Nursing Reflective Essay: Tracheostomy and Pressure Care
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This nursing reflective essay analyzes a critical incident where a patient's tracheostomy tube dislodged during pressure area care. The essay, structured around Gibbs' Reflective Cycle, describes the incident, the student's feelings, and an evaluation of the experience. It explores the application of specialty knowledge related to tracheostomy and pressure ulcer care, supported by evidence-based practice and NMBA standards. The analysis highlights the student's lack of preparedness and the need for improved emergency response skills. The essay concludes with a reflection on learning, emphasizing the importance of multidisciplinary teamwork and the need for enhanced training in tracheostomy care for all nursing staff to improve patient outcomes and safety. Recommendations include having a specialist nurse present during critical procedures and the implementation of an airway nurse to address respiratory distress.
Nursing Reflective Essay 1
NURSING REFLECTIVE ESSAY
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Professor
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Date
NURSING REFLECTIVE ESSAY
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Professor
Name of the School
Date
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Nursing Reflective Essay 2
Introduction
The main purpose of this essay will be to reflect on a critical incident which occurred
during my work placement by analyzing my actions, reactions and feelings during and after the
incident. The essay will cover key concepts related to tracheostomy and pressure area care.
Reflective practice in nursing involves deliberately analyzing one’s actions and thoughts as part
of the process of learning, critical thinking, documentation and coping with critical incidents
(New Zealand Nurses Organization 2015, p.1). The model that will be used for my reflection is
Gibbs Reflective Cycle which involves a description of the critical incident, what my feelings
were, an evaluation of what was good and bad about the experience, an analysis of the incident
and an action plan (2015, p.6). I will also discuss specialty knowledge, evidence-based practice
and reflection under NMBA guidelines for standards of practice as well as reflect on what I
learned to guide my future clinical practice.
Application of Specialty Knowledge to Practice
Pressure ulcers are injuries that occur when there is a breakdown of skin over a period of
time caused by continuous pressure on certain areas of the body. This constant pressure leads to
ischemia of the underlying tissue because of lack of oxygen and blood to the area (Bhattacharya
& Mishra 2015). Pressure sores usually develop in patients who are immobile and suffer from
health conditions that require them to be confined to a bed or chair for extended periods of time
(Cooper 2013). Pressure area care involves activities that are aimed at treating ulcers when they
develop such as assessing the wound, removing necrotic tissue, cleaning and dressing the sore,
relieving any pressure exerted on the wound (Osuala 2014).
Introduction
The main purpose of this essay will be to reflect on a critical incident which occurred
during my work placement by analyzing my actions, reactions and feelings during and after the
incident. The essay will cover key concepts related to tracheostomy and pressure area care.
Reflective practice in nursing involves deliberately analyzing one’s actions and thoughts as part
of the process of learning, critical thinking, documentation and coping with critical incidents
(New Zealand Nurses Organization 2015, p.1). The model that will be used for my reflection is
Gibbs Reflective Cycle which involves a description of the critical incident, what my feelings
were, an evaluation of what was good and bad about the experience, an analysis of the incident
and an action plan (2015, p.6). I will also discuss specialty knowledge, evidence-based practice
and reflection under NMBA guidelines for standards of practice as well as reflect on what I
learned to guide my future clinical practice.
Application of Specialty Knowledge to Practice
Pressure ulcers are injuries that occur when there is a breakdown of skin over a period of
time caused by continuous pressure on certain areas of the body. This constant pressure leads to
ischemia of the underlying tissue because of lack of oxygen and blood to the area (Bhattacharya
& Mishra 2015). Pressure sores usually develop in patients who are immobile and suffer from
health conditions that require them to be confined to a bed or chair for extended periods of time
(Cooper 2013). Pressure area care involves activities that are aimed at treating ulcers when they
develop such as assessing the wound, removing necrotic tissue, cleaning and dressing the sore,
relieving any pressure exerted on the wound (Osuala 2014).
Nursing Reflective Essay 3
Tracheostomy tubes are used to treat airway obstructions, manage secretions and treat
patients who have chronic respiratory failure or sleep apnea that is severe and obstructive
(Sebastian et al. 2015). The management of tracheostomies is a good example of
multidisciplinary care within the healthcare system. Many medical, nursing and allied health
staff such as pathologists, specialist nurses, neck surgeons and respiratory therapists are needed
to provide effective care to tracheostomy patients (Bonvento et al. 2017).
The job duties of a tracheotomy specialist nurse include suctioning of the tubes, stoma
care, checking if the cuff tubes have pressure, maintaining the patient’s airway patency,
responding to and managing tracheostomy emergencies, changing tracheostomies of hospitalized
and community patients, weaning and decannulation procedures, educating the patient and their
family about tracheostomy care and selecting the right tracheostomy tubes. These nurses work in
conjunction with other nursing staff in the unit to care for tracheostomy patients (Agency for
Clinical Innovation 2013, p.6).
Analysis of Actions, Reactions and Feelings in Context of Professional Practice
The first step in Gibbs model is a description of what happened (2015, p.6). The critical
incident that occurred is that my patient’s tracheostomy tube fell out as I was performing
pressure area care. The patient immediately went into respiratory distress by struggling for
breath. The ward person initiated oxygen therapy via nasal cannula to address this while pressing
the emergency button to alert the nurses at the station. She next placed a trachemask that was
next to the bed over the stoma to maintain its patency. Because the tracheostoma was less than a
week old, there was a mad rush to insert a new tube before the stoma collapsed. After this
Tracheostomy tubes are used to treat airway obstructions, manage secretions and treat
patients who have chronic respiratory failure or sleep apnea that is severe and obstructive
(Sebastian et al. 2015). The management of tracheostomies is a good example of
multidisciplinary care within the healthcare system. Many medical, nursing and allied health
staff such as pathologists, specialist nurses, neck surgeons and respiratory therapists are needed
to provide effective care to tracheostomy patients (Bonvento et al. 2017).
The job duties of a tracheotomy specialist nurse include suctioning of the tubes, stoma
care, checking if the cuff tubes have pressure, maintaining the patient’s airway patency,
responding to and managing tracheostomy emergencies, changing tracheostomies of hospitalized
and community patients, weaning and decannulation procedures, educating the patient and their
family about tracheostomy care and selecting the right tracheostomy tubes. These nurses work in
conjunction with other nursing staff in the unit to care for tracheostomy patients (Agency for
Clinical Innovation 2013, p.6).
Analysis of Actions, Reactions and Feelings in Context of Professional Practice
The first step in Gibbs model is a description of what happened (2015, p.6). The critical
incident that occurred is that my patient’s tracheostomy tube fell out as I was performing
pressure area care. The patient immediately went into respiratory distress by struggling for
breath. The ward person initiated oxygen therapy via nasal cannula to address this while pressing
the emergency button to alert the nurses at the station. She next placed a trachemask that was
next to the bed over the stoma to maintain its patency. Because the tracheostoma was less than a
week old, there was a mad rush to insert a new tube before the stoma collapsed. After this
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incident, the unit had a meeting and a new policy was introduced which required that an airway
nurse be present when pressure area care is being performed for patients who are intubated.
In the stage of feelings, I was scared stiff because despite learning about tube
dislodgements, I never expected one to come off when performing care. I was scared because I
caused the dislodgement and I had put my patient’s life at risk by failing to exercise caution.
What was good about the experience is that the wards person was able to act efficiently to
maintain the integrity of the stoma and save the patient. The multidisciplinary team overseeing
my patient’s tracheostomy was able to pull together quickly to reinsert the tube and also prevent
the patient from going into respiratory arrest. What was bad is that I observed everything in a
state of shock and I was unable to continue taking care of the patient until an incident report was
filled and a meeting was called within the unit to discuss what happened.
My analysis of the situation was that I was ill prepared and uncomfortable in handling
tube dislodgements. A study done by Pritchett, Rietz and Ray (2016) to assess the role of nurses
in managing pediatric tracheostomies in emergencies showed that nurses who had experience
working in ICU settings were more comfortable in handling accidental decannulations in
tracheostomies that were either new or mature. Because they managed emergency health issues
on a more frequent basis, they had a higher comfort level with complex medical conditions.
Nurses with experience of less than five years were more uncomfortable with tracheostomy
management and accidental decannulations (Pritchett, Rietz & Ray 2016). I should have been
more prepared before performing pressure care by reading up on tracheostomy care and how to
handle emergencies. In the future, part of my action plan will be to be conversant with
tracheostomy care and how to respond to such emergencies quickly.
incident, the unit had a meeting and a new policy was introduced which required that an airway
nurse be present when pressure area care is being performed for patients who are intubated.
In the stage of feelings, I was scared stiff because despite learning about tube
dislodgements, I never expected one to come off when performing care. I was scared because I
caused the dislodgement and I had put my patient’s life at risk by failing to exercise caution.
What was good about the experience is that the wards person was able to act efficiently to
maintain the integrity of the stoma and save the patient. The multidisciplinary team overseeing
my patient’s tracheostomy was able to pull together quickly to reinsert the tube and also prevent
the patient from going into respiratory arrest. What was bad is that I observed everything in a
state of shock and I was unable to continue taking care of the patient until an incident report was
filled and a meeting was called within the unit to discuss what happened.
My analysis of the situation was that I was ill prepared and uncomfortable in handling
tube dislodgements. A study done by Pritchett, Rietz and Ray (2016) to assess the role of nurses
in managing pediatric tracheostomies in emergencies showed that nurses who had experience
working in ICU settings were more comfortable in handling accidental decannulations in
tracheostomies that were either new or mature. Because they managed emergency health issues
on a more frequent basis, they had a higher comfort level with complex medical conditions.
Nurses with experience of less than five years were more uncomfortable with tracheostomy
management and accidental decannulations (Pritchett, Rietz & Ray 2016). I should have been
more prepared before performing pressure care by reading up on tracheostomy care and how to
handle emergencies. In the future, part of my action plan will be to be conversant with
tracheostomy care and how to respond to such emergencies quickly.
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Evidence-Based Practice and Professional Standards in Reflection Process
One of the major complications of tracheotomies is tube dislodgements which
inadvertently lead to a loss of airway. Tube dislodgements can be caused by accidental
displacement when performing nursing care, turning the patient (Sebastian et al. 2015), the
presence of edema in the patient’s neck and airway, forceful and excessive coughing and a tube
that is too short for the respiratory tract (Morris, Whitmer & McIntosh 2013). If a tube becomes
dislodged, the tracheostoma can collapse quickly especially if the healing time has been under
one week. It therefore becomes an emergency and all healthcare professionals are required to act
promptly to ensure the stoma does not collapse (Sebastian et al. 2015).
Under the NMBA standards of practice for 2016 (NMBA 2017), standard three requires
all nurses to maintain their scope of practice by being accountable for their actions, behaviors
and decisions. I took accountability for what happened and explained this during the incident
report meeting with the unit manager. My actions during the emergency incident were below
standard but I attributed this to my lack of confidence and knowledge with managing
tracheostomies. According to Rajendram, Khan and Joseph (2017), anyone who takes care of a
tracheostomy patient should have clinical knowledge of tube dislodgements or displacements
and respond to them immediately.
Practice standard six of the NMBA requires nurses to provide safe, appropriate and
responsive care to their patients. The nurse should ensure that they are providing safe and quality
care, are practicing within their scope and are using the appropriate protocols to report potential
and actual health risks to the relevant authorities (NMBA 2017). I understood that part of my
duties when taking care of this patient was to provide safe and competent care while taking care
Evidence-Based Practice and Professional Standards in Reflection Process
One of the major complications of tracheotomies is tube dislodgements which
inadvertently lead to a loss of airway. Tube dislodgements can be caused by accidental
displacement when performing nursing care, turning the patient (Sebastian et al. 2015), the
presence of edema in the patient’s neck and airway, forceful and excessive coughing and a tube
that is too short for the respiratory tract (Morris, Whitmer & McIntosh 2013). If a tube becomes
dislodged, the tracheostoma can collapse quickly especially if the healing time has been under
one week. It therefore becomes an emergency and all healthcare professionals are required to act
promptly to ensure the stoma does not collapse (Sebastian et al. 2015).
Under the NMBA standards of practice for 2016 (NMBA 2017), standard three requires
all nurses to maintain their scope of practice by being accountable for their actions, behaviors
and decisions. I took accountability for what happened and explained this during the incident
report meeting with the unit manager. My actions during the emergency incident were below
standard but I attributed this to my lack of confidence and knowledge with managing
tracheostomies. According to Rajendram, Khan and Joseph (2017), anyone who takes care of a
tracheostomy patient should have clinical knowledge of tube dislodgements or displacements
and respond to them immediately.
Practice standard six of the NMBA requires nurses to provide safe, appropriate and
responsive care to their patients. The nurse should ensure that they are providing safe and quality
care, are practicing within their scope and are using the appropriate protocols to report potential
and actual health risks to the relevant authorities (NMBA 2017). I understood that part of my
duties when taking care of this patient was to provide safe and competent care while taking care
Nursing Reflective Essay 6
of their tracheostomy but I failed in this regard when the tube fell off. Displaced tracheostomy
tubes are a life-threatening emergency and a delay of a few seconds could lead to death. Staff
have to communicate efficiently and clearly during such emergency situations to ensure the
proper execution of life saving procedures (Rajendram, Khan and Joseph 2017).
Reflection on Learning to Guide Clinical Practice and Improve Patient Outcomes
What I learned from the critical incident is that I need to improve my response to
emergency situations as part of my scope of practice. Being effective reduces the rate of
mortalities and it improves the reaction time of the multidisciplinary team in the unit. The
experience also identified a learning gap in my knowledge of handling emergency dislodgements
and displacements. I believe this training is important for all nursing staff without having to
specialize in tracheostomy care. The numbers of specialist nurses trained in this field are few and
the majority of staff who take care of such patients are general nurses. Research evidence has
shown that specialist nurses who offer support in caring for the tracheostomy patient have
reduced the incidence of complications that arise with these patients and have reduced cases of
readmissions especially to the ICU (Bonvento et al. 2017).
Tracheostomy care is a high risk-low incidence skill which means that nursing staff
without specialty training take care of patients with tracheostomy tubes on an infrequent basis.
The incidence of patients with tracheotomies especially in general wards is low which is why
many nurses may lack the skills to provide effective care to these patients (Paul 2010, p.78).
Nurses who practice in different specialties should have the knowledge and skills to perform all
aspects of tracheostomy care such as resuscitation in the event of respiratory arrest, cleaning the
stoma, suctioning and maintenance of the equipment (Paul 2010, p.78).
of their tracheostomy but I failed in this regard when the tube fell off. Displaced tracheostomy
tubes are a life-threatening emergency and a delay of a few seconds could lead to death. Staff
have to communicate efficiently and clearly during such emergency situations to ensure the
proper execution of life saving procedures (Rajendram, Khan and Joseph 2017).
Reflection on Learning to Guide Clinical Practice and Improve Patient Outcomes
What I learned from the critical incident is that I need to improve my response to
emergency situations as part of my scope of practice. Being effective reduces the rate of
mortalities and it improves the reaction time of the multidisciplinary team in the unit. The
experience also identified a learning gap in my knowledge of handling emergency dislodgements
and displacements. I believe this training is important for all nursing staff without having to
specialize in tracheostomy care. The numbers of specialist nurses trained in this field are few and
the majority of staff who take care of such patients are general nurses. Research evidence has
shown that specialist nurses who offer support in caring for the tracheostomy patient have
reduced the incidence of complications that arise with these patients and have reduced cases of
readmissions especially to the ICU (Bonvento et al. 2017).
Tracheostomy care is a high risk-low incidence skill which means that nursing staff
without specialty training take care of patients with tracheostomy tubes on an infrequent basis.
The incidence of patients with tracheotomies especially in general wards is low which is why
many nurses may lack the skills to provide effective care to these patients (Paul 2010, p.78).
Nurses who practice in different specialties should have the knowledge and skills to perform all
aspects of tracheostomy care such as resuscitation in the event of respiratory arrest, cleaning the
stoma, suctioning and maintenance of the equipment (Paul 2010, p.78).
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Conclusion
An analysis of the situation and existing literature has shown that not many nurses,
myself included, have the skills to deal with a tracheostomy dislodgement. This is a medical
emergency that needs an effective response from all healthcare personnel. A future
recommendation is to have a specialist nurse trained in tracheotomies to be present when an
untrained nurse is performing pressure area care so that they can react quickly in case of an
emergency. The recommendation that my unit made of having an airway nurse present is also
good as they can react immediately the patient has respiratory distress.
Conclusion
An analysis of the situation and existing literature has shown that not many nurses,
myself included, have the skills to deal with a tracheostomy dislodgement. This is a medical
emergency that needs an effective response from all healthcare personnel. A future
recommendation is to have a specialist nurse trained in tracheotomies to be present when an
untrained nurse is performing pressure area care so that they can react quickly in case of an
emergency. The recommendation that my unit made of having an airway nurse present is also
good as they can react immediately the patient has respiratory distress.
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References
Agency for Clinical Innovation 2013, Care of adult patients in acute care facilities with a
tracheostomy: clinical practice guideline, viewed 16 November 2018,
<https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0005/181454/
ACI_Tracheostomy_CPG.pdf>.
Bhattacharya, S & Mishra, RK 2015, ‘Pressure ulcers: current understanding and newer
modalities of treatment’, Indian Journal of Plastic Surgery, vol. 48, no.1, pp.4-16,
viewed 16 November 2018,
<https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4413488/>.
Bonvento, B, Wallace, S, Lynch, J, Coe, B & McGrath, BA 2017, ‘Role of the multidisciplinary
team in the care of the tracheostomy patient,’ Journal of Multidisciplinary Healthcare,
vol.10, pp. 391-398, viewed 17 November 2018,
<https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5644554/#b68-jmdh-10-391>.
Cooper, KL 2013, ‘Evidence-based prevention of pressure ulcers in the intensive care unit,’
Critical Care Nurse, vol. 33, no. 6, pp.57-66, viewed 16 November 2018,
<http://ccn.aacnjournals.org/content/33/6/57.full>.
Morris, LL, Whitmer, A & McIntosh, E 2013, ‘Tracheostomy care and complications in the
intensive care unit,’ Critical Care Nurse, vol. 33, no. 5, pp. 18-30, viewed 16 November
2018, <http://ccn.aacnjournals.org/content/33/5/18.full>.
Nursing and Midwifery Board of Australia (NMBA) 2017, Registered nurse standards for
practice, NMBA, 1 February 2017, viewed 16 November 2018,
References
Agency for Clinical Innovation 2013, Care of adult patients in acute care facilities with a
tracheostomy: clinical practice guideline, viewed 16 November 2018,
<https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0005/181454/
ACI_Tracheostomy_CPG.pdf>.
Bhattacharya, S & Mishra, RK 2015, ‘Pressure ulcers: current understanding and newer
modalities of treatment’, Indian Journal of Plastic Surgery, vol. 48, no.1, pp.4-16,
viewed 16 November 2018,
<https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4413488/>.
Bonvento, B, Wallace, S, Lynch, J, Coe, B & McGrath, BA 2017, ‘Role of the multidisciplinary
team in the care of the tracheostomy patient,’ Journal of Multidisciplinary Healthcare,
vol.10, pp. 391-398, viewed 17 November 2018,
<https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5644554/#b68-jmdh-10-391>.
Cooper, KL 2013, ‘Evidence-based prevention of pressure ulcers in the intensive care unit,’
Critical Care Nurse, vol. 33, no. 6, pp.57-66, viewed 16 November 2018,
<http://ccn.aacnjournals.org/content/33/6/57.full>.
Morris, LL, Whitmer, A & McIntosh, E 2013, ‘Tracheostomy care and complications in the
intensive care unit,’ Critical Care Nurse, vol. 33, no. 5, pp. 18-30, viewed 16 November
2018, <http://ccn.aacnjournals.org/content/33/5/18.full>.
Nursing and Midwifery Board of Australia (NMBA) 2017, Registered nurse standards for
practice, NMBA, 1 February 2017, viewed 16 November 2018,
Nursing Reflective Essay 9
<https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-
standards/registered-nurse-standards-for-practice.aspx>.
New Zealand Nurses Organization (NZNO) 2015, Reflective writing. NZNO Education and
Professional Development Guideline, viewed 19 November 2018,
<https://www.nzno.org.nz/LinkClick.aspx?fileticket=3oTgEOEbXws%3D&portalid=0>.
Osuala, EO 2014, ‘Innovation in prevention and treatment of pressure ulcer: nursing
implication,’ Tropical Journal of Medical Research, vol. 17, no. 2, pp. 61-68, viewed 16
November 2018, <http://www.tjmrjournal.org/article.asp?issn=1119-
0388;year=2014;volume=17;issue=2;spage=61;epage=68;aulast=Osuala>.
Paul, F 2010, ‘Tracheostomy care and management in general wards and community settings:
literature review,’ Nursing in Critical Care, vol. 15, no.2, pp. 76-85, viewed 17
November 2018,
<https://pdfs.semanticscholar.org/6b94/b25f5c1bc2e88dc3249851ab4f370a883e74.pdf>.
Pritchett, CV, Rietz, MF & Ray, A 2016, ‘Inpatient nursing and parental comfort in managing
pediatric tracheostomy care and emergencies,’ JAMA Otolaryngology Head and Neck
Surgery, vol. 142, no. 2, pp. 132-137, viewed 17 November 2018,
<https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2478313>.
Rajendram, R, Khan, MF & Joseph, A 2017, ‘Tracheostomy tube displacement: an update on
emergency airway management,’ Indian Journal of Respiratory Care, vol. 6, no. 2, pp.
800-806, viewed 16 November 2018, <http://www.ijrconline.org/article.asp?issn=2277-
9019;year=2017;volume=6;issue=2;spage=800;epage=806;aulast=Rajendram>.
<https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-
standards/registered-nurse-standards-for-practice.aspx>.
New Zealand Nurses Organization (NZNO) 2015, Reflective writing. NZNO Education and
Professional Development Guideline, viewed 19 November 2018,
<https://www.nzno.org.nz/LinkClick.aspx?fileticket=3oTgEOEbXws%3D&portalid=0>.
Osuala, EO 2014, ‘Innovation in prevention and treatment of pressure ulcer: nursing
implication,’ Tropical Journal of Medical Research, vol. 17, no. 2, pp. 61-68, viewed 16
November 2018, <http://www.tjmrjournal.org/article.asp?issn=1119-
0388;year=2014;volume=17;issue=2;spage=61;epage=68;aulast=Osuala>.
Paul, F 2010, ‘Tracheostomy care and management in general wards and community settings:
literature review,’ Nursing in Critical Care, vol. 15, no.2, pp. 76-85, viewed 17
November 2018,
<https://pdfs.semanticscholar.org/6b94/b25f5c1bc2e88dc3249851ab4f370a883e74.pdf>.
Pritchett, CV, Rietz, MF & Ray, A 2016, ‘Inpatient nursing and parental comfort in managing
pediatric tracheostomy care and emergencies,’ JAMA Otolaryngology Head and Neck
Surgery, vol. 142, no. 2, pp. 132-137, viewed 17 November 2018,
<https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2478313>.
Rajendram, R, Khan, MF & Joseph, A 2017, ‘Tracheostomy tube displacement: an update on
emergency airway management,’ Indian Journal of Respiratory Care, vol. 6, no. 2, pp.
800-806, viewed 16 November 2018, <http://www.ijrconline.org/article.asp?issn=2277-
9019;year=2017;volume=6;issue=2;spage=800;epage=806;aulast=Rajendram>.
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Sebastian, FB, Mahajan, B, Folch, E, Caviedes, I, Guerrero, J, & Majid, A 2015, ‘Tracheostomy
tube placement: early and late complications,’ Journal of Bronchology and Interventional
Pulmonology, vol. 22, no. 4, pp.357-364, viewed 16 November 2018,
<https://journals.lww.com/bronchology/Fulltext/2015/10000/Tracheostomy_Tube_Place
ment__Early_and_Late.19.aspx. [16 November 2018>.
Sebastian, FB, Mahajan, B, Folch, E, Caviedes, I, Guerrero, J, & Majid, A 2015, ‘Tracheostomy
tube placement: early and late complications,’ Journal of Bronchology and Interventional
Pulmonology, vol. 22, no. 4, pp.357-364, viewed 16 November 2018,
<https://journals.lww.com/bronchology/Fulltext/2015/10000/Tracheostomy_Tube_Place
ment__Early_and_Late.19.aspx. [16 November 2018>.
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