Respiratory Module

Oxygen Delivery Systems

I. Compostion of Air

Remember that human respirations- the air that leaves a person's lung during exhalation contains 14% oxygen and 4.4% carbon dioxide.

II. Oxygen Delivery Systems

Nasal cannula - is used at a flow rate of 1 - 6L/minute, providing approximate oxygen concentration of 24% (at 1L/min) to 44% (at 6L/min).

• Flow rates higher than 6L/min do not significantly increase oxygenation because the oral and nasal cavities are full.  
• Is used for patients with chronic airflow limitations and for long-term oxygen used.  
• Add humidification when a flow rate higher than 2L/min is prescribed and check water levels and change the humidifier as needed.
• Assess the nasal mucosa because high low rate have a drying effect and can increase mucosal irritation - why we use humidification.  
• Assess skin integrity because the tubing can cause skin breakdown.  

Simple face mask - is used to deliver oxygen concentrations of 40% to 60% for short-term oxygen therapy or to deliver oxygen in an emergency.

• A minimal flow rate of 5L/min is needed to prevent the rebreathing of exhaled air and flush the mask of carbon dioxide.
• Be sure the mask fits securely over the nose and mouth because a poorly fitting mask reduces the fraction of inspired oxygen delivered.  
• Assess skin integrity and provide skin care to the area as moisture under the mask cause skin breakdown.  
• Remember a mask may reduce the ability for the patient to clear their mouth - assess for risk of aspiration.

Partial rebreather mask - consists of a mask with reservoir bag that provides an oxygen concentration of 70% (at 6L/min) to 90 % (at 15L/min).  

• The patient rebreathes one third of the exhaled tidal volume, which is high in oxygen.
• Make sure the reservoir bag does not become kink, twisted or deflated.   Ensure a flow rate high enough to maintain the bag two-thirds full during inspiration is needed.

Non-rebreather mask - provides the highest concentration of oxygen, higher than 90% (65% - 100%) depending on the patient's ventilation pattern.  

• Is used on the deteriorating patient.
• Has a one-way valve between the mask and the reservoir and two flaps over the exhalation ports.   The values allow patients to draw the entire quantity of oxygen from the reservoir bag.   And, the flaps prevent room air from entering through the exhalation ports.   During exhalation, air leaves through the exhalation ports while the one-way value prevents exhaled air from reentering the reservoir bag.  
• Maintain flow rates that inflated the bag to two-thirds full.  

  Aerosols mask, hood, tent, tracheostomy tube or collar connected to wide bore tubing that receives aerosolized oxygen from a jet nebulizer.

• Adjusts air entrapment in a manner similar to the Venturi device
• Administers high humidity
• Monitor weight of t tube-stress on trach tube, or drain excess fluid from collar

Venturi Mask is based on a mechanism that pulls in a specific proportional amount of room air for each liter of oxygen delivered.  

• FI02 is delivered at a rate of 24% (4L/min) - 55% (10L/min).  
• Monitor the patient closely to ensure an accurate flow rate for a specific FIO2

CPAP allows spontaneously breathing patients to receive positive airway pressure with or without an artificial airway.

• Improves arterial oxygenation, avoiding intubation, can talk and eat
• Requires very tight fit-some interference with talking and eating-gastric distention, nausea/vomiting/pneumothorax
• Continuous assessment necessary
• May be used intermittently as with BiPap

Blood Gas Interpretation

I. How to Interpret Blood Gases

Step 1 Look at the Oxygenation Status

• Examine the PO2 and SaO2
• Are they within normal range ?
• Is the patient on supplemental O2 ?
• What is going on at the tissue level ?

Step 2  Look at the pH

 < 7.4   =  Acidosis

 > 7.4   =  Alkalosis

Step 3  Study the PCO2 and HCO3

Identify the primary acid-base problem

• Look at the PCO2
• Identifies if the problem is respiratory
• Pco2  < 35 = base/alkaline
• Pco2 > 45 = acid

Look at the HCO3-

• Identifies if the problem is metabolic
• HCO3-  < 22 = acid
• HCO3-  > 26 = base/alkaline

Step 4  Determine if Compensation has occurred

Compensation

• The primary system causing the acid/base abnormality continues to be effected.
• The opposite system begins to adjust (compensate) to return the pH back to NORMAL

Example: PCO2 = 50 => kidneys will retain (reabsorb) HCO3 to counter balance and neutralize the acidosis, hopefully enough to bring the pH back to normal range

 Steps Not to be Forgotten...

Observe the Patient

• Evaluate the VS, physical assessment
• Are ABG values normal for this patient?

Evaluate why abnormal values exist

Implement appropriate interventions needed to correct acid-base imbalance

 II. Normal Arterial Blood Gases

pH        =   (acid) 7.35 - 7.45 (base)

Pco2        =   (base) 35 - 45 mmHg (acid)

HCO3-    =   (acid) 22 - 26  mEq (base)

BE        =   (acid) -2 to +2 (base)

Po2       =    80 - 100 mmHg

SaO2    =    95 - 100%

 III. Interpretation Time

IV. In Summary

Maintaining normal serum pH is essential for life

ABGs are laboratory findings that will help clinicians identify acid-base imbalance and oxygenation status

ABGs are an adjunct to clinical assessments and both should be considered when treating a patient

*If you would like more practice please download the "ABG Worksheet Activity" found on Canvas

Chest Tubes

I.   Chest Tube Drainage System - The chest tube drainage system returns negative pressure to the intrapleural space and is used to remove abnormal accumulation of air and fluids from the pleural space

Collection chamber

• The collection chamber is located where the chest tube from the patient connects to the system
• Drainage from the tubes collects in a series of calibrated columns in this chamber

Water seal chamber

• The tip of the tube is underwater, allowing fluid and air to drain from the pleural space and preventing air from entering the pleural space
• Water oscillates (moves as the patient inhales and moves down as the patient exhales)
• Excessive bubbling indicates an air leak in the chest tube system

Suction control chamber

• The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest
• This chamber is filled with various levels of water to achieve the desired level of suction; without this control, lung tissue could be sucked into the chest tube
• Gentle bubbling in this chamber indicates that there is suction and does not indicate that air is escaping from the pleural space

Dry suction system

• Because this is a dry system, absence of bubbling is noted in the suction control chamber
• A knob on the collection device is used to set up the prescribed amount of suction; then the wall suction source dial is turned until a small floater valve appears in the window on the device

 II. Nursing Interventions

Collection chamber

• Monitor drainage; notify the physician if drainage is more than 100mL/hr or if drainage becomes bright red or increases suddenly
• Mark the chest tube drainage in the collection chamber using a piece of tape

Water seal chamber

• Monitor for fluctuation of the fluid level in the water seal chamber
• Fluctuation in the water seal chamber stops if the tube is obstructed, a dependent loop exists, the suction is not working properly, or if the lung has reexpanded
• If the patient has a known pneumothorax, intermittent bubbling in the water seal chamber is expected as air is drained from the chest, but continuous bubbling indicates an air leak in the system
• Notify the physician if there is continuous bubbling in the water seal chamber

Suction control chamber: gentle (not vigorous) bubbling should be noted in the suction control chamber

An occlusive sterile dressing is maintained at the insertion site

A chest x-ray assesses the position of the tube and determines whether the lung has reexpanded

Assess respiratory status and auscultate lung sounds

Keep the drainage system below the level of the chest and the tubes free of kinks, dependent loops, or other obstructions

Ensure that all connections are secure

Keep a clamp and sterile occlusive dressing at the bedside at all times

Never clamp a chest tube without a written order from the physician

If the drainage system cracks or breaks, insert the chest tube into a bottle of sterile water, remove the cracked or broken system, and replace with a new system

If the chest tube is pulled out of the chest accidentally, pinch the skin opening together; apply an occlusive sterile dressing, tape and call the physician immediately

When the chest tube is removed, the patient is asked to take a deep breath and hold it; the tube is removed; a dry sterile dressing, petroleum gauze dressing or telfa dressing is taped in place after the removal of the chest tube

Tracheostomy Care & Suctioning

I.   Description

A tracheostomy is an opening made surgically directly into the trachea to establish an airway.

A tracheostomy tube is inserted into the opening and tube attaches to the mechanical ventilator or another type of oxygen delivery system.

A tracheostomy can be temporary or permanent.  

II. Interventions

Assess respirations and for bilateral breath sounds. 

Monitor arterial blood gases and pulse oximetry.

Encourage coughing and deep breathing.

Maintain a semi-Fowler's to high Fowler's position.

Monitor for bleeding difficulty with breathing, absence of breath sounds and crepitus, which are indications of hemorrhage or pneumothorax.

Provide respiratory treatments as prescribed.

Suction fluids as needed; Hyperoxygenate the patient before suctioning.

If the patient is allowed to eat, sit the patient up for meals and ensure the cuff in inflated for meals and for one hour after meals to prevent aspiration.

Monitor cuff pressures as prescribed.

Asses the stoma and secretions for blood   or purulent drainage.  

Follow the physician's prescription and agency policy for cleaning the tracheostomy site and inner cannula; usually half-strength hydrogen peroxide is used.

Administer humidified oxygen as prescribed, because the normal humidification process is bypassed.

Replace new ties before removing the old ties - this holds the tracheostomy in place.

Keep a resuscitation bag, obturator and a spare tracheostomy tube of the same size at the bedside.  

III. Complications

  Tube obstruction

                      1.   Assessment to include: difficulty in breathing, noisy respirations, difficulty in

                                inserting the suction catheter, thick, dry secretions.

                      2.   Prevention and interventions include: assisting the patient to cough and deep breathe,

                                provide humidification and suctioning, clean the inner cannula regularly.

   Tube dislodgment

• Prevention and interventions include: secure the tube in place.   Minimize manipulation and traction on the tube.   Ensure that a tracheostomy tube of the same type and size is at the patient's bedside.  

Laryngeal or tracheal injury

Pulmonary infections, sepsis

Dependence on artificial airway

IV. Tracheostomy Care Technique

1. Perform hand hygiene and apply gloves and face shield, if applicable.
2. Verify correct patient using two identifiers.
3. Suction tracheostomy.
4. Remove soiled tracheostomy dressing, remove gloves, and discard dressing in glove with coiled catheter.
5. While patient is replenishing oxygen stores, prepare equipment on bedside table.
6. Apply sterile gloves. Keep dominant hand sterile throughout procedure.
7. Hyperoxygenate the patient, if the patient has oxygen saturation levels below 92%. Apply oxygen source loosely over tracheostomy if patient desaturates during procedure.
8. Perform tracheostomy care.
9. Clean exposed outer cannula surfaces and stoma under faceplate extending 5 to 10 cm (2 to 4 inches) in all directions from stoma.
10. Dry skin and expose outer cannula surfaces by patting lightly with a dry 4 × 4 inch gauze.
11. Secure tracheostomy.
12. Position patient comfortably, and assess respiratory status.
13. Replace any oxygen delivery sources.
14. Remove gloves and face shield and discard in appropriate receptacle. Perform hand hygiene.
15. Replace cap on normal saline solution bottles. The normal saline solution may be used for not more than 24 hours. Store unused supplies in appropriate place.
16. Document the procedure in the patient's record.

Click here for demo

Excerpted and adapted from Perry AG, Potter PA: Clinical nursing skills & techniques, ed 7, St. Louis, 2010, Mosby.

V. Tracheostomy Suctioning Technique

1. Determine appropriate suctioning technique. You will be using OPEN in the med-surg areas.
2. Ensure family understand procedure and questions are answered.
3. Assess patient's respiratory status, including clinical signs of need for tracheal suctioning.
4. Gather needed equipment and supplies.
5. Monitor patient's vital signs and indications of inadequate oxygenation and ventilation before, during, and after suctioning.
6. Ensure suction is turned on and pressure is within recommended range.
7. Perform hand hygiene.
8. Select appropriate size of suction catheter on the basis of internal diameter of the artificial airway.
   1. Use of multi-eyed catheters is preferred over use of single-eyed catheters.
9. Verify measured length for catheter insertion before tracheal suctioning.

10. Put on gloves sterile gloves using sterile technique. Put on personal protective equipment, including eye protection, mask, and a gown (as indicated).

11.With nondominant hand, pick up and manipulate suction connecting tubing while using the dominant hand to hold suction catheter.

12.Disconnect patient from oxygen source with nondominant hand

13. Insert suction catheter into the tracheostomy tube to premeasured length without application of suction.

14. Put thumb over the suction port and apply suction while withdrawing the catheter. As catheter is withdrawn, use a twisting motion.

15. Return patient to oxygen source. Administer hyperoxygenation or hyperventilation with MVB as clinically indicated.

16 Reassess need for further passes of the suction catheter and repeat steps 11 to 15.

17. To dispose of catheter, wrap it around the dominant hand and pull the glove off inside out. Remove other glove and discard it in a waste container.

18. Remove personal protective equipment and discard.

19. Flush connecting tubing with saline solution or sterile water.

20. Turn off suctioning device and secure suction at bedside in clear view for future suctioning needs.

21. Perform postassessment of breath sounds to determine any pertinent changes after suctioning.

22. Perform hand hygiene.

23. Document the procedure in the patient's medical record.

Excerpted and adapted from AACN Procedure Manual for Pediatric Acute and Critical Care, American Association of Critical-Care Nurses, edited by Judy Trivits Verger, PhD, MSN, RN, CCRN; and Ruth M. Lebet, MSN, CCNS, CCRN, St. Louis: Elsevier/Saunders, 2007.