Interventions for Clients Requiring Oxygen Therapy or Tracheostomy

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Interventions for Clients Requiring Oxygen
Therapy or Tracheostomy
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• Therapeutic oxygen is used for both acute and
  chronic respiratory conditions associated with
  decreased blood and tissue oxygen levels as
  indicated by decreased partial pressure of
  arterial oxygen (PaO2) levels or by decreased
  arterial oxygen saturation (SaO2).
• Conditions outside the respiratory system that
  increase oxygen demand, decrease oxygen-carrying
  capability of the blood, or decrease cardiac
  output also are indications for oxygen therapy.
  Such conditions include sepsis, fever, and
  decreased hemoglobin levels or poor hemoglobin
  quality

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• The goal of oxygen therapy is to use the lowest
  fraction of inspired oxygen (FiO2) to obtain the
  most acceptable oxygenation without causing the
  development of harmful side effects
• The average client requires an oxygen flow of 2
  to 4 L/min via nasal cannula or up to 40 via
  Venturi mask.
• The client who is hypoxemic and also has chronic
  hypercarbia (increased partial pressure of
  arterial carbon dioxide PaCO2 levels) requires
  lower levels of oxygen delivery, usually 1 to 2
  L/min via nasal cannula, to prevent decreased
  respiratory effort. (A low PaO2 level is this
  client's primary drive for breathing.

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Hazards and Complications of Oxygen Therapy

• Combustion
• Oxygen-induced hypoventilation
• The central chemoreceptors in the brain (medulla)
  are normally sensitive to increased Paco2 levels,
  which stimulate breathing and cause an increased
  respiratory rate. When the Paco2 increases over
  time to above 60 to 65 mm Hg, this normal
  mechanism shuts off. The central chemoreceptors
  lose their sensitivity to increased levels of
  Paco2 and no longer respond by increasing the
  rate and depth of respiration, a condition called
  CO2 narcosis. For these clients, the stimulus to
  breathe is a decreased arterial oxygen
  concentration as sensed by peripheral
  chemoreceptors found in the carotid sinus areas
  and aortic arch. When partial pressure of
  arterial oxygen (Pao2) levels drop (hypoxemia),
  these receptors signal the brain to increase the
  respiratory rate and depth the hypoxic drive to
  breathe.
• The hypoxic drive occurs only in the presence of
  severely elevated PaCO2 levels (i.e., in the
  client who has hypoxemia and hypercarbia). When
  the client with low Pao2 levels and high Paco2
  levels receives oxygen therapy, the Pao2 level
  increases, removing the stimulation for
  breathing, and the client experiences respiratory
  depression. (The client being ventilated
  mechanically is not at risk for this
  complication.

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Hazards and Complications of Oxygen Therapy

• Oxygen toxicity
• High concentrations of oxygen are avoided unless
  absolutely necessary. The addition of continuous
  positive airway pressure (CPAP) with an oxygen
  mask, bilevel positive airway pressure (Bi-PAP),
  or positive end-expiratory pressure (PEEP) on the
  mechanical ventilator may reduce the amount of
  oxygen needed. As soon as the client's clinical
  condition allows, the physician decreases the
  prescribed amount of oxygen
• Absorption atelectasis
• Nitrogen normally plays a large role in the
  maintenance of patent airways and alveoli. Making
  up 79 of room air, nitrogen prevents alveolar
  collapse. When high concentrations of oxygen are
  delivered, nitrogen is diluted, oxygen diffuses
  from the alveoli into the pulmonary circulation,
  and the alveoli collapse. Collapsed alveoli cause
  atelectasis (called absorption atelectasis),
  which is detected by auscultation
• Drying of the mucous membranes
• Infection

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A bubble humidifier bottle used with oxygen
therapy
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Oxygen Delivery Systems

• Oxygen delivery systems are classified according
  to the rate at which oxygen is delivered. There
  are two systems low-flow systems and high-flow
  systems.
• Low-flow systems do not provide enough flow of
  oxygen to meet the total inspiratory effort of
  the client. Part of the tidal volume is supplied
  by inspiring room air. The total concentration of
  oxygen received depends on the respiratory rate
  and tidal volume.
• In contrast, high-flow systems provide a flow
  rate that is adequate to meet the entire
  inspiratory effort and tidal volume of the client
  regardless of the respiratory pattern. High-flow
  systems are used for critically ill clients and
  when it is particularly important to know the
  precise concentration of oxygen being delivered.
• If the client requires a mask but is able to eat,
  the nurse requests an order for a nasal cannula
  at an appropriate liter flow for mealtimes only.
  The mask is replaced after the meal is completed.
  
• To increase mobility, up to 50 feet of connecting
  tubing can be used with proper connecting pieces.

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Low-flow oxygen delivery systems

• NASAL CANNULA. The nasal cannula, or nasal
  prongs, is used at flow rates of 1 to 6 L/min.
  Approximate oxygen concentrations of 24 (at 1
  L/min) to 44 (at 6 L/min) can be achieved.
• The nasal cannula is frequently used for chronic
  lung disease and for long-term maintenance of
  clients with other illnesses. The nurse places
  the nasal prongs in the nostrils, with the
  openings facing the client

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Low-flow oxygen delivery systems

• SIMPLE FACE MASK. A simple face mask is used to
  deliver oxygen concentrations of 40 to 60 for
  short-term oxygen therapy or in an emergency. A
  minimum flow rate of 5 L/min is needed to prevent
  the rebreathing of exhaled air. The nurse gives
  special attention to skin care and to the proper
  fitting of the mask so that inspired oxygen
  concentration is maintained

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Low-flow oxygen delivery systems

• PARTIAL REBREATHER MASK. A partial rebreather
  mask provides oxygen concentrations of 60 to
  75, with flow rates of 6 to 11 L/min. It
  consists of a mask with a reservoir bag but no
  flaps. The client first rebreathes one third of
  the exhaled tidal volume, which is high in
  oxygen, thus providing a high fraction of
  inspired oxygen (Fio2).
• The nurse ensures that the bag remains slightly
  inflated at the end of inspiration otherwise,
  the client will not be getting the desired oxygen
  prescription. If needed, the nurse calls the
  respiratory therapist for assistance

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Low-flow oxygen delivery systems

• NON-REBREATHER MASK. A non-rebreather mask
  provides the highest concentration of the
  low-flow systems and can deliver an Fio2 greater
  than 90, depending on the client's breathing
  pattern. The non-rebreather mask is used most
  often with deteriorating respiratory status who
  might soon require intubation.
• The non-rebreather mask has a one-way valve
  between the mask and the reservoir and two flaps
  over the exhalation ports. The valve allows the
  client to draw all needed oxygen from the
  reservoir bag, and the flaps prevent room air
  from entering through the exhalation ports.
  During exhalation, air leaves through these
  exhalation ports while the one-way valve prevents
  exhaled air from re-entering the reservoir bag.

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High-flow oxygen delivery systems

• VENTURI MASK. The Venturi mask (commonly called
  Venti mask) delivers the most accurate oxygen
  concentration. Its operation is based on a
  mechanism that pulls in a specific proportional
  amount of room air for each liter flow of oxygen.
  An adaptor is located between the bottom of the
  mask and the oxygen source. Adaptors with holes
  of different sizes allow only specific amounts of
  air to mix with the oxygen. Precise delivery of
  oxygen results. Each adaptor also specifies the
  flow rate to be used for example, to deliver 24
  of oxygen, the flow rate must be 4 L/min. Another
  type of Venturi mask has one adaptor with a dial
  that the nurse uses to select the amount of
  oxygen desired. Humidification is not necessary
  with the Venturi mask. The Venturi system is best
  for the client with chronic lung disease because
  it delivers a precise oxygen concentration

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High-flow oxygen delivery systems

• OTHER HIGH-FLOW SYSTEMS. The face tent, aerosol
  mask, tracheostomy collar, and T-piece are often
  used to administer high humidity. A dial on the
  humidification source regulates the oxygen
  concentration being delivered.
• A face tent fits over the chin, with the top
  extending halfway across the face. The oxygen
  concentration varies, but the face tent, instead
  of a tight-fitting mask, is useful for facial
  trauma or burns.
• An aerosol mask is used when high humidity is
  required after extubation or upper airway surgery
  or for thick secretions.
• The tracheostomy collar can be used to deliver
  high humidity and the desired oxygen to the
  client with a tracheostomy.
• A special adaptor, called the T-piece, can be
  used to deliver any desired Fio2 to the client
  with a tracheostomy, laryngectomy, or
  endotracheal tube. The flow rate is regulated so
  that the aerosol does not disappear on the
  exhalation side of the T-piece

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A T-piece apparatus for attachment to an
endotracheal or tracheostomy tube.
Example of transtracheal oxygen delivery.
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Noninvasive positive-pressure ventilation

• Noninvasive positive-pressure ventilation (NPPV)
  is a newer technique using positive pressure to
  keep alveoli open and improve gas exchange
  without the need for airway intubation.
• This type of ventilation can deliver oxygen or
  may just use room air. Essentially, a nasal mask
  or full-face mask delivery system allows
  mechanical delivery of either bilevel positive
  airway pressure (BiPAP) or continuous nasal
  positive airway pressure.
• For BiPAP, a cycling machine delivers a set
  inspiratory positive airway pressure each time
  the client begins to inspire. As the client
  begins to exhale, the machine delivers a lower
  set end expiratory pressure. Together, these two
  pressures improve tidal volume.
• Nasal continuous positive airway pressure
  delivers a set positive airway pressure
  continually throughout each cycle of inhalation
  and exhalation. The effect is to open collapsed
  alveoli. Clients who might benefit from this form
  of oxygen or air delivery include those with
  postoperative atelectasis or cardiac-induced
  pulmonary edema. This technique is also used for
  sleep apnea. The effect of this use is to hold
  open the upper airways

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Transtracheal oxygen therapy

• Transtracheal oxygen (TTO) is a long-term method
  of delivering oxygen directly into the lungs. The
  physician passes a small, flexible catheter into
  the trachea via a small incision with the use of
  local anesthesia.
• TTO allows better compliance and avoids the
  irritation that nasal prongs cause. Clients also
  report it to be more cosmetically acceptable.
• A TTO team provides formal client education,
  including the purpose of TTO and care of the
  catheter. The physician prescribes a TTO flow
  rate for rest and for activity and a flow rate
  for the nasal cannula, to be used when the TTO
  catheter is being cleaned. The average client
  will have a 55 reduction in required oxygen flow
  at rest and a 30 decrease with activity

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Home care management

• CRITERIA FOR HOME OXYGEN THERAPY
• The client must be clinically stable and
  optimally treated before the need for home oxygen
  is considered.
• For Medicare to cover the cost of continuous
  oxygen therapy, the client must have severe
  hypoxemia.
• For reimbursement purposes, severe hypoxemia is
  generally defined as a partial pressure of
  arterial oxygen (Pao2) level of less than 55 mm
  Hg or an arterial oxygen saturation (Sao2) of
  less than 88 on room air and at rest.
• The criteria are variable when hypoxemia is
  caused by cardiac rather than pulmonary problems,
  or when oxygen is needed only at night or with
  exercise

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Home care management

• CLIENT EDUCATION
• After the need for home oxygen therapy is
  verified, the nurse begins a teaching plan about
  oxygen therapy. The client, with the nurse's
  assistance, selects a durable medical equipment
  (DME) company to deliver oxygen equipment and a
  community health nursing agency for follow-up
  care in the home. The physician re-evaluates the
  need for oxygen therapy approximately 6 months
  after discharge from the health care facility and
  yearly thereafter.
• While providing discharge planning and teaching,
  the nurse is sensitive to the client's
  psychologic adjustment to oxygen therapy. The
  nurse encourages the client to share feelings and
  concerns. The client may be concerned about
  social acceptance and misconceptions of friends.
  The nurse helps him or her realize that
  compliance with oxygen therapy is important so
  that normal activities of daily living (ADLs) and
  events that bring enjoyment can be continued

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TRACHEOSTOMY

• Tracheotomy is the surgical incision into the
  trachea for the purpose of establishing an
  airway.
• Tracheostomy is the (tracheal) stoma, or opening,
  that results from the tracheotomy. A tracheostomy
  can be performed as an emergency procedure or as
  a scheduled surgical procedure and can be
  temporary or permanent

Indications for tracheostomy
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Complications

• Tube obstruction
• Tube dislodgment or accidental decannulation
• Pneumothorax
• Subcutaneous emphysema
• Bleeding
• Infection

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Tracheostomy tubes

• Double-lumen tube
• Single-lumen tube
• Cuffed tube
• Cuffless tube
• Fenestrated tube
• Cuffed fenestrated tube
• Metal tracheostomy tube
• Talking tracheostomy tube

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Dual-lumen cuffed tracheostomy tube with
disposable inner cannula
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Single-lumen cannula cuffed tracheostomy tube
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Dual-lumen cannula cuffed fenestrated
tracheostomy tube
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Care Issues for the Tracheostomy Client

• 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.

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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.

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Suctioning

• Suctioning maintains a patent airway and promotes
  gas exchange.
• Assess need for suctioning from the client 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

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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

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Possible Complications of Suctioning

• Tissue trauma
• Infection of lungs by bacteria from the mouth
• Vagal stimulation stop suctioning immediately
  and oxygenate client manually with 100 oxygen
• Bronchospasm may require a bronchodilator

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Tracheostomy Care

• Assessment of the client
• Secure tracheostomy tubes in place
• Prevent accidental decannulation

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Bronchial and Oral Hygiene

• Turn and reposition every 1 to 2 hours, support
  out-of-bed activities, encourage early
  ambulation.
• Coughing and deep breathing, chest percussion,
  vibration, and postural drainage promote
  pulmonary cure.
• Oral hygieneavoid glycerine swabs or mouthwash
  that contains alcohol assess mouth for ulcers,
  bacterial or fungal growth, or infections.

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Nutrition

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

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Speech and Communication

• Client can speak with a cuffless tube,
  fenestrated tube, or cuffed fenestrated tube that
  is capped or covered.
• Client can write.
• Phrase questions to client 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.

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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 client 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.