This balloon is heavily hyper inflated. Diameter is larger than the trachea itself. Be suspicious and look from above!
#Tracheostomy management is just as important as the insertion itself. Here’s a previously poorly fit apparatus. Balloon at 96cmH20 on arrival. Here is about a 3-4 cm posterior membrane tracheal defect at level of previous balloon. 
A Shiley Distal XLT 6 was picked here. Trachea was larger and needed a bigger size. Extra length made it challenging to bypass the defect. A Bivona Aire hyper flex gave us the length but almost mainsteming. The balloon was just not occlusive. Our go to for these are Fome Cuffs.
How else would you have handled? @AAB_IP @udit_chaddha @emily_fri @IPScottOh @gbosslet @seeweilow @EnamJosan
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