A 49-year-old woman was intubated for acute hypoxemic respiratory failure secondary to pneumonia, which was complicated by empyema. She failed extubation and ultimately required tracheostomy for prolonged mechanical ventilation. After transfer to the intermediate care unit, she was successfully weaned from the ventilator for over 24 hours. She tolerated prolonged deflation of her tracheostomy cuff and swallowed water without aspiration. She underwent a tracheostomy tube occlusion test and there was no obstruction to air flow with a size 7 fenestrated tracheostomy tube in place. She is requiring suctioning once every 12 hours. You are assessing her readiness for tracheostomy decannulation and are considering the utility of a capping trial.    

A 56 yo male with a hx of TBI, subglottic stenosis, tracheomalacia, and tracheal stenosis presents in acute respiratory distress. There is a strange looking trach in place with no balloon for a cuff. You begin to wonder how you will manage this pt if he ultimately requires mechanical ventilation.....

A 44-year-old man with a history of cardiac arrest complicated by hypoxic-ischemic encephalopathy presents to the ED in respiratory distress. He underwent tracheostomy 2 weeks ago for acute respiratory failure and was subsequently weaned to trach collar. He developed acute onset of respiratory distress at rehab this morning and now presents to the ED with acute hypoxic respiratory failure. On exam, he is hypertensive (169/88), tachycardic (HR 178), tachypneic with respirations assisted with bag-valve mask (BVM) ventilation and hypoxemic (SpO2 87%). What is your approach to the management of tracheostomy emergencies?