Background: After tracheal puncture and guide wire insertion, tissues and anterior tracheal wall are dilated using either up to seven progressively larger dilators (basic technique), a curved, hydrophilic-coated single-step dilator (Blue Rhino), or a fluid-filled high-pressure balloon (Blue Dolphin). The procedure concludes with the insertion of a tracheal cannula. Regardless of the technique chosen, continuous bronchoscopic surveillance of the entire procedure is strongly recommended. Ciaglia Blue Rhino kit (Cook Critical Care Inc, Bloomington, IN): 14-gauge catheter introducer needle and syringe, guide wire (J-tipped Seldinger wire type), guiding catheter, introducer dilator, loading dilators, single tapering Blue Rhino dilator, Shiley size 8 double-cannula tracheotomy tube with curved obturator; fiberoptic bronchoscope