When to suction and how to do it safely
The single most tested principle in airway questions is that suctioning is done for a reason, not on a schedule. Correct indications include audible or auscultated coarse crackles or gurgling, visible secretions in the tube, increased peak airway pressures on a ventilator, decreased oxygen saturation, restlessness, and an ineffective cough. A stem that offers 'suction every two hours' as a routine order should trigger suspicion.
Technique details are heavily tested because each one prevents a specific complication. Hyperoxygenate before and after to prevent hypoxaemia. Insert the catheter without suction applied so you do not strip oxygen and damage mucosa on the way in. Apply intermittent suction while withdrawing and rotating, and limit each pass to 10–15 seconds. Allow the client to rest and re-oxygenate between passes, and limit the total to about three passes.
Complications to watch for during and after suctioning include hypoxaemia, bradycardia from vagal stimulation, dysrhythmias, mucosal trauma with bloody secretions, and raised intracranial pressure in neurologically injured clients. If the heart rate drops or the saturation falls significantly, stop suctioning and oxygenate.
- •Assess first: breath sounds, saturation, secretions, work of breathing
- •Hyperoxygenate before and after each suctioning episode
- •No suction on insertion; intermittent suction on withdrawal
- •10–15 seconds per pass, maximum of about three passes
- •Stop for bradycardia, desaturation or new dysrhythmias
Routine tracheostomy care
Tracheostomy care questions test sterile versus clean technique, the order of steps, and safety equipment. In the acute care setting, tracheostomy care and suctioning are performed using sterile technique. The inner cannula is removed and either cleaned or replaced with a disposable one, the stoma is cleaned with normal saline working from the stoma outward, and a pre-cut or manufactured drain sponge is used because cutting gauze creates loose fibres that can be aspirated.
Ties are changed with a second person holding the tube in place, and the new tie is secured before the old one is removed. This detail appears in SATA items constantly because removing the old tie first risks decannulation. Tightness is judged by fitting one or two fingers under the tie.
Because a tracheostomy bypasses the nose and mouth, inspired air is neither warmed nor humidified. Supplemental humidification prevents thick secretions and mucous plugging, and adequate hydration supports the same goal. Expect items where the correct action for tenacious secretions is to increase humidification and fluids rather than to suction more aggressively.
| Item | Purpose |
|---|---|
| Obturator | Guides reinsertion of the same tube |
| Spare tube, same size | Immediate replacement if dislodged |
| Spare tube, one size smaller | Used if the stoma has narrowed and the same size will not pass |
| Curved haemostat | Holds the stoma open during reinsertion |
| Suction equipment and catheters | Clears obstructing secretions |
| Manual resuscitation bag | Ventilation if the airway is lost |
Airway emergencies
Accidental decannulation is the classic emergency item. If the tube comes out within the first 72 hours after surgical placement, the tract is immature and the priority is to maintain the airway: hold the stoma open with a curved haemostat, attempt to insert the spare tube with the obturator, remove the obturator immediately after insertion so air can pass, and call for help. If reinsertion fails, cover the stoma and ventilate with a bag-valve-mask over the mouth and nose while summoning emergency assistance.
Mucous plugging presents as sudden respiratory distress with no air movement through the tube. The sequence is to attempt suctioning first, and if the catheter will not pass, remove the inner cannula because the plug is often lodged there. Only if these fail is the outer tube changed.
Cuff management appears in ventilated-client items. An inflated cuff prevents aspiration and allows positive pressure ventilation, but excessive pressure causes tracheal ischaemia; cuff pressure is generally maintained around 20–25 mmHg. A client who can speak with a cuffed tube inflated may have a cuff leak, which is a finding to investigate rather than to ignore.
How airway content shows up across the exam
Airway is not confined to fundamentals. It appears in prioritization questions where an airway problem outranks circulation and pain, in delegation questions where suctioning an unstable client cannot be delegated to unlicensed personnel, and in paediatric items where smaller tubes obstruct faster. Whenever a stem gives you several problems, scan for airway compromise first.
Practise by working through fundamentals sets and management of care sets side by side, and note how often the correct answer is simply to assess or protect the airway before anything else.