Particularly during the Covid pandemic,we've found ourselves with large numbers of patients with refractory hypoxaemia,ventilated for sufficient time to warrant tracheostomy,and requiring long term respiratory support.

A good number of those had been sufficiently difficult to fit into our proning protocols,and in practice were treated exactly the same as patients with endotracheal tubes.

We always used closed suctioning systems to avoid airborne viral spread if possible,but found that many of the connections in such systems are not very secure,and easy to dislodge.

This was a significant issue.

Another issue worth considering is that the tubing and connections associated with tracheostomy tubes is shorter and less accessible than with an endotracheal tube,and this again should be borne in mind when proning.

Overall therefore,there is no contra-indication to proning a tracheostomised patient,but particular care is needed to ensure that no disconnections occur....that sounds a bit elementary but replacing a tube of any sort under those conditions is a bit fraught.

@Ian Ewart:- Thanks for valuable opinion .2nd wave of covid was more virulent,more morbidity and mortality . We put many patients on mechanical ventilator. Actually we delayed tracheostomy who were requiring prone ventilation for the same reason.... once they were stabilised and required no more prone ventilation,but prolonged ventilation underwent tracheostomy ... May be we need better equipments, tubes so that we can put trachesostamised patients for prone ventilation hussle free .... I hope we get them soon...

You can, however the issue becomes supporting the trach tube so that there is no kinking or it is under pressure

Tracheotomy tubes present a logistic difficulty when considering prone positioning, but there are several ways by which patients can be supported such that these tubes will have no direct contact with the bed or the supporting padding and would not be subjected to undue torsion.

@shalendra Singh:- thank u sir. We tried for one patient...faced difficulties, not satisfied... We will keep trying..

Answer is Yes. To put in prone for ventilation in tracheostomised patient is cumbersome. It require alteast 4 -5 medical staff, one trained Doctor ( Anaesthesiologist) required for Head in postion to secure airway 2 person for Trunk area abd one person for leg end . and proper padding of alk pressure point by Cushion or pillow to require to prevent pressure related problems like corneal abrasion , Retinopathy etc. It is particularly more difficult for obese patients get tracheostomised. It is particularly useful for ARDS patients and improve V/Q match. Suctioning can done by turning the head of patient to RT of Lt side

I and my colleges have great expierence pron ventilation patients during this COVID pandemic. As I think pron position for patients with tracheostomy are more comfortable than for intubated patients and safer We did not use pron position if patient has hemodinamic unstability with high dose of sympatomimetics.

Prone ventilation in tracheostomised patients is really difficult one task but adding catheter mount to tracheostomy then attached to Ventilator circuit ,doing so we can avoid undue traction over trachecheostomy tube and Prevent to getting erosion of stoma.

For prone ventilation of tracheostomy patients we usually sutures the tracheostomy tube properly. We place doughnut below the anterior neck for securing the tracheostomy tube.

Pateel Praveen ....we certainly delayed tracheostomy in some patients because we were proning them,and clearly did not think that submitting a patient to tracheostomy who was already on high FIO2 and PEEP would be a good risk/benefit ratio.

A lot of our second wave patients were sicker than our first wave patients,in part due to the greater use of NIV and CPAP on a ward based setting,prior to the sickest of those being admitted to ITU.

Alok Kumar Bharti ....your point re catheter mounts is a good one,and a method we did use,but the potential for disconnections also rises with the number of connections,and the security of some of the catheter mount connections we found was quite poor.

We ended up taping them for added security.

Dead space can also be an issue if the catheter mount is extended fully(if of the collapsible type),and CO2 clearance again was an issue with many of our patients.

Ok I am agree with You I Ewart but if don't add connector like C mount that will undue traction on tracheostomy connector and erosion of stoma ,bleeding or delay track of stoma formation

@Ian ewart: I agree with your point dilemma of submitting patient to tracheostomy who he on high fio2,PEEP and getting prone ventilation.....but we have given multiple prone ventilations each lasting 24 to 36 hours....means mechanical ventilation more than week to 10days,even more with prone ventilations.... They need tracheostomy .. I am talking about them....

Prone ventilation in a patient with a tracheostomy is possible but difficult. Need to use chest rolls and head supports to elevate the neck off the bed. This facilitates access to the tracheostomy.

However, many centres are delaying tracheostomy in patients with COVID-19 because of the many challenges associated with this.

Alok Kumar Bharti

Totally agree.....there are many connectors on the market,and it does come down to choosing the right one in terms of limiting dead space and also allowing sufficient flexibility to avoid the complications you mention.

Shortages during the first wave were a problem that thankfully seems to have receded.

Pateel Praveen

Again,I agree.....we also had a number of patients that we elected to ventilate prone on a number of occasions according to how their disease was progressing,and I think we are talking about the same groups of patients.

With respect to when to do a tracheostomy,obviously a lot will depends on local protocols,and into that we add concerns such as loss of recruitment etc etc.....it's often not an easy decision.

Prone ventilation in a patient with a tracheostomy is possible but difficult. erosion of stoma ,bleeding may happen. we should sutures the tracheostomy tube properly. and safer did not use prone position if patient has hemodynamic instability.

Prone ventilation in tracheostomised Patients is job of really dedicated Team work and Require too much Vigilancy . Do not hesitate to go for prone ventilation in tracheostomised Patients if meet the criteria .