A 47-year-old male with a tracheostomy has shallow respirations and mottled skin after replacing the tracheostomy tube. What is the most appropriate next step?

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When a patient with a tracheostomy becomes hypoventilating with signs of poor perfusion after tube replacement, the priority is to restore ventilation and oxygen delivery. Ventilating with a bag-valve-mask provides immediate tidal breaths to the lungs via the tracheostomy, addressing the root problem of hypoxia first. While you’re doing this, you should quickly assess the tracheostomy setup for potential obstruction, displacement, or cuff issues and correct them as needed. In short, deliver breaths right away to reverse hypoxia, then evaluate the tube for problems that may be impairing ventilation.