Uncuffed Tracheostomy Research Articles

Tracheal airway pressure in tracheostomy tube capping trials: an experimental study

BackgroundTracheostomy tube capping is a commonly used test to determine if the tracheostomy tube can be removed. The success of the capping trial depends on the patient’s ability to maintain sufficient spontaneous breathing with an occluded tracheostomy tube. The impact of an occluded tracheotomy tube on airway resistance is currently unknown. The aim of this study was to investigate tracheal pressure during capping or stoma button insertion and potential determinants concerning cuff.MethodsEight cuffed and uncuffed tracheostomy tubes and three stoma buttons of various manufacturers and sizes were inserted into the trachea model. Cuffs were completely deflated or contained atmospheric pressure. The trachea was ventilated bidirectional with a respirator in volume-controlled mode and volume flows 15–60 L/min. Tracheal pressure drop during inspiration as a parameter of pressure required to move gas through the airway was measured.ResultsTracheal pressure drops occurred linearly or irregularly during capping trials to a maximum of 4.2 kPa at flow rates of 60 L/min for atmospheric pressure cuffs. In tracheostomy tubes with completely deflated cuffs, pressure drop in the trachea reaches a maximum of 3.4 kPa at a flow rate of 60 L/min. For tracheostomy tubes with cuff smaller inner or outer diameters do not regularly result in lower tracheal pressure drop. The pressure drop varies between different tracheostomy tubes depending on the manufacturer. In cuffed tracheostomy tubes, we observed three phenomena: sail-like positioning, folding over, and tightening of the cuff during flow. The maximum tracheal pressure drop during stoma button insertion reaches 0.014 kPa.ConclusionsThe cuff is a central element for the pressure drop in the airway and thus airway resistance during spontaneous translaryngeal breathing with a capped TT. Complete deflation reduces the pressure drop in the trachea. Due to deformation of the cuff, measured pressures are irregular as the volume flow is increased. Incomplete deflated cuffs and material characteristics of tracheostomy tubes and cuffs in addition to anatomical and clinical variables may cause unsuccessful capping trials due to increased airway resistance. All stoma buttons showed that pressure drop and thus airway resistance due to stoma buttons has no clinical relevance.

A Novel Use of Modified Tracheostomy Tubes in Preventing External Auditory Canal Stenosis.

Background: Postoperative or post-traumatic canal restenosis in patients with external auditory canal (EAC) stenosis is a troublesome complication faced by many ear surgeons following canalplasty or meatoplasty. Many ear prostheses and surgical methods have been introduced to prevent the occurrence of such complication. Our aim in this study is to explore the feasibility of using modified non-fenestrated uncuffed tracheostomy tubes (TT) as postoperative stents after ear canal surgery.Methods:Canalplasty or meatoplasty was performed under general anesthesia via the posterior auricular transcanal approach. The EAC diameter and length were measured and a non-fenestrated uncuffed TT of suitable size was fitted into the ear canal. The TT was then modified during fitting, to fit onto the concha. Patients were advised on the importance of compliance. The adequacy of the size of the EAC after the surgery was assessed during follow-ups.Results:A total of 3 patients (4 ears) were included in our study. Various sizes of TTs were fitted into their EAC following canalplasty or meatoplasty. All of them showed excellent postoperative outcome on follow up 2 years after the surgery, with no evidence of postoperative EAC stenosis.Conclusion:Modified TT stent after canalplasty or meatoplasty is proposed as an excellent alternative in preventing restenosis of EAC in centers with limited resources.

Intraoperative Airway Management Considerations for Adult Patients Presenting With Tracheostomy: A Narrative Review.

Tracheotomy is a surgical procedure through which a tracheostomy, an opening into the trachea, is created. Indications for tracheostomy include facilitation of airway management during prolonged mechanical ventilation, treatment of acute upper airway obstruction when tracheal intubation is unfeasible, management of chronic upper airway obstructive conditions, and planned airway management for major head and neck surgery. Patients who have a recent or long-term tracheostomy may present for a variety of surgical or diagnostic procedures performed under general anesthesia or sedation/analgesia. Airway management of these patients can be challenging and should be planned ahead of time. Anesthesia personnel should be familiar with the different components of cuffed and uncuffed tracheostomy devices and their connectivity to the anesthesia circuits. An appropriate airway management plan should take into account the indication of the tracheostomy, the maturity status of the stoma, the type and size of tracheostomy tube, the expected patient positioning, and presence of patient's concurrent health conditions. Management of the patient with a T-tube is highlighted. Importantly, there is a need for multidisciplinary care involving anesthesiologists, surgical specialists, and perioperative nurses. The aim of this narrative review is to discuss the anesthesia care of patients with a tracheostomy. Key aspects on relevant tracheal anatomy, tracheostomy tubes/devices, alternatives of airway management, and possible complications related to tracheostomy are summarized with a recommendation for an algorithm to manage intraoperative tracheostomy tube dislodgement.

Successful respiratory management of a Marshall-Smith syndrome patient with a tracheo-innominate artery fistula

BackgroundTracheo-innominate artery fistula (TIF) is a life-threatening complication of tracheostomy. We describe perioperative management for innominate artery transection in a case with TIF.Case presentationA 4-year-old Japanese female with Marshal-Smith syndrome presented for management of TIF. She underwent tracheostomy at the age of 3 months and an uncuffed tracheostomy tube was inserted. One month before admission to our hospital, intermittent tracheal bleeding, suggesting TIF, occurred. Although we considered to change to a cuffed endotracheal tube, craniofacial abnormality suggested difficult oral intubation, and there was a possibility of rebleeding. Finally, innominate artery transection was performed under total intravenous anesthesia without changing the tracheostomy tube. Surgery completed uneventfully and she received mechanical ventilation under sedation for a day, followed by weaning without complications.ConclusionsA cuffed tracheostomy tube should have been inserted before surgery for effective hemostasis against sudden bleeding from TIF even though conversion to oral intubation was difficult.

A RARE CASE OF TRACHEOINOMINATE FISTULA

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Within 2-4 weeks after placement, a tip or cuff of a tracheostomy tube may erode into the anterior wall of the trachea, resulting in a morbid and often fatal outcome. We present a rare case of tracheoinnominate fistula (TIF) after a tracheostomy. CASE PRESENTATION: A 51-year-old woman with non-ischemic cardiomyopathy after a complicated ascending aortic aneurysm status post orthotopic heart transplant presented with gradual onset of dyspnea and facial swelling. CTA of the chest revealed an aneurysm of the innominate artery measuring 3.7 x 3.4 cm and a significant subglottic tracheal stenosis. A large multinodular goiter was noted on ultrasound. Due to her diffuse facial swelling, exophthalmos, and engorged veins, her culprit diagnosis was thought to be SVC syndrome. After a subsequent CT venography, she underwent stenting of the right innominate vein. However, her symptoms persist, and as a result of her worsening stridor, the patient was intubated. She then underwent a tracheostomy and partial thyroidectomy. Twelve days post tracheostomy, patient had a self-resolving episode of non-massive hemoptysis. Given her innominate artery aneurysm, a sentinel bleed for a tracheoinnominate fistula was suspected. Her uncuffed tracheostomy tube was quickly exchanged for a cuffed one, and the balloon was hyperinflated. After a temporary tamponade, she was emergently taken to the operating room for an innominate artery ligation and a carotid-to-carotid bypass. DISCUSSION: Development of tracheoinnominate fistula is a rare complication of tracheostomy occurring in only 1% with nearly a 90% mortality. When faced with a massive hemoptysis or even a sentinel bleed, one must have a high index of suspicion for TIF in a patient with a recent tracheotomy placement. Common risk factors include low tracheostomy, high innominate artery, cuff overinflation, infection, and immunosuppressed state. Our patient unfortunately had a perfect storm—a history of a complicated ascending aortic aneurysm involving the innominate artery, on chronic immunosuppressants, and subglottic tracheal stenosis requiring a low tracheostomy. To minimize exsanguination, suspect TIF and quickly tamponade the anterior wall of the tracheal with one’s finger or overinflating the balloon. CONCLUSIONS: Tracheoinnominate fistula, although more rare since the advent of low-pressure tracheostomy tubes, remains a highly lethal complication of tracheostomy. Successful management relies on early diagnosis and prompt management. Reference #1: 1. Allan JS, Wright CD: Tracheoinnominate fistula: Diagnosis and management. Chest Surg Clin North Am 13:331-341, 2003 GrilloCG: Tacheal fistulato barchiocephalic artery,inGrilloCG (ed): Surgery of the Trachea and Bronchi. Hamilton, Ontario, BC Decker, Ch. 13, 2003, pp 1-9 Reference #2: 2. GrilloCG: Tacheal fistulato barchiocephalic artery,inGrilloCG (ed): Surgery of the Trachea and Bronchi. Hamilton, Ontario, BC Decker, Ch. 13, 2003, pp 1-9 Reference #3: 3. Technique for Managing Tracheo-Innominate Artery Fistula, Gorav Ailawadi, MD DISCLOSURES: No relevant relationships by Bindu Akkanti, source=Web Response No relevant relationships by Kha Dinh, source=Web Response No relevant relationships by Samim Jafri, source=Web Response

Immediate Use of Uncuffed Tracheostomy after Free Flap Reconstruction of the Head and Neck.

Objective To determine if immediate postoperative uncuffed tracheostomy placement following oral cavity or oropharyngeal head and neck free flap reconstruction is associated with shorter hospital length of stay and higher inpatient decannulation rates without an increase in respiratory complications, as compared with immediate placement of cuffed tracheostomy. Study Design Retrospective cohort. Setting Tertiary referral center. Subjects and Methods Patients were included if they underwent free flap reconstruction for oral cavity or oropharyngeal squamous cell carcinoma and had an intraoperative tracheostomy placed between 2005 and 2016. In 2012, head and neck surgeons changed from routine placement of cuffed to uncuffed tracheostomy tubes immediately after free flap reconstruction. This study compares length of hospital stay, inpatient decannulation rates, and respiratory complications between patients who had cuffed and uncuffed tracheostomies. Analysis of variance and chi-square test were used to examine continuous and categorical variables, respectively. Multivariable regression analyses were performed to determine whether cuff status was independently associated with primary outcomes of length of hospital stay, decannulation, and respiratory complications. Results Of 752 patients who underwent free flap reconstruction, 493 patients met inclusion criteria (cuffed, n = 366; uncuffed, n = 127). Patient variables (ie, age, sex, body mass index, prior chemoradiation) and tumor characteristics (ie, location, stage) did not differ significantly between groups. Adjusted analysis showed that an uncuffed tracheostomy (vs a cuffed tracheostomy) was associated with shorter length of stay (7.7 vs 9.7 days, P < .001) and did not increase the rate of respiratory complications. Conclusion Immediate placement of a uncuffed tracheostomy after oral cavity or oropharyngeal free flap reconstruction is associated with shorter hospital stays without an increase in respiratory complications.

Microbiological evaluation of different reprocessing methods for cuffed and un-cuffed tracheostomy tubes in home-care and hospital setting.

Background: Manufacturers’ recommendations on cleaning of tracheostomy tubes focus on general warning information and non-specific manual cleaning procedures. The aim of this experimental study was to evaluate different reprocessing methods and to determine the mechanical integrity and functionality of tracheostomy tubes following reprocessing.Methods: Sixteen cuffed or un-cuffed tracheostomy tubes obtained from hospital in-patients were reprocessed using one of the following reprocessing methods: a) manual brushing and rinsing with tap water, b) manual brushing followed by disinfection with a glutaraldehyde solution, c) manual brushing followed machine-based cleaning in a dishwasher, and d) manual brushing followed by ultrasound cleaning in a commercially available ultrasound device. Microbial burden of the tubes before and after reprocessing was assessed by measurement of microbial colony-forming units per mL (CFU/mL) of rinsing fluid. After cleaning, tracheostomy tubes were investigated for loss of functionality. Findings: Manual brushing and rinsing with tap water reduced microbial colonization in average by 102 CFU/mL, but with poor reproducibility and reliability. Complete microbial reduction was achieved only with additional chemical or machine-based thermal disinfection. Ultrasound sonification yielded no further microbial reduction after manual brushing. Conclusion: Manual brushing alone will not result in complete eradication of microorganism colonising cuffed or un-cuffed tracheostomy tubes. However, manual cleaning followed by chemical or thermal disinfection may be regarded as safe and reproducible reprocessing method. If a machine-based reprocessing method is used for cuffed tubes, the cuffs’ ventilation hose must be secured in a safe position prior to thermal disinfection.

Tracheostomy management

Tracheostomy management

Poorly placed tracheostomy tubes: Effects on flow and resistance.

This study aimed to investigate the effects of an incorrectly positioned tracheostomy tube on flow resistance. A laboratory-based model of the trachea was used with both cuffed and uncuffed tracheostomy tubes inserted to variable depths. With a constant metered flow through the model, the pressure for given depths of insertion was recorded. The model was then re-run to test the effect of different flow rates on the system. A total of 468 individual results were grouped and statistically analysed. They showed that both over- and under-insertion increase the pressure within the circuit and that a cuffed tracheostomy tube offers a degree of protection against this. These results were statistically significant with P < 0.05 demonstrating that incorrect positioning has a greater resistance to flow. These results provide an essential scientific basis for further work to assess the clinical significance of incorrect positioning as well as suggesting the need to monitor tube position.

General anesthesia utilizing a laryngeal mask airway in a patient with an existing uncuffed tracheostomy tube

General anesthesia utilizing a laryngeal mask airway in a patient with an existing uncuffed tracheostomy tube

The effect of cuff presence and cuff inflation on airway pressure in a canine tracheostomy tube model

To evaluate the effect of cuff presence and cuff inflation on airway pressure in an inspiratory model of canine tracheostomy. Ex vivo experimental study. Cadaver tracheas from Beagle dogs were attached aborally to a vacuum. Airway pressure and flow rate was measured before and after placement of tracheostomy tubes. None. Adult uncuffed tubes and cuffed tracheostomy tubes (sizes 4, 6, 8, and 10) were placed within tracheas. Cuffs were investigated without inflation and at maximum cuff inflation. Airway pressure was measured at constant airflow rates at 30 and 60 L/min. At set flow rates, airway pressures of tracheostomy tubes were compared to the intact trachea. A size 4 uncuffed tracheostomy tube showed the lowest airway pressure and a size 4 cuffed trachestomy tube with inflation showed the highest airway pressures. For sizes 6, 8, and 10 tubes, the presence of a cuff with and without inflation significantly increased airway pressure. Inflation of a cuff always significantly increased airway pressure. Similar pressure is seen between sizes 4 and 6 uncuffed tubes. Cuffed tracheostomy tubes should not be used unless specifically indicated due to increased airway pressure.

Intraoperative Tracheostomy Tube Customization

Objectives: This article describes how to make a customized tracheostomy tube immediately in the operating room setting. This is particularly critical when a commercial customized tracheostomy tube cannot be readily obtained. Study Design: Case presentation. Methods/Results: A 73-year-old female was seen in our clinic for management of a recurrent invasive paraganglioma of the thyroid. She underwent a total laryngopharyngectomy, cervical esophagectomy, and anterolateral thigh free flap reconstruction followed by post-operative radiation. In follow-up, the patient presented with dyspnea related to two areas of stenosis, one at the level of her stoma and one at the distal trachea. The patient was therefore taken to the operating room urgently for dilation and placement of a tracheostomy tube. Available tracheostomy tubes were tried and ill fitting as each tube narrowed the patient’s stoma or abutted her distal granulation tissue. To custom create a tracheostomy tube, we used a standard rib shearer to shorten a #6 uncuffed tracheostomy tube by 2 cm. The edges were further smoothed and beveled using sand paper and a diamond burr drill. The finished product was a wide diameter tube with a custom length suited to our patient. Conclusions: Although a simple solution, the use of a rib shearer provides a quick and feasible solution to creating custom length tracheostomy tubes in situations where custom length tubes are needed yet unavailable.

Emergency airway management of tracheo-innominate fistulas in the pediatric population

Tracheo-innominate fistula (TIF) is a rare but well recognized complication of tracheostomy placement, and it is universally fatal in the absence of surgical management. Adult algorithms for TIF management do not address the unique dilemmas that exist in the pediatric population with respect to uncuffed tracheostomy tubes (TT). We present a case that highlights the need to modify the adult algorithm when applying it in children. Parental informed consent has been obtained for publication of the following case. A seven-year-old 25 kg encephalopathic ventilatordependent patient with a 4.0 uncuffed TT presented with emergency tracheostomy bleeding, which resulted in an inability to ventilate and subsequent loss of airway. The attending anesthesiologist was summoned immediately to the patient’s bedside and elected to secure the airway by placing a 4.0 cuffed endotracheal tube (ETT) through the tracheostomy stoma. Profuse bleeding ensued within an hour, and the patient was transported immediately to the operating room for further management. The patient was tachycardic and hypertensive, with 95% oxygen saturation on 100% O2 and unobtainable end-tidal CO2 due to copious blood in the sampling line. An earnose-and-throat (ENT) surgeon performed rigid bronchoscopy, confirming the diagnosis of TIF, and partially blocked the bleeding fistula by applying anterior pressure against the sternum. With hyperinflation of the cuff of the ETT and application of direct pressure with the rigid bronchoscope, the bleeding decreased so central venous and arterial accesses could be secured. A sternotomy was then performed, allowing identification and resection of a 0.5 cm TIF. Postoperatively, the ETT was sutured in place via the tracheostomy stoma and replaced by an uncuffed TT on postoperative day nine. The patient was discharged home at baseline condition a few days later. Previous reports have typically described the existing adult management algorithm being completely appropriate in pediatric patients with a cuffed TT who were older than age ten. The adult algorithm involves TT cuff hyperinflation distal to the fistula. If hyperinflation proves unsuccessful, digital compression of the innominate artery against the sternum via the tracheostomy stoma should be attempted. This maneuver has been reported as being successful in up to 90% of cases. It is important to recognize that the paucity of prior pediatric reports may be attributed to the primary utilization of uncuffed TT and the rarity of TIF in the pediatric population younger than age eight. This is highlighted by the longstanding recommendation in major pediatric textbooks to place an uncuffed ETT in all patients younger than age eight. With increased cuffed TT utilization, one might posit that this pediatric complication may become more prevalent in the future. Therefore, despite the current rarity of pediatric TIF in patients with an uncuffed TT, we feel that this alternate algorithm may be critical to the survival of future patients. There are several major distinctions between the adult algorithm and our proposed algorithm for emergency management of pediatric patients with uncuffed trachestomies (Figure). Cuff hyperinflation, recommended as the first step in most adult algorithms, is an obvious impossibility in most pediatric patients with an uncuffed TT. Additionally, the small pediatric airway does not allow for the next step of digital compression through the stoma, as J. B. Tuchman, MD (&) M. Concetta Lupa, MD E. H. Jooste, MB, ChB Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA e-mail: tuchmanj@upmc.edu

Prolonging Survival in Amyotrophic Lateral Sclerosis

To assess the efficacy of noninvasive ventilatory support and intermittent positive pressure ventilation via uncuffed tracheostomy tubes (uTIPPV) to prolong survival in amyotrophic lateral sclerosis. Survival was prolonged by continuous noninvasive ventilatory support or TIPPV dependence. Once noninvasive ventilatory support was no longer adequate for six noninvasive ventilatory support users, they and 22 others underwent tracheotomy within 1 mo of measurement of spirometry (forced vital capacity and forced volume expired in 1 sec), peak cough flows, maximum insufflation capacity, manually assisted peak cough flows, and mechanically assisted peak cough flows. Glottic function was estimated by maximum insufflation capacity, FVC difference, and bulbar-innervated muscle function by Norris scale bulbar-innervated muscle subscore. Cuffless tubes were replaced by cuffed ones when hypoventilation developed despite increasing uTIPPV volumes. The survival of 22 patients was prolonged by continuous noninvasive ventilatory support dependence for 7.8 +/- 8.1 mos (range, 1-36 mos; median, 5 mos) after 13.9 +/- 11.2 mos (range, 2-36 mos) of part-time noninvasive ventilatory support. Six of these and 22 others underwent tracheotomy and initially used uTIPPV effectively. For ten of the 28 (35.7%) patients, the tubes had to be replaced by cuffed ones after 5.7 +/- 7.8 mos with the other 18 still using tracheostomy intermittent positive pressure ventilation volumes via uncuffed tubes for 20.2 +/- 17.6 mos at data collection. Pretracheotomy FVC was significantly lower in the ten patients who eventually required cuffed tubes (0.70 +/- 0.44 vs. 1.06 +/- 0.43 L, P < 0.05). The bulbar-innervated muscle was significantly lower when the uTIPPV users required cuffed TIPPV than when beginning uTIPPV (Norris scale bulbar-innervated muscle subscore, 3.20 +/- 1.30 vs. 8.00 +/- 3.20, P < 0.05), respectively. Noninvasive and tracheostomy IPPV via cuffless tubes can prolong survival for patients with amyotrophic lateral sclerosis until excessive air leak and hypoventilation necessitate a cuffed tube.

Amyotrophic Lateral Sclerosis

Bach JR, Hon A: Amyotrophic lateral sclerosis: Noninvasive ventilation, uncuffed tracheostomy tubes, and mechanically assisted coughing.

Use of high-frequency jet ventilation for respiratory immobilization during coronary artery CT angiography

Multidetector ECG-gated CT angiography permits imaging of structures such as the coronary arteries and pulmonary veins with peripheral administration of contrast media. Respiratory motion artifact limits the applicability of this technique in critically ill patients due to an inability to cooperate with prolonged breath holds necessary for quality images. A case in which high-frequency jet ventilation via an uncuffed tracheostomy tube in an unmedicated patient permitted respiratory immobilization sufficient to acquire diagnostic images, is presented.

Care of the Child Assisted by Technology

Care of the Child Assisted by Technology

The Larynxane ST® intralaryngeal endoprosthesis for laryngotracheal pathologies

The authors present their experience of a new intralaryngeal silicone prosthesis used to manage laryngotracheal pathologies associated with severe deglutition and respiratory disorders. This retrospective study, conducted in the head and neck surgery department of the Strasbourg University Hospital, France, included 10 patients (12 prostheses inserted) and was conducted from November 2000 to November 2003. A pre-operative clinical examination and a computed tomography and/or magnetic resonance scan assessed patients' laryngeal function. Two different semirigid laryngotracheal prostheses were used, inserted under general anaesthetic into the region from the supraglottic area to the first tracheal cartilages including the vocal folds and the ventricles. In group one (n = 5), patients presented with laryngeal stenosis with preserved deglutition function, and patent prostheses were used to restore laryngeal patency. In group two (n = 5), patients suffered from severe deglutition disorders and were in poor general condition and so required a cuffed tracheostomy tube, therefore obstructed prostheses were inserted to stop aspirations and to suppress the cuff of the tracheostomy tube. The study was performed under the authorization of the Biomedical Research Patients' Protection Committee of Alsace I, France. The mean implantation duration was six months. The prosthesis used in the first group restored laryngeal patency without further complications such as aspiration or prosthesis (mucous) obstruction. The prosthesis used in group two prevented aspiration and allowed to change a cuff by an uncuffed tracheostomy tube. The intralaryngeal prosthesis used in group one constituted a reversible and effective method of treating laryngotracheal stenoses. The intralaryngeal prosthesis used in group two constituted an alternative to classical larynx exclusion techniques. The insertion is performed in few minutes under general anaesthetic through an endoscopic procedure. This reversible technique aimed to treat patients rapidly to reduce complications and post-operative morbidity.

Home Ventilator Low-Pressure Alarms Fail To Detect Accidental Decannulation With Pediatric Tracheostomy Tubes

Positive-pressure ventilators are equipped with low-inspiratory-pressure alarms to protect patients from hypoventilation. Small uncuffed tracheostomy tubes have a high resistance, and may not trigger these alarms during decannulation. To determine whether ventilator low-inspiratory-pressure alarms are effective in detecting tracheostomy decannulation. We connected tracheostomy tubes of varying inner diameters (3.0 to 6.0 mm) to a home ventilator and simulated decannulation using low (tidal volume [VT], 600 mL; peak inspiratory pressure [PIP], 25 cm H(2)O), medium (VT, 800 mL; PIP, 30 cm H(2)O), and high (VT, 1,000 mL; PIP, 35 cm H(2)O) ventilator settings. When the ventilator low-inspiratory-pressure alarm was set at 4 cm H(2)O below the desired PIP, it failed to alarm for simulated decannulation of tracheostomy tubes < 4.5 mm on low and medium settings, and < 4.0 mm on high settings. When the ventilator low-inspiratory-pressure alarm was set at 10 cm H(2)O below the desired PIP, it failed to alarm with tracheostomy tubes < 6.0 mm. We conclude that ventilator low-inspiratory-pressure alarms fail to alarm during simulated decannulation with small tracheostomy tubes commonly used in children. We speculate that low-inspiratory-pressure alarms set at 4 cm H(2)O below the desired PIP will detect more decannulation than when set at 10 cm H(2)O below the desired PIP.

Ernst Trier Mørch: inventor, medical pioneer, heroic freedom fighter.

Ernst Trier Mørch: inventor, medical pioneer, heroic freedom fighter.