Overview: Tracheostomy is a safe, effective procedure that can be performed via an open or percutaneous technique. Indications include relief of airway obstruction, secretion management, and secure access for prolonged mechanical ventilation. Indications for elective tracheostomy include: Prolonged ventilator dependence Prophylactic tracheostomy prior to head and neck cancer treatment Obstructive sleep apnea refractory to other treatments Chronic aspiration Neuromuscular disease Subglottic stenosis Brief of the case study: A critical patient underwent a stormy course in the intensive care unit. There were three failures of the Spontaneous breathing trial (SBT) in him. Treatment given: On day 11, the patient was tracheotomized as prolonged ventilator support was required. Discussion: Many times, there is an increase in the work of breathing due to edema around the vocal cords and edema in the airway. This can increase the resistance and thus the increase in the work of breathing after a tracheostomy. When flow through a tube is laminar as per Poisueilles equation, resistance is directly proportional to the length of the tube and inversely proportional to radius raised to the 4th power.1 When the flow is turbulent, the resistance becomes inversely proportional to the radius raised to the power of 5th power. The flow becomes turbulent when the inner diameter of the tube is <10 mm. Due to the high flow through the ET tube, curvature, and the presence of secretions, the flow is generally turbulent. Tracheostomy tubes are smaller, more rigid, easier to be kept clean. This reduces expiratory flow limitation, dynamic hyperinflation, auto-PEEP, and the work of breathing. Reference: Raimonde AJ, Westhoven N, Winters R. Tracheostomy. [Updated 2021 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559124/   244

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