Chapter 30

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

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.

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. 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.

23. Cuff Pressures

24. 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.

25. 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.

26. Suctioning(Cont’d) • 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.

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.

35. Weaning from a Tracheostomy Tube(Cont’d) • 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.