1. Care of Patients Requiring Oxygen Therapy or Tracheostomy
Chapter 30
Care of Patients Requiring Oxygen Therapy or Tracheostomy

2. Chapter 30 Care of Patients Requiring Oxygen Therapy or Tracheostomy Learning Outcomes
1. Use medical asepsis when providing tracheostomy care. 2. Verify safe use of appropriate oxygen delivery systems and tracheostomy equipment. 3. Teach the patient requiring oxygen therapy to not smoke when using oxygen. 4. Perform a focused respiratory assessment and re-assessment to determine adequacy of oxygenation and tissue perfusion.

3. Chapter 30 Care of Patients Requiring Oxygen Therapy or Tracheostomy Learning Outcomes (Continued)
5. Administer oxygen therapy by nasal cannula, mask, endotracheal tube, or tracheal tube, and evaluate the patient's response.
6. Teach the patient and family about home management of oxygen therapy or tracheostomy.
7. Assess for complications of oxygen therapy for those patients whose respiratory efforts are controlled by the hypoxic drive.
8. Describe patients who require oxygen therapy and/or tracheostomies and the related nursing interventions and rationales.

4. Why Do We Need Oxygen?
Essential for life and function of cells/tissues
Respiratory, cardiovascular, hematologic systems work together, providing sufficient tissue perfusion to the body
Oxygen therapy improves oxygenation and tissue perfusion

5. Clinical Manifestations of Respiratory Distress
Dyspnea
Nasal flaring
Use of accessory muscles to breathe
Pursed-lip or diaphragmatic breathing
Decreased endurance
Skin, mucous membrane changes (pallor, cyanosis)

6. Respiratory Assessment
Nose and sinuses
Pharynx, trachea, larynx
Lungs and thorax
Movement /symmetry/fremitus
Resonance
Breath sounds
General appearance (muscle development)
Skin and mucous membranes

7. Oxygen Therapy Purpose—relieves hypoxemia
Hypoxemia—low levels of oxygen in the blood
Hypoxia—decreased tissue oxygenation
Goal—use lowest fraction of inspired oxygen for acceptable blood oxygen level without causing harmful side effects

8. Oxygen Intake and Oxygen Delivery
Restoration of adequate oxygenation and tissue perfusion by oxygen delivery adjustments and oxygen therapy when respiratory problems interfere with meeting tissue oxygen needs. Hgb, Hemoglobin. RBCs, red blood cells.

9. Assessment of Oxygenation
ABG analysis is best way to determine need for oxygen therapy

10. Hazards & Complications of Oxygen Therapy
Combustion
Oxygen-induced hypoventilation
Hypercarbia—retention of CO2
CO2 narcosis—loss of sensitivity to high levels of CO2
Oxygen toxicity
Nitrogen keeps aveoli open. When high levels of oxygen are present in the aveoli, it replaces the nitrogen content (diminishes it) and then the oxygen diffuses across the aveoli/capillary membrane and the aveoli collapse.

11. Hazards & Complications of Oxygen Therapy (continued)
Absorption atelectasis—new onset of crackles/decreased breath sounds (oxygen replaces nitrogen)
Drying of mucous membranes
Infection

12. Oxygen Delivery Systems
Type used depends on:
Oxygen concentration required/achieved
Importance of accuracy and control of oxygen concentration
Patient comfort
Importance of humidity
Patient mobility

13. What’s the difference between low and high flow oxygen delivery systems?
Low flow:
High flow:

14. Low-Flow Oxygen Delivery Systems
Does not provide enough flow to meet total oxygen and air volume
Nasal cannula (1-6 L)
Facemask
Simple
Partial rebreather
Non-rebreather

15. Nasal Cannula Flow rates of 1-6 L/min
O2 concentration of 24%-44% (1-6 L/min)
Flow rate >6 L/min does not increase O2 because anatomical dead space is full
Assess patency of nostrils
Assess for changes in respiratory rate and depth
A nasal cannula (prongs).

16. Simple Facemask Delivers O2 up to 40%-60% Minimum of 5 L/min
Mask fits securely over nose and mouth
Monitor closely for risk of aspiration
A simple facemask used to deliver oxygen.

17. Partial Rebreather Mask
Provides 60%-75% with flow rate of 6-11 L/min
One-third exhaled tidal volume with each breath
Adjust flow rate to keep reservoir bag inflated
A partial rebreather mask.

18. Non-Rebreather Mask Highest O2 level Can deliver FIO2 greater than 90%
Used for unstable patients requiring intubation
Ensure valves are patent and functional
A non-rebreather mask.

19. What Do You Think?
If the oxygen source should fail or be depleted when both flaps of a non-rebreather mask are in place, what would happen?
ANS: The patient would not be able to inhale room air.

20. High-Flow Oxygen Delivery Systems
High-flow—can deliver 24%-100% at 8-15 L/min
Venturi mask
Face tent
Aerosol mask
Tracheostomy collar
T-piece

21. Venturi Mask Adaptor located between bottom of mask and O2 sources
Delivers precise O2 concentration—best source for chronic lung disease
Switch to nasal cannula during mealtimes
A Venturi mask for precise oxygen delivery.

22. T-Piece Delivers desired FIO2 for tracheostomy, laryngectomy, ET tubes
Ensures humidifier creates enough mist
Mist should be seen during inspiration and expiration
A T-piece apparatus for attachment to an endotracheal or tracheostomy tube.

23. Noninvasive Positive-Pressure Ventilation (NPPV)
Uses positive pressure to keep alveoli open, improve gas exchange without airway intubation
BiPAP – cycles different pressures between inspiration and expiration
CPAP – continuous pressure

24. Continuous Positive Airway Pressure (CPAP)

25. CPAP (cont’d)
Delivers set positive airway pressure throughout each cycle of inhalation and exhalation
Opens collapsed alveoli
Used for atelectasis after surgery or cardiac-induced pulmonary edema; sleep apnea

26. Transtracheal Oxygen Delivery (TTO)
Long-term delivery of O2 directly into lungs
Small flexible catheter is passed into trachea through small incision
Avoids irritation that nasal prongs cause; is more comfortable
Flow rates prescribed for rest, activity

27. Home Oxygen Therapy Criteria for equipment Patient education:
Compressed gas in tank or cylinder
Liquid oxygen in reservoir
Oxygen concentrator

28. Oxygen Therapy
Left: Small E size oxygen tank (cylinder) for portability.
Right: Portable liquid oxygen.

29. Tracheostomy
Tracheotomy—surgical incision into trachea for purpose of establishing an airway
Tracheostomy—stoma (opening) that results from tracheotomy
May be temporary or permanent

30. Tracheostomy (cont’d)
A vertical tracheal incision for a tracheostomy.

31. Priority Problems For Patients With Tracheostomies
Reduced oxygenation
Inadequate communication
Inadequate nutrition
Potential for infection
Damaged oral mucosa

32. Interventions Preoperative care Operative procedures
Postoperative care—ensure patent airway
Assess for possible complications
Tube obstruction/dislodgment

33. Other Possible Complications
Pneumothorax
Subcutaneous emphysema
Bleeding
Infection

34. Tracheostomy Tubes Disposable or reusable
Cuffed tube or tube without cuff for airway maintenance
Inner cannula disposable or reusable
Fenestrated tube

35. Tracheostomy Tubes (cont’d)
A, Dual-lumen cuffed tracheostomy tube with disposable inner cannula. B, Single-lumen cannula cuffed tracheostomy tube. C, Dual-lumen cuffed fenestrated tracheostomy tube.

36. Care Issues for the Patient with a Tracheostomy
Prevention of tissue damage:
Cuff pressure can cause mucosal ischemia
Use minimal leak and occlusive techniques
Check cuff pressure often – keep between 14 to 20 mm Hg or 20 to 30 cm H2O.
Prevent tube friction and movement
Prevent/treat malnutrition, hemodynamic instability, hypoxia

37. Cuff Pressures An aneroid pressure manometer for cuff inflation and measuring cuff pressures.

38. Air Warming and Humidification
Tracheostomy tube bypasses nose and mouth, which normally humidify, warm, and filter air
Air must be humidified

39. Suctioning Maintains patent airway, promotes gas exchange
Assess the need in patients who cannot cough adequately
Done through nose, mouth or tracheostomy

40. Complications of Suctioning
Hypoxia
Tissue (mucosal) trauma
Infection
Vagal stimulation, bronchospasm
Cardiac dysrhythmias from induced hypoxia

41. Causes of Hypoxia in the Tracheostomy
Ineffective oxygenation before, during, after suctioning
Use of catheter that is too large for the artificial airway
Prolonged suctioning time
Excessive suction pressure
Too frequent suctioning

42. Tracheostomy Care Assess the patient
Secure tracheostomy tubes in place
Prevent accidental decannulation

43. Fenestrated Tracheostomy Tube
Placement of tracheostomy gauze dressing and Velcro tracheostomy tube holder.

44. The patient is a 68-year-old woman who was admitted with respiratory failure 3 weeks ago. She required an artificial airway (tracheostomy) to help clear her secretions. The previous shift nurse reports that the patient had a very restless night with a drop in her O2 saturation level several times despite her O2 being set at 40% via trach collar. The previous shift nurse also reports that the patient experienced tachycardia and tachypnea during the night.

45. Heart rate: 114 (sinus tachycardia) Respiratory rate: 24 and labored
(cont’d)
The nurse immediately checks on the patient and finds that she appears anxious and her vital signs are as follows:
Blood pressure: 128/84 mm Hg
Heart rate: 114 (sinus tachycardia)
Respiratory rate: 24 and labored
Temperature: 99.4° F (axillary)
O2 saturation: 91% on 40% O2 via trach collar
Which of these findings are cause for concern?
The BP is within normal range and only slightly elevated. Her heart rate is elevated, so the nurse could check the patient’s medications to see if she is on a bronchodilator or other medication that could cause her heart rate to increase. The priority reading is the increased respiratory rate and the decreased oxygen saturation despite the 40% oxygen setting.

46. The BP is within normal range and only slightly elevated
The BP is within normal range and only slightly elevated. Her heart rate is elevated, so the nurse could check the patient’s medications to see if she is on a bronchodilator or other medication that could cause her heart rate to increase. The priority reading is the increased respiratory rate and the decreased oxygen saturation despite the 40% oxygen setting.

47. Based on the patient’s vital signs, what should the nurse do first?
(cont’d)
Based on the patient’s vital signs, what should the nurse do first?
Inform the provider of her abnormal vital signs.
Complete an assessment of the patient’s airway and respiratory status.
Explain to the patient that she must try to relax.
Notify the Rapid Response Team for extra assistance.
ANS: B
The patient may be experiencing some problems with her respiratory system. She had problems maintaining her saturation during the night, and her low oxygen saturation has not improved. Therefore, the nurse should first complete an assessment to be able to report any abnormal findings to the health care provider. The nurse should not call the provider before doing this. Her anxiety is likely related to the lack of oxygen and once this problem is resolved, her heart rate and respiratory rate will probably return to normal. The Rapid Response Team should be notified only if the patient has a further decline in respiratory status.

48. ANS: B
The patient may be experiencing some problems with her respiratory system. She had problems maintaining her saturation during the night, and her low oxygen saturation has not improved. Therefore, the nurse should first complete an assessment to be able to report any abnormal findings to the health care provider. The nurse should not call the provider before doing this. Her anxiety is likely related to the lack of oxygen and once this problem is resolved, her heart rate and respiratory rate will probably return to normal. The Rapid Response Team should be notified only if the patient has a further decline in respiratory status.

49. (cont’d)
As the assessment is completed, the nurse notes that the patient has a large amount of secretions visible from her trach, which are tenacious in appearance.
What is the nurse’s next best action?
Call the respiratory therapist for a stat bronchodilator treatment.
Suction the artificial airway and remove the secretions using 100% oxygen.
Instruct the UAP to give her a massage to try to calm her down.
Add pulmonary toileting to her daily interventions.
ANS: B
The most important intervention is to clear the airway. It is not necessary to call the respiratory therapist at this time. The secretions are tenacious and copious, which indicates a potential problem. Once her airway is clear, then all of the other options can be considered. The patient should be monitored very carefully and the health care provider notified about these findings.

50. ANS: B
The most important intervention is to clear the airway. It is not necessary to call the respiratory therapist at this time. The secretions are tenacious and copious, which indicates a potential problem. Once her airway is clear, then all of the other options can be considered. The patient should be monitored very carefully and the health care provider notified about these findings.

51. (cont’d)
After morning care, the student nurse is to perform tracheostomy care under the RN’s supervision.
Which instructions does the RN give the student nurse? (Select all that apply.)
Suction the tracheostomy tube after the trach care.
Create a sterile field.
Remove old dressings and excess secretions.
Clean the inner cannula with full strength hydrogen peroxide.
Change trach ties if soiled.
ANS: B, C, E
The student nurse should be taught to suction the tracheostomy tube before performing trach care if needed. The inner cannula should be cleaned with half-strength hydrogen peroxide, followed by sterile saline, and dried to prevent any of the solution from entering the tracheostomy.

52. ANS: B, C, E
The student nurse should be taught to suction the tracheostomy tube before performing trach care if needed. The inner cannula should be cleaned with half-strength hydrogen peroxide, followed by sterile saline, and dried to prevent any of the solution from entering the tracheostomy.

53. Question 1
True or False: Flammable solutions containing high concentrations of alcohol or oil should not be used in rooms with oxygen. Therefore, hand hygiene using alcohol-based foams or gels should be avoided when caring for patients on oxygen therapy.
True
False
Answer: B (False)
Rationale: Flammable solutions containing high concentrations of alcohol or oil are not used in rooms in which oxygen is in use. However this does not include alcohol-based hand rubs.
(Source: Accessed August 1, 2011, from

54. Answer: B (False)
Rationale: Flammable solutions containing high concentrations of alcohol or oil are not used in rooms in which oxygen is in use. However this does not include alcohol-based hand rubs.
(Source: Accessed August 1, 2011, from

55. Question 2 What complication would the patient with a
cuffed tracheostomy be at risk for developing?
Tracheomalacia
Pneumothorax
Subcutaneous emphysema
Trachea–innominate artery fistula
Answer: A
Rationale: Tracheomalacia can develop because of the constant pressure exerted by the cuff, causing tracheal dilation and erosion of cartilage. Pneumothorax can develop during any tracheostomy procedure if the thoracic cavity is accidentally entered. Subcutaneous emphysema can develop during any tracheostomy procedure if air escapes into fresh tissue planes of the neck. Trachea–innominate artery fistula can occur any time a malpositioned tube causes its distal tip to push against the lateral wall of the tracheostomy.

56. Answer: A
Rationale: Tracheomalacia can develop because of the constant pressure exerted by the cuff, causing tracheal dilation and erosion of cartilage. Pneumothorax can develop during any tracheostomy procedure if the thoracic cavity is accidentally entered. Subcutaneous emphysema can develop during any tracheostomy procedure if air escapes into fresh tissue planes of the neck. Trachea–innominate artery fistula can occur any time a malpositioned tube causes its distal tip to push against the lateral wall of the tracheostomy.

57. Question 3
If vagal stimulation occurs during suctioning, what should the nurse do?
Place the patient in a high Fowler’s position.
Oxygenate the patient with 100% oxygen.
Instruct the patient to breathe slowly and deeply.
Instruct the patient to cough.
Answer: B
Rationale: Vagal stimulation may occur during suctioning and result in severe bradycardia, hypotension, heart block, ventricular tachycardia, asystole, or other dysrhythmias. If vagal stimulation occurs, stop suctioning immediately and oxygenate the patient manually with 100% oxygen. Repositioning the patient, slow deep breathing, and coughing will not address the cardiovascular effects of vagal stimulation.

58. Answer: B
Rationale: Vagal stimulation may occur during suctioning and result in severe bradycardia, hypotension, heart block, ventricular tachycardia, asystole, or other dysrhythmias. If vagal stimulation occurs, stop suctioning immediately and oxygenate the patient manually with 100% oxygen. Repositioning the patient, slow deep breathing, and coughing will not address the cardiovascular effects of vagal stimulation