization Project data.4 This number doesn’t include short-term tracheostomies, such as those created for

acute facial trauma or to establish an emergent airway in the hospital.

The reasons for a tracheostomy vary but may

include a need for long term mechanical

ventilation, poor swallowing with a high risk for

aspiration, an upper airway obstruction that

can’t be resolved surgically (example: a

cancerous mass), and other reasons where the

patient is simply unable to protect his or her

airway.

While not exactly a surgical procedure sitting on

everyone’s bucket list, a tracheostomy is far

from handing a patient a death sentence. Many

patients with a tracheostomy are able to lead independent lives at home without the need for a mechanical

ventilator. In many cases, they simply need way to bypass air movement from the upper airway but otherwise

have enough chest and diaphragm strength and control for spontaneous breaths.

Alexander the Great depicted as cutting the

Gordian Knot. Maybe cutting a throat for one of

the earliest tracheostomies offers more truth

than legend?

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The benefits of a tracheostomy:4

• Improved patient comfort and less sedative use compared to long term intubation with an

endotracheal tube;

• Less time spent in the hospital (reduced length of stay)

• Earlier mobility; the patient does not have to be confined to bed;

• Less risk for injury to the tracheal structures;

• Earlier oral feeding. Gastrointestinal movement in response to food is important for overall health.

It’s not without risks though… risk of complications from the tracheostomy procedure itself can be as high as

39%.5,6 In addition, the patient with a tracheostomy has lost a lot of airway protection from environmental

pathogens. For example, our nosehairs help to filter contaminants from the air. So, this leaves the individual

more susceptible to infectious diseases and respiratory contaminants. Air is normally humidified through our

nose and downward towards the trachea, but this is lost with a tracheostomy as well. With the drier air and

structural airway change, it’s more difficult for a person

with a tracheostomy to cough up mucus and clear

secretions, increasing their dependency on tracheal

suctioning. This may be compounded by the

individual’s underlying medical condition or injury that

necessitated tracheostomy placement in the first place.

The education will compare the different types of

surgical airways, the devices used to maintain a

tracheostomy, and how to assess and effectively treat

the patient during a respiratory emergency. Most of

the information applied to both the adult and pediatric

patient unless otherwise indicated.

IS IT JUST A TRACHEOSTOMY, OR IS THERE MORE? LARYNGECTOMIES.

Laryngectomy: What is it? As described earlier, there’s several reasons why a person may need a

tracheostomy. Depending on the cause, the individual may also need a laryngectomy as well, which

essentially closes off the airway from the first tracheal rings on up.

A laryngectomy basically removes the connection from the upper airway to the trachea --- the entire larynx is

surgically removed and/or closed. The vocal folds and cords are removed along with the epiglottis. The nasal

passages and esophagus route directly down to the epigastrium without any access to the trachea. The airway

now begins at the tracheostomy’s stoma, as shown on the next page.

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Who gets this procedure? Most laryngectomies are performed due to cancer of the larynx. The most

common cause is through years of smoking, and alcohol consumption along with smoking can increase this

risk. A laryngectomy is usually reserved for those who were unsuccessfully treated with radiation and

chemotherapy for the cancer, or for those who have very large tumors that cannot be treated with either of

these therapies. However, non-cancerous tumors or abnormal growths may also necessitate this procedure.

Usually, the only way you can tell if someone has a laryngectomy versus a tracheostomy that preserved the

larynx is by asking, digging through the medical history, looking for a medical ID bracelet, or if unconscious,

seeing if any air passes through the nostrils. The stoma on the neck looks the same as a tracheostomy.

What the person with a laryngectomy can and can’t do: A person with a laryngectomy can still

eat and drink by mouth after healing, but there is little to no sensation of taste since the sense of smell does

not work effectively without air passing through the nostrils. The individual can shower if the stoma is

protected from water intrusion, but swimming or submersion of the stoma without protection (laryngectomy

snorkel, for example) is obviously contraindicated.

With the vocal cords removed, the normal way of speaking is also gone. However, there are electronic and

physical devices that can help a person speak even after a laryngectomy, such as an electrolarynx or voice

prosthesis.

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An electrolarynx is a medical device that

facilitates speech by generating sound when

held on the neck or at times intraorally. The

best way to describe the sound is as monotone

and almost robotic-sounding, but newer

advancements are now allowing the individual

to control some of the tone and inflection

during speech using a pressure-sensitive button

controlled with their thumb.

Individuals with a laryngectomy may want a

more natural voice and opt for a surgery called

a tracheoesophageal puncture (TEP), which is

done during the actual laryngectomy or later as

a second surgery. A fistula (interconnecting hole) is surgically-created between the trachea and esophagus

and a plastic voice prosthesis is inserted. This prosthesis produces sound from esophageal vibrations created

during the exhalation phase. To do this, the individual breathes in and then occludes the tracheostomy stoma

with their thumb or go “hands free” with a stoma valve while exhaling. Occluding the stoma diverts air from

the trachea through the voice prosthesis instead. The person creates a voice by altering the flow of air and

tension within the esophagus to create vibration, which takes a lot of time to learn effectively. The prosthesis

has a one-way valve to prevent food or drink from entering the trachea, but unfortunately, this small device is

also prone to developing yeast and bacterial infections.

Prehospital emergencies: For EMS, the most important concern about a laryngectomy is that intubation

is now impossible. There is no way to direct an endotracheal tube through the mouth to the trachea, while

on the other hand, most patients with

a tracheostomy (and without a

laryngectomy) can be intubated

emergently, if needed. Also, a BVM

won’t work over the nose and mouth.

You can attach a neonate mask and

ventilate the stoma though.

A second concern: If the patient has a

tracheoesophageal puncture with a

voice prosthesis, another respiratory

emergency can occur if the small

plastic prosthesis dislodges from the

fistula. The prosthesis is normally

replaced every five months or so,7 but

can also accidentally work its way out

of the fistula at any time.

An electrolarynx device. The one to the left is placed under

the mandible to create speech, while the one shown to the

right is inserted in the mouth (intraorally).

Speaking with a voice prosthesis post-tracheoesophageal puncture.

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The loose voice prosthesis has only three places to go:

• Coughed out of the stoma (the best situation),

• Down the esophagus (a close second),

• Or worst-case scenario, inhaled into the trachea and lodged at the

carina or within a lung.

Regardless of the travel route, these patients need to have this prosthesis

replaced or the fistula kept open with an appropriate catheter to prevent

fistula closure, which may occur in only a few hours.7 You may find these

patients with a soft 12 to 16 French catheter,8 the prosthesis’ puncture

dilator, or other small, flexible, tube-like object already placed in the

fistula to keep it open. If the catheter is not impeding their ventilation and

can be or appears secured well enough, just leave it there and transport.

Do not give any medications or fluid by mouth. If the patient is

complaining of sharp chest pain immediately after the catheter insertion,

it may have been accidently directed into transesophageal wall.8

Some prostheses are patient removable/insertable so he or she can clean them weekly or even more often. If

these patients call EMS because of the dislodged prosthesis, it’s usually because they accidentally aspirated

the device. A dilator or another prosthesis may already be in the fistula prior to EMS arrival.

TRACHEOSTOMY VERSUS SURGICAL CRICOTHYROECTOMY

A tracheostomy may be performed for the following conditions:

• Obstruction of the mouth or throat that cannot be corrected with surgery or would be unsafe to do so.

• Breathing difficulty caused by edema, physical injury, or pulmonary conditions where breathing support

may need to be long term.

• Airway reconstruction following tracheal or laryngeal surgery.

• Airway protection from secretions or food because of swallowing problems.

• Airway protection after head and/or neck surgery.

• Long-term need for ventilator support. For example, individuals with amyotrophic lateral sclerosis (ALS).

A tracheotomy is a surgical opening made to the anterior neck and through the tracheal rings. A tracheostomy

tube is inserted and used to administer positive-pressure ventilation, to provide a patent airway, and to provide

access to the lower respiratory tract for airway clearance. There are several similarities and differences between a

tracheostomy and the more familiar surgical cricothyrotomy used in the prehospital setting.

Voice prosthesis in place with the plastic access tab visible, which is exiting from the upper stoma. Image: Erman 2010

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Surgical cricothyrotomy: A surgical cricothyrotomy’s incision is made at the large space referred to as the

cricothyroid membrane, which is nested between the thyroid cartilage and the crico(thyroid) cartilage. The

cricothyroid membrane may also be referred to as the cricothyroid ligament.

The opening that houses the cricothyroid

membrane is about 8 to 10 mm tall (vertically) in

most adults, and the membrane has a glossy

appearance. The cricothyroid membrane is an

ideal site for a surgical airway since it does not

calcify with advancing age and it also lies well

above a cluster of tracheal blood vessels. It found

easily in non-obese males with a prominent

“Adam’s Apple”, and although more difficult, it can

also be palpated in women and obese individuals.

The general rule is that the cricothyroid membrane

should be located about three finger breadths

above the sternal notch9 (memory aid: “three to

breathe”), and this may a better way to start

searching for it in women and those with thicker

necks.

A surgical cricothyrotomy is considered as only a temporary airway fix due to its location and limited space within

the cartilage junction that makes it more difficult to accommodate permanent tracheostomy devices such as a

Shiley® tracheostomy tube. Instead, the long-term or permanent surgical airway of choice is a tracheostomy using

a more appropriate tracheostomy tube to maintain airway patency.

Location for the surgical cricothyrotomy: The cricothyroid membrane.

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Tracheostomy: A tracheostomy is a long term or permanent method of preserving the airway when there is an

occlusion to the upper airway. Occlusions can be

caused by swelling, tumors, granular growth, or even

deformity of the larynx from traumatic injury. Like a

surgical cricothyrotomy, a tracheostomy is formed

below the patient’s vocal cords.

The tracheostomy is positioned lower in the airway,

usually between the second and fourth tracheal rings.

There are several methods of creating the surgical hole

ranging from forming a flap with the tracheal tissue to

completely removing a window of trachea to

accommodate the tracheostomy tube. The skin is

manipulated to form a round stoma to ease insertion of

the tracheostomy tube and provide a solid, non-tearing

base for the stoma.

Most tracheotomies are a planned procedure performed in the controlled environment of an operating suite. As

shown below, there’s room for a lot of potential complications with the proximity of nerves and blood vessels

traversing alongside or even across the anterior trachea.

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PARTS OF THE TRACHEOSTOMY DEVICE

There are several types of tracheostomy devices and different ways to secure it, which are often selected with

consideration towards:

• The underlying reason for the tracheostomy;

• If ventilator support is needed;

• Any difficulties found with swallowing;

• The individual’s communication needs;

• Age and mobility;

• And other factors.

Tracheostomy devices and securement options should be individualized. For example, it’s generally not

recommended that Velcro tracheostomy ties are used to secure the tracheostomy tube for a younger child who

likes to tug. These ties can be unfastened easily, yet the child may not understand the consequences of undoing

them and inadvertently removing the tracheostomy tube. Instead, tracheostomy tubes for children are usually

secured with a soft cotton band that can be tied together with a knot and are more difficult to loosen.

The tracheostomy tube: Basic parts. Most tracheostomy tubes consist of four parts: An outer cannula

with flange (neck plate), an inner

cannula, an obturator that’s only used

when exchanging out the tracheostomy

tube, and tracheostomy ties. There

are exceptions though, such as a tube

setup with only the outer cannula and

obturator (described later). The most

common configuration is a dual-

cannula tracheostomy, which includes

the outer cannula, inner cannula, and

use of the obturator when needed.

Outer cannula. The outer cannula

is the largest diameter and outermost

tube that holds the tracheostomy’s

stoma open. A neck plate (also called

the flange) extends from both sides of the outer tube and has holes to attach cloth ties or Velcro straps around the

neck.

The outer cannula remains inserted in the individual’s trachea most of the time. The only time it’s removed is to

exchange it for a clean replacement as directed by the individual’s physician (usually once every few weeks or even

longer) or if it is accidently removed. The outer cannula should be secured at all times with ties, straps, or held in

place manually except during the quick exchange.

Parts of a common tracheostomy configuration: Outer cannula, inner cannula, and the temporary use of an obturator.

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Cuffed or uncuffed? The outer cannula may have an inflatable cuff or instead, be uncuffed. The pilot balloon can

be inflated or deflated with a standard 10 mL Luer-lock syringe. Most long-term tracheostomy devices have a cuff

filled with air, but there are exceptions, such as the softer Portex/Bivona™ cuffs that use sterile water instead.

Like an endotracheal tube or blind-insertion airway

device, the inflatable cuff is used to prevent fluid from

entering the airway and also helps ensure that positive

pressure ventilations from a bag-valve-mask (BVM) or

ventilator is effectively inflating the lungs and not

leaking past the airway. A person with a cuffed

tracheostomy tube may be producing a lot of

secretions that are difficult to control, needs positive

pressure ventilation, and/or has a higher risk of

aspiration for other reasons.

An uncuffed tube is usually reserved for those

individuals who are spontaneously breathing without

assistance, can control their secretions and have a

strong swallow, and may also be using a speaking valve or other breath-driven voice device with their

tracheostomy. With an uncuffed tube, some of the breath is allowed to be drawn in and exhaled into the upper

airway.

Inner cannula. The inner cannula slips inside the outer cannula, is usually disposable, and it allows air to travel

from the environment or oxygen source into the trachea. It’s secured or “locked” into the outer cannula by either

a quarter turn twist or by using side clips you pinch with your thumb

and forefinger. The inner cannula is secured to the outer cannula to

prevent it from being coughed out.

If a patient has a buildup of secretions that’s blocking his

tracheostomy, this is the part that is normally removed to facilitate

airway suctioning and the inner cannula is then usually replaced

with a new one --- most are disposable now. Some inner cannulas

are designed to be cleaned instead using sterile saline and sterile

pipe cleaners that are packaged in a single-use disposable kit.

If the patient is using an inner cannula, he or she can be suctioned easily without concern that the stoma itself will

close up and narrow the airway. Since inner cannula is inserted into the outer cannula, there’s no risk that it could

enter the stoma and end up somewhere else besides the trachea during re-insertion. For outer cannulas, that

insertion risk exists since the tube could tunnel between the skin and trachea by accident and create a false track.

Disadvantage of an inner cannula? The biggest disadvantage is that the effective airway diameter is reduced by

about 1 mm since it’s a tube-inside-of-a-tube design (outer and inner cannula). This is why pediatric

tracheostomies may only have an outer cannula… the airway would become too narrow otherwise.

A cuffed outer cannula (left) and an uncuffed one (right). Air can slip past the tracheostomy tube in the uncuffed cannula.

An inner cannula inserts into the outer cannula and can easily be removed for replacement.

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The obturator. The obturator is a rigid, rod-like device used to

help insert the outer cannula of a tracheostomy tube though the

stoma. It fits inside of the outer cannula to guide the tracheostomy

tube into place, much like a stylet helps shape and guide an

endotracheal tube while performing laryngoscopy with standard

blades.

The obturator is an *absolute-must* device when inserting a softer,

more flexible outer cannula such as the silicone ones (example:

Bivona™ / Portex™ tracheostomy tubes). But, even the more rigid

Shiley™ (pronounced as shy-lee) tracheostomy tubes also benefit

from using an obturator --- it reduces the risk of injury to the

patient. Unlike an endotracheal tube stylet, the obturator has a

rounded tip that extends a little past the outer cannula’s opening,

so it helps to prevent tissue trauma to the patient’s airway during

insertion.

Keep in mind that an obturator should never be left in the patient’s

tracheostomy any longer than needed to insert and position the

outer cannula. The styles differ, but the obturator is usually solid

and does not allow enough breath to pass through the

tracheostomy. Leaving it in place for longer than needed causes

asphyxiation.

Tracheostomy ties. Whether the patient has a dual cannula tracheostomy tube (inner and outer cannula) or a

single (just the outer cannula), most tracheostomy tubes are secured to the individual with cotton twill ties,

padded fabric straps, beaded chain, or commercial Velcro straps that wrap around the back of the neck.

When replacing an outer cannula secured with cotton twill ties, one person should hold the cannula in place to

prevent it from accidentally dislodging. Another person cuts the soiled, old ties since they’re normally secured

with a knot. New ties are threaded from one end of the cannula flange, back around the posterior neck, and

secured with a knot on the other end of the flange. The ties or Velcro straps should not be too loose where the

outer cannula can dislodge with coughing or movement. But, they

shouldn’t be tight enough to cause pain or skin breakdown either. The

general consensus is that you should be able to slip one finger under the

tie or strap comfortably;10 this is tight enough.

Not all tracheostomy tubes have ties or Velcro straps though. Individuals

with a permanent tracheostomy or laryngectomy and with no perceived

need for assisted ventilation may have a only a “button” that maintains

the stoma opening (shown on next page). It appears discreet and nearly

flush with the skin. These type of airway devices usually do not have a

tube entering and curving down into the trachea. Instead, the device is

An obturator already inserted in the Portex™ tracheostomy tube. Notice that the rounded distal end of the obturator extends past the end of the tracheostomy tube to prevent injury to the airway structures during cannula insertion.

An obturator for an outer cannula.

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secured to the anterior tracheal wall, which reduces the amount of airway restriction from the tube and potential

irritation from the tube itself.

The tracheostomy button may

be set up as a dual cannula

tube with cannula cap sitting

inside of the outer tube. This

inner cannula (the cannula cap)

can be easily removed for

cleaning or replacement.

During respiratory failure or

other need for assisted

ventilation, you’ll find that the

button will not fit your

standard BVM port. In this

case, attach a neonatal mask to

a pediatric or adult BVM

(depending on tidal volume

needs of patient) and place the

mask over the stoma/button.

Ventilate for chest rise only.

If the patient has a

laryngectomy, the upper airway is surgically closed. If instead the patient has a patent upper airway, you’ll need

someone to to occlude the nares (pinch them closed like a kid jumping into a pool) and keep the mouth closed to

prevent ventilated air from escaping while giving a breath. Otherwise, your ventilations will take the path of least

resistance: the upper airway.

TRACHEOSTOMY ENHANCEMENTS

Most tracheostomy devices are just a tube within a tube that’s secured to the patient with twill or Velcro

tracheostomy ties.

In the past, tracheostomy tubes used to be manufactered

entirely with stainless steel or even silver. Today, softer

silicone and polyvinyl chloride (plastic) tubes are the most

common ones worn for short and long term use. They are

lighter in weight, less expensive to replace, usually more

comfortable for the individual, and can be disposible,

reducing the risk for bacterial or fungal colonization.

A tracheostomy or laryngectomy button. Keep in mind that this does not have a 15mm connector, so if you need to ventilate, use a neonatal mask on the BVM and apply directly over the stoma.

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When assessing your patient with a tracheostomy, you may find him receiving

titrated oxygen by a ventilator, with a humidfied oxygen collar placed over the

tracheostomy, or even spontaneously breathing without any supplemental

oxygen. In some cases, you may find a cap-like device covering the

tracheostomy hole but not occluding it completely. One example is shown to the

right, and this is a Passy-Muir® speaking valve. There are different

manufacturers and styles available, but most of the commonly-used ones are

recognizable as a speech valve by the four, six, or eight spoked-wheel

appearance on the outside of the device. Some have a port to allow oxygen

tubing for low-flow needs, while others are very lightweight and low profile.

A few words about those speaking valves. Most speaking valves work by allowing a thin flap of flexible

plastic (the valve itself) to bend open during inhalation. Air can enter the tracheostomy tube easily with only a

little bit of resistance. However, when the individual exhales, the valve is closed --- air is forced towards the upper

airway and through the vocal folds to produce speech. Before the advent of these valves, the individual with a

tracheostomy would simply occlude the stoma with his thumb while exhaling and produce speech. A valve helps

decrease the risk of infection from whatever pathogens are residing on his thumb and also makes speech a hands-

free process. Understandably, this valve cannot be used for those with a laryngoectomy since their upper airway

is completely closed.

This valve does add some resistance to the airway, so should

be one of the first devices removed when trying to improve

the patient’s ventilation during an emergent situation. But

during normal day-to-day life, this resistance has benefits,

even for those patients who cannot speak. It add positive

pressure to the airway (PEEP) to help prevent atelectasis

(alveolar collapse) and improve oxygenation. It may also

improve swallowing and decrease the risk for aspiration.

These are some of the reasons you could find a speaking valve

attached in-line to a ventilator circuit.

If someone has a speaking valve in place, their

tracheostomy cannula should either be an uncuffed

style or the cuff must be completely deflated during

use.

If you think back to the way the valve works, it

prevents air from leaving the tracheostomy tube

during exhalation. But, if the tracheostomy cuff is

inflated, this blocks the upper airway route as well.

The patient will not be able to exhale and will quickly

suffocate.

A Passy-Muir® speaking valve. This one offers a snap-on supplemental oxygen port.

A Passy-Muir® speaking valve (PMV 2001) shown in-line with the ventilator circuit. The tracheostomy’s outer cannula cuff must be deflated to prevent barotrauma and suffocation.

Deflated cuff

Vocal cords

Speaking valve

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Fenestrated cannulas. Speaking of speech,

another alternative to a speaking valve is a fenetrated

outer (or a fenestrated outer with a matching

fenestrated inner) tracheostomy cannula. These devices

look like ordinary cuffed tracheostomy cannulas except

they have one or more additional holes along the shaft

to allow exhaled breath to escape.

When using the fenetrated cannula for speech, the

individual inhales and exhales normally, but the hole

allows air to escape into the upper airway and pass

through the vocal cords to produce speech. Like a

speaking valve or the thumb technique, the stoma needs to be closed for speech to prevent air from leaving the

tracheostomy tube instead. A cap or plug is usually used, but when it’s applied, the cuff also needs to be deflated

to allow air to escape. Keep in mind that the cuff is located below the fenestrations, so applying a cap to the end

of the tube and inflating the cuff greatly reduces the amount of air from leaving. It only has the small fenestration.

A matter of choice. A person may not want the effects of a fenestrated cannula all of the time. For example, if the

individual is producing a lot of secretions (such as during sleep) or

needs mechanical ventilation, a cuffed tube without the free-flow of

air into the upper airway is preferred. In this case, the fenestrated

inner cannula can be removed, a regular inner cannula (non-

fenetrated) can be inserted in its place, and this effectively blocks the

fenetration(s) in the outer cannula. Any plugs, caps, or speaking

valves are removed. With the outer cannula’s cuff inflated, the

tracheostomy now functions just like a non-fenestrated one.

A fenetrated cannula can also be used for those who are being

weaned off of a tracheostomy. A cap/plug can be attached to the

end of the uncuffed cannula to force air to enter and exit the upper

airway, but easily removed if needed to improve ventilation.

Disadvantage: Since the extra holes offer more plastic edges to contact

tracheal lining, it can cause irritation and trauma to this tissue. In

response to this irritant, the body deposits additional tissue at the site

and forms a granuloma.11,12 A granuloma is a reactive tissue formation

(like a blister or callous) that developes into a ball-like shape and will

continue to grow as irritation continues, sometimes right into the

outer cannula’s fenestration (hole). This not only blocks the air hole,

but can cause painful bleeding when the cannula is removed.

Granulomas can be very vascular with small vessels throughout the

mass.

A tracheal granuloma visualized with

bronchoscopy. Image: Watters KF, 2017

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Caps and plugs. A trachestomy may be capped off as a final phase towards decannulation (intentional and

planned removal of the tracheostomy) if the individual can breathe through their upper airway. Remember that a

cap fully-occludes the airway; it doesn’t take a rocket scientist to figure out what

happens if a cap is applied to a patient with a laryngecomy or an inflated cuff.

Caps and plugs that completely occlude the airway are red in color. Like a stop

sign, red = stop. In this case, air flow stops. On the other hand, a speaking valve

can be transparent, purple, white, or even other colors, but never red.

Cuff inflation. Just like an endotracheal tube cuff, the tracheostomy cuff should not be overinflated or

underinflated. Tracheal capillary perfusion pressure is normally 25 to 35 mmHg.11 To avoid exceeding that

pressure against the tracheal tissues and causing necrosis of the area under the cuff, it’s generally accepted that 30

cmH2O is the maximum amount of pressure11 that should be applied to the cuff. However, most EMS services do

not have a manometer on hand to measure this pressure at the pilot balloon.

If the pressure is too low, secretions can seep under the cuff and enter the lower airway. If the pressure is too

high, tracheal wall tissue damage will occur. One technique that offers an appropriate pressure requires only a

stethoscope. Keep in mind this will not work with laryngoectomy patients since their upper airway is closed off.

The Minimal Leak (or even no-leak) Technique: When you need to inflate a deflated tracheostomy cuff, attach an

air or sterile water filled Luer-lock syringe to the pilot balloon. Remember that the type of cuff dictates whether

you use air or water. Place the stethoscope head to one side of

the patient’s trachea and above the stoma and listen for breath

or ventilatory sounds (if on a vent or assisted with a BVM). This

is your starting point where air is passing by the cuff freely.

Begin to slowly push air or fluid into the pilot balloon while

listening at the same location. At some point, the respiratory

sounds will decrease and then stop. This indicates that little to

no air is leaking past the cuff, and:

• Spontanously-breathing patients: Withdrawl just a

little so just a very slight amount of leak is present.

• Ventilated or BVM, or patient has plenty of secretions:

Don’t withdraw that bit of air or fluid like you would

for spontaneous breathers. Instead, you’ll want that

complete seal to prevent aspiration.

Confirm that the pressure does not feel too firm or very soft at the pilot balloon before disconnecting the syringe.

What you feel in the firmness of the balloon is the same pressure across the cuff. Advise the receiving hospital

that the cuff was inflated by this method and not verified with a manometer.

Important: The cuff does NOT secure the tracheostomy tube in place… the tracheostomy ties are what keeps the

cannula in place. Don’t overinflate the cuff to try and “secure” the tube in the airway. Think of how easily an

endotracheal tube dislodges even when inflated and with a pair of vocal cords trying to resist it’s movement. It’s

not the cuff that secures the tube in the endotracheal or tracheostomy airway.

Auscultating above the stoma and to one side of the trachea.

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QUICK REFERENCE CHART ON TRACHEOSTOMY DEVICES

Clear as mud yet? To add to the confusion, there’s several ways to combine or alter a tracheostomy’s function by

using different cannulas or caps. The chart below offers a quick review of the different basic devices:

Device: What it looks like: Description:

Cannula materials:

Metal (stainless steel or silver)

Metal is long lasting and may be less susceptible to hosting bacterial colonies.11 It’s an earlier material for tracheostomy tubes, and has now been mostly replaced by plastic/silicone tubes.

Plastic (PVC, polyurethane, or silicone)

The most common tracheostomy material. It’s lightweight, inexpensive compared to metal, and may be more comfortable since the plastic softens a bit with body heat. There are clean-and-reuse varieties as well as disposable ones. Silicone is the softest material.

Cannula types:

Outer cannula - Cuffed

The outer cannula has an inflatable cuff that may be filled with air or sterile water, depending on the type. The cuffed outer cannulas are usually used for those individuals who need positive pressure ventilation (ventilator) or have an increased risk for aspiration.

Outer cannula - Uncuffed

An uncuffed outer cannula is usually reserved for pediatrics and those individuals who can better control their airway. It’s usually not used for those who need positive pressure ventilation.

Inner cannula

The inner cannula slips into and locks inside of the outer cannula. It’s an optional device. While it reduces the effective airway diameter a little bit, it makes it easier to keep the airway clean. You can quickly resolve breathing difficulties by removing it, such as those caused by mucus plugs or excessive secretions.

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Cannula specializations:

Fenestrated (single)

A fenestrated cannula can have a single hole configuration or multiple holes. Multiple holes may help reduce the risk of large granuloma formations. A fenestrated cannula can be used to enable speech or as part of a weaning program to help acclimate the individual to using his upper airway again. To work as a fenestrated cannula, both the outer and inner cannulas must have matching holes. The fenestrated inner cannula must be replaced with a smooth (no holes) one if ventilating the patient.

Fenestrated (multiple)

Obturators:

Metal cannulas

The obturator is used as a temporary insertion device for the outer cannula. The rounded tip extends past the outer cannula to help guide it into the trachea smoothly without causing injury. Once the outer cannula has been inserted, the obturator must be removed immediately since it blocks air movement in the tube.

Plastic/silicone cannulas

Specialized adjuncts:

Speaking valve

A speaking valve fits on the end of the exposed tracheostomy cannula and allows the individual to speak. When he inhales, the valve opens and lets air pass into the trachea. When he exhales, the valve shuts closed and forces air into the upper airway, past the vocal cords. The cannula must be uncuffed or the cuff deflated, otherwise, the individual cannot exhale.

Cap or plug

A red cap or plug occludes the tracheostomy port completly. This is usually used for those who are in the final stages of tracheostomy weaning and are preparing to breathe through their upper airway entirely. It can be quickly detached in case of mucus buildup that can’t be coughed up or if the individual needs positive pressure ventilation during an emergency.

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TRACHEOSTOMY EMERGENCIES

Since many patients with a tracheostomy or laryngectomy may be unable to speak (not a candidate for a speaking

valve, etc.), let their signs guide you in the respiratory assessment.

Difficulty breathing is usually characterized with one or more of the following:

• Altered mental status, restless, and/or increased combativeness;

• Pale or cyanotic skin color (a late sign);

• Tachycardia (may be masked by beta-blocker or calcium channel medications);

• Tachypnea (increased respiratory rate);

• Labored attempts at breathing or alarms sounding off on a

ventilator;

• Low pulse oximetry; high capnography readings;

• Grunting, snoring, gurgling, or stridor;

• Accessory muscle use;

• Decreased or abnormal breath sounds on auscultation of the lungs.

One of the most common causes of respiratory decline or failure is a mucus

plug, where excess secretions have built up in the tracheostomy cannula and

effectively reduced the airway diameter. It doesn’t take much built-up

mucus to cause a major restriction in airflow.

FIRST TREATMENT STEPS

The first treatment steps depend on the type of respiratory complaint you’re dealing with. Is it an emergent

airway with a patient unable to breathe? Or is it a reactive airway such as a COPD patient in need of a beta-agonist

medication (example: albuterol)? Or, are you caring for a febrile patient with suspected pneumonia or even sepsis

from an airway infection?

Restricted airway --- Patient appears to be unable to breathe or be ventilated effectively?

As with any emergent airway, oxygenation and ventilation are the priority. The first question that should come to

mind is: What kind of tracheostomy am I dealing with? The flowsheet that follows offers a rapid assessment of the

device sitting in the stoma and immediate first steps.

A mucus plug in the distal cannula. Life-threatening for a tracheostomy.

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Managing an Emergent Tracheostomy Airway

Does the patient have a laryngectomy?

If so, remember that any upper airway ventilation will be ineffective.

Apply supplemental oxygen to the stoma.

Is there a cap, plug, or speaking valve in place?

If yes, remove it. If this doesn’t take care of the problem, proceed to the next step.

Is this a dual cannula tracheostomy?

If yes, remove the inner cannula. If this does not fix the problem or there’s only one cannula, try the next step.

Suction the airway using sterile technique.

Still unable to ventilate the stoma or upper airway (non-laryngectomy patients)?

Consider deflating the tracheostomy cuff (if a cuffed cannula) and re-attempt ventilation.

Still unable to ventilate?

May need to consider removing the outer cannula and replacing it using an obturator or gently inserting a cuffed endotracheal (ET) tube into the stoma --- only insert a few inches into the trachea if using an ET tube.

Laryngectomy? All ventilation attempts will have to be made to the stoma. Consider using a neonate mask on a BVM or LMA/i-Gel over the stoma to form a good seal.

Sometimes someone gets their caps and valves confused, or they will inflate the cuff with a speaking valve in place. All can prevent the patient from exhaling, so just remove the device.

Mucus plugs are the #1 cause of airway obstruction. Just removing the clogged inner cannula may fix the problem completely. The outer cannula maintains the stoma opening.

Even single cannula patients get mucus plugs. Use sterile suction to clear the airway. The procedure is described on the next page.

If the airway is still occluded, deflate the cuff. The cannula may not be sitting in the stoma correctly and the cuff is causing an obstruction.

If the outer cannula is sitting in a false track or is damaged, it needs to be removed and replaced. Use an obturator to help guide it in. Or, insert a sterile, lubricated endotracheal tube in its place and inflate the cuff.

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HELPFUL TIPS

Cuffed dual-cannula tracheostomy and need to ventilate? Removing the inner cannula fixes most of the respiratory problems

faced by a patient with a tracheostomy. The cannula may be crusted

with secretions and needs to be cleaned or replaced with a new one,

and this might take a few minutes. Don’t let your patient decline… he

or she should be oxygenated and/or ventilated while awaiting the

inner cannula’s replacement.

If the patient has a dual-cannula tracheostomy tube, you’ll find

that the outer cannula will probably not fit the 15mm connection

on your BVM directly. You will either need to reinsert a clean

inner cannula, use a neonatal mask or an LMA/i-Gel over the

stoma, or see if the facility has a flexible silicone adapter designed to connect the BVM to the outer cannula.

Inner cannulas should have the 15mm connection and are designed for use with standard ventilator tubing or

a BVM.

Also, check that the cuff’s pilot balloon feels inflated upon palpation. Ventilating with a deflated cuff reduces

the amount of air that reaches the lungs.

Uncuffed outer cannulas and the need to ventilate? If the patient needs positive pressure ventilation

at the stoma and does NOT have a laryngectomy, be sure to occlude the nares and mouth to prevent ventilations

from escaping through the oro/nasopharynx.

Does the patient have a fenestrated cannula? If ventilating the stoma, you’ll need to replace the inner

fenestrated cannula with a non-fenestrated (smooth) one so it functions like a standard tracheostomy tube. The

standard inner cannula will block the holes in the outer cannula.

Replacing the outer cannula? If you need to help replace the outer cannula, keep the tube portion of the

cannula sterile if at all possible. Remember that both

the inner and outer cannula tubes can introduce

harmful pathogens directly into the respiratory tract.

Align the patient’s head and neck in an exaggerated

sniffing position to ease insertion. Oxygenate. Insert

an appropriate obturator into the outer cannula and

lubricate the cannula’s exterior with a sterile, water-

soluble gel. Introduce the cannula into the stoma and

direct it into the airway following the natural

curvature. The patient may cough or “buck” during

insertion… it’s not an entirely comfortable process. Inserting the outer cannula into the stoma.

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When inserted correctly, the cannula flange should

rest against the neck. Remove the obturator and

check for breath sounds, using capnography during

ventilation to confirm placement. Make sure the

cannula did not form a false track or was only partially-

inserted, as illustrated to the right.

The outer cannula needs to be secured with

tracheostomy ties or straps before anyone releases

the tube. One strong cough can dislodge it if the ties

are not secured in place. One finger should be able to

slide between the tie and the neck.

VIDEO OF OUTER CANNULA INSERTION

Reinsertion of a dislodged outer cannula while on scene may be the only way to maintain effective

ventilation/respiration. Waveform capnography and pulse oximetry should be obtained and recorded after the

procedure to confirm correct placement of the tube into the trachea.

A four-minute video of an outer cannula removal/replacement (produced by the Medical College of

Georgia/Georgia Regents University) is available online at: https://youtu.be/LrAMAwBfbcI. The individual was very

anxious/nervous about the procedure, and the cuffless tracheostomy tube was

well-overdue for a replacement. However, the respiratory therapist remained

calm and explained the process to the patient and his family to help ease his fears.

If the outer cannula was cuffed instead, remember to completely deflate the cuff

with a syringe first before removing the cannula.

Their procedure left some room for improvement, so there’s two additional learning points to gain from this video:

• Remember to avoid contacting the cannula’s tube --- the part that’s inserted into the trachea. Just pick it

up using the outer flange and external port to avoid airway contamination.

• It took a while before the obturator was removed from the outer cannula. This should be done sooner to

allow the patient to breathe. No air can enter the tracheostomy tube when the obturator is in place.

Partial insertion (left) where the cuff is not aligned properly, and for the right-side image, the cannula forms a “false track” between the skin and trachea, missing the airway completely.

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PROCEDURE: STERILE SUCTIONING

Although we were taught sterile tracheal suctioning during EMT-Intermediate/Advanced or Paramedic class, a

review of the procedure helps to ensure the best outcome for our tracheostomy patient and reduce the risk of

healthcare-associated infections.

Equipment:

• You’ll need an appropriately-sized sterile suction catheter. These catheters are made of a soft plastic

and usually have a thumb hole to control suction. A chart of approximate suction catheter sizes is

provided below, which in this case is based on the patient’s age. While there’s a calculation that

more accurately predicts the size based on the tracheostomy tube diameter, this is the most

convenient method for EMS and applies to endotracheal tubes as well:

Patient’s age: Approximate size of the suction catheter:

Newborn 6 Fr

Up to 3 years old 8 Fr

5 to 16 years old 10 Fr

Adult female 12 Fr

Adult male 14 Fr

• Sterile gloves;

• Sterile water or sterile saline;

• Suction source with tubing and canister;

• 4x4 gauze, because this gets messy.

Steps for the procedure:

1. Explain what you will do for the patient. This can be

uncomfortable and they appreciate being forewarned.

2. If the patient is using supplemental oxygen, maintain

this source whenever possible to keep him oxygenated.

3. Find an area to work (small table, countertop) next to

the patient that is cleared off --- prevents accidental

contamination.

A pristine uncluttered ambulance countertop? Unheard of. But at least shove most of the stuff away.

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4. Personal protective equipment (PPE) --- it’s recommended

that you wear a disposable gown, eye protection, and

gloves as misdirected secretions will happen.

5. There are different sterile suction kits on the ambulance

and also in the nursing facilities. Some kits contain

everything from the sterile water to sterile table drapes,

while others only offer the sterile suction catheter.

Remember back to your education: Keep what needs to

remain sterile: Sterile. If water is not included in the kit, ask your partner to pour sterile water or saline

into a container and attach the suction tubing to the unit. Let him work the “dirty side” while you don on

sterile gloves and are the only one handling the sterile items that enter the trachea.

Open sterile packages by pulling the lid or cover away from you, not towards you and your “dirty”

uniform. Place sterile items on a sterile drape only, and drop them at least an inch away from the drape’s

edge. Closer to the center, the better. Always know where your hands are; if you have to do this

procedure by yourself, designate one hand as sterile and the other as dirty. Keep it that way.

6. With the suction hooked up and running at a lower suction setting (50 to 100 mmHg) and sterile

water/saline poured (thank you, partner), ask your partner or

other healthcare provider to unhook the patient’s ventilator

tubing (if present) or remove any caps or speaking valves from

the external port. If you are alone, use your designated “dirty

hand” only to remove these devices.

7. Use your designated dirty hand to manipulate the thumb

suction hole to activate and deactivate the suction, while the

other sterile hand is the only one that maneuvers the suction

catheter into the patient’s tracheostomy.

8. Insert the suction catheter into the water to confirm it’ll draw

fluid, then release the suction using the thumb hole. Insert the

end of the empty suction catheter into the tracheostomy tube.

Do not activate the suction just yet.

9. After inserting the catheter about four to five inches (adult, less

for children), you’ll either feel some resistance or the patient will

begin to cough. Immediately back the catheter up a bit to

prevent further irritation.

10. Now begin suctioning by occluding the thumb hole with your

designed dirty hand. With your sterile hand still on the suction

catheter, twirl and begin drawing the catheter back out,

suctioning during the entire time. As you reach the end of the

catheter, control it so it does not pop out and fling secretions.

A barebones sterile suction kit: Sterile catheter, gloves, and disposable container.

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11. The suctioning attempt should not exceed 10 seconds per round.

It should only take two or three rounds of sterile suctions to

clear most tracheostomy patient’s airways.

12. If you’re having difficulty suctioning out thick secretions, a small

squirt of sterile saline can help moisten and loosen them. Keep

the patient oxygenated between suction attempts to prevent

desaturation.

13. Use gauze to wipe the patient’s skin and external port of any

secretions. Dispose of PPE properly.

ABOUT THE PERSON WITH A TRACHEOSTOMY

Sometimes it’s easy to focus on the tracheostomy and neglect the fact that there’s a person tied to it. Or, there’s

the stigma that this change in lifestyle was entirely their fault. While many tracheostomies are necessary as a

result of laryngeal cancer secondary to tobacco use, there are other indications such as laryngeal cancer from

other causes, non-cancerous tumor growths, neuromuscular disorders such as amyotrophic lateral sclerosis (ALS)

or myasthenia gravis (MS), high level spinal cord injury, or severe, acute infections/toxin exposures. A lot of that

can’t be prevented.

A tracheostomy can become a permanent part

of an individual’s life or just a temporary fix. A

person can live independently with only a small

affect on their quality of life, or could be

bedbound and living in a skilled nursing facility.

Tracheostomies are placed in the newly born

and also those nearing the end of life.

When assessing your patient, be open to their

recommendations for care and treatment. Like

a mother who cares for a chronically-ill child,

your patient will know what works best for them

based on their past experience.

Most independently-living people with a tracheostomy will clean and suction their tracheostomy devices and

airway at least twice a day. Humidified and heated oxygen or air directed towards the tracheostomy helps

decrease the risk of mucus plugs and respiratory problems from dried secretions. Those who need more frequent

tracheostomy care are usually on a every four to eight hour schedule of cleaning and suctioning.

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If your patient’s tracheostomy cuff needs to remain inflated, this is a sign that secretions cannot be controlled well

by the individual and/or they need positive pressure ventilatory support.

Many who live independently or with minimal assistance and have a tracheostomy use an uncuffed outer cannula

or keep their cuffed one deflated most of the time. This allows them to eat by mouth and produce an less-

impeded swallow, cough, and speech. They can clean or

change out their inner cannula daily or more often as directed

by their physician. Many are able to self-suction, and may

prefer to do that versus allowing a paramedic to take over.

Don’t take offense --- it’s an uncomfortable process and they

may prefer to control their degree of discomfort.

Tracheostomy bibs may be used to help hide the cannula

while out shopping or to prevent dirt and other contaminants

from entering the airway. There’s even devices available that

allow a person with a tracheostomy to enjoy activities we

take for granted, like swimming.

CARDIAC ARREST CONSIDERATIONS

If the patient is in cardiac arrest, have a high degree of suspicion that it may be respiratory-related unless you find

evidence otherwise. While the American Heart Association’s C-A-B approach (circulation-airway-breathing) to CPR

still applies, this is not the patient you want to passively oxygenate for six minutes before securing the airway.

Start chest compressions and defibrillate as needed, but make the airway and breathing a high priority as well.

Unless the patient has a laryngectomy, oral intubation is possible if you are unable to ventilate the stoma. When

performing oral intubation, be sure to remove the outer cannula first.

If the best option for the patient is to intubate the stoma instead, use a smaller cuffed endotracheal tube than you

would expect for oral intubation.

For example, use a 5.5 or 6.0

endotracheal tube for adults or a

size that fits into the stoma easily

without additional trauma.

Advance the tube to where the cuff

is only 2 cm past the stoma.13

Obviously, don’t use a tube tamer

or other commercial securing device

as this will occlude blood flow from

the major neck vessels. Instead, a

transparent occlusive dressing

Using an LMA (above) to form a seal for BVM ventilation over the stoma. An endotracheal tube (right) inserted in the stoma and secured with a transparent occlusive dressing.

Page 27 of 29

(Tegaderm™, for example) would be ideal.

Keep in mind that when you’re providing BLS ventilations at the upper airway, you’ll need to occlude the stoma to

prevent air from escaping by that route.

It may be difficult to detect carotid artery

pulse in the neck of some laryngectomees

because of post-radiation fibrosis that

developed after their cancer treatment.14

Some patients may not have a radial artery

pulse in one of their arms if tissues from that

arm were used for a free flap to reconstruct

the upper esophagus.14

Look for surgical scars on the extremities and

if they exist, consider avoiding those limbs for

a pulse check. Use a femoral pulse or use the

Doppler to help with pulse detection, if

needed.

Questions? Please contact a member of the training staff.

Preparing to remove skin and vessels for a lateral arm flap in a patient who needed reconstruction of the lateral pharynx. Legend: BOT, base of tongue; GOT, glossotonsillar sulcus; PH, pharynx including tonsillar fossa and pillars; R, radial artery. Radial pulses may no longer be palpable on this extremity, so look for surgical scars before declaring pulselessness.

Page 28 of 29

REFERENCES

1 Pierson DJ. Tracheostomy from A to Z: historical context and current challenges. Respir Care

2005;50(4):473–475.

2 Trubuhovich RV. Primary Sources and the Tracheostomy Legend about Alexander the Great. J Anest

History 2018; 4(1):38.

3 McClelland RM. Tracheostomy: its management and alternatives. Proc R Soc Med 1972;65(4):401–404

4 Mehta AB, Syeda SN, Bajpayee L, et al. Trends in Tracheostomy for Mechanically Ventilated Patients in

the United States, 1993-2012. Am J Respir Crit Care Med. 2015 Aug 15;192(4):446-54. doi:

10.1164/rccm.201502-0239OC.

5 Terragni PP, Antonelli M, Fumagalli R, et al. Early vs late tracheotomy for prevention of pneumonia in

mechanically ventilated adult ICU patients: a randomized controlled trial. JAMA 2010;303:1483–1489.

6 Young D, Harrison DA, Cuthbertson BH, et al. Effect of early vs late tracheostomy placement on survival in

patients receiving mechanical ventilation: the TracMan randomized trial. JAMA 2013;309:2121–2129.

7 Karatayl SK, Özgürsoy O, Yüksel C, et al. Life-Threatening Respiratory Distress in a Total Laryngectomy

Patient: Aspirated Voice Prosthesis or Lung Tumor? Turk Arch Otorhinolaryngol 2016; 54: 131-133.

8 Emergency Procedures for Tracheoesophageal Puncture After Total Laryngectomy. Nova Scotia Hearing

and Speech Centres. Available at

http://www.nshsc.nshealth.ca/sites/default/files/For%20website%20EMERGENCY%20PROCEDURES%20F

OR%20TRACHEOESOPHAGEAL%20PUNCTURE.pdf. Accessed December 24, 2018.

9 Levitan J. A Primer on the Surgical Airway. Emergency Physicians Monthly. Available at

http://epmonthly.com/article/a-primer-on-the-surgical-airway/. Accessed December 26, 2018.

10 Watters KF. Tracheostomy in Infants and Children. Resp Care 2017;62(6)799-825.

11 Hess DR, Altobelli NP. Tracheostomy Tubes. Resp Care 2014;59(6):956-973.

12 Siddharth P, Mazzarella L. Granuloma associated with fenestrated tracheostomy tubes. Am J Surg

1985;150(2):279-280.

13 Long B Koyfman A. Managing the Tracheostomy Patient. Emergency Physicians Monthly (November

2016). Web site: http://epmonthly.com/article/managing-tracheostomy-patient/. Accessed December

30, 2018.

14 Brook I. Rescue Breathing for Laryngectomees and other Neck Breathers (2015). Atos Medical AB.

Available at https://www.atosmedical.com/wp-content/uploads/2015/10/rescue-breathing.pdf.

Accessed December 31, 2018.

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IMAGE CREDITS

Erman AB, Deschler DG. Voice Rehabilitation after Laryngectomy. Otorhinolaryngology Clin 2010;2(3):231-236.

Discharge Instructions: Tracheostomy or Stoma Care. Mount Nittany Health. Available at

https://www.mountnittany.org/articles/healthsheets/2910. Accessed December 28, 2018.

Watters KF. Tracheostomy in Infants and Children. Resp Care 2017;62(6)799-825.