Patients with a tracheostomy and concomitant respiratory failure either due to massive hemoptysis or central airway obstruction is a very challenging clinical scenario.  This talk will provide a construct for the systematic evaluation of a patient with a tracheostomy and respiratory failure.  In addition the talk will focus on a clinical construct and systematic process of stabilization, resuscitation and management/safe disposition of these patients when there are other clinical considerations such as massive hemoptysis and/or central airway obstruction from mucous plugging or indwelling airway stents.