Care of Patients Requiring Oxygen Therapy or Tracheostomy Chapter 30 Care of Patients Requiring Oxygen Therapy or Tracheostomy Mrs. Marion Kreisel MSN, RN NU230 Adult Health 2 Fall 2011

Oxygen Therapy Hypoxemia—low levels of oxygen in the blood Hypoxia—decreased tissue oxygenation Goal of oxygen therapy—to use the lowest fraction of inspired oxygen for an acceptable blood oxygen level without causing harmful side effects

Oxygen Intake and Oxygen Delivery

Hazards and Complications of Oxygen Therapy Combustion Oxygen-induced hypoventilation Oxygen toxicity Absorption atelectasis Drying of mucous membranes Infection

Low-Flow Oxygen Delivery Systems Nasal cannula Simple facemask

Low-Flow Oxygen Delivery Systems (Cont’d) Partial rebreather mask Non-rebreather mask

High-Flow Oxygen Delivery Systems Venturi mask Face tent Aerosol mask Tracheostomy collar T-Piece

Venturi Mask

T-Piece

Noninvasive Positive-Pressure Ventilation Technique uses positive pressure to keep alveoli open and improve gas exchange without airway intubation BiPAP—mechanical delivery of set positive inspiratory pressure each time the patient begins to inspire; as the patient begins to exhale, the machine delivers a lower set end-expiratory pressure, together improving tidal volume. CPAP—continuous positive airway pressure

Continuous Positive Airway Pressure (CPAP)

Continuous Nasal Positive Airway Pressure Technique delivers a set positive airway pressure throughout each cycle of inhalation and exhalation. Effect is to open collapsed alveoli. Patients who may benefit include those with atelectasis after surgery or cardiac-induced pulmonary edema; it may be used for sleep apnea. Assess pt for improved sleep. If not make sure patient is using the CPAP on a regular basis.

Transtracheal Oxygen Delivery Used for long-term delivery of oxygen directly into the lungs Avoids the irritation that nasal prongs cause and is more comfortable Flow rate prescribed for rest and for activity

Home Oxygen Therapy Criteria for home oxygen therapy equipment Patient education for use: Compressed gas in a tank or cylinder Liquid oxygen in a reservoir Oxygen concentrator

Oxygen Therapy

Tracheostomy Tracheotomy is the surgical incision into the trachea for the purpose of establishing an airway. Tracheostomy is the stoma, or opening, that results from the procedure of a tracheotomy. Procedure may be temporary or permanent.

Tracheostomy

Interventions Preoperative care Operative procedures Postoperative care—ensure patent airway Possible complications assessment: Tube obstruction Tube dislodgment—accidental decannulation

Other Possible Complications Assess for: Pneumothorax Subcutaneous emphysema Bleeding Infection

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

Tracheostomy Tubes

Tracheostomy Tubes

Care Issues for the Tracheostomy Patient Prevention of tissue damage: Cuff pressure can cause mucosal ischemia. Use minimal leak technique and occlusive technique. Check cuff pressure often. Prevent tube friction and movement. Prevent and treat malnutrition, hemodynamic instability, or hypoxia.

Cuff Pressures

Air Warming and Humidification The tracheostomy tube bypasses the nose and mouth, which normally humidify, warm, and filter the air. Air must be humidified. Maintain proper temperature. Ensure adequate hydration.

Suctioning Suctioning maintains a patent airway and promotes gas exchange. Assess need for suctioning from the patient who cannot cough adequately. Suctioning is done through the nose or the mouth. Suctioning can cause: Hypoxia (see causes to follow) Tissue (mucosal) trauma Infection Vagal stimulation and bronchospasm Cardiac dysrhythmias from hypoxia caused by suctioning

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

Possible Complications of Suctioning Tissue trauma Infection of lungs by bacteria from the mouth Vagal stimulation—stop suctioning immediately and oxygenate patient manually with 100% oxygen Bronchospasm—may require a bronchodilator

Tracheostomy Care Assessment of the patient. Secure tracheostomy tubes in place. Prevent accidental decannulation. Patient may shower as long as they are careful not to get water into the stoma.

Bronchial and Oral Hygiene Turn and reposition every 1 to 2 hr, support out-of-bed activities, encourage early ambulation. Coughing and deep breathing, chest percussion, vibration, and postural drainage promote pulmonary cure. Oral hygiene—avoid glycerin swabs or mouthwash that contains alcohol; assess mouth for ulcers, bacterial or fungal growth, or infections.

Nutrition Swallowing can be a major problem for the patient with a tracheostomy tube in place. If the balloon is inflated, it can interfere with the passage of food through the esophagus. Elevate the head of bed for at least 30 minutes after the patient eats to prevent aspiration during swallowing.

Speech and Communication Patient can speak with a cuffless tube, fenestrated tube, or cuffed fenestrated tube that is capped or covered. Patient can write. Phrase questions to patient for “yes” or “no” answers. A one-way valve that fits over the tube and replaces the need for finger occlusion can be used to assist with speech.

Fenestrated Tracheostomy Tube

Weaning from a Tracheostomy Tube Weaning is a gradual decrease in the tube size and ultimate removal of the tube. Cuff is deflated as soon as the patient can manage secretions and does not need assisted ventilation. Change from a cuffed to an uncuffed tube. Size of tube is decreased by capping; use a smaller fenestrated tube. Tracheostomy button has a potential danger of getting dislodged.

NCLEX TIME

Question 1 Nitrogen gas makes up what percentage of room air? 10% 21% 49% 79% Answer: D Rationale: Nitrogen makes up 79% of room air. Oxygen is 21% of room air.

Question 2 What is a possible outcome when oxygen delivery is combined with smoking? The oxygen will burn. An explosive effect will be produced. The combustion process will be supported and enhanced. The combustion process will be sped up. Answer: C Rationale: Oxygen supports and enhances (not speeds up) the process of combustion. Oxygen itself does not burn.

Question 3 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.

Question 4 A patient who is hypoxemic also has chronic hypercarbia (increased Paco2 levels). What is the appropriate flow of oxygen delivery for this patient? 1 L/min via nasal cannula 4 L/min via nasal cannula 6 L/min via nasal cannula 40% oxygen via Venturi mask Answer: A Rationale: The patient who is hypoxemic and has chronic hypercarbia (increased partial pressure of arterial carbon dioxide [Paco2] levels) needs lower levels of oxygen delivery, usually 1 to 2 L/min via nasal cannula, to prevent decreased respiratory effort because a low Pao2 level is this patient’s primary drive for breathing.

Question 5 A patient experiences vagal stimulation during deep tracheal suctioning. The nurse would expect to see: Severe tachycardia Severe bradycardia Hypertension Bronchospasm Answer: B Rationale: Vagal stimulation may occur during suctioning and results in severe bradycardia, hypotension, heart block, ventricular tachycardia, asystole, or other dysrhythmias. Bronchospasm may also occur during suctioning but is not due to vagal stimulation.