1. 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

2. 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

3. Oxygen Intake and Oxygen Delivery

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

5. Low-Flow Oxygen Delivery Systems
Nasal cannula
Simple facemask

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

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

8. Venturi Mask

9. T-Piece

10. 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

11. Continuous Positive Airway Pressure (CPAP)

12. 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.

13. 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

14. 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

15. Oxygen Therapy

16. 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.

17. Tracheostomy

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

19. Other Possible Complications
Assess for:
Pneumothorax
Subcutaneous emphysema
Bleeding
Infection

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

21. Tracheostomy Tubes

22. Tracheostomy Tubes

23. 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.

24. Cuff Pressures

25. 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.

26. 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

27. 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

28. 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

29. 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.

30. 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.

31. 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.

32. 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.

33. Fenestrated Tracheostomy Tube

34. 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.

35. NCLEX TIME

36. 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.

37. 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.

38. 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.

39. 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.

40. 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.