Inclusion Criteria:  It includes tracheostomized adult patients (age > 16 years) from both sexes with tube in situ for more than 7 days.  Exclusion Criteria:  Patients will be excluded if they underwent an emergency tracheostomy tube change (i.e from dislodgement or obstruction), continue to require ongoing active machine ventilation, have an active lower respiratory tract infection or are immunosuppressed