might indicate an intratracheal granuloma, which should be evaluated by direct visualization, typically performed by an otorhinolaryngologist A large amount of bleeding is a surgical emergency IV access should be obtained immediately and volume replacement should be initiated The tracheostomy tube should not be removed because it may be the best way to ensure an airway Frequent suctioning aids in preventing aspiration If the site of bleeding can be identified, direct pressure should be applied to the area Overinflating the cuff may tamponade a bleeding vessel and provide a temporary treatment until it can be ligated Peristomal granulomas can usually be treated with topical antibiotics In refractory cases, cauterization with silver nitrate is indicated Home Ventilators Some patients with tracheostomies will require home mechanical ventilation Caregivers may come in to the ED because the ventilator is alarming at home or the patient is requiring higher levels of support or oxygen Understanding the basics of home ventilators is useful in the workup and management of complications The low pressure alarm on the ventilator will sound if two consecutive breaths not reach the pressure limit; this is usually caused by a leak or disconnect The physician should start at the patient and work toward the ventilator, checking for loose connections Finally, the tracheostomy cuff should be evaluated for leaks and the low pressure alarm should be confirmed to be set at the correct setting The high pressure alarm on the ventilator will sound when the pressure in the circuit has increased This can be caused by frequent coughing, tracheostomy tube obstruction, kinks in the tubing, and water in the circuit Because tracheostomy tube obstruction is so common, the tube should be changed or suctioned and the inner cannula of the tracheostomy tube changed as needed Increased oxygen or ventilator requirements suggest an infectious process and appropriate testing should be obtained, including a chest radiograph and tracheal secretion Gram stain and cultures Hospital admission is often indicated for more aggressive treatment If a patient with a tracheostomy tube and home ventilator is stable to be discharged from the ED, it must be confirmed with the caregivers that they have adequate battery life and oxygen for the drive home CEREBROSPINAL FLUID SHUNTS Background