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.
Hazards and Complications of Oxygen Therapy
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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.
Hazards and Complications of Oxygen
Therapy
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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
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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
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Drying of the mucous membranes
Infection
A bubble humidifier bottle used with
oxygen therapy
Oxygen Delivery Systems
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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.
Low-flow oxygen delivery systems
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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
Low-flow oxygen delivery systems
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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
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 nonrebreather 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 oneway 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
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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
High-flow oxygen delivery systems
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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
A T-piece apparatus for attachment to an
endotracheal or tracheostomy tube.
Example of transtracheal oxygen delivery.
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
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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
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
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
TRACHEOSTOMY
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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
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
Single-lumen cannula cuffed tracheostomy tube
Dual-lumen cannula cuffed fenestrated tracheostomy tube
Care Issues for the Tracheostomy Client
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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.
Air Warming and Humidification
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The tracheostomy tube bypasses the nose and
mouth, which normally humidify, warm, and
filter the air.
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Air must be humidified.
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Maintain proper temperature.
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Ensure adequate hydration.
Suctioning
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Suctioning maintains a patent airway and promotes gas
exchange.
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Assess need for suctioning from the client who cannot
cough adequately.
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Suctioning is done through the nose or the mouth.
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Suctioning can cause:
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Hypoxia (see causes to follow)
Tissue (mucosal) trauma
Infection
Vagal stimulation and bronchospasm
Cardiac dysrhythmias from hypoxia caused by suctioning
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
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Turn and reposition every 1 to 2 hours, support
out-of-bed activities, encourage early
ambulation.
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Coughing and deep breathing, chest percussion,
vibration, and postural drainage promote
pulmonary cure.
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Oral hygiene—avoid glycerine swabs or
mouthwash that contains alcohol; assess mouth
for ulcers, bacterial or fungal growth, or
infections.
Nutrition
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Swallowing can be a major problem for the
client with a tracheostomy tube in place.
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If balloon is inflated, it can interfere with the
passage of food through the esophagus.
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Elevate head of bed for at least 30 minutes after
client eats to prevent aspiration during
swallowing.
Speech and Communication
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Client can speak with a cuffless tube, fenestrated tube,
or cuffed fenestrated tube that is capped or covered.
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Client can write.
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Phrase questions to client for “yes” or “no” answers.
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A one-way valve that fits over the tube and replaces the
need for finger occlusion can be used to assist with
speech.
Weaning from a Tracheostomy Tube
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Weaning is a gradual decrease in the tube size and
ultimate removal of the tube.
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Cuff is deflated as soon as the client can manage
secretions and does not need assisted ventilation.
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Change from a cuffed to an uncuffed tube.
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Size of tube is decreased by capping; use a smaller
fenestrated tube.
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Tracheostomy button has a potential danger of getting
dislodged.