CH. 16: Promoting Oxygenation Pg. 389-405, and 406 Oropharyngeal Suctioning

Promoting Oxygenation

Skills and Procedures

• Skill 16.1 Oxygen Administration, 391

• Skill 16.2 Airway Management: Noninvasive Positive-Pressure Ventilation, 397

• Procedural Guideline 16.1 Use of a Peak Flowmeter, 400

• Procedural Guideline 16.2 Using an Acapella Device, 401

• Procedural Guideline 16.3 Performing Percussion and Vibration (Chest Physical Therapy), 402

• Skill 16.3 Airway Management: Suctioning, 406

• Procedural Guideline 16.4 Closed (In-Line) Suctioning, 416

• Skill 16.4 Care of Artificial Airways, 418

• Skill 16.5 Managing Closed Chest Drainage Systems, 428

Introduction

Oxygen is necessary for the body's organs and tissues to function properly. When oxygen levels decrease due to reasons such as ineffective breathing patterns, obstructed airways, or excess mucus, patients show signs of hypoxia or hypoxemia, such as dyspnea, tachypnea, tachycardia, anxiety, or confusion. Interventions to treat the cause of decreased oxygenation need to be completed quickly to prevent permanent tissue or organ damage (Lewis et al., 2017).

Practice Standards

• American Association for Respiratory Care (AARC), 2010: AARC clinical practice guidelines: endotracheal suctioning of mechanically ventilated patients with artificial airways

• Institute for Healthcare Improvement (IHI), 2012: How-to guide: prevent ventilator-associated pneumonia—Guidelines for preventing the development of VAP in patients with artificial airways

• Intensive Care Society (ICS), 2014: ICS tracheostomy standards—Comprehensive multidisciplinary care of a patient requiring tracheostomy

• The Joint Commission (TJC), 2019: National Patient Safety Goals—Patient identification and infection prevention

Evidence-Based Practice

Ventilator-Associated Pneumonia

Ventilator-associated pneumonia (VAP) is defined as a pneumonia that occurs 48 hours or more after endotracheal intubation (Institute for Healthcare Improvement [IHI], 2016; Letchford and Bench, 2018). It is the most frequent nosocomial infection seen in patients in intensive care settings (Li et al., 2017). It has a mortality rate between 4.4% and 13%, with each instance of infection increasing patient costs by $20,000 to $40,000 (American Association of Critical Care Nurses [AACN], 2017b; Larrow and Klich-Heartt, 2016). IHI (2012) developed a set of bundled guidelines for the prevention of VAP.

Detailed Interventions for the Prevention of VAP

• Elevating the head of the bed between 30 and 45 degrees

• Daily sedative interruption with daily assessment of the patient's readiness to extubate

• Peptic ulcer disease prophylaxis

• Deep venous thrombosis prophylaxis

• Daily oral care with chlorhexidine

• Continuous subglottic suctioning

• Closed-system suctioning (for late-onset VAP)

• Continuous control of cuff pressure on endotracheal and tracheostomy tubes (Letchford and Bench, 2018; Li et al., 2017; Rouzé et al., 2017)

Future research is ongoing to attempt to identify the best method to perform oral care (toothbrush versus oral swabs) and different tracheostomy tube designs (AACN, 2017a; Chacko et al., 2017; Rouzé et al., 2017). Additional interventions are provided in Box 16.1.

Box 16.1

Care Bundle for Ventilator-Associated Pneumonia

• Practice good hand hygiene.

• Check internal endotracheal cuff pressure at 25 to 30 cm H2O every 2 hours.

• Maintain head of bed at 30 to 45 degrees.

• Provide prophylaxis for deep vein thrombosis and peptic ulcer disease.

• Provide daily interruptions of sedation to assess accurately for readiness to extubate.

• Provide oral care with chlorhexidine 0.12% every 12 hours and general oral care every 2 hours secondary to microbial colonization within the mouth.

• Perform complete subglottal suctioning to decrease risk of oral fluid aspiration.

• Maintain timely ventilator circuit changes and removal of condensation.

• Provide for mobility through turning and repositioning every 2 hours.

Data from American Association of Critical Care Nurses (AACN): AACN practice alert: prevention of ventilator-associated pneumonia in adults, 2017b. https://www.aacn.org/clinical-resources/practice-alerts/ventilator-associated-pneumonia-vap; Chacko R et al: Oral decontamination techniques and ventilator-associated pneumonia, Br J Nurs 26(11):594, 2017; Institute for Healthcare Improvement (IHI): How-to guide: prevent ventilator-associated pneumonia, 2012. http://www.ihi.org/resources/Pages/Tools/HowtoGuidePreventVAP.aspx; Larrow V, Klich-Heartt EI: Prevention of ventilator-associated pneumonia in the intensive care unit: beyond the basics, J Neurosci Nurs 48(3):160, 2016; Letchford E, Bench S: Ventilator-associated pneumonia and suction: a review of the literature, Br J Nurs 27(1):13, 2018; Li J et al: Evaluation of the safety and effectiveness of the rapid flow expulsion maneuver to clear subglottic secretions in vitro and in vivo, Respr Care 62(8):1007, 2017; and Wiegand D: AACN procedure manual for high acuity, progressive, and critical care, ed 7, St. Louis, 2017, Elsevier.

Safety Guidelines

Oxygen is a medication, requiring the seven rights of medication administration, and should be treated with care (Table 16.1). Patients who require oxygen therapy should have a thorough assessment with appropriate diagnostic testing performed before the administration of oxygen. Patients who require more invasive measures for assistance with their oxygenation needs, such as mechanical ventilation or artificial airways, have additional safety needs:

TABLE 16.1

Oxygen Safety Guidelines

Patient Assessment Guidelines

• Know a patient's normal range of vital signs, pulse oximetry (SpO2) values, most recent hemoglobin values, and past and current arterial blood gas (ABG) values, when available.

• Review a patient's previous respiratory assessment and perform a systematic respiratory assessment, noting rate, pattern, accessory muscle use, breath sounds, ability to cough, and integrity of the rib cage.

• Assess patient's cognitive level of function and medical and surgical history.

• Document a patient's smoking history. Smoking damages the mucociliary clearance mechanism of the lungs, resulting in a decreased ability to clear mucus from the airways.

• A home environmental assessment must be performed for patients who receive home oxygen therapy.

• Be aware of environmental conditions. Patients with chronic respiratory diseases have difficulty maintaining optimal oxygen levels in polluted environments or in the presence of allergens.

• Suction equipment should be available to help clear airway secretions, particularly in patients with artificial airways such as an endotracheal tube (ETT) or a tracheostomy.

• Use caution when suctioning patients with head injuries. The procedure causes an elevation in intracranial pressure (Galbiati and Paola, 2015).

• Most health care agencies require that a self-inflating resuscitation bag and appropriate-size mask be available in patient rooms, particularly for patients requiring mechanical ventilation.

SKILL 16.1 Oxygen Administration

Purpose

The purpose of supplemental oxygen therapy is to prevent or treat hypoxia (a state in which the supply of oxygen is insufficient for normal life functions) or hypoxemia (a lower-than-normal concentration of oxygen in arterial blood). Routes of administration include, but are not limited to, nasal cannula, face masks, noninvasive ventilation, and positive-pressure ventilators. Special care is required for each of these types of delivery devices (Table 16.2).

TABLE 16.2

Oxygen-Delivery Systems

*FiO2 delivered may differ by manufacturer. Check manufacturer's guidelines.

CO2, Carbon dioxide; FiO2, fraction of inspired oxygen concentration.

Source for high-flow nasal cannula: Walsh BK, Smallwood CD: Pediatric oxygen therapy: a review and update, Respir Care 62(6):645, 2017.

Source for noninvasive ventilation: Wiegand D: AACN procedure manual for high acuity, progressive, and critical care, ed 7 St. Louis, 2017, Elsevier.

Delegation and Collaboration

The skill of applying a nasal cannula or oxygen mask (but not adjusting oxygen flow) can be delegated to nursing assistive personnel (NAP). The nurse is responsible for assessing the patient's respiratory system and the response to oxygen therapy. The nurse, in some agencies, may collaborate with the respiratory therapist in the setup of oxygen therapy, including adjustment of oxygen flow rate. The nurse directs the NAP by:

• Informing how to safely adjust the device (e.g., loosening the strap on the oxygen cannula or mask) and clarifying its correct placement and positioning.

• Instructing to inform the nurse immediately about any changes in vital signs; changes in pulse oximetry (SpO2); changes in level of consciousness (LOC); skin irritation from the cannula, mask, or straps; or patient complaints of pain or shortness of breath.

• Instructing personnel to provide extra skin care around patient's ears and nose or other parts of the patient's body that might be irritated by the device.

Equipment

• Oxygen-delivery device as ordered by health care provider

• Oxygen tubing (consider extension tubing as needed)

• Humidifier, if indicated

• Sterile water for humidifier

• Oxygen source

• Oxygen flowmeter

• “Oxygen in use” sign

• Pulse oximeter

• Stethoscope

• Clean gloves

• Face shield, if risk of splash from secretions is present

Assessment

1. Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy.Rationale: Ensures correct patient. Complies with The Joint Commission standards and improves patient safety (TJC, 2019).

2. Review accuracy of health care provider's order for oxygen, noting delivery method, flow rate, duration of oxygen therapy, and parameters for titration of oxygen settings.Rationale: Ensures safe and accurate oxygen administration. Safe oxygen delivery includes the seven rights of medication administration (see Chapter 22).

3. Obtain data from patient's electronic health record (vital signs, pulse oximetry, arterial blood gas values).Rationale: Need to know patient baseline values to accurately evaluate effectiveness.

4. Perform hand hygiene and apply clean gloves. Perform respiratory assessment, including symmetry of chest wall expansion, chest wall abnormalities (e.g., kyphosis), temporary conditions affecting ventilation (e.g., pregnancy, trauma), respiratory rate and depth, sputum production, and lung sounds and for signs and symptoms associated with hypoxia (Box 16.2).Rationale: Reduces transmission of microorganisms. Changes in ventilation and gas exchange resulting in hypoxia require oxygen therapy.

   Box 16.2

   Signs and Symptoms of Hypoxia

   • Apprehension

   • Restlessness

   • Irritability

   • Confusion

   • Lethargy

   • Tachypnea

   • Dyspnea

   • Accessory muscle use

   • Inability to speak in complete sentences

   • Tachycardia

   • Mild hypertension

   • Diaphoresis

   • Fatigue

   • DysrhythmiasFrom Lewis SL et al: Medical-surgical nursing: assessment and management of clinical problems, ed. 10, St. Louis, 2017, Elsevier.

5. Observe for cognitive and/or behavioral changes (e.g., apprehension, anxiety, confusion, decreased ability to concentrate, decreased LOC, fatigue, and dizziness).Rationale: Decreased levels of oxygen (hypoxia) or increased levels of carbon dioxide (hypercapnia) affect a person's cognitive abilities, interpersonal interactions, and mood (Lewis et al., 2017).

   Safe Patient Care

   Patients with sudden changes in their vital signs, LOC, or behavior may be experiencing profound hypoxia. Patients who demonstrate subtle changes over time may have worsening of a chronic or existing condition or a new medical condition (Lewis et al., 2017).

6. Assess airway patency and remove airway secretions by having patient cough and expectorate mucus or by suctioning (see Skill 16.3). NOTE: Perform additional hand hygiene and change gloves if there is contact with mucus.Rationale: Secretions plug the airway, decreasing the amount of oxygen that is available for gas exchange in lungs.

   Safe Patient Care

   Excessive amounts of secretions, signs of respiratory distress (increased work of breathing, increased respiratory rate), presence of rhonchi on auscultation, excessive coughing, or decrease in patient pulse oximeter can indicate need for suctioning.

7. Inspect condition of skin around nose and ears.Rationale: Provides baseline for monitoring development of skin breakdown from medical device irritation.

8. Assess patient's or family caregiver's knowledge, experience, and health literacy level.Rationale: Ensures patient has the capacity to obtain, communicate, process, and understand basic health information (Centers for Disease Control and Prevention [CDC], 2016).

Planning

1. Expected outcomes following completion of procedure:

• Patient's SpO2 (peripheral capillary oxygen saturation) and/or arterial blood gases (ABGs) return to or remain within normal limits or baseline levels.

  • Objective determinants of stable or improved arterial oxygenation.

• Patient's vital signs remain stable or return to baseline.

  • When there is no underlying cardiovascular disease, patients adapt to decreased oxygen levels by increasing pulse and blood pressure. This is a short-term adaptive response. Once signs of hypoxia are reduced or controlled, patient's vital signs usually return to normal.

• Patient's work of breathing decreases.

  • Pulmonary conditions such as pneumonia or asthma cause varying degrees of airway narrowing. With improved oxygenation, patient's airways are open, and work of breathing decreases.

• Patient experiences increased lung expansion.

  • Improved oxygenation helps resolve collapsed and constricted airways, improves work of breathing, and thus improves lung expansion.

• Patient's LOC returns to baseline.

  • Improvement in oxygenation relieves hypoxia and improves patient's mental status.

• Patient verbalizes improved levels of comfort, and subjective sensations of anxiety, fatigue, and breathlessness decrease.

  • Increased oxygen levels in the blood reduce patient's anxiety, fatigue, and breathlessness.

• Patient's ears, nares, and nasal mucosa remain intact.

  • Intact skin indicates no device-related pressure to underlying skin and mucous membrane (Pittman et al., 2015; Schallom et al., 2015).

2. Close room door or curtains around bed and prepare equipment and environment.

• Provides privacy and facilitates a smooth and organized procedure.

3. Adjust bed to appropriate height. Check locks on bed.

• Minimizes caregiver muscle strain and prevents injury. Prevents bed from moving.

4. Instruct patient and/or family caregiver about need for oxygen. If the oxygen is for home use, educate the patient about oxygen safety in the home (see Table 16.1) and the equipment that will be utilized.

• Education helps reduce patient and caregiver anxiety. Proper education about the use of and need for the oxygen equipment will help to ensure the safe and proper use of the equipment.

Implementation

1. Perform hand hygiene. Apply face shield if risk of exposure to splashing mucus exists. Apply clean gloves if patient has oral or nasal secretions.

• Reduces transmission of microorganisms.

2. Attach oxygen-delivery device (e.g., nasal cannula, face mask) to oxygen tubing and attach end of tubing to humidified oxygen source adjusted to prescribed flow rate (see illustration).

• Humidity prevents drying of nasal and oral mucous membranes and airway secretions. Flowmeters with smaller calibrations may be required for patients requiring low-dose oxygen such as pediatric patients (Hockenberry et al., 2017).

3. Apply oxygen device:

a. Place tips of the nasal cannula into patient's nares. If tips are curved, they should point downward inside nostrils. Then loop cannula tubing up and over patient's ears. Adjust lanyard so that cannula fits snugly but not too tight, without pressure to patient nares and ears (see illustration).

• Tips of nasal cannula direct flow of oxygen into patient's upper respiratory tract.

b. Apply a face mask by placing it over patient's mouth and nose. Then bring straps over patient's head and adjust to form a comfortable but tight seal.

• A properly fitting device that does not create pressure on nares or ears is comfortable, and patient is more likely to keep it in place; reduces risk for skin breakdown (Schallom et al., 2015).

c. Maintain sufficient slack on oxygen tubing and secure to patient's clothes.

• Allows patient to turn head without causing mask to shift position or dislodge nasal cannula.

4. Observe for proper function of oxygen-delivery device:

• Ensures patency of delivery device and accuracy of prescribed oxygen flow rate (see Table 16.2). a. Nasal cannula: Cannula is positioned properly in nares; oxygen flows through tips.

• Provides prescribed oxygen rate and reduces pressure on tips of nares.

b. Partial nonrebreather mask: Mask seals tightly around mouth. Reservoir fills on exhalation and almost collapses on inspiration. Reservoir should not collapse completely (see illustration).

• Easily humidifies oxygen and does not dry mucous membranes. Useful for short-term therapy of 24 hours or less.

c. Oxygen-conserving cannula (Oxymizer): Fit as for nasal cannula. Reservoir is located under patient's nose or worn as a pendant.

• Delivers higher flow of oxygen with nasal cannula. Delivers 2 : 1 ratio (e.g., 6 L/min nasal cannula is approximately equivalent to 3.5 L/min with Oxymizer device).

d. Nonrebreather mask: Apply as regular mask. Contains one-way valves with reservoir; exhaled air does not enter reservoir bag. Can be combined with nasal cannula to provide higher inspired oxygen concentration (FiO2).

• Device of choice for short-term high FiO2 delivery. Valves on mask side ports permit exhalation but close during inhalation to prevent inhaling room air.

e. Simple face mask: Select appropriate flow rate (see illustration).

• Used for short-term oxygen therapy.

f. Venturi mask (see illustration): Apply as regular mask. Select appropriate flow rate (see Table 16.2).

• Used when high-flow device is desired.

g. Face tent: Apply tent under patient's chin and over mouth and nose. It will be loose, and a mist is always present (see illustration).

• Excellent source of humidification; however, you cannot control oxygen concentrations, and patient who requires high oxygen cannot use this device.

h. High-flow nasal cannula (see illustration).

• Provides adjustable O2 delivery and flow-dependent CO2 clearance to reduce work of breathing and better match inspiratory demand during respiratory distress (Drake, 2018).

5. Verify setting on flowmeter and oxygen source for proper setup and prescribed flow rate.

• Ensures delivery of prescribed oxygen therapy in conjunction with specific cannula/mask.

6. Check nasal cannula/face mask every 8 hours or as agency policy indicates. Keep humidification container filled at all times.

• Ensures patency of cannula and oxygen flow. Oxygen is a dry gas; when it is administered via nasal cannula of 4 L/min or more, or administered to pediatric patients, you must add humidification to prevent thickening of secretions, minimize atelectasis, and prevent heat loss (Walsh and Smallwood, 2017).

7. Post “Oxygen in use” signs on wall behind bed and at entrance to room.

• Alerts visitors and care providers that oxygen is in use.

8. Properly dispose of gloves (if used) and perform hand hygiene.

• Reduces transmission of microorganisms.

9. Raise side rails (as appropriate) and lower bed to lowest position.

• Ensures patient safety.

10. Be sure nurse call system is accessible and within patient's reach. Instruct the patient on its use.

• Helps decrease incidence of falls; alerts the nurse when the patient needs assistance.

Evaluation

1. Monitor patient's response to changes in oxygen flow rate with SpO2. NOTE: Monitor ABGs when ordered; however, obtaining ABG measurement is an invasive procedure, and ABGs are not measured frequently.

• Continual monitoring with SpO2 is required for patients on oxygen therapy. Base changes in supplemental oxygen on individual patient's oxygen saturation levels.

2. Perform physical assessment, auscultating lung sounds; palpating chest excursion; inspecting color and condition of skin; and observing for decreased anxiety, improved LOC and cognitive abilities, decreased fatigue, and absence of dizziness. Measure vital signs.

• Evaluates patient's response to supplemental oxygen. As patient's oxygen level improves, physical signs and symptoms improve.

3. Assess adequacy of oxygen flow each shift or as agency policy dictates.

• Ensures patency of oxygen-delivery device.

4. Observe patient's external ears, bridge of nose, nares, and nasal mucous membranes for evidence of skin breakdown.

• Oxygen therapy sometimes causes drying of nasal mucosa. The delivery device can cause skin breakdown where device comes in contact with face, neck, and ears (Schallom et al., 2015).

5. Use Teach-Back: “I want to be sure I explained how oxygen will help you. Tell me why oxygen is beneficial for you.” Revise your instruction now or develop a plan for revised patient/family caregiver teaching if patient/family caregiver is not able to teach back correctly.

• Determines patient's/family caregiver's level of understanding of instructional topic.

Unexpected Outcomes and Related Interventions

1. Patient experiences skin irritation or breakdown (e.g., at ears, bridge of nose, nares, other pressure areas).

• Provide appropriate skin care. Do not use petroleum-based gel around oxygen because it is flammable (American Lung Association, 2018).

2. Patient experiences continued hypoxia.

• Notify health care provider.

• Obtain health care provider's orders for follow-up SpO2 monitoring or ABG determinations.

• Consider measures to improve airway patency, including but not limited to coughing techniques and oropharyngeal or orotracheal suctioning.

3. Patient experiences nasal and upper airway mucosa drying.

• If oxygen flow rate is greater than 4 L/min, use humidification. At rates greater than 5 L/min, nasal mucous membranes dry, and pain in frontal sinuses may develop (Lewis et al., 2017).

• Assess patient's fluid status and increase fluids if appropriate.

• Provide frequent oral care.

Recording

• Record the respiratory assessment findings, method of oxygen delivery and flow rate, patient vital signs and pulse oximetry values, and patient's response and any adverse reactions.

• Document evaluation of patient learning.

Hand-Off Reporting

• Report patient status, including recent assessment findings, vital signs, and SpO2 before oxygen administration.

• Report the type of oxygen-delivery device initiated and utilized, the initial flow rates, and if any adjustments to the flow rates were made during the shift. Include the patient response to the flow-rate adjustments and what interventions were successful.

• Report any unexpected outcomes, such as the development of reddened areas on ears or nose.

SKILL 16.2 Airway Management: Noninvasive Positive-Pressure Ventilation

Purpose

Noninvasive positive-pressure ventilation (NIPPV or NPPV) treats a variety of conditions, including obstructive sleep apnea (OSA), chronic obstructive pulmonary disease (COPD), and neuromuscular disorders (see Table 16.2). There are two types of NIPPV: continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP). NIPPV has fewer complications than invasive ventilation strategies, and it allows patients an increased ability to communicate with family caregivers.

Delegation and Collaboration

The skill of caring for a patient receiving noninvasive ventilation cannot be delegated to nursing assistive personnel (NAP). The nurse collaborates with the respiratory therapist when providing care for the patient. However, the skills of patient positioning and mask application can be delegated to NAP. The nurse directs the NAP by:

• Informing about the need to immediately report to the nurse any changes in patient's vital signs; oxygen saturation; mental status; skin color; or skin abrasions, bruising, or blistering around mask area.

• Informing about the need to immediately report to the nurse any ventilator or CPAP/BiPAP machine alarms or patient monitor alarms.

• Instructing on how to modify care, such as for how long the mask can be removed, oral care, or any special skin-care needs.

• Informing about the prescribed settings on the NIPPV equipment and instructing personnel to immediately notify the nurse of any change in settings or patient comfort.

Equipment

• Nasal mask/full face mask (with quick release straps) or nasal pillows

• Oxygen source and tubing

• BiPAP and/or CPAP machine/ventilator as per health care provider order

• Humidification source

• Delivery tubing

• Pulse oximeter

• Clean gloves

• Personal protective equipment as appropriate

• Stethoscope

• Suction equipment

• Self-inflating manual resuscitation bag-valve-mask device

• Appropriate signs for in-use oxygen

Assessment

1. Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy.Rationale: Ensures correct patient. Complies with The Joint Commission standards and improves patient safety (TJC, 2019).

2. Review accuracy of health care provider's order.Rationale: Health care provider's order is necessary for this therapy.

3. Perform hand hygiene and apply clean gloves, and assess patient's respiratory status, including symmetry of chest wall expansion, respiratory rate and depth, sputum production, and lung sounds (see Chapters 7 and 8). When possible, ask patient about dyspnea and observe for signs and symptoms associated with hypoxia (see Box 16.2).Rationale: Decreased chest wall movement, crackles or decreased lung sounds, increased respiratory rate, increased sputum production, or signs of worsening hypoxia may make patient a candidate for noninvasive positive-pressure ventilation or changes in NIPPV settings.

4. Observe patient's skin over bridge of nose, around external ears, back of head.Rationale: The mask can place pressure on skin and increase risk for skin breakdown (Schallom et al., 2015).

5. Observe patient's ability to clear and remove airway secretions by coughing.Rationale: Secretions plug the airway, decreasing amount of oxygen that is available for gas exchange in the lung.

6. Assess patient's vital signs and pulse oximetry; when available, note patient's most recent arterial blood gas (ABG) results.Rationale: Objectively documents patient's pH, arterial oxygen, arterial carbon dioxide, or arterial oxygen saturation. Identifies need for NIPPV.

7. Assess patient's level of consciousness, behaviors, and ability to maintain and protect airway. Remove and dispose of gloves. Perform hand hygiene.Rationale: Patients who cannot maintain their own airway or who are uncooperative are not candidates for NIPPV.

Safe Patient Care

NIPPV is contraindicated in patients in cardiac or respiratory arrest or with facial deformities, hemodynamic instability, inability to protect airway, severe agitation, excessive secretions, or high inspired oxygen concentration (FiO2) requirements (Wiegand, 2017). Its use in palliative care and end-of-life care is still being investigated (Gale et al., 2015).

8. Assess patient's or family caregiver's knowledge, experience, and health literacy level.Rationale: Ensures patient or caregiver has the capacity to obtain, communicate, process, and understand basic health information (CDC, 2016).

Planning

1. Expected outcomes following completion of procedure:

• Patient has increased lung expansion.Patient experiences improved gas exchange when lungs are expanded from constant pressure of NIPPV.

• Patient maintains ABG levels and/or pulse oximetry (SpO2) readings improve or remain normal.NIPPV delivered is appropriately based on patient assessment data.

Safe Patient Care

When first initiating CPAP/BiPAP, it is important to monitor gas exchange, especially in patients with COPD, cardiogenic pulmonary edema, or acute respiratory failure. You do this to observe for carbon dioxide retention. If patient has “do not resuscitate” orders or is receiving palliative care services, careful consideration is given before starting noninvasive ventilation (Wiegand, 2017).

• Patient experiences reduction in feelings of dyspnea and work of breathing.In patients with acute conditions, dyspnea usually improves. Patients with chronic pulmonary diseases often require nocturnal CPAP/BiPAP indefinitely to achieve long-term benefits.

• Patient's vital signs and respiratory assessment parameters improve.Reduced pulse and respiratory rate, improved mental status, improved skin color, and decreased use of accessory and abdominal muscles occur because patient's work of breathing decreases as level of oxygenation improves.

• Patient's skin around bridge of nose, ears, and back of head remains clear, without breakdown.Mask applied properly and monitored for pressure occurrence.

• Patient able to teach back how to use CPAP/BiPAP in the home setting.Demonstrates learning.

2. Close room door or curtains around bed and prepare equipment and environment.

Provides privacy and facilitates a smooth and organized procedure.

3. Collaborate with the respiratory therapist to prepare and organize equipment, including the mask, oxygen source, ventilator/CPAP machine, and suction equipment.

Provides organized implementation of the noninvasive ventilation.

4. Explain to patient and family the purpose and reasons for CPAP/BiPAP.

Helps reduce sense of claustrophobia from mask. In addition, information reduces anxiety and increases cooperation and adherence to therapy.

Implementation

1. Perform hand hygiene; apply clean gloves. Apply mask, gown, and goggles/face shield if secretions are projectile or if patient is in isolation (see Chapter 5).

Reduces transmission of infection and exposure to pulmonary secretions.

2. Adjust bed to appropriate height and lower side rail on side nearest you. Raise head of bed. Check locks on bed wheel.

Minimizes caregiver's muscle strain and prevents injury. Raising head of bed eases ventilatory effort. Prevents bed from moving.

3. Determine correct mask size. Use masking chart to determine correct size (S, M, L, XL). NOTE: It is imperative that masks have quick-release straps.

Mask should fit snugly over patient's nose (CPAP) or nose and/or mouth (BiPAP) to create a tight seal for delivering positive pressure. In case of emergency (e.g., vomiting, respiratory arrest), quick-release straps allow mask to be removed quickly. This system also allows patient to remove mask quickly as needed (Urden et al., 2016).

Safe Patient Care

A patient receiving NIPPV via a full-face mask should never be restrained. The patient must be able to remove the mask if he or she begins to vomit, needs to remove excess secretions, or needs to reposition a mask that has moved. A displaced mask can force the patient's jaw inward, which can obstruct the patient's airway (Urden et al., 2016).

4. Connect CPAP/BiPAP device-delivery tubing to pressure generator or ventilator.

Ensures that patient is receiving proper NIPPV as ordered.

5. Connect patient to pulse oximetry.

It is important to continually monitor patient's level of oxygenation when initiating NIPPV.

6. Set CPAP/BiPAP initial settings per health care provider order:

These settings allow the health care team to determine initial patient response.

• a. CPAP: 5 to 15 cm H2O is the typically prescribed pressure range (Pooboni et al., 2015)CPAP provides single positive pressure throughout breathing cycle, which helps keep alveoli open at end-expiration.

• b. BiPAP: Inspiratory pressure is usually set at 10 to 12 cm H2O initially and can be titrated up to 15 to 20 cm H2O as patient condition dictates; expiratory pressure is usually set at 5 to 7 cm H2O initially and can be titrated up as patient condition warrants (Pooboni et al., 2015).BiPAP supplies pressure at both inhalation and exhalation. The inhalation pressure is set according to health care provider's order and helps prevent airway closure. Expiratory pressure is set according to health care provider's order and keeps alveoli open at end-expiration (Wiegand, 2017).

7. Select FiO2 level as indicated and per prescriber order.

Patients on NIPPV may also need supplemental oxygen to decrease signs and symptoms of hypoxia (Hill and Kramer, 2018).

8. Ensure that humidification and heating appliances are connected and on.

Humidification of gas is thought to improve comfort in patients receiving NIPPV (Elliott and Elliott, 2018).

9. Ensure that mask is tight fitting, no air leak is present, and there are no excessive pressure points.

An ill-fitting mask leads to loss of pressure getting into airways or desynchrony with ventilator. It also can lead to air blowing into eyes, which can cause patient discomfort (Wiegand, 2017). Pressure points around mask area can cause device-related pressure injuries (Schallom et al., 2015).

10. If patient is to use CPAP at home, have patient or family caregiver demonstrate mask placement and adjustment of settings.

Return demonstration indicates learning.

11. Dispose of supplies as appropriate, remove gloves and other personal protective equipment, and perform hand hygiene.

Reduces transmission of microorganisms.

12. Raise side rails (as appropriate) and lower bed to lowest position.

Ensures patient safety.

13. Ensure that the patient is in a comfortable position and that the nurse call system is in an accessible location with the patient's reach. Instruct the patient on its use.

Increase patient's comfort level. Allows the patient to alert the nurse when they need assistance.

14. Continuous care of patient:

• a. Ensure that all alarms are on and active and that ventilator circuit is intact and properly functioning.

Ensures patient safety.

• b. Ensure that emergency resuscitation equipment is at bedside.

Allows for quick resuscitation in case of worsening patient condition (Wiegand, 2017).

• c. Investigate all alarms that come with ventilator/CPAP machine and/or patient monitor.

Alarms can alert health care team to problems with patient or with circuit that adversely affects patient status.

• d. Change patient's position every 2 hours or encourage patient to change position every 2 hours.

Reduces incidence of atelectasis or pneumonia secondary to stasis of secretions.

15. Weaning patient from NIPPV:

• a. Ensure that all alarms are on and properly functioning.

Amount of positive airway pressure is being reduced, and alarms alert if patient status declines (Hyzy et al., 2018a).

• b. Begin ambulating the patient when he or she has been disconnected from NIPPV.

Weaning allows the patient to be disconnected for longer periods (Hyzy et al., 2018a).

Evaluation

1. Observe for decreased anxiety, improved level of consciousness and cognitive abilities, decreased fatigue, and absence of dizziness.

Determines patient's response to NIPPV. As hypoxia and hypercapnia are reduced or corrected, patient's behavioral assessment parameters improve.

2. Measure vital signs, perform respiratory assessment, and observe skin color, and ask patient to describe sense of dyspnea.

Physical assessment parameters reveal oxygenation status.

3. Monitor pulse oximetry.

Documents patient's level of oxygenation. When first initiating NIPPV, it is important to also obtain ABG levels in patients in whom abnormal gas exchange is suspected, after the first hour, and per agency protocol.

4. Observe skin integrity over bridge of patient's nose every 2 hours. Ask patient about level of comfort.

Mask that is too tight causes skin breakdown, and frequent skin assessment is necessary (Pittman et al., 2015; Schallom et al., 2015).

5. If NIPPV is planned for use in home, observe and monitor patient's and family's ability to manipulate CPAP or BiPAP machine/ventilator and face mask.

Determines patient's ability to perform self-care and adhere to CPAP/BiPAP plan. Success of noninvasive ventilation depends largely on patient acceptance and adherence (Gale et al., 2015).

6. Monitor patient's response to weaning from NIPPV.

Monitor for a minimum of the first 8 hours. Review blood gas measurements and notify health care provider if pH or PaCO2 rises, indicating failure to wean from NIPPV (Hyzy et al., 2018a).

7. Use Teach-Back: “I want to be sure I explained how NIPPV works and why you are receiving this therapy. Explain to me why this therapy is necessary.” Revise your instruction now or develop a plan for revised patient/family caregiver teaching if patient/family caregiver is not able to teach back correctly.

Determines patient's/family caregiver's level of understanding of instructional topic.

Unexpected Outcomes and Related Interventions

1. Patient experiences hypoxia, hypercapnia, or other signs of worsening respiratory function.

   • Notify health care provider.

   • Reassess patient.

   • Determine correct settings and integrity of NIPPV.

2. Patient develops skin breakdown at mask sites or sites where mask straps are located, such as bridge of nose, nasal septum, or ears.

   • Notify health care provider.

   • Place protective synthetic coverings on nasal bridge or areas of irritation/possible irritation to protect skin.

   • Fit mask so that it is tight enough to not cause air leak but loose enough to not cause skin breakdown.

   • Reassess patient (Pooboni et al., 2015).

3. Patient states sense of smothering or claustrophobia.

   • Explain system to patient again.

   • Demonstrate use of quick-release straps.

   • Have patient demonstrate use of quick-release straps.

4. Patient develops stomach distention secondary to positive-pressure air being forced into esophagus and trachea (Pooboni et al., 2015).

   • Notify health care provider.

   • Be prepared for possible insertion of nasogastric tube (see Chapter 20).

Recording

• Record type of NIV, including pressure and oxygen flow rates, assistance needed with positioning, coughing effectiveness, and respiratory assessment findings.

• Record patient adherence and tolerance, mask fit and skin assessment beneath mask, effectiveness of therapy, witnessed periods of apnea, and status of daytime hypersomnolence.

• Document evaluation of patient learning.

Hand-Off Reporting

• Report patient status, including respiratory assessment findings, before initiation of noninvasive ventilation.

• Report the type of noninvasive ventilation initiated and utilized, the initial pressure and oxygen flow rates, and if any adjustments to the pressures and flow rates were made during the course of the shift. Include the patient response to the flow-rate adjustments and what other interventions were successful.

• Report any unexpected outcomes, such as development of reddened areas on ears or nose.

Procedural Guideline 16.1

Use of a Peak Flowmeter

Purpose

Peak expiratory flow rate (PEFR) measurements are useful for patients with asthma who have measurable changes in the flow of air through the airways. The PEFR is the maximum flow that a patient forces out during one quick, forced expiration and is measured in liters per minute. These measurements are used as an objective indicator of a patient's status or to evaluate the effectiveness of treatment (e.g., bronchodilators) (Gerald et al., 2018).

Delegation and Collaboration

Initial assessment of the patient's condition is a nursing responsibility and cannot be delegated. The skills of follow-up PEFR measurements in a stable patient can be delegated to nursing assistive personnel (NAP). The nurse directs the NAP to:

• Report immediately to the nurse patient's difficulty breathing or decrease in PEFR measurement.

Equipment

• Peak flowmeter (Fig. 16.1)

• Patient diary/action plan (if appropriate)

• Writing utensil to record value

• Clean gloves

Procedural Steps

1. Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy (TJC, 2019).

2. Assess previous PEFR readings from patient's electronic health record (EHR) and the target set by patient's health care provider.

3. Assess patient's and family caregiver's baseline knowledge of when and how to use PEFR and correct response to results.

4. Assist patient to a standing or a high-Fowler's position, as able, to promote optimum lung expansion.

5. Instruct patient to remove any food or gum from mouth.

6. Perform hand hygiene and apply clean gloves.

7. Slide clean mouthpiece into base of the numbered scale or clean the mouthpiece of the flowmeter if it is permanently attached.

8. Instruct patient to take a deep breath through the nose and slowly blow out through the mouth. Take a second deep breath.

9. Have patient place metered mouthpiece in mouth and close lips, making a firm seal.

10. Have patient blow out as hard and fast as possible through the mouth only.

11. Record the number or mark it on the flowmeter with the attached marker.

12. Repeat Steps 8 to 11 two more times.

13. Record the highest number of the three attempts.

14. If patient is to record PEFR at home, have him or her demonstrate how to record it accurately on chart using “traffic light” pattern that is often located on the patient's asthma action plan as set by the health care provider.

• Green indicates that the PEFR is 80% to 100% of patient's personal best value and means that he or she should continue with the currently prescribed treatment regimen.

• Yellow indicates that the PEFR is 50% to 90% of the personal best and that the person should add the prescribed quick-relief medication to the treatment regimen and continue with his or her daily long-term control medications.

• Red indicates that the PEFR is less than 50% of the patient's personal best and that the person should take the prescribed quick-relief medication and seek medical attention.

15. Remove gloves and dispose in appropriate receptacle, perform hand hygiene.

16. Instruct patient to clean unit following the manufacturer instructions.

17. Document procedure, PEFR target achieved, and patient’s tolerance.

Procedural Guideline 16.2

Using an Acapella Device

Purpose

The Acapella device is a handheld airway clearance device for patients who have cystic fibrosis, COPD, asthma, and lung diseases with secretory problems, as well as for patients with atelectasis (Fig. 16.2). It utilizes positive expiratory pressure to open the airways and mobilize secretions (Naswa et al., 2017).

Delegation and Collaboration

The skill of using an Acapella device can be delegated to nursing assistive personnel (NAP). The nurse is responsible for performing respiratory assessment, determining that the procedure is appropriate and that a patient can tolerate it, and evaluating a patient's response to it. The nurse instructs the NAP to:

• Be alert for patient's tolerance of procedure, such as comfort level and changes in breathing pattern, and immediately report changes to the nurse.

• Use specific patient precautions such as positioning restrictions related to disease or treatment.

Equipment

• Stethoscope

• Pulse oximeter

• Glass of water

• Chair

• Tissues and paper bag

• Clear graduated screw-top container

• Suction equipment (if patient unable to cough and clear own secretions)

• Acapella device (see Fig. 16.2)

• Clean gloves

• Patient education materials

Procedural Steps

1. Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy (TJC, 2019).

2. Verify the need for a health care provider's order per agency policy.

3. Perform hand hygiene and complete a respiratory assessment (including lung auscultation, inspection of mucus, and oxygen saturation) to determine oxygenation status and lung segments requiring percussion and/or vibration.

4. Assess patient's and family's understanding of the device and procedure and explain and clarify procedure as needed (CDC, 2016).

5. Prepare prescribed Acapella device:

   • Safe Patient Care: Verify that the correct device is used to match patient's expiratory flow rate.

     • Blue: patients who cannot maintain their expiratory flow above 15 L/min for greater than 3 seconds.

     • Green: patients who can maintain expiratory flow above or equal to 15 L/min for at least 3 seconds.

   • a. Initial setting: turn Acapella frequency adjustment dial counterclockwise to lowest resistance setting.

   • b. As patient improves or is more proficient, adjust the proper resistance level upward by turning the dial clockwise. This initial setting helps patient adjust to the device.

   • Safe Patient Care: Determine if aerosol drug therapy is ordered. If so, attach a nebulizer to the end of the Acapella valve, or administer medication before using the Acapella.

6. Instruct patient to:

   • a. Sit comfortably.

   • b. Take in a breath that is larger than normal but not to fill lungs completely. Instruct patient to inhale to about 75% of inspiratory capacity.

   • c. Place mouthpiece into mouth, maintaining a tight seal.

   • d. Hold breath for 2 to 3 seconds.

   • e. Try not to cough and to exhale slowly for 3 to 4 seconds through the device while it vibrates.

   • Safe Patient Care: If patient cannot maintain an exhalation for this length of time, adjust the dial clockwise. Clockwise adjustment increases the resistance of the vibrating opening, which allows the patient to exhale at a lower flow rate. Or it may be necessary to change from the blue to green device.

   • f. Repeat cycle for 5 to 10 breaths as tolerated.

   • g. Remove mouthpiece and perform one or two forceful exhalations and “huff” coughs.

   • h. Repeat Steps 6b through 6e, as ordered.

7. Auscultate lung fields.

8. Obtain vital signs, SpO2.

9. Inspect color, character, and amount of sputum.

10. Perform hand hygiene and assist patient with oral hygiene as needed.

11. Document procedure and patient's tolerance.

Procedural Guideline 16.3

Performing Percussion and Vibration (Chest Physical Therapy)

Purpose

The purpose of percussion and vibration overlying the rib cage is to help loosen and remove mucus from the lung airways. Percussion is the manual external clapping of a patient's chest wall, with cupped hands or with a mechanical device, in a rhythmic fashion to loosen secretions from the bronchial walls. Vibration augments the natural movement of the rib cage during exhalation and helps with secretion clearance. Apply vibration to a patient's external chest wall by placing both hands (one over the other) over the areas to be vibrated (Strickland et al., 2015).

High-Frequency Chest Wall Compression

An additional method for percussion and vibration is high-frequency chest wall compression (HFCWC). The purpose of HFCWC is to deliver high-frequency, small-volume expiratory pulses to a patient's external chest wall; one example is the vest airway clearance system, which helps loosen and remove secretions from the airways (Fig. 16.3). This mechanical action helps loosen and mobilize airway secretions (Chatwin et al., 2018). It is beneficial for selected patients with neuromuscular diseases, cystic fibrosis, and ineffective coughing and airway clearance.

Delegation and Collaboration

The skill of performing percussion and vibration can be delegated to trained nursing assistive personnel (NAP; see agency policy). The nurse is responsible for the respiratory assessment and review of the patient's chest x-ray film (with a health care provider) to determine patient stability, which areas of the lungs are affected, and specific positions for the patient to assume. The nurse instructs the NAP about:

• Any patient precautions related to disease or treatment.

• Reporting to the nurse any problems with tolerance of the procedure, pain, dyspnea, or changes in vital signs.

In some health care agencies, the respiratory therapist is responsible for performing percussion and vibration. The nurse must collaborate with the respiratory therapist when planning care for the patient in the acute care setting.

Equipment

• Stethoscope

• Hospital bed (tilt table placed in Trendelenburg's position is optional; check agency policy)

• Chair (for upper lobes)

• 1 to 4 pillows

• Water pitcher (with water) and glass

• Tissues and paper bag

• Clear graduated screw-top container

• Mechanical vibrator or percussor (optional)

• HFCWC device such as the vest airway clearance system

• Single layer of clothing

• Clean gloves

• Oral hygiene care items (toothbrush, toothpaste, mouthwash, or chlorhexidine oral rinse if ordered)

• Suction equipment (optional)

• Pulse oximeter

Procedural Steps

1. Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy (TJC, 2019).

2. Assess patient and review medical record for x-ray findings and signs, symptoms, and conditions that indicate the need to perform percussion and vibration (see Skill 16.1).

3. Review medical record for risks (e.g., use of steroids) and contraindications for percussion and vibration.

   • Safe Patient Care: Percussion and/or vibration can cause rib fractures and are contraindicated with rib fracture, fracture of other rib-cage structures such as clavicle or sternum, pain, severe dyspnea, and severe osteoporosis. Thin, frail patients with osteoporosis are most susceptible to injury and are taught other secretion-control measures (e.g., forceful coughing, humidification).

4. Perform hand hygiene and perform respiratory assessment (including vital signs, pulse oximetry, and chest inspection and palpation) to assess breathing pattern, including muscles used for breathing, respiratory rate and depth, extent of excursion, chest wall movement, and oxygen saturation.

5. Auscultate lung sounds over lung segments drained during postural drainage.

6. Inspect and gently palpate rib cage over affected bronchial segment(s) for pain, tenderness, abnormal configuration, abnormal excursion or chest wall movement during breathing, and muscle tension. Percussion or vibration is contraindicated if one of these assessment findings is present because the treatment has the potential to cause further injury and impair chest wall motion. Remove gloves and perform hand hygiene.

7. Determine patient's understanding and assess ability to cooperate with therapy, both in health care agency and at home.

8. Explain procedure in detail: patient's positioning, sensations to be felt, how it will be done, how long it will take, use of vest (if applicable), and any discomforts or side effects.

9. Help patient relax and deep breathe during the procedure. Have him or her practice exhaling slowly through pursed lips while relaxing chest wall muscles and blow out using abdominal muscles, not rib-cage muscles.

10. Perform hand hygiene and apply clean gloves (only if risk of contacting mucus secretions).

11. Elevate bed to comfortable working height and stand close to bed with arms directly in front and knees slightly bent.

12. Use findings from physical assessment and chest x-ray film to select congested areas of the lung. Position patient in appropriate drainage position (Table 16.3) and place pillows for support and comfort.

13. Perform percussion and vibration. a. Percussion and vibration with hands: (1) Perform percussion for 3 to 5 minutes in each position as tolerated. Begin on the appropriate part of the chest wall over the draining area (see Table 16.3). Always ask if the patient is experiencing any discomfort such as undue pressure or stinging of the skin. (2) Place hands side by side on chest wall over the area to be drained. Cup hands with fingers and thumbs held tightly together. Make sure that the entire outer part of the hand makes contact with the chest wall to avoid air leaks (see illustration). (3) When clapping, most arm movement comes from the elbow and wrist joints. Clapping is often done for 5 minutes without stopping or for 2 to 3 minutes, alternating with vibration. (4) Alternately clap chest with cupped hands to create a rhythmic popping sound resembling a galloping horse. Perform clapping at moderate or fast speed, whichever is most comfortable and effective. (5) Perform chest wall vibration over each affected area (see Table 16.3). (a) Place flat part of hand over area and have patient take a slow, deep breath through the nose. (b) Gently resist chest wall as it rises during inhalation. (c) Have patient hold breath for 2 to 3 seconds and exhale through pursed lips while contracting abdominal muscles and relaxing chest wall muscles. Chest wall relaxes and falls. (d) While the patient is exhaling, gently push down and vibrate the chest wall with the flat part of the hand (Volsko, 2013). (e) Repeat vibration three times and have the patient cascade cough by taking a deep breath and doing a series of small coughs until the end of the breath. Instruct the patient not to inhale between coughs. Vibrate the chest wall as the patient coughs. When applying pressure to the ribs, always follow the natural movement of the rib cage. Allow the patient to sit up and cough as needed. (f) Monitor the patient’s tolerance of vibration and ability to relax the chest wall and breathe properly as instructed. (g) Perform a total of three or four sets of three vibrations with vibration followed by coughing over each lung segment as tolerated. Strength and frequency of vibration will vary. b. HFCWC device: (1) Place vest on patient and assess for proper fit. (a) With vest deflated, adjust closures so that it fits comfortably. (b) Vest should rest on the shoulder and extend to the top of the hip bone. (2) Assess chest wall motion. Breathing should not be restricted when vest is deflated. (3) Connect tubing to the generator and ports of the vest. Turn on power. (4) Adjust pressure control as ordered; usually pressure is between 5 and 6. (5) Adjust frequency; usually set between 10 and 15 Hz (Ntoumenopoulos, 2012; Clinkscale et al., 2012). (6) Administer any aerosol therapy as prescribed. (7) Depress and maintain pressure on the hand/foot control to initiate vest therapy. (8) After 5 to 10 minutes, release the hand/foot control.

14. Instruct patient to cough or suction if he or she is unable to cough up mucus (see Skill 16.3).

15. Continue with treatment; usually 15 to 30 minutes.

16. Assist patient with oral hygiene.

17. Remove gloves and perform hand hygiene.

18. If long-term therapy is needed, teach patient and significant others the procedure for home use for Acapella or HFCWC devices. If they cannot learn or use, refer for outpatient or home care follow-up.

19. Auscultate lung fields.

20. Obtain vital signs, pulse oximetry.

21. Inspect color, character, and amount of sputum.

22. Document procedure and patient's response.

TABLE 16.3

Positions and Procedures for Drainage, Percussion, Vibration, and Shaking

*In adult settings, Trendelenburg's position is not used as frequently. Verify use with agency policy and health care provider's order.

SKILL 16.3 Airway Management: Suctioning

Purpose

Airway suctioning is necessary to assist with the removal of airway secretions. For some patients, coughing, chest physical therapy (PT), nebulization, and medications are insufficient to remove secretions and maintain a patent airway. Suctioning oropharyngeal secretions is done with a rigid plastic catheter (e.g., Yankauer) with one large and several small eyelets to remove mucus (Fig. 16.4). Nasotracheal suction is a sterile technique used to remove deeper secretions in the airways using a flexible plastic catheter.

When patients have an endotracheal tube (ETT), subglottic suctioning is advocated to minimize pooling of oral secretions above the ETT cuff. Subglottic suctioning was found to decrease the risk of ventilator-associated pneumonia (VAP) (Letchford and Bench, 2018). Suctioning of the lower airway is needed when patients cannot cough forcefully enough to clear secretions and requires the use of sterile technique. ETTs and tracheostomy tubes (TTs) allow direct access to the lower airways for suctioning.

Delegation and Collaboration

The skill of suctioning endotracheal (ET) or nasotracheal (NT) tubes or newly inserted tracheostomy tubes cannot be delegated to nursing assistive personnel (NAP). In some agencies, the NAP may suction a patient with a well-established tracheostomy that the nurse has determined to be stable. The nurse may need to collaborate with the respiratory therapist because respiratory therapists are also allowed to perform this procedure at certain health care agencies. The nurse directs the NAP about:

• Any modifications of the skill, such as the need for supplemental oxygen.

• Appropriate suction limits for suctioning ETTs and TTs and risks of applying excessive or inadequate suction pressure.

• Reporting any changes in the patient's respiratory status, level of consciousness, restlessness, secretion color and amount, and unresolved coughing or gagging.

• Reporting any changes in the patient's color, vital signs, or complaints of pain.