Tracheostomy Care on the NCLEX
Trach suctioning rules, cuff pressure, the bedside emergency kit, and accidental decannulation.
A trach patient's airway is one dislodged tube away from an emergency. The NCLEX tests whether you are ready for that minute.
Suctioning rules
Sterile technique. Hyperoxygenate with 100% oxygen for 30 to 60 seconds before each pass. Insert without suction; apply suction only while withdrawing, rotating the catheter. No more than 10 seconds of suction per pass, no more than 2 to 3 passes, with rest and reoxygenation between. Suction only when indicated (coarse crackles, visible secretions, desaturation), not on a schedule.
Cuff care
The cuff seals the trachea for ventilation and reduces gross aspiration. Keep cuff pressure 20 to 30 cm H2O and check it with a manometer each shift. Overinflation causes tracheal mucosal ischemia, necrosis, and later stenosis. A cuffed trach with the cuff up means no airflow past the vocal cords: the patient cannot speak, and a speaking valve must never be placed with the cuff inflated.
The bedside emergency kit
At the bedside at all times: the obturator for the current tube, a spare trach of the same size, a spare one size smaller, and suction ready to run. Add a bag-valve mask and sterile saline. If you float to a trach patient, checking this setup is your first act of the shift.
Accidental decannulation
Call for help and stay with the patient. Fresh trach (first 5 to 7 days, tract not mature): do not force the tube back blindly; the tract can collapse and you can create a false passage. Cover the stoma and ventilate with bag-valve mask over the mouth and nose while help comes. Mature stoma: insert the spare tube with the obturator, remove the obturator immediately, and confirm airflow. If it will not pass, drop to the smaller tube. A total laryngectomy patient has no upper-airway connection: ventilate through the stoma only.
Frequently asked
How long can one suction pass last?
Apply suction no more than 10 seconds. The catheter is occluding an artificial airway; long passes cause hypoxia and vagal bradycardia.
Trach ties: when to change?
When soiled, with a second person stabilizing the tube. Never remove old ties before new ones are secure. Snug enough for one finger underneath.
Inner cannula care?
Clean or replace per policy, typically every shift with sterile technique. A crusted inner cannula is the most common cause of trach obstruction.
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