A tracheostomy is an opening into the trachea through the neck just below the larynx through which an indwelling tube is placed and thus an artificial airway is created. It is used for clients needing long-term airway support.
Tracheostomy tubes have an outer cannula that is inserted into the trachea and a flange that rests against the neck and allows the tube to be secured in place with tape or ties. Tracheostomy tubes also have an obturator which is used to insert the outer cannula which is then removed afterwards. The obturator is kept at the client’s bedside in case the tube becomes dislodged and needs to be reinserted.
Nurses provide tracheostomy care for clients with new or recent tracheostomy to maintain patency of the tube and minimize the risk for infection (since the inhaled air by the client is no longer filtered by the upper airways). Initially a tracheostomy may need to be suctioned and cleaned as often as every 1 to 2 hours. After the initial inflammatory response subsides, tracheostomy care may only need to be done once or twice a day, depending on the client.
Definition of Terms
- Decannulation: The process whereby a tracheostomy tube is removed once patient no longer needs it.
- Humidification: The mechanical process of increasing the water vapour content of an inspired gas.
- Stoma: An opening, either natural or surgically created, which connects a portion of the body cavity to the outside environment (in this case, between the trachea and the anterior surface of the neck).
- Tracheostomy: A surgical procedure to create an opening between 2-3 (3-4) tracheal rings into the trachea below the larynx.
- Tracheal Suctioning: A means of clearing thick mucus and secretions from the trachea and lower airway through the application of negative pressure via a suction catheter.
- Tracheostomy tube: A curved hollow tube of rubber or plastic inserted into the tracheostomy stoma (the hole made in the neck and windpipe (Trachea) to relieve airway obstruction, facilitate mechanical ventilation or the removal of tracheal secretions.
Components of Tracheostomy Tube
- Outer tube
- Inner tube: Fits snugly into outer tube, can be easily removed for cleaning.
- Flange: Flat plastic plate attached to outer tube – lies flush against the patient’s neck.
- 15mm outer diameter termination: Fits all ventilator and respiratory equipment.
All remaining features are optional
- Cuff: Inflatable air reservoir (high volume, low pressure) – helps anchor the tracheostomy tube in place and provides maximum airway sealing with the least amount of local compression. To inflate, air is injected via the…
- Air inlet valve: One way valve that prevents spontaneous escape of the injected air.
- Air inlet line: Route for air from air inlet valve to cuff.
- Pilot cuff: Serves as an indicator of the amount of air in the cuff
- Fenestration: Hole situated on the curve of the outer tube – used to enhance airflow in and out of the trachea. Single or multiple fenestrations are available.
- Speaking valve / tracheostomy button or cap: Used to occlude the tracheostomy tube opening (a) former – during expiration to facilitate speech and swallow, (b) latter – during both inspiration and expiration prior to decannulation.
Providing Tracheostomy Care
- To maintain airway patency by removing mucus and encrusted secretions.
- To maintain cleanliness and prevent infection at the tracheostomy site
- To facilitate healing and prevent skin excoriation around the tracheostomy incision
- To promote comfort
- To prevent displacement
- Respiratory status (ease of breathing, rate, rhythm, depth, lung sounds, and oxygen saturation level)
- Pulse rate
- Secretions from the tracheostomy site (character and amount)
- Presence of drainage on tracheostomy dressing or ties
- Appearance of incision (redness, swelling, purulent discharge, or odor)
Tracheostomy care involves application of scientific knowledge, sterile technique, and problem solving, and therefore needs to be performed by a nurse or respiratory therapist.
- Sterile disposable tracheostomy cleaning kit or supplies (sterile containers, sterile nylon brush or pipe cleaners, sterile applicators, gauze squares)
- Sterile suction catheter kit (suction catheter and sterile container for solution)
- Sterile normal saline (Check agency protocol for soaking solution)
- Sterile gloves (2 pairs)
- Clean gloves
- Towel or drape to protect bed linens
- Moisture-proof bag
- Commercially available tracheostomy dressing or sterile 4-in. x -in. gauze dressing
- Cotton twill ties
- Clean scissors
This well-organized, fixed, step-by-step sequence of the whole process of tracheostomy care is taken from Kozier & Erb’s Fundamentals of Nursing.
1. Introduce self and verify the client’s identity using agency protocol. Explain to the client everything that you need to do, why it is necessary, and how can he cooperate. Eye blinking, raising a finger can be a means of communication to indicate pain or distress.
2. Observe appropriate infection control procedures such as hand hygiene.
3. Provide for client privacy.
4. Prepare the client and the equipment.
- To promote lung expansion, assist the client to semi-Fowler’s or Fowler’s position.
- Open the tracheostomy kit or sterile basins. Pour the soaking solution and sterile normal saline into separate containers.
- Establish the sterile field.
- Open other sterile supplies as needed including sterile applicators, suction kit, and tracheostomy dressing.
5. Suction the tracheostomy tube, if necessary.
- Put a clean glove on your nondominant hand and a sterile glove on your dominant hand (or put on a pair of sterile gloves).
- Suction the full length of the tracheostomy tube to remove secretions and ensure a patent airway.
- Rinse the suction catheter and wrap the catheter around your hand, and peel the glove off so that it turns inside out over the catheter.
- Unlock the inner cannula with the gloved hand. Remove it by gently pulling it out toward you in line with its curvature. Place it in the soaking solution. Rationale: This moistens and loosens secretions.
- Remove the soiled tracheostomy dressing. Place the soiled dressing in your gloved hand and peel the glove off so that it turns inside out over the dressing. Discard the glove and the dressing.
- Put on sterile gloves. Keep your dominant hand sterile during the procedure.
6. Clean the inner cannula.
- Remove the inner cannula from the soaking solution.
- Clean the lumen and entire inner cannula thoroughly using the brush or pipe cleaners moistened with sterile normal saline. Inspect the cannula for cleanliness by holding it at eye level and looking through it into the light.
- Rinse the inner cannula thoroughly in the sterile normal saline.
- After rinsing, gently tap the cannula against the inside edge of the sterile saline container. Use a pipe cleaner folded in half to dry only the inside of the cannula; do not dry the outside. Rationale: This removes excess liquid from the cannula and prevents possible aspiration by the client, while leaving a film of moisture on the outer surface to lubricate the cannula for reinsertion.
7. Replace the inner cannula, securing it in place.
- Insert the inner cannula by grasping the outer flange and inserting the cannula in the direction of its curvature.
- Lock the cannula in place by turning the lock (if present) into position to secure the flange of the inner cannula to the outer cannula.
8. Clean the incision site and tube flange.
- Using sterile applicators or gauze dressings moistened with normal saline, clean the incision site. Handle the sterile supplies with your dominant hand. Use each applicator or gauze dressing only once and then discard. Rationale: This avoids contaminating a clean area with a soiled gauze dressing or applicator.
- Hydrogen peroxide may be used (usually in a half-strength solution mixed with sterile normal saline; use a separate sterile container if this is necessary) to remove crusty secretions. Check agency policy. Thoroughly rinse the cleaned area using gauze squares moistened with sterile normal saline. Rationale: Hydrogen peroxide can be irritating to the skin and inhibit healing if not thoroughly removed.
- Clean the flange of the tube in the same manner.
- Thoroughly dry the client’s skin and tube flanges with dry gauze squares.
9. Apply a sterile dressing.
- Use a commercially prepared tracheostomy dressing of non- raveling material or open and refold a 4-in. x 4-in. gauze dressing into a V shape. Avoid using cotton-filled gauze squares or cutting the 4-in. x 4-in. gauze. Rationale: Cotton lint or gauze fibers can be aspirated by the client, potentially creating a tracheal abscess.
- Place the dressing under the flange of the tracheostomy tube.
- While applying the dressing, ensure that the tracheostomy tube is securely supported. Rationale: Excessive movement of the tracheostomy tube irritates the trachea.
10. Change the tracheostomy ties.
- Change as needed to keep the skin clean and dry.
- Twill tape and specially manufactured Velcro ties are available. Twill tape is inexpensive and readily available; however, it is easily soiled and can trap moisture that leads to irritation of the skin of the neck. Velcro ties are becoming more commonly used. They are wider, more comfortable, and cause less skin abrasion.
Two-Strip Method (Twill Tape)
- Cut two unequal strips of twill tape, one approximately 25 cm (10 in.) long and the other about 50 cm (20 in.) long. Rationale: Cutting one tape longer than the other allows them to be fastened at the side of the neck for easy access and to avoid the pressure of a knot on the skin at the back of the neck.
- Cut a l-cm (0.5-in.) lengthwise slit approximately 2.5 cm (1 in.) from one end of each strip. To do this, fold the end of the tape back onto itself about 2.5 cm (1 in.), then cut a slit in the middle of the tape from its folded edge.
- Leaving the old ties in place, thread the slit end of one clean tape through the eye of the tracheostomy flange from the bottom side; then thread the long end of the tape through the slit, pulling it tight until it is securely fastened to the flange. Rationale: Leaving the old ties in place while securing the clean ties prevents inadvertent dislodging of the tracheostomy tube. Securing tapes in this manner avoids the use of knots, which can come untied or cause pressure and irritation.
- If old ties are very soiled or it is difficult to thread new ties onto the tracheostomy flange with old ties in place, have an assistant put on a sterile glove and hold the tracheostomy in place while you replace the ties. This is very important be- cause movement of the tube during this procedure may cause irritation and stimulate coughing. Coughing can dislodge the tube if the ties are undone.
- Repeat the process for the second tie.
- Ask the client to flex the neck. Slip the longer tape under the client’s neck, place a finger between the tape and the client’s neck and tie the tapes together at the side of the neck. Rationale: Flexing the neck increases its circumference the way coughing does. Placing a finger under the tie prevents making the tie too tight, which could interfere with coughing or place pressure on the jugular veins.
- Tie the ends of the tapes using square knots. Cut off any long ends, leaving approximately 1 to 2 cm (0.5 in.). Rationale: Square knots prevent slippage and loosening. Adequate ends beyond the knot prevent the knot from inadvertently untying.
- Once the clean ties are secured, remove the soiled ties and discard.
One-Strip Method (Twill Tape)
- Cut a length of twill tape 2.5 times the length needed to go around the client’s neck from one tube flange to the other.
- Thread one end of the tape into the slot on one side of the flange.
- Bring both ends of the tape together. Take them around the client’s neck, keeping them flat and untwisted.
- Thread the end of the tape next to the client’s neck through the slot from the back to the front.
- Have the client flex the neck. Tie the loose ends with a square knot at the side of the client’s neck, allowing for slack by placing two fingers under the ties as with the two-strip method. Cut off long ends.
11. Tape and pad the tie knot.
Place a folded 4-in. x. 4-in. gauze square under the tie knot, and apply tape over the knot. Rationale: This reduces skin irritation from the knot and prevents confusing the knot with the client’s gown ties.
12. Check the tightness of the ties.
Frequently check the tightness of the tracheostomy ties and position of the tracheostomy tube. Rationale: Swelling of the neck may cause the ties to become too tight, interfering with coughing and circulation. Ties can loosen in restless clients, allowing the tracheostomy tube to extrude from the stoma.
13. Document all relevant information.
Record suctioning, tracheostomy care, and the dressing change, noting your assessments.
12/23/2012 0900 Respirations 18-20/min. Lung sounds clear. Able to expectorate secretions requiring little suctioning. Large amount of thick secretions cleansed from inner cannula. Inner cannuLa changed. Trach dressing changed. Skin around trach is intact but slightly red in color 0.2 cm around entire opening. No broken skin noted in the reddened area. — G. Wayne, RN
Variation: Using a Disposable Inner Cannula
- Check policy for frequency of changing inner cannula because standards vary among institutions.
- Open a new cannula package.
- Using a gloved hand, unlock the current inner cannula (if present) and remove it by gently pulling it out toward you in line with its curvature.
- Check the cannula for amount and type of secretions and discard properly.
- Pick up the new inner cannula touching only the outer locking portion.
- Insert the new inner cannula into the tracheostomy.
- Lock the cannula in place by turning the lock (if present).
Infant and Child
- An assistant may be necessary during tracheostomy care to prevent active children from dislodging or expelling their tracheostomy tubes.
- Always make a sterile, packaged tracheostomy available at bedside for emergency purposes.
- Encourage parents to participate with the procedure in an effort to comfort the child and promote client teaching.
- Care for the skin at the tracheostomy site is important especially for the elders whose skin is more fragile and prone to breakdown.
Home Care Modifications
- Emphasize the importance of handwashing before performing tracheostomy care.
- Describe the function of each part of the tracheostomy tube.
- Explain the proper way on how to remove, change, and replace the inner cannula.
- Clean the inner cannula two or three times a day.
- Check and clean the tracheostomy stoma.
- Suction tracheal secretions if necessary.
- Assess for symptoms of infection (i.e., increased temperature, increased amount of secretions, change in color or odor of secretions).
- Advise and encourage parents to participate with the procedure in an effort to comfort the child and promote client teaching.
- Provide contact information for emergencies.
Suctioning a Tracheostomy Tube
Suctioning of tracheostomy tube is only done as necessary. Sterile technique must be observed. Nurses should be aware that there is a frequency for the need of suctioning during immediate postoperative period.
- Removes thick mucus and secretions from the trachea and lower airway to maintain patent airway and prevent airway obstructions
- To promote respiratory function (optimal exchange of oxygen and carbon dioxide into and out of the lungs)
- To prevent pneumonia that may result from accumulated secretions
- Assess the client for the presence of congestion on auscultation of the thorax.
- Note the client’s ability or inability to remove the secretions through coughing.
Suctioning a tracheostomy or endotracheal tube is a sterile, invasive technique requiring application of scientific knowledge and problem solving. This skill is performed by a nurse or respiratory therapist and is not delegated to UAP.
- Resuscitation bag (Ambu bag) connected to 100% oxygen
- Sterile towel (optional)
- Equipment for suctioning
- Goggles and mask if necessary
- Gown (if necessary) as Sterile gloves
- Moisture-resistant bag
Determine if the client has been suctioned previously and, if so, review the documentation of the procedure. This information can be very helpful in preparing the nurse for both the physiologic and psychologic impact of suctioning on the client
This well-organized, fixed, step-by-step sequence of the whole process of tracheostomy suctioning is taken from Kozier & Erb’s Fundamentals of Nursing.
1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. Inform the client that suctioning usually causes some intermittent coughing and-that this assists in removing the secretions.
2. Perform hand hygiene and observe other appropriate infection
control procedures (e.g., gloves, goggles).
3. Provide for client privacy.
4. Prepare the client.
If not contraindicated because of health, place the client in the semi-Fowler’s position to promote deep breathing, maximum lung expansion, and productive coughing. Rationale:
Deep breathing oxygenates the lungs, counteracts the hypoxic effects of suctioning, and may induce coughing. Coughing helps to loosen and move secretions.
If necessary, provide analgesia before suctioning. Endotracheal suctioning stimulates the cough reflex, which can cause pain for clients who have had thoracic or abdominal surgery or who have experienced traumatic injury. Rationale: Premedication can increase the client’s comfort during the suctioning procedure.
5. Prepare the equipment.
- Attach the resuscitation apparatus to the oxygen source. O
- Adjust the oxygen flow to 100%.
- Open the sterile supplies in readiness for use.
- Place the sterile towel, if used, across the client’s chest below the tracheostomy.
- Turn on the suction, and set the pressure in accordance with agency policy. For a wall unit, a pressure setting of about 100 to 120 mm Hg is normally used for adults, 50 to 95 mm Hg for infants and children.
- Put on goggles, mask, and gown if necessary.
- Put on sterile gloves. Some agencies recommend putting a sterile glove on the dominant hand and an unsterile glove on the nondominant hand to protect the nurse.
- Holding the catheter in the dominant hand and the connector in the nondominant hand, attach the suction catheter to the suction tubing
6. Flush and lubricate the catheter.
- Using the dominant hand, place the catheter tip in the sterile saline solution.
- Using the thumb of the nondominant hand, occlude the thumb control and suction a small amount of the sterile solution through the catheter. Rationale: This determines that the suction equipment is working properly and lubricates the outside and the lumen of the catheter. Lubrication eases insertion and reduces tissue trauma during insertion. Lubricating the lumen also helps prevent secretions from sticking to the inside of the catheter.
7. If the client does not have copious secretions, hyperventilate the lungs with a resuscitation bag before suctioning.
- Summon an assistant, if one is available, for this step.
- Using your nondominant hand, turn on the oxygen to 12 to 15 L/min.
- If the client is receiving oxygen, disconnect the oxygen source from the tracheostomy tube using your nondominant hand.
- Attach the resuscitator to the tracheostomy or endotracheal tube.
- Compress the Ambu bag three to five times, as the client inhales. This is best done by a second person who can use both hands to compress the bag, thus, providing a greater inflation volume.
- Observe the rise and fall of the client’s chest to assess the adequacy of each ventilation.
- Remove the resuscitation device and place it on the bed or the client’s chest with the connector facing up.
Variation: Using a Ventilator to Provide Hyperventilation
If the client is on a ventilator, use the ventilator for hyperventilation and hyperoxygenation. Newer models have a mode that provides 1 0 0 % oxygen for 2 minutes and then switches back to the previous oxygen setting as well as a manual breath or sigh button. Rationale: The use of ventilator settings provides more consistent delivery of oxygenation and hyperinflation than a resuscitation device.
8. If the client has copious secretions, do not hyperventilate with a resuscitator. Instead:
- Keep the regular oxygen delivery device on and increase the liter flow or adjust the Fi02 to 100% for several breaths before suctioning. Rationale: Hyperventilating a client who has copious secretions can force the secretions deeper into the respiratory tract.
9. Quickly but gently insert the catheter without applying any suction.
- With your nondominant thumb off the suction port, quickly but gently insert the catheter into the trachea through the tracheostomy tube. Rationale: To prevent tissue trauma and oxygen loss, suction is not applied during insertion of the catheter.
- Insert the catheter about 12.5 cm (5 in.) for adults, less for children, or until the client coughs or you feel resistance. Rationale: Resistance usually means that the catheter tip has reached the bifurcation of the trachea. To prevent damaging the mucous membranes at the bifurcation, withdraw the catheter about 1 to 2 cm (0.4 to 0.8 in.) before applying suction.
10, Perform suctioning.
- Apply suction for 5 to 10 seconds by placing the nondominant thumb over the thumb port. Rationale: Suction time is restricted to 10 seconds or less to minimize oxygen loss.
- Rotate the catheter by rolling it between your thumb and forefinger while slowly withdrawing it. Rationale: This prevents tissue trauma by minimizing the suction time against any part of the trachea.
- Withdraw the catheter completely, and release the suction.
- Hyperventilate the client.
- Suction again, if needed.
11. Reassess the client’s oxygenation status and repeat suctioning.
- Observe the client’s respirations and skin color. Check the client’s pulse if necessary, using your nondominant hand.
- Encourage the client to breathe deeply and to cough between suctions.
- Allow 2 to 3 minutes with oxygen, as appropriate between suctions when possible. Rationale: This provides an opportunity for reoxygenation of the lungs.
- Flush the catheter and repeat suctioning until the air passage is clear and the breathing is relatively effortless and quiet.
- After each suction, pick up the resuscitation bag with your nondominant hand and ventilate the client with no more than three breaths.
12. Dispose of equipment and ensure availability for the next suction.
- Flush the catheter and suction tubing.
- Turn off the suction and disconnect the catheter from the suction tubing.
- Wrap the catheter around your sterile hand and peel the glove off so that it turns inside out over the catheter.
- Discard the glove and the catheter in the moisture-resistant bag.
- Replenish the sterile fluid and supplies so that the suction is ready for use again. Rationale: Clients who require suctioning often require it quickly, so it is essential to leave the equipment at the bedside ready for use.
- Be sure that the ventilator and oxygen settings are returned to pre suctioning settings. Rationale: On some ventilators this is automatic, but always check. It is very dangerous for clients to be left on 100% oxygen.
13. Provide for client comfort and safety.
- Assist the client to a comfortable, safe position that aids breathing. If the person is conscious, a semi-Fowler’s position is frequently indicated. If the person is unconscious, Sims’ position aids in the drainage of secretions from the mouth.
14. Document relevant data.
Record the suctioning, including the amount and description of suction returns and any other relevant assessments.
12/23/2012 1000 Coarse rales in RLL and LLL. Requires suctioning every 1-2 hrs. Obtain large amount of pinkish tinged white thin mucous via ETT. Breath sounds clearer after suctioning. Pt. signals when he wants to be suctioned. — J. Roberts, RN
Variation: Closed Airway/Tracheal Suction System (In-Line Catheter)
- If a catheter is not attached, put on clean gloves, aseptically open a new closed catheter set, and attach the ventilator connection on the T piece to the ventilator tubing. Attach the client connection to the endotracheal tube or tracheostomy.
- Attach one end of the suction connecting tubing to the suction connection port of the closed system and the other end of the connecting tubing to the suction device.
- Turn suction on, occlude or kink tubing, and depress the suction control valve (on the closed catheter system) to set suc- tion to the appropriate level. Release the suction control valve.
- Use the ventilator to hyperoxygenate and hyperinflate the client’s lungs.
- Unlock the suction control mechanism if required by the manufacturer.
- Advance the suction catheter enclosed in its plastic sheath with the dominant hand. Steady the T piece with the non- dominant hand.
- Depress the suction control valve and apply suction for no more than 10 seconds and gently withdraw the catheter.
- Repeat as needed remembering to provide hyperoxygenation and hyperinflation as needed.
- When completed suctioning, withdraw the catheter into its sleeve and close the access valve, if appropriate. Rationale:
- If the system does not have an access valve on the client connector, the nurse needs to obsen/e for the potential of the catheter migrating into the airway and partially obstructing the artificial airway.
- Flush the catheter by instilling normal saline into the irrigation port and applying suction. Repeat until the catheter is clear.
- Close the irrigation port and close the suction valve.
Infant and Child
- Restrain the child gently with the help of an assistant and maintain the child’s head in the midline position.
- To be aware of any special problems, do a thorough lung assessment before and after the whole procedure.
Home Care Considerations
- Encourage the client to clear airway by coughing, if possible.
- If cannot cough properly, encourage the client to suction their secretions.
- Advise the client or caregiver to use clean gloves in performing the procedure.
- The nurse should teach the caregiver on how to determine the need for suctioning.
- Discuss to the caregiver the correct process and rationale underlying the practice of suctioning.
- Emphasize the importance of adequate hydration as it thins secretions, which can aid in the removal of secretions by coughing or suctioning.
Dealing with Emergencies
If the tracheostomy tube falls out
- DON’T PANIC!
- Once the tracheostomy tube has been in place for about 5 days the tract is well formed and will not suddenly close.
- Reassure the patient
- Call for medical help.
- Ask the patient to breathe normally via their stoma while waiting for the doctor.
- The stay suture (if present) or tracheal dilator may be used to help keep the stoma open if necessary.
- Stay with patient.
- Prepare for insertion of the new tracheostomy tube
- Once replaced, tie the tube securely, leaving one finger-space between ties and the patient’s neck.
- Check tube position by (a) asking the patient to inhale deeply – they should be able to do so easily and comfortably, and (b) hold a piece of tissue in front of the opening – it should be “blown” during patient’s exhalation.
Patient is having Acute Dyspnea
Acute dyspnea for patient with tracheostomy is most commonly caused by partial or complete blockage of the tracheostomy tube retained secretions. To unblock the tracheostomy tube:
- ASK THE PATIENT TO COUGH: A strong cough may be all that is needed to expectorate secretions.
- REMOVE THE INNER CANNULA: If there are secretions stuck in the tube, they will automatically be removed when you take out the inner cannula. The outer tube – which does not have secretions in it – will allow the patient to breath freely. Clean and replace the inner cannula.
- SUCTION: If coughing or removing the inner cannula do not work, it may be that secretions are lower down the patients airway. Use the suction machine to remove secretions.
- If these measures fail – commence low concentration oxygen therapy via a tracheostomy mask, and call for medical assistance.
It is possible that the tracheostomy may have become displaced. Stay with the patient until assistance arrives. Prepare for change of tracheostomy tube.
Patient needing Cardiopulmonary Resuscitation
In the event of cardiopulmonary arrest, treat tracheostomy patients as other patients:
- Step 1: Expose the patient’s neck. Remove any clothing covering the tracheostomy tube and the neck area. Do not remove tracheostomy.
- Step 2: Check the patency of the inner cannula. To check inner cannula: Wearing a non-sterile glove, remove inner cannula. If clean, reinsert and lock into place. If soiled – replace. Continue resuscitation.
- Step 3: Ventilate. Use the ambu-bag directly to the t-tube.
- If unable to ventilate:
- Try to suction. To remove or clear the secretions blocking the tube.
- If still unable to ventilate. The tube may be displaced and the doctor may:
- Change the tube
- Intubate orally