ATI Gas Exchange and Oxygenation

Airway Management Overview

Scope of Practice

PN scope of practice varies by state. PNs may contribute to or assist the RN in developing a plan of care, usually under RN supervision. It is the PN’s responsibility to know and abide by state-specific guidelines for safe practice.

Airway Clearance Goals

Effective airway management involves clearing secretions, maintaining patency, and using artificial airways when necessary. Key techniques include suctioning, chest physiotherapy (CPT), and the management of endotracheal (ET) or tracheostomy tubes.

Chest Physiotherapy (CPT)

CPT is a set of techniques used to loosen and move secretions into central airways for removal via coughing or suctioning. It is crucial for conditions like cystic fibrosis and is often used with bronchodilators or mucolytics.

  1. Percussion

    • Involves striking congested lung fields with cupped hands or mechanical devices.

    • Avoid percussion over the breasts, sternum, spinal column, and kidneys.

    • Perform for 3 to 5 minutes per area.

  2. Vibration

    • Used after or alternately with percussion to increase turbulence of exhaled air.

    • Apply pressure with a shaking motion during exhalation only.

  3. Postural Drainage

    • Uses gravity to drain secretions. Scheduled 2-3 times daily (usually before meals and bedtime).

    • Check gastric residuals if the client is on tube feedings at least 30 minutes prior.

Artificial Airways

Oropharyngeal and Nasopharyngeal Airways

  • Oropharyngeal: Used for altered consciousness to prevent tongue obstruction; stimulates gag reflex. Measure from the corner of the mouth to the angle of the jaw.

  • Nasopharyngeal (Nasal Trumpet): Used for alert clients; doesn't stimulate gag reflex. Measure from the tip of the nose to the earlobe.

Endotracheal (ET) and Tracheostomy Tubes

  • ET Tubes: Short-term (under 14 days) for anesthesia or mechanical ventilation. Cuffs prevent air leaks and aspiration.

  • Tracheostomy Tubes: Long-term support via a surgically created opening.

    • Emergency Equipment at Bedside: Manual resuscitation bag, extra trach tube (same size), insertion tray, and obturator.

    • Complications: Tube dislodgement (first 72hours), obstruction, pneumothorax, and infection.

Suctioning Techniques

Suctioning clears secretions in clients unable to expectorate. It can cause hypoxia, so hyperoxygenation is required before the procedure.

  • Oropharyngeal/Yankauer: For mouth/throat secretions; clean technique used.

  • Nasotracheal/Tracheal: Requires surgical asepsis (sterile technique). Suction the mouth last if suctioning both areas.

  • Closed (Inline) Suctioning: Used for mechanically ventilated clients. Allows suctioning without disconnecting the ventilator, reducing the risk of oxygen desaturation and infection.

    • Duration: Apply suction for no more than 10 seconds while withdrawing.

    • Interval: Wait at least 1 minute between passes.

Oxygen Therapy

Hypoxia Manifestations

  • Early: Restlessness, confusion, anxiety, elevated $BP$, increased heart rate ($HR$), and respiratory rate ($RR$).

  • Late: Hypotension, bradycardia, metabolic acidosis, and cyanosis.

  • Chronic: Clubbing of fingers/toes, peripheral edema, right-sided heart failure, and $SpO_{2} < 87\%$.

Delivery Devices

  • Nasal Cannula: Low flow ($1$-$6 L/min$), concentration $24\%$ to $44\%$. Humidify if $> 4 L/min$.

  • Simple Face Mask: Flow $5$-$10 L/min$, concentration $35\%$ to $60\%$. Do not use $< 5 L/min$ due to $CO_{2}$ buildup.

  • Nonrebreather Mask: High flow ($10$-$15 L/min$), concentration up to $95\%$. Ensure reservoir bag remains inflated.

  • Venturi Mask: Most accurate delivery ($24\%$ to $60\%$). Ideal for COPD clients.

  • Face Tent: Loose fit for claustrophobic clients; provides high humidification.

  • Manual Resuscitation Bag: Highest concentrations during emergencies or prior to procedures.

Oxygen Safety

  • No smoking or open flames; use "Oxygen in Use" signs.

  • Ensure electrical equipment is grounded to prevent sparks.

  • Store tanks upright and secured.

Closed Chest Drainage

Closed chest drainage restores negative pressure in the pleural space to resolve lung collapse (pneumothorax) or fluid accumulation (hemothorax/effusion).

System Components

  1. Collection Chamber: Collects drainage; mark levels every $8$ hours.

  2. Water Seal Chamber: Prevents air from reentering.

    • Tidaling: Normal fluctuation with breathing.

    • Continuous Bubbling: Indicates an air leak.

  3. Suction Control: Wet (determined by water height, usually $-20 cm$) or Dry (uses a regulator dial).

Nursing Care and Troubleshooting

  • Positioning: Semi- or high-Fowler’s promotes lung expansion.

  • Tubing: Keep below chest level; avoid kinks/dependent loops. Do not "milk" or "strip" the tube.

  • Dislodgement: If the tube disconnects from the system, submerge the end in $2.5 cm$ ($1 in$) of sterile water. If it comes out of the chest, cover the site with sterile gauze (non-occlusive if air is leaking).

  • Assessment: Palpate for subcutaneous emphysema (crepitus).

Documentation Guidelines

  • General: Document date, time, breath sounds, $SpO_{2}$, and client tolerance.

  • Suctioning: Note amount, color, consistency, and odor of secretions.

  • Oxygen: Record flow rate, delivery method, and skin integrity at pressure points (ears/nose).

  • Chest Tubes: Document site status, drainage characteristics, amount of suction, and any bubbling in the water seal.