# 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%. Later he suddenly becomes restless, his oxygen saturation falls to 84%, and little air moves through the tube. The nurse cannot pass the suction catheter more than a few centimeters. The tube is in place, and the ties are secure. What should the nurse do FIRST?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629785  
> 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%.

Later he suddenly becomes restless, his oxygen saturation falls to 84%, and little air moves through the tube. The nurse cannot pass the suction catheter more than a few centimeters. The tube is in place, and the ties are secure. What should the nurse do FIRST?

## 보기

1. Call for help and ventilate through the tube with a manual bag
2. Remove the inner cannula and insert a clean one **✔ 정답**
3. Deflate the cuff and raise the oxygen to 60%
4. Instill 5 mL of normal saline, then suction again

**정답: 2**

## 해설

Sudden distress, poor air movement, and a catheter that will not pass point to a mucus plug blocking the tube. Removing the inner cannula and inserting a clean one removes the blockage at once, often with the plug inside the cannula. Routine saline instillation is not recommended, deflating the cuff is a later step if airflow does not return, and the nurse calls for help without leaving the client.

## 심화 해설

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.

## 임상 시나리오

Blocked Tracheostomy TubeSudden distress with a mucus plug
Sudden restlessness, SpO2 falling to 84%, little air movement, and a suction catheter that will not pass point to a mucus plug in the tube.

First remove the inner cannula and insert a clean one. The plug often comes out with the cannula and airflow returns at once.

If airflow does not return, deflate the cuff so the client can breathe around the tube, and follow the emergency plan with the team.

CautionBagging cannot push air through a plugged tube, and routine saline instillation is not recommended. Call for help without leaving the client.

## 핵심 개념

- **Inner cannula** — A removable tube inside a tracheostomy tube that can be cleaned or replaced to clear secretions.
- **Mucus plug** — A mass of thick, dried secretions that can suddenly block an artificial airway.
- **Tracheostomy cuff** — An inflatable balloon around the tube that seals the trachea; deflating it allows air to pass around the tube.
- **Humidification** — Adding moisture to inspired gas to keep secretions thin, since a tracheostomy bypasses the nose.

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