# Situation: A 55-year-old man is on the surgical ward 3 days after a tracheostomy was created for prolonged mechanical ventilation. He now breathes on his own through a cuffed tracheostomy tube with a removable inner cannula and receives humidified oxygen at 35% by tracheostomy collar. His oxygen saturation by pulse oximetry has been 95% to 97%. The nurse reviews his flow sheet for the morning: 08:00 — respiratory rate 18/min; saturation 96%; rhonchi over the trachea that clear completely after he coughs; secretions wiped from the tube opening 10:00 — respiratory rate 20/min; saturation 95%; fine crackles at both bases that clear after deep breaths 12:00 — respiratory rate 26/min; saturation 91%; coarse rhonchi over the trachea that persist after coughing 14:00 — respiratory rate 18/min; saturation 96%; clear breath sounds; the unit routine lists tracheostomy suctioning every 2 hours At which time was suctioning through the tracheostomy indicated?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629784  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 55-year-old man is on the surgical ward 3 days after a tracheostomy was created for prolonged mechanical ventilation. He now breathes on his own through a cuffed tracheostomy tube with a removable inner cannula and receives humidified oxygen at 35% by tracheostomy collar. His oxygen saturation by pulse oximetry has been 95% to 97%.

The nurse reviews his flow sheet for the morning:
08:00 — respiratory rate 18/min; saturation 96%; rhonchi over the trachea that clear completely after he coughs; secretions wiped from the tube opening
10:00 — respiratory rate 20/min; saturation 95%; fine crackles at both bases that clear after deep breaths
12:00 — respiratory rate 26/min; saturation 91%; coarse rhonchi over the trachea that persist after coughing
14:00 — respiratory rate 18/min; saturation 96%; clear breath sounds; the unit routine lists tracheostomy suctioning every 2 hours
At which time was suctioning through the tracheostomy indicated?

## 보기

1. 10:00
2. 14:00
3. 08:00
4. 12:00 **✔ 정답**

**정답: 4**

## 해설

Suctioning is indicated when there are secretions the client cannot clear, heard as coarse rhonchi over the large airways or shown by falling saturation, not on a schedule. At 12:00, coarse rhonchi over the trachea persisted after coughing, and saturation fell to 91% with a faster rate. At 08:00 he cleared his own secretions, the 10:00 crackles were in small airways and cleared with deep breathing, and at 14:00 only time had passed.

## 심화 해설

Clinical context

A tracheostomy bypasses the upper airway, so the patient loses the normal warming, humidifying, and filtering functions of the nose and pharynx [4]. Secretions therefore tend to become thicker and more difficult to mobilize. The purpose of tracheostomy suctioning is not to meet a clock schedule but to remove secretions the patient cannot clear independently [1][2]. The decision to suction is based on assessment findings that indicate retained secretions or inadequate oxygenation.

Interpreting the flow sheet

The key question is whether the patient is effectively clearing secretions and maintaining gas exchange. Each time point must be judged against that standard.

| Time | Findings | Interpretation |
| --- | --- | --- |
| 08:00 | RR 18/min, SpO2 96%, rhonchi over trachea clear completely after cough, secretions wiped from tube opening | Patient cleared secretions independently; no suctioning needed |
| 10:00 | RR 20/min, SpO2 95%, fine crackles at both bases clear after deep breaths | Crackles are small-airway sounds that resolved with deep breathing; not an indication for tracheal suctioning |
| 12:00 | RR 26/min, SpO2 91%, coarse rhonchi over trachea persist after coughing | Retained secretions in large airway with falling saturation and rising respiratory rate; suctioning indicated |
| 14:00 | RR 18/min, SpO2 96%, clear breath sounds | No clinical indication; routine schedule alone does not justify suctioning |

Why 12:00 is the correct answer

At 12:00, the patient had coarse rhonchi over the trachea that persisted after coughing, meaning the patient could no longer clear secretions by his own effort. At the same time, oxygen saturation dropped to 91% and respiratory rate rose to 26/min. This combination of retained large-airway secretions plus deteriorating oxygenation is a direct indication for suctioning [1][2].

The earlier findings do not support suctioning. At 08:00, rhonchi cleared completely after coughing, which shows effective clearance. At 10:00, fine crackles at the bases cleared with deep breaths; these are small-airway findings, not secretions pooled in the trachea. At 14:00, breath sounds were clear and saturation was normal, so the only reason to suction would be the unit routine, which is not an evidence-based trigger.

Pathophysiology link

Because the artificial airway bypasses upper-airway conditioning, inspired gas can be inadequately humidified. This increases evaporative stress on the tracheobronchial mucosa, depletes airway surface liquid, concentrates mucus, and impairs mucociliary clearance [4]. The result is secretion retention and possible mucus plugging. When secretions accumulate in the large airways, they produce coarse rhonchi. If the patient cannot cough them out, they obstruct airflow and impair gas exchange, which is reflected in falling SpO2 and increased respiratory rate.

Key point! Suctioning is triggered by assessment findings—retained secretions the patient cannot clear, or signs of oxygenation compromise—not by a fixed time interval.

Watch out! Fine crackles that clear with deep breathing are not an indication for tracheal suctioning. They represent small-airway opening, not pooled secretions in the trachea.

Watch out! A routine order for suctioning every 2 hours does not override clinical judgment. Performing suctioning when it is not indicated increases mucosal trauma, bleeding risk, and infection risk [2].References (research sources)

- [1]Care of the Patient With an Artificial Airway.Research articleEvers JM, Minton LA, Webb C, Taylor RM, York NL (2024) · DOI: 10.1097/DCC.0000000000000648

- [2]Providing the nurse with a guide to tracheostomy care and management.Research articleRussell C (2005) · DOI: 10.12968/bjon.2005.14.8.17934

- [4]Airway hydration homeostasis in artificial airways: from mucus biophysics to monitoring and humidification strategies in critical care: a narrative review.Research articleChen H, Qiu X, Ye K, Wang Q. (2026) · DOI: 10.3389/fmed.2026.1922639

## 임상 시나리오

Tracheostomy Suctioning: Assess, Don't ScheduleSuction only when the patient cannot clear secretions
Suctioning is indicated when coarse rhonchi persist over the trachea after coughing or when SpO2 falls with increased work of breathing. At 12:00, rhonchi persisted and saturation dropped to 91%.

Do not suction on a fixed every-2-hour schedule. If the patient clears secretions by coughing or deep breathing and breath sounds are clear, suctioning is not needed.

CautionRoutine suctioning can cause mucosal trauma, hypoxia, and infection. Always base the decision on assessment findings, not the clock.

## 핵심 개념

- **Tracheostomy suctioning** — Removal of secretions from the trachea through a tracheostomy tube when the patient cannot clear them independently.
- **Coarse rhonchi** — Low-pitched, rattling breath sounds indicating secretions in large airways such as the trachea.
- **Fine crackles** — High-pitched, discontinuous sounds heard in small airways, often clearing with deep breathing.
- **SpO2** — Peripheral oxygen saturation measured by pulse oximetry; falling SpO2 may indicate retained secretions or impaired gas exchange.
- **Inner cannula** — Removable part of a tracheostomy tube that can be cleaned to maintain airway patency.

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