2/21/2015 TracheostomyTubeChange

TracheostomyTubeChange
Author:WilliamAJohnsonChiefEditor:ZabMosenifar,MDmore...

Updated:Dec17,2013

Overview
Tracheotomyhasbeenperformedsince1500BCEandisoneoftheoldestreportedsurgicalproceduresinthe
medicalliterature. [1]Beforethe19thcentury,however,theprocedurewasfraughtwithdifficultyandonlyalimited
numberofsuccessfultracheotomieswerereported.Duringthisearlyperiod,theindicationsfortracheotomywere
few,but,beginningintheearly20thcentury,ChevalierQ.Jacksonrefinedandstandardizedtheprocedure. [2]As
experiencewiththeproceduregrewwithinthesurgicalcommunity,morbidityandmortalityratesdecreasedandits
indicationswerebroadened.In1999,morethan83,000tracheostomieswereplacedintheUnitedStates,most
commonlyforpurposesofmechanicalventilationinchronicallyillpatients. [2]Theimagebelowdepictstracheostomy
equipment.

Obturator,innercannula,cuffedtracheostomytube,andtracheostomytubeVelcrotie.

Thetracheaisnearly,butnotquite,cylindricalandflattenedposteriorly.Incrosssection,itisDshaped,with
incompletecartilaginousringsanteriorlyandlaterally,andastraightmembranouswallposteriorly.Thetrachea
measuresabout11cminlengthandischondromembranous.Thisstructurestartsfromtheinferiorpartofthelarynx
(cricoidcartilage)intheneck,oppositethesixthcervicalvertebra,totheintervertebraldiskbetweenT45vertebrae
inthethorax,whereitdividesatthecarinaintotherightandleftbronchi.Formoreinformationabouttherelevant
anatomy,seeTracheaAnatomy.

Fordiscussionoftheprocedureoftracheotomy(theoriginalinsertionofthetubeintothetrachealincision),see
MedscapeReferencearticleTracheostomy.

Thepostoperativecareofpatientsundergoingthisprocedureisoftenunderemphasized.Perhapsthemostcritical
eventaftertracheotomyisthetubechange,althoughmanyotheraspectsofthecareofthesetubesarecritical(eg,
suctioning,hygiene,humidity,emergencypreparedness).Thesafetyofcurrentpracticepatternsintracheostomy
managementispoorlydefined.Littleattentionhasbeendevotedtothemorbidityandmortalityassociatedwith
postoperativetracheostomytubechangesasapartofroutinecare,despitemultiplereportsdescribingtheincidence
ofperioperativecomplicationsassociatedwiththeprocedure. [3]

Casesofairwaylossandevendeathhavebeenreported,typically,althoughnotalways,intheperioperativeperiod.
Inasurveyadministeredto46otolaryngologytrainingprograms,42%ofrespondentsreportedawarenessofaloss
ofairwayand15%reportedawarenessofadeathasaresultofthefirsttubechangeattheirinstitutionduringtheir
residency. [3]Althoughtracheotomiesthemselvesrepresentoneofthemostfrequentlyundertakenhospital
procedures,thereisatpresentremarkablylittleevidencewithwhichtodirectpracticeinthepostoperativecare
period. [3]Theseoccurrenceswarrantanexaminationoftherationaleandsafetyofthisprocedure,aswellasspecific
guidelinesfortechnicalaspectsofthechangeinbothperioperativeandroutinesettings.

Considerations

Criticalaspectstotakeintoaccountwhenpreparingtochangethetracheostomytubeincludetiming,available
lighting,thetypeoftubebeingused,setting,timeofday,frequencyofprevioustubechanges,andindividual
patientcharacteristicssuchassize,age,weight,andgeneralhealthfactors.

Timing
Theintervalbetweenthetracheostomytubeplacementandthefirsttubechangeallowsatractbetweentheskin
andthetracheatodevelop.Confirmingstomalmaturityatthetimeofthefirsttubechangelikewiseminimizesthe
riskofestablishingafalsetract,whichcarriestheattendantmorbiditiesofsubcutaneousemphysema,lossofthe
airway,mediastinitis,andevendeath.Confirmingasafehealedtractallowsfornursesorothertrainedpersonnel
(eg,respiratorytherapist)tosafelyperformsubsequenttracheostomytubechanges.

Theexacttimingpriortothefirstpostoperativechangecanvary.Attheauthorsinstitution,thefirsttracheostomy
tubechangeisperformedafter5daysbutcanlikewisebeoccasionallydelayedinpatientswithimpairedwound
healing(eg,patientstakingsteroids,patientswithpoorlycontrolleddiabetes,patientswithnutritionaldeficits).This
timingfitswithsurveystudiesofcurrentpractice.Forexample,themeantimeintervalbetweensurgeryandthefirst
tubechangehasbeenreportedas5.3days(range,37d)accordingtoasurveyof46trainingprograms. [3]

Itisalsoworthnoting,however,thatonerecentstudyrecommendedwaitinglongertochangethetube,suggesting
awindowof714daysfollowingplacement,soastoallowtimeforastableendotrachealcutaneoustracttoform. [4]
Inaretrospectivecaseseries,thefirsttracheostomytubechangewassafelyperformedat34daysafterroutine
tracheotomyproceduresin20of21pediatricpatients. [5]

Typeoftube

Thevarioustypesoftracheostomytubeshavesubtledifferencesthatareoftenunderappreciatedyetpossess
specificindicationsbasedontheneedsoftheindividualpatient.Adiscussionofthevariousnuancesofrespective
tubedesignsisbeyondthescopeofthisarticle,butthesedifferencescandependontheindicationforthe
tracheotomy,anatomicconsiderations,patientage,andavailability,amongotherconditions.Assuch,some
principlestokeepinmindwhenselectingatubearediscussedbriefly.

Tracheostomytubesareavailableinvarioussizesandstyles.Thedimensionsoftracheostomytubesaregivenby
theirinnerdiameter,outerdiameter,length,andcurvature. [6]Tracheostomytubescanbeangledorcurvedto
optimizefitintothetrachea.Tubescanbecustomizedwithadditionallengthattheproximalend(toaccommodate

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patientswithlargeordeepnecks)ordistalend(toaccommodatepatientswithtrachealanomalies,eg,stenosis). [6]

Tracheostomytubesareavailablewithandwithoutacuff.Cuffedtubesareusedtoallowforasealinthesettingof
positiveendexpiratorypressureortopreventdownwardflowofsecretions.Specificcuffsontracheostomytubescan
includelowpressure,highvolumecuffstighttoshaftcuffsandfoamcuffs. [6]Fenestratedtracheostomytubeshave
anopeningintheposteriorportionofthetubeabovethecuff,whichallowsthepatienttobreathethroughtheupper
airwaywhentheinnercannulaisremoved,facilitatingphonation. [6]Knowledgeastothespecifictypeof
tracheostomytubebeingusedandtherelevantfactorstotheparticularsituationthatdetermineditsselectionare
bothcritical,especiallypriortoatubechange.

Thematerialofatubeislikewiseanimportantconsiderationastheappropriatenessofagiventubetoaspecific
situationmayvaryaccordingtopatientnecessitiesandthetypeofprocedureinvolved.Themajorityoftracheostomy
tubesaremadeofplasticandhavevariablerangeofflexibility.Theycanbemadefrompolyvinylchloride,a
materialthatbecomessofterwhenincontactwithbodytemperatures,orsilicone,whichisbynaturesoftandis
unaffectedbybodytemperature. [7]Inrarecases,patientsmayprefermetaltubesorthosereinforcedwithwire,and
thesecanlikewisebeusedtosecureairwaypatency. [6]Plastictubescanbecuffedorcuffless,butmetalonesare
uniformlycuffless. [7]

Setting

Thesettingofthefirsttracheostomytubechangeshouldbeconsidered.Attheauthorsinstitution,patientswho
underwentatechnicallychallengingtubeplacement(eg,challengingbodyhabitus,morbidobesity,cervical
instability/presenceofahalo,highdegreeofrespiratorysupport,criticalcondition)havetheirtracheostomytubes
changedinamoreacutecaresetting(eg,operatingroom).However,forstablepatientsintheroutinesetting,
tracheostomytubechangesareperformedinvariouslocationsinthehospital,includingthegeneralinpatientward,
astepdownunit,ortheICU.

Tabaeeetaldemonstratedthattheinitialtubechangeonthefloorhasbeenassociatedwithhigherriskofairway
loss. [3]Theyconcludedthatthelevelofnursingandancillarysupportonthefloormayresultinaninadequatelevel
ofcareforsafeairwaymanagement. [3]Theauthorsbelievethatchangesongeneralwardsaresafeinmost
patients,aslongasadequatetraining,equipment,andsupportareavailable.Indeed,therespiratorytherapyservice
attheauthorshospitalperformsroutinechangesinstablepatientsweekly.

Patientissues

Pulseoximetryandsupplementaloxygenmaybewarrantedinpatientswhohavecomorbiditiesassociatedwithpoor
pulmonaryreserve.Inaddition,patientswithaboveaverageneckcircumference,elevatedbodymassindices,or
otherwiseunusualairwayanatomycanbeatgreaterriskofhavingatubeplacedintoafalsepassageintheanterior
mediastinum. [8]Incasesofpediatricpatients,tracheostomyrelatedmortalityratesashighas3.4%hasbeen
reported,inpartasaresultofpneumothoraxandthecreationoffalsepassageways. [9]Asaresultofthisdanger,
andbecausepediatricpatientsaresometimesunabletoverbalizetheirdiscomfort,carefulmonitoringofvitalsigns
shouldbeundertakenduringthefirsttracheostomytubechangeperformedonachild.Additionally,tracheostomy
tubechangeshouldbedeferredinpatientswhoarehemodynamicallyunstable.

Formoreinformation,seetheMedscapeReferencearticlePediatricTracheostomy.

Frequency

Studieshaveshownthatregulartracheostomytubechangescanoftenresultinastatisticallysignificantdecreasein
thenumberofpatientswhorequiresurgicalinterventionforremovalofgranulationtissue,informationthatishighly
germanetobestpracticeofthetimingoftracheostomytubechanges. [10]Granulationtissueisacommon
consequenceoftracheotomy,occurringin1080%ofcases,andittypicallyappearsaspinkandfleshyprotuberant
tissue. [10]Histologically,itiscomposedoffriable,immaturebloodvessels,whicharepronetobleedingandcan
complicateatracheostomytubechangebyobstructingthestomaorwithbleeding,resultinginlossofairway.

Topicalapplicationsofcorticosteroidcreams,antibioticpreparations,andsilvernitratehavebeenproposedto
addressgranulationtissue. [10]However,thequestionofwhethertracheostomytubechangesthataremorefrequent
thanonceevery2weeksmighteliminatetheproblementirelyorwhetheracertainsubsetofpatientswouldrequire
lessfrequentchangesremainstobedetermined. [10]Anotherimportantelementpertainstothedesignandmaterial
ofthespecifictracheostomytubeusedonagivenpatientbasedonthecurrentavailableinformation.Foran
inpatient,apolyvinylchloridetubemaybechangedevery8weeks,whereasasiliconetubeshouldbechanged
every4weeks.Meanwhile,foranoutpatient,atracheostomytubeisbestchangedevery812weeks. [11]The
authorsrecommendtubechangesweeklyorbiweeklytoreducethisincidenceandthepossibilityofbacterial
colonizationorsuperinfection.

Otherissues

Atpresent,thereisnodefinitivesetofpublishedrecommendationsbywhichtosetastandardforadult
tracheostomytubechanges,andmostcurrentprotocolsaretheresultoflocalpractices. [11]Regardingpediatricbest
practice,theAmericanThoracicSocietyhaspublishedguidelinesonthespecificsoftheprocedureastheypertain
tothecareofchildrenhowever,thisinformationwasreleasedoveradecadeagoandmaynolongerbecurrent. [12]
Asaresult,futureinvestigationsdesignedinaprospective,randomizedmannerandwithasufficientnumberof
patientsareneededinordertoenableclinicianstodrawvalid,concreteconclusionsastotheoptimalmethodsof
evaluatingandcaringforthesepatients. [13]

Ingeneral,atracheotomyisroutinelyperformedinasterilesettingintheoperatingroom.Postoperativechangeof
dressings,suctioning,andfirstpostoperativetracheostomytubechangesareperformedwithsterileequipmentbut
undercleanconditions. [6]Thereafter,careisusuallyperformedundercleanconditions. [10]

Whiletheprocessofchangingatracheostomytube(seethevideobelow)isgenerallystraightforwardinthemajority
ofpatients,bestpracticedictateschangesbeperformedonlybysomeonewhoisskilledintheprocedure.
Furthermore,itishighlyadvisabletohave2peoplepresentduringanytracheostomytubechangeandthatpriorto
removingtheoldtube,allcomponentsofthenewtracheostomytubebecheckedforintegrity. [12]
TracheostomyTubeChange.VideocourtesyofThereseCanares,MD,andJonathanValente,MD,RhodeIslandHospital,Brown
University.

Thedesignationofspecificteamsdedicatedtoperformingtracheostomytubechangesalsowarrantsserious
consideration.Forexample,JohnsHopkinsHospitalcreatedaprogramwhereinpreidentifiedspecialistteams
composedofsurgicalstaff,includingcredentialedotolaryngologists,traumasurgeons,interventionalpulmonologists,
speciallytrainedanesthesiologists,atracheostomytrainednursepractitioner(NP),atracheostomycoordinator,
equipmentspecialists,ICUnurses,respiratorytherapists,andexperiencedspeechandlanguagepathologists.

AninstitutionalreviewwasperformedbyJohnsHopkinsafterimplementingthisprogramitcomparedoutcomesin

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patientswhohadreceivedtracheostomiesin2004,theyearbeforetheprogramsimplementation,andthosewho
receivedtracheostomiesin2008.Thereviewfoundthatcomparativeoutcomes,includingtheefficiencyof
procedurethesubsequentlengthofpatientstayinanICUcomplicationratesforbleeding,hypoxia,lossofairway
andafinancialcostbenefitanalysis,weregreatlyimprovedasaresultoftheprogram. [14]

Otherprogramsthatincludedaspecialistserviceforthecareofpatientswithtracheostomytubeshavelikewise
beenfoundtohavesignificantlyreducednumbersofpatientstransferredfromtheICUtothewardswith
tracheostomiesinsitu. [15]Thus,itseemsevidentthatthecombinationoffewertracheostomypatientsperward,the
existenceofadailyoutreachservice,andbetternurseeducationarealllikelytoreducetheoccurrenceof
tracheostomyrelatedcomplications.

Indications
Themostcommonacceptedindicationsfortracheotomyincludetheneedforprolongedventilatorysupport,upper
airwayobstruction,andpulmonarytoilet.Thebenefitscommonlyascribedtotracheotomycomparedwithprolonged
endotrachealintubationincludeimprovedpatientcomfort,moreeffectiveclearanceofairwaysecretions,improved
ventilatoryparametersthroughdecreasedairwayresistance,enhancedpatientmobility,increasedopportunitiesfor
articulatedspeech,abilitytoeatorally,decreasedcomplicationsofprolongedpressureoftheendotrachealtubeon
thelarynxandtrachea,andamoresecureairway. [16]

Indicationsfortracheostomychangeincludeminimizingriskofpostoperativeinfectionandgranulationtissue
formation,verifyingformationofastabletractforancillarysupportstaff,anddownsizingthetracheostomytubeif
thepatientisclinicallyimproving.

Contraindications
Changingatracheostomytubetoosoonafteroperation(generally<5d)beforetracthashealedadequately,
whichincreasesthelikelihoodofentryintoafalsepassage
Inadequatelighting,exposure,andequipment
Performerinexperienceandunavailabilityofstaffversedinairwaymanagement
Extremelyhighventilatorsettings,whichincreasestheriskofdecannulation
Patientnoncooperationwithoutancillarysupport

Anesthesia
Anesthesia,sedation,andanalgesiaarenotrequiredfortracheostomytubechange.

Equipment
Tracheostomytubes,samesizeaspatientand1sizesmaller(Ifstomalobstructionisencountered,asmaller
tubecanbeplacedwithmoreeaseseeimagesbelow.)

Obturator.

Innercannula.

Cuffedtracheostomytube.

Obturator,innercannula,cuffedtracheostomytube,andtracheostomytubeVelcrotie.

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Emptysyringe(forcuffdeflation/inflationandforsuctionpriortothechangetoremovesecretionsbeingheld
upbythecuffseeimagebelow)

Top(lefttoright):gauzeandhydrogenperoxidemiddle(lefttoright):syringe,forceps,scissors,lubricantbottom:soft
suctioncatheter.

Softsuctioncatheter(Softcatheterspreventmucosaltraumausecautionregardinglatexallergyseeimage
above.)
Gauze,hydrogenperoxide(diluted50%seeimageabove)
Waterbasedlubricant(facilitatesatraumaticplacementoftube)
Suctionsource
Mask,gloves,gown,eyeprotection(seeimagebelow)

Gloves,gown,andmask.

Shoulderroll(seeimagebelow)

Shoulderroll.

Ambubag/tracheostomycollarwithoxygensource(forpreoxygenation)
Sutureremovalkit
Velcroties
Tracheostomytray(containsTrousseaudilators,whichcanaidindifficultplacementnasalspeculumcould
alsobeusedforthispurpose)
Fiberopticscope

Positioning
Patientpositioningiscriticaltothesafetyoftheprocedure.Thebedshouldbeadjustedtoacomfortable
height,andtherailsshouldbereleasedtoallowthepractitionertogetclosetothepatient.
Thepatientshouldbeplacedsupinewiththeneckinmildhyperextensionoverashoulderroll,ifthepatients
generalconditioncantoleratesuchpositioning.Thispositioningbringsthetrachealorificeclosertothe
surface.
Ifthepractitionerchangingthetubeisrighthanded,thepractitionershouldstandonthepatientsrightand
theassistantshouldstandonthepatientsleft.Reversepositionsifthepersonchangingthetubeisleft
handed.

Technique
Ensurethatthelightingintheroom,specificallyoverthepatientsbedandneck,isadequatetovisualizethe
stoma.Insomecases,theuseofaheadlightishelpful.
Ensurethatthenecessaryequipmentisavailable,includinganassistantwhoiscompetentintracheostomy
care,ifpossible.Checktheequipmentforfunctionality.Forexample,iftheexistingtracheostomytubeis
beingreplacedwithanewcuffedtube,theballoonshouldbecheckedforleaks.
Positionthepatientasdescribedabove.
Iftheindwellingtracheostomytubeiscuffed,deflatetheballoonandsuctionthepatientgentlywithasoft
suctioncathetertoremovesecretionsbeingheldabovethecuffandinthelowerairway.Afterdoingso,the
cuffcanbereinflated,ifneeded,whileremainingpreparationsaremade.Additionally,thisopportunitycan
betakentopreoxygenatethepatientforseveralminutestomaximizehisorheroxygenreserve.
Removeanysuturesandtiestofreethetracheostomytube.Theassistantneedstostabilizetheflangeinits
placeatalltimestopreventprematuredecannulation.
Deflatethecuffandremovethetracheostomytube.
Inspectthestomaforwoundbreakdown,granulationtissue,andadequacyofatractintothetrachea.Clean
theareawithgauzemoistenedwithhydrogenperoxide,sweepingdebrisawayfromthetracheatoprevent
foreignbodiesfromfallingintothelowerairway.Next,cleantheareawithdrygauzeinasimilarfashion.
Ifstaysutureswereplacedatthetimeofthetracheotomy,applytractiongently,raisingthemupandoutto
providebetterexposure,exteriorizingthetracheaagainsttheskin.
Applythenewlubricatedtracheostomytube,withtheobturatorwithinitslumeninitiallyrotated90fromits
correctposition,toengagethetracheostoma.Thenturntheobturatorback90toitscorrectpositiontobe
insertedintothetrachea.Thisreducestheriskofcreatingafalseanteriorpassageinthepretrachealspace.
Ifanyresistanceisencountered,donotadvancefurther.Instead,removethetube,inspectthetractagain,
andreinsertthetube.
Assoonasthetubeisinplace,removetheobturator,asitoccludesthelumenofthetube.
Replacetheobturatorwiththeinnercannula,whichshouldbereconnectedtotheventilatortubingifthe
patientisstillmechanicallyventilated.
Inflatethecuff.
Passthesoftsuctioncathetertoconfirmplacement.Breathsoundsshouldbeelicitedbilaterallytheyshould
beauscultatedeasilyandconfirmedtobeunchangedfromthepreoperativecondition.Placementcanalso
beconfirmedwithaflexiblefiberopticendoscope,ifneeded.
Whenplacementisconfirmed,securethetracheostomytubeinplacewiththeVelcrotiesandremovethe
shoulderroll.Finally,anystaysuturesorBjorkflapsuturescanberemovedatthistime.

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Pearls
Ifrecannulationappearspotentiallydifficult,therailroadtechniquecanbeused.Therailroadtechnique,described
byLevyin1982,isbasedontheSeldingertechniqueandcanbeusedindifficultcaseswithcontinuedmaintenance
oftheairway. [17]

Preparethepatientandequipmentasdescribedabove.Ifaninnercannulaispresent,itisreplacedwitha
hollowtubethatisatleast3timesthelengthofthetracheostomytube. [17]Thetubechosenmaydependon
resourcesavailableandcouldincludeasoft,flexiblesuctioncatheteroranoralgastrictube.
Holdtheupperendofthetubebythethumbandindexfinger.
Removethetracheostomytubeoverthistubing.
Theindwellingguidetubingfunctionsasanairwaythroughwhichthepatientcanbreathe,ifnecessary.
UsingaSeldingertechnique,slipthenewtracheostomytubeinoverthetubing.
Oncethenewtubeisinplace,removetheguidetubing.Thepatientmayresumeventilationafter
replacementoftheinnercannula.
Confirmationandreassessmentareperformedasabove.

Inthecaseofunanticipateddifficultywithatracheostomytubechangeandapoorlyvisualizedstomaltract,the
illuminatedbladeofastandardlaryngoscopecanbeusedasaretractortoenhancevisualization,therebyallowing
theinsertionofthetracheostomytubeunderdirectvision. [17]Criticallyillpatientswithrespiratoryfailurecan
undergostabilizationbyemergencyendotrachealintubationintheabsenceofupperairwayobstruction.The
tracheostomytubecanthenbereinsertedelectivelyundermorecontrolledconditions.

Complications
Althoughtracheostomytubechangesareroutinelyperformed,theprocedureisnotwithoutcomplications. [17]As
such,aproperunderstandingoftheprocedure,aswellasanticipationofpotentialproblems,canfacilitatean
uneventfultracheostomytubechange.

Theconsequencesoftracheostomytubedisplacementcanbedireandcanincludelossofadequateairwayand
death.Tubedisplacementisarareeventthatmayoccuratanytimeduringthepatient'scourse,althoughitismost
commonduringtheperioperativeperiodbeforethetracthasmatured.Occasionally,displacementoccursatthetime
ofthefirsttubechange,resultingfromcreationofafalsetractinthepretrachealorperistomalregion.Thismay
presentinsidiouslywithrespiratoryfailureandsubcutaneousemphysema.Preventioniscriticaltoavoidthisgrave
complication.Measuresthatreducetheriskincludeconfirmationofplacementfollowingtheprocedurewithpassage
ofaflexiblesuctioncatheter.Resistancemetwiththismaneuvermayrepresentimproperplacement.

Asanymedicalprocedureinvolvesinherentrisks,itisofvitalimportancetobepreparedinadvancetobeableto
controlanylifethreateningsituationsthatmayariseinpatientswithtracheostomytubes.Havingbasicemergency
equipmentonhandatthebedsideofapatient,suchasamanualventilatorbag,atleast2extratracheostomy
tubes(oneofwhichisthesamesizeasthepatientscurrentdeviceandtheotherofwhichissmaller),andan
obturatorandsuctioningdevicesandcatheters,caninsomecasesrepresentthedifferencebetweenlifeanddeath
foragivenpatient. [18]

ContributorInformationandDisclosures
Author
WilliamAJohnsonMD,StaffPhysician,DepartmentofSurgery,SectionofOtolaryngologyHeadandNeck
Surgery,FlowerHospital,ToledoChildren'sHospital

WilliamAJohnsonisamemberofthefollowingmedicalsocieties:AmericanAcademyofOtolaryngologyHead
andNeckSurgery

Disclosure:Nothingtodisclose.

Coauthor(s)
JayantMPinto,MDAssistantProfessor,SectionofOtolaryngologyHeadandNeckSurgery,Universityof
ChicagoDivisionoftheBiologicalSciences,ThePritzkerSchoolofMedicine

JayantMPinto,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofAllergyAsthmaand
Immunology,AmericanAcademyofFacialPlasticandReconstructiveSurgery,AmericanAcademyof
OtolaryngicAllergy,AmericanAcademyofOtolaryngologyHeadandNeckSurgery,AmericanCollegeof
Surgeons,AmericanGeriatricsSociety,AmericanRhinologicSociety,AmericanSocietyofHumanGenetics,and
SocietyofUniversityOtolaryngologistsHeadandNeckSurgeons

Disclosure:Nothingtodisclose.

MarianellaPaz,MDResearcher,UniversityofChicago

Disclosure:Nothingtodisclose.

FuadMBaroody,MDDirectorofPediatricOtolaryngology,ProfessorofSurgery,SectionofOtolaryngology
HeadandNeckSurgery,TheUniversityofChicago

FuadMBaroody,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofAllergyAsthmaand
Immunology,AmericanAcademyofOtolaryngicAllergy,AmericanAcademyofOtolaryngologyHeadandNeck
Surgery,AmericanCollegeofSurgeons,andAmericanSocietyofPediatricOtolaryngology

Disclosure:GaxoSmithKlineHonorariaSpeakingandteachingMerckHonorariaSpeakingandteaching

SpecialtyEditorBoard
PrajoyPKadkade,MDAssistantProfessorofOtolaryngology,AlbertEinsteinCollegeofMedicineAttending
Physician,DepartmentofOtolaryngologyandCommunicativeDisorders,DirectorofOtolaryngology,NorthShore
UniversityHospital,NorthShoreLongIslandJewishHospitalSystem

PrajoyPKadkade,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofFacialPlasticand
ReconstructiveSurgery,AmericanAcademyofOtolaryngicAllergy,AmericanAcademyofOtolaryngologyHead
andNeckSurgery,AmericanCollegeofSurgeons,andMedicalSocietyoftheStateofNewYork

Disclosure:Nothingtodisclose.

MaryLWindle,PharmDAdjunctAssociateProfessor,UniversityofNebraskaMedicalCenterCollegeof
PharmacyEditorinChief,MedscapeDrugReference

Disclosure:Nothingtodisclose.

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2/21/2015 TracheostomyTubeChange
LaurieScudder,DNP,NPNursePlanner,MedscapeClinicalAssistantProfessor,SchoolofNursing,George
WashingtonUniversity,Washington,DC

Disclosure:Nothingtodisclose.

ChiefEditor
ZabMosenifar,MDDirector,DivisionofPulmonaryandCriticalCareMedicine,Director,Women'sGuild
PulmonaryDiseaseInstitute,ProfessorandExecutiveViceChair,DepartmentofMedicine,CedarsSinaiMedical
Center,UniversityofCalifornia,LosAngeles,DavidGeffenSchoolofMedicine

ZabMosenifar,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofChestPhysicians,
AmericanCollegeofPhysicians,AmericanFederationforMedicalResearch,andAmericanThoracicSociety

Disclosure:Nothingtodisclose.

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