# A nurse is caring for a patient who underwent a tracheostomy 4 days ago and is breathing room air through the cuffless tracheostomy tube. Which actions reflect safe nursing care of the tracheostomy? Select all that apply.

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> language: en  
> subject: System-Specific Assessments  
> category: ROR

## Question

A nurse is caring for a patient who underwent a tracheostomy 4 days ago and is breathing room air through the cuffless tracheostomy tube. Which actions reflect safe nursing care of the tracheostomy? Select all that apply.

1

Clean the reusable inner cannula every 8 hours or as needed using sterile technique to prevent secretion buildup and airway obstruction

2

Provide continuous humidification of inspired air to compensate for the bypassed nasal mucosa and prevent mucus plugging

3

Keep a replacement tracheostomy tube of the same size and one size smaller, an obturator, and a manual resuscitation bag with both face mask and tracheostomy adaptor at the bedside

4

Cut both old tracheostomy ties and remove them before applying new ties, without keeping the tube manually stabilized during the change

5

Suction using sterile technique, hyperoxygenating before each pass, limiting each pass to 10 to 15 seconds, and applying suction only on withdrawal

6

Apply continuous suction during both catheter insertion and withdrawal to optimize secretion removal while minimizing the number of passes

## Explanation

Clean the inner cannula according to the tracheostomy tube type and facility policy (Choice 1). Provide prescribed humidification because the upper airway is bypassed (Choice 2). Keep a same-size and one-size-smaller replacement tube, an obturator, and bag-mask ventilation equipment at the bedside (Choice 3). Use appropriate sterile or clean suction technique according to the care setting, preoxygenate when indicated, and limit each suction pass (Choice 5). Secure the new ties before removing the old ties to prevent accidental decannulation (Choice 4). Never connect continuous suction directly to the tracheostomy tube because it can cause severe mucosal injury and hypoxia (Choice 6).

## In-depth explanation

Memorize tracheostomy care around four anchors. (1) Humidification: bypassed nose means external humidification is essential — heated humidifier, HME, or aerosol; failure to humidify is the leading cause of obstructed tubes. (2) Suctioning safety: sterile, hyperoxygenate pre-suction, no more than 10-15 seconds per pass, suction only on withdrawal, no more than 3 passes per session, allow recovery between passes. (3) Tie change safety: two-person technique; new ties secured BEFORE old removed; one finger should fit between tie and neck (not too tight, not too loose); replace ties when soiled or wet. (4) Emergency tray at bedside (mandatory by Joint Commission for tracheostomy patients): SAME size + one size smaller replacement tubes, obturator (used for reinsertion of replacement tube), bag-valve-mask with tracheostomy adaptor, suction setup and catheters, sterile gloves, sterile NS, oxygen, hemostat. Inner cannula cleaning q8h or PRN. Cuff pressure 20-25 cm H2O if cuffed (minimal occlusive volume). Recognize partial obstruction (high-pitched sound, increased work of breathing, decreased SpO2) and decannulation (no airflow at trach, severe distress) as airway emergencies.

## Clinical scenario

Medical-surgical unit. Patient: 72-year-old man post-op day 4 from tracheostomy placement for prolonged mechanical ventilation that has been weaned. Cuffless Shiley size 6 tracheostomy tube in place. Patient is alert, breathing room air, with intermittent thick secretions that are easier to suction in the morning. Patient is scheduled for first elective tie change today.

## Key concepts

- **Tracheostomy Humidification** — External humidification of inspired gases is essential because the tracheostomy bypasses the natural humidification function of the nasopharynx; methods include heated humidifier, heat and moisture exchanger (HME), or aerosol; failure to humidify causes thick secretions, mucus plugging, and airway obstruction
- **Inner Cannula Care** — Reusable inner cannulas are removed and cleaned every 8 hours or as needed with sterile saline (and hydrogen peroxide per facility policy with sterile saline final rinse), then reinserted and locked; disposable inner cannulas are exchanged for new ones; this prevents secretion buildup that can cause life-threatening airway obstruction
- **Bedside Emergency Tray** — Joint Commission required equipment for the bedside of every tracheostomy patient: a replacement tracheostomy tube of the same size and one size smaller, the obturator, a manual resuscitation bag with both face mask and tracheostomy adaptor, suction setup with catheters, sterile gloves, sterile saline, oxygen source, and hemostat

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