A blocked tube: clear the obstruction first
Three days after a tracheostomy, this client suddenly becomes restless, his oxygen saturation falls from the mid-90s to 84%, little air moves through the tube, and the suction catheter cannot pass beyond a few centimeters. The tube is in place and the ties are secure, so dislodgement is unlikely. These findings point to a mucus plug blocking the tube, and removing the inner cannula and inserting a clean one clears the obstruction at once. The plug often comes out inside the cannula, and airflow returns immediately if the blockage was in the inner lumen.
Why the inner cannula comes first
A tracheostomy tube with a removable inner cannula is designed for this situation. Secretions dry and collect on the inner surface, especially when humidification is inadequate, and a plug can form suddenly. Changing the inner cannula is fast, needs no special order, and addresses the most likely cause without disturbing the outer tube in a fresh stoma. The nurse calls for help while staying with the client, because leaving a client with an obstructed airway is never safe.
Why the other actions are wrong as the first step
Manual ventilation with a bag cannot move air through a plugged tube; the obstruction has to be cleared first, and forceful bagging against a blockage can cause barotrauma. Deflating the cuff is a later step used when changing the inner cannula does not restore airflow, because it lets the client breathe around the tube through the upper airway. Increasing oxygen to 60% does not help when oxygen cannot pass the blockage. Instilling 5 mL of normal saline is not recommended as routine practice; it does not dissolve a plug, it can push secretions deeper, and it is associated with desaturation and infection.
| Step | Action | Purpose |
|---|
| 1 | Remove the inner cannula and insert a clean one | Clears a plug in the inner lumen |
| 2 | Attempt suction again | Confirms the lumen is open |
| 3 | Deflate the cuff if airflow does not return | Allows breathing around the tube |
| 4 | Follow the emergency plan for a blocked tube | Tube change or oral airway management by the team |
Watch out! Prevention matters as much as rescue. Humidified oxygen, adequate fluid intake, regular inner cannula care, and suctioning based on assessment reduce the risk of plugging. Emergency equipment, including a spare tube and an obturator, should be at the bedside.
Exam takeaway
Key point! In a tracheostomy client with sudden distress, poor air movement, and a suction catheter that will not pass, think obstruction. Remove the inner cannula first; it is the fastest way to relieve a plug in the tube. Call for help without leaving the client.