Chapter 30
Care of
Patients Requiring
Oxygen Therapy
or
Tracheostomy
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
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.
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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.
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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
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Clinical Manifestations of
Respiratory Distress
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Dyspnea
Nasal flaring
Use of accessory muscles to breathe
Pursed-lip or diaphragmatic breathing
Decreased endurance
Skin, mucous membrane changes (pallor,
cyanosis)
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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
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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
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Oxygen Intake and
Oxygen Delivery
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Assessment of Oxygenation
ABG analysis is best way to determine need for
oxygen therapy
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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
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Hazards & Complications of Oxygen
Therapy (continued)
• Absorption atelectasis—new onset of
crackles/decreased breath sounds (oxygen
replaces nitrogen)
• Drying of mucous membranes
• Infection
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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
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What’s the difference between low
and high flow oxygen delivery
systems?
• Low flow:
• High flow:
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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
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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
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Simple Facemask
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Delivers O2 up to 40%-60%
Minimum of 5 L/min
Mask fits securely over nose and mouth
Monitor closely for risk of aspiration
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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
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Non-Rebreather Mask
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Highest O2 level
Can deliver FIO2 greater than 90%
Used for unstable patients requiring intubation
Ensure valves are patent and functional
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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?
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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
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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
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T-Piece
• Delivers desired FIO2 for tracheostomy,
laryngectomy, ET tubes
• Ensures humidifier creates enough mist
• Mist should be seen during inspiration and
expiration
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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
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Continuous Positive Airway Pressure
(CPAP)
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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
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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
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Home Oxygen Therapy
• Criteria for equipment
• Patient education:
– Compressed gas in tank or cylinder
– Liquid oxygen in reservoir
– Oxygen concentrator
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Oxygen Therapy
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Tracheostomy
• Tracheotomy—surgical incision into trachea
for purpose of establishing an airway
• Tracheostomy—stoma (opening) that
results from tracheotomy
• May be temporary or permanent
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Tracheostomy (cont’d)
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Priority Problems For Patients
With Tracheostomies
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Reduced oxygenation
Inadequate communication
Inadequate nutrition
Potential for infection
Damaged oral mucosa
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Interventions
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Preoperative care
Operative procedures
Postoperative care—ensure patent airway
Assess for possible complications
– Tube obstruction/dislodgment
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Other Possible Complications
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Pneumothorax
Subcutaneous emphysema
Bleeding
Infection
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Tracheostomy Tubes
• Disposable or reusable
• Cuffed tube or tube without cuff for airway
maintenance
• Inner cannula disposable or reusable
• Fenestrated tube
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Tracheostomy Tubes (cont’d)
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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
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Cuff Pressures
An aneroid pressure manometer for cuff inflation and measuring cuff
.
pressures
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Air Warming and Humidification
• Tracheostomy tube bypasses nose and
mouth, which normally humidify, warm,
and filter air
• Air must be humidified
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Suctioning
• Maintains patent airway, promotes gas
exchange
• Assess the need in patients who cannot
cough adequately
• Done through nose, mouth or
tracheostomy
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Complications of Suctioning
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Hypoxia
Tissue (mucosal) trauma
Infection
Vagal stimulation, bronchospasm
Cardiac dysrhythmias from induced hypoxia
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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
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Tracheostomy Care
• Assess the patient
• Secure tracheostomy tubes in place
• Prevent accidental decannulation
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Fenestrated
Tracheostomy Tube
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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.
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(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?
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• 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.
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(cont’d)
Based on the patient’s vital signs, what should
the nurse do first?
A. Inform the provider of her abnormal vital
signs.
B. Complete an assessment of the patient’s
airway and respiratory status.
C. Explain to the patient that she must try to
relax.
D. Notify the Rapid Response Team for extra
assistance.
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• 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.
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(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?
A. Call the respiratory therapist for a stat bronchodilator treatment.
B. Suction the artificial airway and remove the secretions using 100%
oxygen.
C. Instruct the UAP to give her a massage to try to calm her down.
D. Add pulmonary toileting to her daily interventions.
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• 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.
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(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.)
A. Suction the tracheostomy tube after the trach care.
B. Create a sterile field.
C. Remove old dressings and excess secretions.
D. Clean the inner cannula with full strength hydrogen
peroxide.
E. Change trach ties if soiled.
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• 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.
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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.
A. True
B. False
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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)
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Question 2
What complication would the patient with a
cuffed tracheostomy be at risk for
developing?
A. Tracheomalacia
B. Pneumothorax
C. Subcutaneous emphysema
D. Trachea–innominate artery fistula
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• 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.
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Question 3
If vagal stimulation occurs during suctioning,
what should the nurse do?
A. Place the patient in a high Fowler’s
position.
B. Oxygenate the patient with 100% oxygen.
C. Instruct the patient to breathe slowly and
deeply.
D. Instruct the patient to cough.
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• 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
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