Airway Management

E   Narrative Review Article

Intraoperative Airway Management Considerations

for Adult Patients Presenting With Tracheostomy:
A Narrative Review
Eric B. Rosero, MD, MSc,* John Corbett, PhD,† Ted Mau, MD, PhD,‡
and Girish P. Joshi, MBBS, MD, FFARCSI*

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 pro-
longed mechanical ventilation, treatment of acute upper airway obstruction when tracheal intu-
bation 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 chal-
lenging 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 indi-
cation 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 mul-
tidisciplinary care involving anesthesiologists, surgical specialists, and perioperative nurses.
The aim of this narrative review is to discuss the anesthesia care of patients with a trache-
ostomy. 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 dislodge-
ment.  (Anesth Analg 2021;132:1003–11)

GLOSSARY
ENT = ear, nose, throat; ETT = endotracheal tube; ID = internal diameter; N/A = not applicable; OD =
outer diameter; SGAD = supraglottic airway device

T
racheotomy is a common surgical procedure
through which a tracheostomy, an opening into
the trachea, is created. Most commonly, this pro-
cedure is performed on critically ill patients requiring
prolonged mechanical ventilation due to acute respi-
ratory failure and other critical acute conditions; on
From the *Department of Anesthesiology and Pain Management, University
of Texas Southwestern Medical Center, Dallas, Texas; †Paul L. Foster School
of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas;
and ‡Department of Otolaryngology-Head and Neck Surgery, University of
Texas Southwestern Medical Center, Dallas, Texas.
Accepted for publication November 11, 2020.
Funding: This study was funded by internal funds from the Department
of Anesthesiology and Pain Management and the Department of
Otolaryngology-Head and Neck Surgery of the University of Texas
Southwestern Medical Center at Dallas.
The authors declare no conflicts of interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of
this article on the journal’s website (www.anesthesia-analgesia.org).
Reprints will not be available from the authors.
Address correspondence to Eric B. Rosero, MD, MSc, Department of
Anesthesiology and Pain Management, University of Texas Southwestern
Medical Center, 5323 Harry Hines Blvd, MC 9202, Dallas, TX 75390. Address
e-mail to eric.rosero@utsouthwestern.edu.
Copyright © 2020 International Anesthesia Research Society
DOI: 10.1213/ANE.0000000000005330
patients with upper airway obstruction where tra-
cheal intubation is unfeasible (eg, severe acute airway
edema, obstructive upper airway tumors, oropha-
ryngeal or neck hematoma, or abscess); on patients
with chronic upper airway obstructive conditions (eg,
obstructive sleep apnea and bilateral vocal cord paral-
ysis); or as part of a planned airway management for
major head and neck surgery.1
Many patients who receive a tracheostomy will
undergo decannulation once they are capable of effec-
tive spontaneous breathing with eventual wound clo-
sure typically occurring within 7–14 days. However,
a subset of patients may continue to have a tracheos-
tomy present. Whether due to ongoing need for tra-
cheostomy or pathologies preventing tracheostomy
closure, some of these patients may require anesthe-
sia care either in the operating room or nonoperating
room locations for a variety of surgical or diagnostic
procedures. These patients pose several challenges.
Therefore, it is important for anesthesia personnel
to become familiar with the airway management
options and potential complications in this patient
population.

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 Anesthesia in Patients With Tracheostomy

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. Of note, postoperative care on the
wards is not the focus of this review.
RELEVANT TRACHEAL ANATOMY
To create a tracheostomy, the surgical procedure of
a tracheotomy must be completed. The tracheot-
omy is usually performed at the level of the second
to third tracheal cartilage rings. The average length
of a tracheostomy tract (ie, the distance from skin
to anterior tracheal wall) is 2.6 ± 0.7 cm (1.8–5.5 cm
for men and 1.5–4.2 cm for women) and the average
intratracheal length (ie, the distance from the tracheal
opening to the carina) is 4.3 cm (2.2–6.6 cm, range).2,3
Accordingly, although the average length of the adult
trachea is 10.0–11.8 cm,4 the distance available for the
insertion of a tracheostomy tube or a tracheal tube
through a tracheostomy, to avoid endobronchial intu-
bation (sum of the tracheostomy tract length plus the
intratracheal length), is on average about 7 cm but
could be as short as 4 cm in small individuals. The
tracheal diameter in adult men is about 1.9–2.1 cm
and in women about 1.7–1.9 cm.5 This information
is used to select the appropriate tracheostomy tube
size.6 Of note, the size of most tracheostomy tubes is
determined by the internal diameter (ID) of the outer
cannula.
From the standpoint of tracheal anatomy, total lar-
yngectomies are typically performed for advanced
laryngeal cancer or, infrequently, for intractable aspi-
ration. During a laryngectomy, the proximal tracheal
end is diverted anteriorly to the skin to form a per-
manent stoma and there is no upper airway. Of note,
the laryngectomy stoma can look similar to the stoma
created in a tracheotomy; however, mask ventilation
and oral tracheal intubation will not be possible.
using the minimal occlusive volume technique for cuff
inflation. For patients presenting with nonstandard
tracheal anatomy, extra length tracheostomy tubes are
available. Tubes with extra distal length can be used to
stent across a low tracheal stenosis or tracheomalacia,
while those with extra proximal length are for obese
patients with a long tracheostomy tract.7 Appropriate
selection of size and shape of the tracheostomy tube is
substantially important, as use of oversized tubes may
result in impaired ventilation if the distal lumen of the
tube gets occluded by the tracheal wall.8,9
Fenestrated tubes have an opening in the poste-
rior section of the tube above the cuff and are used
to assess the patient’s ability to breath via an oral/
nasal route and facilitate speech. However, friction
from the fenestrations can stimulate granulation tis-
sue formation along the posterior tracheal wall mak-
ing replacement challenging. Some tracheostomy
tubes designed to accept speaking valves (also known
as a Passy-Muir valve), which are 1-way flap valve
that directs exhaled air through the upper airway for
phonation.10 Of note, a speaking value is avoided with
cuffed tracheostomy tubes because inadvertent cuff
inflation would prevent exhalation with catastrophic
consequences (eg, pneumothorax, cardiac arrest, and
death).11
Stoma maintenance devices consist of small
uncuffed tubes or stents used in patients who can-
not be decannulated and therefore need to keep the
stoma open, but do not need the tube to project into
the tracheal lumen. A tracheostomy button is simply a
hollow cannula that extends from the skin to the ante-
rior wall of the trachea allowing the patient to breathe
through the upper airway or the button. The T-tube
(eg, Montgomery tube and Hood T-tube; Figure 1) is
indicated in the management of a variety of malignant
and benign tracheal stenosis, as a bridge to definitive
reconstructive surgery or a definitive treatment when
surgical repair is not possible.12 These tubes consist
of a vertical, intraluminal main tube that serves as a

TRACHEOSTOMY DEVICES
In general, these devices can be categorized in 3 broad Table 1. External Diameter and Length of Some
groups: tracheostomy tubes, stomal maintenance Commercially Available Tracheostomy Tubes
Internal diameter (mm)
devices, and attachment accessories.7 Tracheostomy
Tracheostomy tube 5.0 6.0 7.0 8.0 9.0 10.0
tubes, cuffed or uncuffed, consist of outer and inner
PortexFlex D.I.C., Smiths Medical, Minneapolis, MN, USAa
cannulas of varying dimensions (Table 1), and an obtu-   External diameter N/A 8.2 9.6 10.9 12.3 13.7
rator to ease tube insertion or replacement (Figure 1).  Length N/A 64 70 74 80 80
Of note, some uncuffed tubes lack the 15-mm con- Shiley SCT, Medtronic, Minneapolis, MN
  External diameter 7.0 8.3 9.6 10.9 12.1 13.3
nector that fits the breathing circuit of the anesthesia  Length 58 67 80 89 89 105
machine. A Bivona Tight To Shaft (Smiths Medical, Bivona Mid-Range Aire-Cuf, Smiths Medical, Minneapolis, MNb
Minneapolis, MN) tracheostomy tube has a low-profile   External diameter 7.4 8.8 10.0 11.0 12.3 13.3
high-pressure low-volume cuff, which should be filled  Length 60 67 80 89 89 105
with water, not air, because air will leak out of the cuff Abbreviation: N/A, not applicable.
a
Tracheostomy tube with internal diameter <6.0 mm not available from this
over time. However, cuff pressures cannot be measured manufacturer.
with a manometer and the manufacturer recommends b
Maximum internal diameter of Bivona tube is 9.5 mm, instead of 10 mm.

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 E  Narrative Review Article
Figure 1. Examples of tracheostomy tubes: cuffed tubes, uncuffed
tube with inner cannula and obturator, and Montgomery T-tube.
tracheal stent, and a horizontal, extratracheal limb
that serves as a tracheostomy tube, protrudes through
the tracheotomy orifice, and works as a fastening
component that minimizes the risk of migration.13 Of
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Table 2. Preanesthetic Checklist for Tracheostomized
Patients
1. Identify the indication for tracheostomy including total laryngectomy
2. Determine whether the trachea could be intubated orally
3. Determine the timing of tracheostomy: greater or less than 7 d
4. Determine the size and type of tracheostomy device
5. Confirm patient position during procedure: prone, supine, or lateral
6. Determine the need for neuromuscular blockade and positive
pressure ventilation
7. Assess other relevant medical aspects of the patient: coagulation
status, respiratory status, morbid obesity, thick and short neck, etc.
8. Determine the need to consult an ear, nose, and throat surgeon
note, T-tubes often have smaller ID compared to other
tracheostomy devices.
Attachment accessories are designed to facilitate
phonation, humidification, oxygen administration, or
decannulation.
PREPROCEDURE CONSIDERATIONS
Standardized Multidisciplinary Care
It is well documented that major causes of avoidable
harm in tracheostomy patients include inconsistent
and poorly coordinated care.14 Therefore, the British
National Tracheostomy Safety Project, which included
key stakeholder groups with multidisciplinary exper-
tise in airway management, developed guidelines
and algorithms to assist in the management of a tra-
cheostomy and laryngectomy emergencies.14 A recent
multicenter study reported that implementation of
multidisciplinary standardized care using protocols/
pathways improved quality and safety of tracheos-
tomy care.15 Although much of the guidelines focused
on postoperative care and airway emergencies on the
ward, a standardized multidisciplinary approach to
periprocedure management should improve care of
patients with tracheostomy.
Assessment Specific for a Tracheostomized
Patient
The first step to standardized care includes using a
preprocedure checklist (Table  2). Understanding the
indication for tracheotomy should allow determina-
tion if upper airway is patent and oral tracheal intu-
bation would be possible in case of unexpected loss
of the tracheostomy. For example, if the tracheotomy
was performed for bilateral vocal fold paralysis where
a glottic airway is still present, yet insufficient for daily
activity, the trachea can be intubated orally because the
vocal folds can still part passively with passage of the
tracheal tube. However, if the patient has complete ste-
nosis of the subglottis or proximal trachea, the trachea
would not be intubated orally, and the tracheostomy
remains the only access to the airway. Similarly, if the
patient had a total laryngectomy or a tracheal diversion
procedure that eliminated upper airway access, the air-
way cannot be managed from the oral or nasal route.16
 Anesthesia in Patients With Tracheostomy
If the tracheostomy is performed for prolonged tracheal
intubation significant tracheal inflammation may be
present, with friable or edematous tissues predisposed
to bleeding or obstruction in case of manipulation.
The timing when the tracheostomy was created is
critical. Patients with recent (<7 days) tracheotomy
may not have a mature stoma, which may increase the
possibility of misplacement during exchange of tra-
cheostomy tube (ie, insertion into a pretracheal pocket
or the anterior mediastinum), which would result in
inability to ventilate the patient, and increased risk of
hemorrhage, subcutaneous emphysema, pneumome-
diastinum, and infection.17,18 Typically, patients who
present with an uncuffed tracheostomy tube or stent
will have developed a mature stoma.
Patient comorbidities may also influence trache-
ostomy management. Morbidly obese patients may
require an extralength tracheostomy tube because of
a longer skin–trachea distance. In patients on antico-
agulation or with coagulopathies, there is a concern of
bleeding while exchanging the airway device.
Figure 2. Management of patients presenting to anesthesia with a tracheostomy in place.
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AIRWAY MANAGEMENT DURING PROCEDURE
The approach to airway management is included in
Figure  2. Patients with properly functioning cuffed
tracheostomy tube usually do not need a change to
another airway device if they remain in a supine posi-
tion. Of note, for the dual-cannula cuffed tracheos-
tomy tubes, the breathing circuit must be connected
to the inner cannula, which has the corresponding
15-mm connector. It is necessary to be familiar with
the locking mechanism to the outer cannula and be
aware that higher airway resistances will be encoun-
tered due to the smaller diameter of the inner cannula.
Exchanging a Tracheostomy Tube for an
Endotracheal Tube
Many choose to exchange a cuffed tracheostomy tube
with a tracheal tube, particularly for prolonged proce-
dures and patients in prone position, because it pro-
vides more flexibility and alleviates the concern that the
shorter length of tracheostomy tube may lead to dis-
lodgment or airway obstruction from malposition.19–22
ANESTHESIA & ANALGESIA
 E  Narrative Review Article
The type of tracheal tube (ie, reinforced versus standard)
used to replace a tracheostomy tube remains debatable;
however, we recommend a reinforced tracheal tube
because it is flexible and easy to manage. Patients requir-
ing laser airway surgery would require a laser-resistant
tracheal tube.23,24 Of note, patients using speaking valves
for phonation will require their speaking valves to be
removed, saved, and returned on surgical completion.
Replacement of tracheostomy tube with tracheal tube
may be performed using topical anesthesia and mini-
mal sedation/analgesia while patient’s spontaneously
respiration is maintained, and neuromuscular block-
ade (if needed) achieved after confirmation of proper
placement. Once the tracheostomy tube is replaced,
assessment for airway leakage may be completed
via auscultation over the lateral neck or suprasternal
notch. It may be safer to confirm proper position using
a flexible endoscope, particularly in short patients, as
the distance from tracheostomy stoma to carina dis-
tance may be shorter than the distance from the tip of a
tracheal tube to the proximal edge of the cuff.
If the tracheostomy was performed <7 days, it is
preferable to avoid exchanging it with a tracheal tube
because of the concerns of creating a false passage. If
an exchange to tracheal tube is necessary, it should be
performed over a soft tube exchanger, ideally, in the
presence of the surgeon familiar with tracheostomy.
A patient with an uncuffed tracheostomy tube
requiring sedation/analgesia for diagnostic or thera-
peutic procedures or general anesthesia may require
tracheal tube placement because of concerns of respi-
ratory depression from anesthetic and analgesic
drugs, which may require positive pressure ventila-
tion. An uncuffed tracheostomy tube may be left in
place for procedures that can be performed exclu-
sively with minimal or no sedation so the patients’
spontaneous ventilation is not impaired.
Management of Stoma Maintenance Devices
Patients presenting with a tracheostomy stoma main-
tenance device (eg, stoma stent and tracheostomy
button), the device should be removed and replaced
with a cuffed tracheostomy or tracheal tube. Of
note, patients who use a stoma stent are advised to
routinely remove the stent for cleaning and to mini-
mize granulation tissue formation. However, due to
underlying pathology or poor patient compliance,
granulation tissue may grow over or around the stent
preventing easy removal. In such a case, the patency
of the upper airway may be assessed by endoscopy.
Presence of significant granulation with tracheal nar-
rowing may require surgical consultation.25
Management of Patients With T-Tube
Patients with the T-tube can be particularly challeng-
ing, as the airway management is more complex than
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a standard tracheostomy. The difficulties of providing
positive pressure ventilation through T-tubes can be
attributed to: (1) the extratracheal (horizontal) limb
of the T-tube may not fit the 15-mm breathing circuit
connector, (2) positive pressure ventilation may be
ineffective due to leak through the proximal end of
the intraluminal (vertical) limb, and (3) oral tracheal
intubation may not be feasible because of the pres-
ence of airway disease (ie, tracheal stenosis) and the
presence of a small diameter T-tube. Depending on
the anatomic location and type of procedure, several
options have been described for the management of
patients with T-tube. The first option utilizes a T-tube
cap accessory to plug the external limb and placement
of a supraglottic device for airway management.26–28
A second option is the insertion of a small (4.5–5.0
ID) cuffed tracheal tube into the extratracheal limb of
the T-tube and a placement of a supraglottic device
with its shaft clamped to occlude the leak through the
upper airway (Figure 3). Positive pressure ventilation
is then provided through the tracheal tube.29 A similar
option is to identify a tracheal tube adaptor that fits
the external limb of the T-tube and use it to connect
the anesthesia circuit to the external limb directly. A
third option is the use of jet ventilation with a manual
injector through a rigid bronchoscope, whose tip is
positioned just above the proximal intraluminal end
of the T-tube.12 A fourth option is to position the tip of
a small tracheal tube just above the top of the T-tube
(not to pass it into its lumen) such that enough seal is
created between the tracheal tube cuff and the vocal
folds/subglottis to allow ventilation. Although some
have suggested passing oral tracheal tube through the
Figure 3. Airway management of patient with T-tube using a small
size cuffed tracheal tube connected to the extra-tracheal limb of
the T-tube and a supraglottic airway device (SGAD) with its shaft
clamped to occlude the leak through the upper airway. ETT indicates
endotracheal tube; SGAD, supraglottic airway device.
 Anesthesia in Patients With Tracheostomy

Figure 4. Algorithm for management of accidental tracheostomy decannulation during anesthesia.

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 E  Narrative Review Article
T-tube, such small tracheal tubes that are long enough
to pass beyond the glottis of an adult are difficult to
find. Of note, insertion and removal of the T-tube
requires special training and expertise, and thus
consultation with an otolaryngologist is warranted.
In case of emergency, the T-tube can be removed by
forcefully pulling the extraluminal limb anteriorly
so the entire tube is pulled out. Ventilation can then
be achieved by insertion of a small-size cuffed tra-
cheal tube through the stoma. However, removal of
the T-tube could result in collapse of the tracheal seg-
ment, so should only be done as a last resort.
EMERGENCE FROM SEDATION/ANESTHESIA OR
GENERAL ANESTHESIA
On emergence from sedation or general anesthesia,
the patients should receive the original device (ie,
cuffed or uncuffed tracheostomy tube or tracheos-
tomy stoma maintenance device). It is important to
remember that in patients with cuffed tracheostomy
tubes with speaking valves, the cuff must be deflated
before placing the speaking valve.
TRACHEOSTOMY EMERGENCIES
Tracheostomy-related complications include tube
obstruction or accidental dislodgment, which are
manifested by increased airway pressures and inef-
fective patient oxygenation and ventilation. The tra-
cheostomy tube can become blocked with secretions
or blood clots.30 Obstruction can also occur when the
distal orifice of the tracheostomy tube gets in con-
tact with the posterior tracheal wall14 (Supplemental
Digital Content, Figure 1, http://links.lww.com/
AA/D293) or the tube is misplaced in the pretracheal
location creating a false passage.
It is critical to avoid vigorous attempts at ventilation
via the tube, as excessive positive pressure can cause
significant pretracheal or mediastinal emphysema. In
this situation, repositioning or exchange of the trache-
ostomy tube may become extremely difficult.31–37
Assessment of airway patency by passing a suction
catheter through the tracheostomy is the first step.
The catheter should pass easily beyond the tip of the
tube.31,38,39 The forceful use of bougies or similar stiff
introducers should be avoided because of the higher
risk of creating a false route if the tracheal tube tip is
partially dislodged.14,40,41 Sometimes, deflation of the
cuff of the tracheostomy tube may resolve the obstruc-
tion. If not resolved, remove the inner tube and con-
firm patency. Finally, remove tracheostomy tube and
reinsert new tracheostomy or tracheal tube.
Figure 4 describes a suggested algorithm for man-
agement of accidental tracheostomy dislodgment/
extubation during anesthesia. Similar algorithms to
guide management of tracheostomy emergencies
have been published.14 It is important to realize that
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oxygenation takes priority over securing the airway
immediately and definitively. Also, it is necessary to
call for help and equipment early. Prepare for emer-
gency oxygenation through mask ventilation or
supraglottic device, and assessment of the upper air-
way and trachea, using fiberscope.
For a well-established mature tracheostomy, reinser-
tion of a smaller size tracheal tube should establish a
patent airway. However, for a recent tracheostomy with
immature stoma, oral intubation should be the preferred
approach, if the patient does not have laryngeal or proxi-
mal tracheal obstruction such as a tumor or stenosis. The
tube should be advanced beyond the tracheal stoma to
prevent a leak. If oral intubation is not feasible, inser-
tion of a small tracheal tube through the tracheostomy
stoma should be attempted with the help of a flexible
endoscope or a tube exchange catheter. Reinsertion of a
tracheal tube through an immature percutaneous trache-
ostomy, the morbidly obese, or in those with a short thick
neck can be challenging. In case of difficulty, depending
on patient’s anatomy, ventilation through a facemask or
tracheostomy stoma may be attempted. Tracheostomy
stoma ventilation has been described using a pediat-
ric facemask or a small-size classic laryngeal mask air-
way.42–45 In all cases, appropriate tube position should
be confirmed by flexible endoscopic inspection and an
otolaryngologist should be consulted for repositioning
the tracheostomy tube at the end of the case.
SUMMARY
Patients with tracheostomy may present for anesthetic
management for a variety of surgical and diagnostic
procedures. Airway management of these patients may
be challenging and need to be adequately planned. A
multidisciplinary approach involving anesthesiolo-
gists, surgeons, and nurses improves patient care and
safety. Understanding of the different tracheostomy
devices and their accessories is key to determine appro-
priate patient care. Because of its complexity, under-
standing management of the patient with a T-tube is
of paramount importance. Information regarding the
indication for tracheostomy, maturity status of the
stoma, and positioning of the patient during the pro-
cedure should be used to formulate an appropriate air-
way management plan. In addition, understanding the
causes and mechanisms of tracheostomy emergencies
that may arise can guide decision making to provide
effective rescue maneuvers. E
DISCLOSURES
Name: Eric B. Rosero, MD, MSc.
Contribution: This author helped with conception and design
of article, analysis and interpretation of articles used as refer-
ences, drafting of the manuscript, critical revision of the manu-
script for important intellectual content, final approval of the
version to be published, and agreement to be accountable for
all aspects of the work.
 Anesthesia in Patients With Tracheostomy
Name: John Corbett, PhD.
Contribution: This author helped with conception and design
of article, analysis and interpretation of articles used as refer-
ences, drafting of the manuscript, critical revision of the manu-
script for important intellectual content, final approval of the
version to be published, and agreement to be accountable for
all aspects of the work.
Name: Ted Mau, MD, PhD.
Contribution: This author helped with conception and design
of article, analysis and interpretation of articles used as refer-
ences, drafting of the manuscript, critical revision of the manu-
script for important intellectual content, final approval of the
version to be published, and agreement to be accountable for
all aspects of the work.
Name: Girish P. Joshi, MBBS, MD, FFARCSI.
Contribution: This author helped with conception and design
of article, analysis and interpretation of articles used as refer-
ences, drafting of the manuscript, critical revision of the manu-
script for important intellectual content, final approval of the
version to be published, and agreement to be accountable for
all aspects of the work.
This manuscript was handled by: Narasimhan Jagannathan,
MD, MBA.
REFERENCES
1. Cheung NH, Napolitano LM. Tracheostomy: epidemiology,
indications, timing, technique, and outcomes. Respir Care.
2014;59:895–915.
2. Mallick A, Bodenham A, Elliot S, Oram J. An investigation
into the length of standard tracheostomy tubes in critical
care patients. Anaesthesia. 2008;63:302–306.
3. Pang G, Edwards MJ, Greenland KB. Vocal cords-carina
distance in anaesthetised Caucasian adults and its clinical
implications for tracheal intubation. Anaesth Intensive Care.
2010;38:1029–1033.
4. Furlow PW, Mathisen DJ. Surgical anatomy of the trachea.
Ann Cardiothorac Surg. 2018;7:255–260.
5. Breatnach E, Abbott GC, Fraser RG. Dimensions of the nor-
mal human trachea. AJR Am J Roentgenol. 1984;142:903–906.
6. Epstein SK. Anatomy and physiology of tracheostomy.
Respir Care. 2005;50:476–482.
7. Morris LL, Whitmer A, McIntosh E. Tracheostomy care and
complications in the intensive care unit. Crit Care Nurse.
2013;33:18–30.
8. Gupta S, Zwaal JW. Radio-opaque stripes on tracheal and
tracheostomy tubes. Anaesthesia. 2000;55:819.
9. Trivedi M, Park G. Occlusion of a tracheostomy tube after
misinsertion. Anaesthesia. 2006;61:407–408.
10. Kunduk M, Appel K, Tunc M, et al. Preliminary report
of laryngeal phonation during mechanical ventilation
via a new cuffed tracheostomy tube. Respir Care. 2010;55:
1661–1670.
11. Selleng S, Antal M, Hansen T, Meissner K, Usichenko TI.
Pneumothorax and cardiac arrest caused by speaking valve
mistaken as moisture exchanger: an incident report. Br J
Anaesth. 2013;111:297–298.
12. Wahidi MM, Ernst A. The Montgomery T-tube tracheal
stent. Clin Chest Med. 2003;24:437–443.
13. Hu H, Zhang J, Wu F, Chen E. Application of the
Montgomery T-tube in subglottic tracheal benign stenosis. J
Thorac Dis. 2018;10:3070–3077.
14. McGrath BA, Bates L, Atkinson D, Moore JA; National
Tracheostomy Safety Project. Multidisciplinary guidelines
for the management of tracheostomy and laryngectomy air-
way emergencies. Anaesthesia. 2012;67:1025–1041.
15. McGrath BA, Wallace S, Lynch J, et al. Improving trache-
ostomy care in the United Kingdom: results of a guided
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quality improvement programme in 20 diverse hospitals.
Br J Anaesth. 2020;125:e119–e129.
16. Wurtz A, De Wolf J. Anterior Mediastinal tracheostomy:
past, present, and future. Thorac Surg Clin. 2018;28:277–
284.
17. Rajendram R, Khan M, Joseph A. Tracheostomy tube dis-
placement: an update on emergency airway management.
Indian J Respir Care. 2017;6:800–806.
18.
Ardekian L, Barak M, Rachmiel A. Subcutaneous
emphysema following emergent surgical conventional
tracheostomy. Craniomaxillofac Trauma Reconstr. 2014;7:290–
293.
19. Messerole E, Peine P, Wittkopp S, Marini JJ, Albert RK. The
pragmatics of prone positioning. Am J Respir Crit Care Med.
2002;165:1359–1363.
20. Abola RE, Tan J, Wallach D, Kier C, Seidman PA, Tobias
JD. Intraoperative airway obstruction related to trache-
ostomy tube malposition in a patient with achondro-
plasia and Jeune’s syndrome. Middle East J Anaesthesiol.
2010;20:735–738.
21. Oliveira VM, Weschenfelder ME, Deponti G, et al. Good
practices for prone positioning at the bedside: construc-
tion of a care protocol. Rev Assoc Med Bras (1992). 2016;62:
287–293.
22. Rosenblatt WH, Popescu WM. Master Techniques in Upper
and Lower Airway Management. Wolters Kluwer Health;
2015.
23. McRae K. Anesthesia for airway surgery. Anesthesiol Clin
North Am. 2001;19:497–541, vi.
24. Asai T, Mastumoto S, Shingu K. Use of a metal tracheos-
tomy tube for laser surgery to a subglottic stenosis. Eur J
Anaesthesiol. 2001;18:126.
25. Bhatia G, Abraham V, Louis L. Tracheal granulation as a
cause of unrecognized airway narrowing. J Anaesthesiol Clin
Pharmacol. 2012;28:235–238.
26. Park JS, Kwon YS, Lee S, Yon JH, Kim DW. Airway man-
agement using laryngeal mask airway in insertion of the
Montgomery tracheal tube for subglottic stenosis -a case
report-. Korean J Anesthesiol. 2010;59(suppl):S33–S36.
27. Mather CM, Sinclair R, Gurr P. Tracheal stents: the
Montgomery T-tube. Anesth Analg. 1993;77:1282–1284.
28. Guha A, Mostafa SM, Kendall JB. The Montgomery
T-tube: anaesthetic problems and solutions. Br J Anaesth.
2001;87:787–790.
29. Kerai S, Gupta R, Wadhawan S, Bhadoria P. Anesthetic
management of a patient with Montgomery t-tube in-
situ for direct laryngoscopy. J Anaesthesiol Clin Pharmacol.
2013;29:105–107.
30. Bodenham AR. Removal of obstructing blood clot from the
lower airway: an alternative suction technique. Anaesthesia.
2002;57:40–43.
31.
Young CS. Recommended guide lines for suction.
Physiotherapy. 1984;70:106–108.
32. Seay SJ, Gay SL. Problem in tracheostomy patient care: rec-
ognizing the patient with a displaced tracheostomy tube.
ORL Head Neck Nurs. 1997;15:10–11.
33. Cook TM, Woodall N, Frerk C; Fourth National Audit
Project. Major complications of airway management in the
UK: results of the Fourth National Audit Project of the Royal
College of Anaesthetists and the Difficult Airway Society.
Part 1: anaesthesia. Br J Anaesth. 2011;106:617–631.
34. van Heurn LW, Welten RJ, Brink PR. A complication of per-
cutaneous dilatational tracheostomy: mediastinal emphy-
sema. Anaesthesia. 1996;51:605.
35. Douglas WE, Flabouris A. Surgical emphysema follow-
ing percutaneous tracheostomy. Anaesth Intensive Care.
1999;27:69–72.
ANESTHESIA & ANALGESIA
 E  Narrative Review Article

36. Showmaker JA, Page MP. Life-threatening tension subcuta-
neous emphysema as a complication of open tracheostomy.
Otolaryngol Head Neck Surg. 2010;142:628–629.
37. Powell HRF, Hanna-Jumma S, Philpott JM, Higgins D. National
survey of fenestrated versus non-fenestrated tracheostomy
tube use and the incidence of surgical emphysema in UK adult
intensive care units. J Intensive Care Soc. 2011;12:25–28.
38. Glass CA, Grap MJ. Ten tips for safer suctioning. Am J Nurs.
1995;95:51–53.
39. Lomholt N. Design and function of tracheal suction cath-
eters. Acta Anaesthesiol Scand. 1982;26:1–3.
40. Lewis RJ. Tracheostomies. Indications, timing, and compli-
cations. Clin Chest Med. 1992;13:137–149.
41. Young CS. A review of the adverse effects of airway suction.
Physiotherapy. 1984;70:104–106, 108.
42. Sharma R. Mask for stoma ventilation: rescue using a
Rendell-Baker-Soucek mask after a dislodged tracheostomy
tube. Acta Anaesthesiol Scand. 2008;52:1305–1306.
43. Bhalla RK, Corrigan A, Roland NJ. Comparison of two face
masks used to deliver early ventilation to laryngectomized
patients. Ear Nose Throat J. 2004;83:414, 416.
44. Kannan S, Birch JP. Controlled ventilation through a trache-
ostomy stoma. Anaesth Intensive Care. 2001;29:557.
45. Padley A. Yet another use for the laryngeal mask airway–
ventilation of a patient with a tracheostomy stoma. Anaesth
Intensive Care. 2001;29:78.

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