Module 8 - Oxygen Therapy & Trach Care

Coughing Techniques

Pursed-lip Breathing

• Deep inspiration and prolonged expiration through pursed lips

Diaphragmatic Breathing

• During exhalation, air carrying CO2 is expelled from the body

• This cycle is essential for maintaining energy and body balance

Deep Breathing & Coughing

• Facilitates diaphragm excursion and enhances thorax expansion

• Deep breaths expand the lungs fully

Incentive Spirometer

Benefits

• Prevents post-op lung complications

• Improves lung expansion and oxygenation

• Better recovery after surgery

Nasal Prongs

• A low-flow device

• Breathe through the nose

• Observe for pressure points

• Each addition literally adds 3% FiO2 to the inspired air (up to 6L)

Simple Mask

40-60% FiO2 at 5-8L/min

Partial Rebreather (PNRB) / Non-Rebreather (NRB)

Low-flow with reservoir bag

Partial

• Min flow of 10L/min

• 40-60% O2 concentration

Non-rebreather high concentration

• Min flow of 10L/min

• 60-90% O2 concentration

• 80-95% FiO2 at 10-15L/min

Venturi Mask

High flow

24-60% O2 concentration

Entrains room air to achieve a consistent and precise O2 concentration

Tracheostomy

A surgical opening in the anterior wall of the trachea just below the larynx

• Provides an alternative airway, bypassing the upper passages

• Facilitates the removal of secretions

• Permits long-term mechanical ventilation

Securing Tracheostomy Tube

• First 24 hours - securement devices is not changed until an order is received

• After 24 hours - can be changed with 2 HCP (risk for decannulation)

• One finger should fit between the patient and the device

• Change at least daily or when soiled

Outer Cannula Change

• Initial change will be by a physician or RT

• Once established - can be changed by authorized practitioner or RN

• Risk for accidental decannulation - airway obstruction (emergency)

Inner Cannula Change

1. Stabilize the neck plate of the trach tube with one hand and squeeze the inner cannula to prepare for removal

2. Inspect inner cannula for cleanliness and integrity

3. Reinsert new cannula after lubricating it with NS

Trach Stoma Care

1. Cleanse with NS

2. Q-tip or 2×2 drain sponge to gently cleanse around the stoma 5-10cm out from the stoma and both sides

3. Premade trach sponges or 4×4 drain sponge between the patient’s skin and ties

4. Dressings are not necessary for long-term trachs

Suctioning

For when a patient is unable to clear respiratory tract secretions with cough

Oral Suction

• Patient can cough but can’t expel or swallow

Oropharyngeal

• Patient unable to cough and clear secretions

Tracheal

• Semi fowlers (30-45°)

• Wall suction for adults is 80-120mmHg

• During inhalation: insert suction catheter until resistance

• Max suction time: 10 seconds

Chest Tube

One-way drains that allow fluid (serous, sanguineous, purulent) and/or air to escape the pleural or mediastinal space

Recognize Cues

• Respiratory Status Changes

  • Use of accessory muscles

  • Tachypnea

• Insertion Site Cues

  • Increasing pain at the insertion site

  • Subcutaneous emphysema

• Patient behaviour and changes in VS

  • Restlessness, anxiety, agitation

  • Hypotension, tachycardia

  • Increasing pain that limits breathing effort

• Chest tube drainage and equipment

  • Sudden increase in drainage

  • Change in drainage colour and consistency

  • Continuous bubbling → air leak in the system

  • No tidaling → indicate obstruction or full lung re-expansion or kink

Chest Tube Indications

Pneumothorax - accumulation of air in the pleural cavity that leads to partial or complete lung collapse; can be closed or open pneumothorax, hemothorax, or pneumohemothorax

COTS (Closed, open, tension, or spontaneous pneumothorax)

Chest Tube Insertion

Air → placed anteriorly through the 2nd intercostal space

Fluid & Blood → placed posteriorly through the 8th or 9th intercostal space

Chest Tube Management

Chest tubes attached to a drainage unit with adjustable suction levels require an order for amount of suction

Drainage units must be maintained below the chest level in an upright position

A bottle of sterile water must be at the bedside in case of disconnection

Two chest tube clamps must be with patient while chest tubes are in place

• Chest tubes may be clamped to assess whether a chest is ready to removed per order

• Chest tube may be clamped for <1 minute to:

  • Change drainage unit

  • Locate an air leak

  • Assess bubbling & fluctuating (tidaling) of the unclamped chest tube

Chest Tube Disconnection

If chest tube falls out of patient’s chest

• Cover the area with dry, sterile gauze

If chest tube disconnects from the drainage system

• Put the end of tube in a container of sterile water

• Keep below the level of patient’s chest

Chest Tube Complications

An obstructed or displaced chest tube is a common cause of tension pneumothorax

No No’s

• Never milk or strip the chest tube

• No continuous bubbling in the water seal/air leak chamber

• Never clamp during transport - only done before removal or changing the drainage device

SOBeIT

Suction - setup and function

Oxygen - verifies O2 rate and device

Bed - lifts to safe working height

IV - rate, solution, and site

Tubes - verifies fluid levels, presence, and patency