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

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.

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.

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

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)

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

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

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.

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

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.

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

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

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

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

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).

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.

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.

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.

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.

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

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.

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.

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

Continuous Positive Airway Pressure (CPAP)

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

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

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

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

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

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

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

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

Other Possible Complications Pneumothorax Subcutaneous emphysema Bleeding Infection

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

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.

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

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

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

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

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

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

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

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

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.

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.

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.

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.

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.

(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.

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.

(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.

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.

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 http://www.cdc.gov/handhygiene/Basics.html)

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 http://www.cdc.gov/handhygiene/Basics.html)

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.

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 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.

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