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Oxygen Therapy, Suctioning

and Tracheostomy Care

Judith Moore-Hepburn
RN, BScN, MScN, ET
Goals

 Indications for oxygen use

 Various delivery systems used to administer oxygen

 Safety precautions necessary during the administration of O2

 Indications for the need for oral suctioning

 Technique for safe suctioning

 Protocol for tracheostomy care and suctioning


Oxygenation
• Respiration: controlled in the respiratory center in the
brain stem; receives chemical and mechanical signals
from the body and sends messages to diaphragm and
accessory muscles via the spinal cord.
• Ventilation: accomplished through respiration,
inhalation and exhalation (The movement of gases into and out
of the lungs).
• Diffusion: exchange of CO2 and O2 across the alveolar
membrane
• Perfusion: depends on the heart and circulatory system
to move oxygen to the tissues and cells
Conditions that Alter Oxygenation
• Decreased LOC • Pneumothorax
• Neuromuscular impairment • Pulmonary edema (CHF)
• Spinal injuries (Cervical C4) • Chronic Bronchitis
• Altered respirations (dyspnea, • Pneumonia
orthopnea) • Emphysema
• Airway obstruction • COPD
• Obesity • Pulmonary embolism
• Pregnancy • Cardiac conditions
• Full stomach • Anemia
• Musculoskeletal deformities • Acid-base imbalances
• Trauma to chest
Oxygen Therapy

• Administration of supplemental oxygen to a


patient to prevent hypoxia

• Hypoxia is a condition where there is


insufficient oxygen to meet the metabolic needs
of tissues/cells
S & S of Acute Hypoxia

• Apprehension, Anxiety, Restlessness, Confusion,


↓LOC
• ↑pulse, ↑RR, ↑BP
• Dyspnea
• Use of accessory muscles
• Cool clammy cyanotic extremities, lips
• Cardiac dysrhythmias
S & S of Insidious Hypoxia
• Pallor
• Increased fatigue
• Decreased ability to concentrate
• Dizziness
• Behavioural changes
• Cyanosis
• Clubbing
• Adventitious breath sounds
Laboratory Tests
Arterial/Capillary Blood Gases:
• pH: 7.35-7.45
• pO2: 80-100mmHg
• pCO2: 35-45 mmHg
• O2 Saturation: 95-100%

**pO2 decreases with age; lower limit of normal


decreases by 1mmHg for every year over the age
of 60
Nursing Interventions for Patients Receiving O2
1. Oxygen is considered a drug & requires a doctors order.
2. Monitor patient’s respiratory status.
3. Check O2 flow rate regularly, sometimes family/patient fiddle
with equipment.
4. Check that O2 system is patent, water in chamber, no kinked
tubing etc.
5. Provide skin and nasal care: check behind ears and nares for any
pressure trauma.
6. Provide frequent mouth care. O2 therapy is very drying on mucus
membranes of mouth and nose. Set up mouth care tray at bedside,
(oral swabs, H2O, water-based lip protection).
7. Post “No smoking: Oxygen in Use” signs on door.
Oxygen Therapy
Goals:
• Correction of arterial hypoxemia
• Minimize cardiopulmonary workload
compensatory response

Detrimental Effects:
• Oxygen induced hypoventilation
• Absorption atelectasis
• Oxygen toxicity
Hypoxic Breathing Stimulus
• Normally body is stimulated to breathe because of
buildup of CO2 which stimulates the respiratory centre

• Chronic high CO2 levels → respiratory center loses its


sensitivity to excess CO2 → body is stimulated to breathe
by falling O2 levels

• Administration of high concentrations of oxygen to


someone who has a “hypoxic breathing stimulus” can
result in a suppression of the drive to breath
Absorption Atelectasis
• The gas mixture in our lungs is 79% nitrogen and
21% oxygen

• The nitrogen does not participate in gas exchange,


but rather acts as a stint to keep the alveoli open at
all times

• High levels of oxygen will wash out the nitrogen


resulting in areas of alveolar collapse = atelectasis
Oxygen Toxicity
• Breathing high levels of O2 for extended periods
will place the patient at risk for oxygen toxicity

• Exposure to 50% or greater for more than 24 hours


increases risk

• Symptoms include alveolar edema, congestion and


inflammation

• Usually reversible
Nasal Prongs

• Flow rate 1-6 Lpm (Litres per min)


• Higher flow rates dry the nasal mucosa
and do not increase inspired oxygen
• Ensure patient is not using oil based products around
nasal prongs (i.e.,Vaseline)
• Always ensure the prongs are tightened around their
chin and not their neck
• Humidification used with more than 4 Lpm
• Delivered oxygen varies depending on RR and depth
of breath
Conversion Chart
Flow through the Prongs Approximate FiO2

1 Lpm 21-24%
2 Lpm 24-28%
3 Lpm 28-32%
4 Lpm 32-36%
5 Lpm 36-40%
6 lLpm 40-44%

FiO2 = fraction of inspired oxygen


Simple Face Mask

• Oxygen-air mixture is not constant


• Oxygen flow rates used allow oxygen to be drawn in
through exhalation ports on the side of the mask
• Oxygen delivered can approach 35-50% with rates of
6-10 Lpm
• Shaped to fit snuggly over the patient’s mouth and
nose with metal flap which can be shaped to fit over
the nose and secured with an elastic strap
Conversion Chart

Flow Rate FiO2

5-6 Lpm 40%


6-7 Lpm 50%
7-10 Lpm 60%

FiO2 = fraction of inspired oxygen


Venturi Mask

• Provides controlled precise high flow rate


• At the jet site, air is entrained (through the
ports) in direct proportion to the flow rate with
which the oxygen moves through the tubing
• As long as the total flow rate exceeds the
patient’s peak inspiratory flow demands, the
desired percentage is delivered
Conversion Chart
Flow Rate FiO2

4 Lpm 24%
5 Lpm 28%
6 Lpm 31%
7 Lpm 35%
8 Lpm 40%
10 Lpm 50%

FiO2 = fraction of inspired oxygen


Non-Rebreathing Mask

• Provides between 60 - 90% oxygen concentrations


• A one-way valve between the respirator bag and mask allows O2
flow to enter into the mask from the reservoir bag during inspiration,
but prevents exhaled air from entering bag
• One way valve(s) on the exhalation ports are positioned to not allow
gas to enter the mask from the room during inspiration but to allow
gas to leave the mask during expiration
• Set the wall flow meter to 12-15 Lpm
• Bag should remain full during inspiration and exhalation
Nebulizer to Mask

• Large volume nebulizer is an aerosol generator


used to provide humidification to the respiratory
tract
• Indications for use: tracheostomy or thick,
tenacious bronchial secretions
• Oxygen concentration is a variable setting
• One end of 6 feet of corrugated tubing is attached
to the nebulizer, the other to the wall
Incentive Spirometer or
Sustained Maximal Inspiration device (SMI)
How to Use an Incentive Spirometer
Purpose:
• Deep breathing exercises with your incentive spirometer
(breathing exerciser) will help open the air sacs in your
lungs and may reduce future problems. You can use this
incentive spirometer on your own and take an active part in
your recovery!

Steps:
1. Attach the open end of the clear tubing to the port or
opening at the bottom of the incentive spirometer. The
mouthpiece is at the other end of the tubing.

2. Hold the incentive spirometer upright.


How to Use an Incentive Spirometer
3. Your respiratory therapist (RT) or nurse will determine how
deeply you should be able to normally breathe, based on your sex,
height, and age.

4. Breathe out normally, close your lips tightly around the


mouthpiece and inhale slowly and deeply through your mouth.
This slow deep breath will raise the piston in the clear chamber of
the spirometer. This is similar to trying to suck a thick milkshake
through a straw.
• It is important to breathe in slowly to allow the air sacs in your
lungs time to open.
• Your incentive spirometer may have an indicator to let you know
if you are breathing in too fast.
How to Use an Incentive Spirometer
5. Continue to breathe in, trying to raise the piston as high as you
can. Read the volume that you have achieved at the top of the
piston.
• If you have had surgery on your chest or stomach area, do not be
alarmed if your breath is not very deep. Each day you use your
incentive spirometer you should see improvement in how deep a
breath you can take.

6. When you feel you cannot breath in any longer take the
mouthpiece out of your mouth. Hold your breath for 3-5 seconds
then breath out slowly.
How to Use an Incentive Spirometer
7. Breathe normally for a few breaths and let the piston return to
the bottom of the chamber.

8. Set the goal indicator tab at the level that you reached.

9. Repeat the slow, deep breath in and slow breath out again.
Continue this cycle for a total of 15 breaths. If you start to feel
lightheaded or dizzy, slow your breathing down and take a longer
time with normal size breaths between the deep breaths
Tracheostomy
• Surgical creation of a stoma into the trachea
• Emergency or Elective

Why Is it Done?
• Relief of acute or chronic upper airway obstruction
• Access for continuous mechanical ventilation
• Prevention of aspiration pneumonia
• Prolonged endotracheal tube insertion resulting in
erosion or pain
Tracheostomy
• Tracheostomy is fitted with a tube to maintain airway patency
• Tubes vary in size, shape and number of parts

Universal Tracheostomy Tube:


• Most common, has 3 parts: outer cannula with a cuff, flange and
pilot tube; inner cannula which can be removed; obturator
which facilitates non-traumatic insertion of the outer cannula
• Obturator should be kept at the head of the bed and travel with
client
• Inner cannula inserts into the outer cannula and locks into place,
can be removed to clean usually 1-4 x day depending on
secretions
• Outer cannula can have a cuff that is inflated to protect the
lower airway from secretions
Shiley Trach
Jackson Trach
Tracheostomy
Single Lumen Tracheostomy Tubes:
Does not have inner cannula that can be removed for
cleaning
Should not be used for clients with lots of secretions or
difficulty clearing secretions
Needs humidification to prevent obstruction by
accumulated secretions
Fenestrated Tracheostomy Tube:
Has one large opening or several small on the posterior
side of the tube which permits speech and more effective
coughing, only works when the inner cannula is not in
place
Tracheostomy
Tracheostomy Speaking Valves:
• One-way valve that permits speaking without
the need to plug the trachea

Permanent Tracheostomy:
• Often with laryngectomy patients the trachea is
sutured to the skin so they do not need tube
once the stoma is healed
Potential Problems
Associated with a Tracheostomy
Tracheal Wall Necrosis:
• Can lead to the formation of a fistula with the esophagus
• Abdominal distension because air escapes into the stomach
• Can also lead to life threatening hemorrhage if erosion goes into
the artery; you may detect pulsation in the tracheostomy tube
before erosion takes place
• Associated with extended use of cuffed trach and or a trach cuff
that has been over inflated

Tracheal Dilation:
• Suspect when it takes increasing amounts of air to seal the cuff
Potential Problems
Associated with a Tracheostomy
Tracheal Stenosis:
• Narrowing of the trachea resulting from the formation of scar
tissue
• Prevented by choosing right size of tube, maintaining proper cuff
inflation
Airway Obstruction:
• Occlusion of trachea for several reasons, most common is the
accumulation of dried secretions
• First step is to remove the inner cannula, if it does not clear,
suction, & inject 3-5 mL normal saline into trach if you need to
loosen secretions
• Long term: ensure adequate hydration to promote thinner
secretions
Potential Problems
Associated with a Tracheostomy
Infection:
• Increased risk b/c bypass the upper airway protective mechanisms,
decreased mucociliary action and often a diminished cough
• Can also get a stoma infection
• Protocol for complete changes of the tracheostomy tube, maximum
time b/t changes should not exceed 6-8 weeks

Accidental Decannulation:
• To reinsert remove the inner cannula, deflate the cuff, place the
obturator into the out cannula, insert into the stoma and
immediately remove the obturator
• Call for help
Weaning from a Tracheostomy:
• Begins by deflating the cuff to determine the client’s ability to
manage secretions without aspirating them
• May insert a smaller uncuffed tube to ensure adequate ventilation
around the tube
• The tube is then plugged to determine the client’s ability to breath
through the upper airway, start with short time and lengthen as ct is
able to tolerate
• Weaning can take 2-5 days

Removing Tracheostomy Tube:


• Place a dry sterile dressing over the tube, occlusive to prevent hole
from remaining open because of air flow through the stoma,
change bid - tid.
Tracheostomy Care
• Tracheostomy care should be performed q shift and PRN
• Remove old dressing, note amount and colour of
drainage and discard dressing and gloves
• With second set of gloves inspect stoma site for signs of
infection or irritation
• If secretions are encrusted use sterile NaCl soaked gauze
to loosen and cleanse the area
• Clean trach site with cotton tipped applicator using
sterile NaCl, use only a single sweep with each
applicator; move from the stoma outwards
• Allow stoma to air dry if possible then apply sterile
dressing
Cleaning the Inner Cannula
• Remove the inner cannula by stabilizing the
outside of the tracheostomy tube
• 1:1 hydrogen peroxide solution is poured
over/through the cannula to loosen secretions,
may require pipe cleaners to loosen secretions
• Rinse inner cannula thoroughly with sterile NaCl
to remove secretions and H2O2 before reinserting
• Do not leave the inner cannula to soak because it
increases the risk of bacterial proliferation
Suctioning
Indications that suctioning is required:
• patient is unable to clear secretions by coughing
• mucus bubbling in trach tube
• gurgles heard on auscultation
• trouble breathing
• restless
• low O2 Saturation
• audible gargling sounds
• cyanosis
• increased ventilator inspiratory pressure
(for pt on ventilator, a high pressure alarm may sound)
• patient request
• stridor or changes in breathing sounds
Suctioning
• Administer ventilation with ambu bag (manual
resuscitation bag) as necessary for patient prior to
suctioning or have patient take few deep breaths
• Moisten the catheter with saline
• Occlude the suction port to check suction pressure and
effectiveness
• Do not cover the suction port while inserting the catheter
• During suctioning insert the catheter into trach
approximately 2 - 3 inches beyond distal end of trach
tube
Suctioning
• As you start to withdraw, rotate catheter between thumb
and first finger. The catheter should be in constant motion
to prevent irritation due to prolonged suction of the
sensitive trachea tissues.
• Periodically release suction pressure to ensure that tracheal
tissues are not being damaged by constant suction.
• Each suction should not exceed 10 seconds in total
(from insertion of catheter to withdrawal of catheter).
Flush catheter with saline between suctions.
• Allow the patient to breathe and/or cough between
suctions. Replace trach mask to allow patient to breathe
humidified oxygen between suctions.
Suctioning
• Observe pt response. A grimace or cough may
indicate that the catheter is too deep and irritating the
tracheal mucosa or carina.

• Observe for signs of respiratory distress. If the pt


becomes distressed, stop suctioning immediately. In
this case, ask the pt if they are okay. Administer
ventilation using manual resuscitation bag as
necessary and monitor pt’s vital signs.

• Flush catheter with saline.

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