Comprehensive Study Notes: Oxygenation, Airway Management, and Tracheostomy Care

Fundamentals of Oxygenation and Physiology

• Chemical Properties of Oxygen:

  • Chemical element symbol: $\text{O}$

  • Atomic number: $8$

  • Group: Member of the chalcogen group in the periodic table

  • Characteristics: Highly reactive nonmetal and oxidizing agent that readily forms oxides with most elements and compounds

  • Physical state: Colorless, odorless, and tasteless gas essential to living organisms

• Physiological Function:

  • Cellular metabolism: Oxygen is required by all cells of the body to metabolize nutrients and produce the energy necessary for cellular function

  • Respiratory gas exchange: Oxygen is taken up by animals and converted to carbon dioxide ($\text{CO}_2$); plants in turn utilize carbon dioxide as a source of carbon and release oxygen back into the atmosphere

Hypoxia: Clinical Manifestations and Assessment

• Definition and Impact:

  • Hypoxia is defined as a reduced oxygen content in tissue and cellular structures

  • Cellular cellular metabolism slows down significantly when oxygen levels drop, eventually leading to cell death

  • Oxygen therapy is prescribed to prevent or relieve tissue hypoxia

• Signs and Symptoms of Hypoxia:

  • Anxiety and restlessness

  • Behavioral changes

  • Cyanosis: Characterized specifically by a blue discoloration of the mouth and tongue (Note: Cyanosis is distinct from pallor)

  • Decreased level of consciousness (LOC)

  • Increased rate of respirations (tachypnea)

  • Clubbed fingers (seen in chronic hypoxia)

• Associated Nursing Diagnoses:

  • Inability to Clear airway / Ineffective airway clearance

  • Inability to Maintain Adequate Breathing Pattern

  • Inability to Tolerate Activity

  • Anxiousness, Fearfulness, or Despair

  • Compromised Verbal Communication

  • Risk for Injury

Safe Administration and Protocol Guidelines

• Standard Nursing Protocols Prior to Performing Skills:

  • Refer to the client's medical record for specific orders and history

  • Identify the client using two unique identifiers

  • Introduce yourself to the client

  • Identify client allergies

  • Perform hand hygiene and don clean gloves before entering the room and executing procedures

• Seven Rights of Medication Administration Applied to Oxygen:

  • Oxygen is classified and treated as a drug; therefore, it strictly requires a physician's or healthcare provider's order

  • $\text{Right Drug}$

  • $\text{Right Indication}$

  • $\text{Right Dose}$

  • $\text{Right Route}$

  • $\text{Right Time}$

  • $\text{Right Patient}$

  • $\text{Right Documentation}$

• Safety Precautions and Storage Requirements:

  • Combustion: Oxygen is colorless, odorless, and tasteless; while it does not burn or explode on its own, it actively supports combustion. Avoid open flames, smoking, and spark-producing electrical appliances nearby

  • Storage: Oxygen cylinders must always be secured upright in an approved rack or carrier. Cylinders must never be freestanding

  • Humidification: Oxygen gas exerts a drying effect on respiratory mucous membranes. A humidifier bottle filled with distilled water must be utilized for flow rates exceeding $4\,\text{L/min}$

  • Toxicity: High concentrations of oxygen administered over prolonged periods can cause oxygen toxicity, resulting in scarring of respiratory tract tissues

  • Hemodynamic Effects: Oxygen serves as a potent pulmonary vasodilator, making oxygen therapy particularly beneficial in clients experiencing cardiovascular complications such as heart failure

Supplemental Oxygen Delivery Devices

• Nasal Cannula:

  • Most common low-flow oxygen delivery device

  • Flow Rate: $1-6\,\text{L/min}$

  • Delivered Oxygen Concentration ($\text{FiO}_2$): $25-40\%$ (increases by approximately $4\%$ per $1\,\text{L/min}$ increase in flow rate)

  • Advantage: Allows the patient to speak and eat without interrupting therapy

• Simple Face Mask:

  • Flow Rate: $5-10\,\text{L/min}$ (or $5-8\,\text{L/min}$)

  • Delivered Oxygen Concentration ($\text{FiO}_2$): $40-60\%$

• Face Tent:

  • Flow Rate: $10-15\,\text{L/min}$

  • Delivered Oxygen Concentration ($\text{FiO}_2$): $\sim 40\%$

  • Advantage: Ideal for patients who cannot tolerate facial masks or have facial trauma/burns

• Venturi Mask:

  • Flow Rate: $2-15\,\text{L/min}$ (or $4-10\,\text{L/min}$, depending on the specific color-coded adapter or dial setting)

  • Delivered Oxygen Concentration ($\text{FiO}_2$): $24-60\%$

  • Advantage: Delivers precise, controlled concentrations of oxygen regardless of breathing pattern

• Partial Rebreather Mask:

  • Flow Rate: $6-12\,\text{L/min}$

  • Delivered Oxygen Concentration ($\text{FiO}_2$): $60-90\%$

• Non-Rebreather Mask:

  • Flow Rate: $6-15\,\text{L/min}$ or $12-15\,\text{L/min}$

  • Delivered Oxygen Concentration ($\text{FiO}_2$): $70-100\%$ or $80-95\%$

  • Feature: Equipping reservoir bag and one-way valves prevents rebreathing of expired air to provide maximal high-flow oxygen

• High-Flow Nasal Cannula (HFNC):

  • Flow Rate: Up to $60\,\text{L/min}$

  • Delivered Oxygen Concentration ($\text{FiO}_2$): $21-100\%$

• Pediatric Delivery Enclosures:

  • Includes oxygen hoods, halos, or oxygen tents used to provide humidified oxygen to pediatric patients

Skill 14.1: Oxygen Administration and Patient Teaching

• Procedural Steps:

  • Verify physician orders and assemble necessary equipment

  • Position the patient in Fowler's or Semi-Fowler's position to assist lung expansion

  • Auscultate lung sounds, obtain baseline vital signs, and measure pulse oximetry

  • Attach flowmeter to oxygen source; if flow rate is $> 4\,\text{L/min}$, attach a prefilled humidification bottle filled with distilled water

  • Insert nasal prongs into nares curving downward, loop cannula tubing securely over the ears, and adjust the slide adapter beneath the chin

  • Ensure oxygen tubing is sufficiently long to permit patient mobility

  • Continuously evaluate equipment function and reassess patient respiratory status

  • Inspect nares and mucous membranes regularly; apply water-soluble lubricant to soothe dry nares (never use oil-based lubricants)

• Patient Teaching Points:

  • Explain proper device application and function

  • Review oxygen fire safety precautions: strictly no heat sources, no open flames, no smoking; ensure tanks are stored upright in racks

  • Instruct patient to ambulate and change positions frequently to encourage mobilization of respiratory secretions

  • Teach effective deep breathing techniques

  • Emphasize maintaining adequate fluid intake to thin respiratory secretions

  • Reinforce routine oral hygiene care

• Documentation Requirements:

  • Date and exact time of administration

  • Oxygen flow rate ($\text{L/min}$) and method of delivery

  • Assessment and evaluation of patient's respiratory status and response to therapy

  • Any changes in healthcare provider orders

  • Occurrence of any adverse reactions to oxygen therapy

  • Inspection and condition of skin around oxygen delivery devices (ears, nose, cheeks)

Artificial Airway Management: Endotracheal Tubes vs. Tracheostomy

• Endotracheal (ET) Tubes:

  • Description: A tube inserted through the mouth or nose into the upper trachea to establish a patent airway

  • Purpose: Emergency airway stabilization, acute mechanical ventilation, or airway maintenance during general anesthesia

  • Duration: Short-term management ($< 10-14\,\text{days}$ or $< 2\,\text{weeks}$)

  • Requirement: Converts to a tracheostomy if artificial airway support is required for longer than $10-14\,\text{days}$

  • Dietary Restriction: Patient must remain NPO (nothing by mouth) while intubated

• Tracheostomy:

  • Description: A surgically created opening (stoma) made through the neck tissues into the trachea below the vocal cords, into which a breathing tube is inserted

  • Purpose: Short- or long-term airway management when a patient cannot maintain their own airway, experiences airway obstruction, or requires long-term mechanical ventilation ($> 10-14\,\text{days}$)

  • Emergency Placement: Performed urgently when endotracheal intubation is impossible

• Clinical Conditions Indicating Tracheostomy:

  • Anaphylaxis

  • Congenital birth defects of the respiratory tract

  • Airway burns resulting from inhalation of corrosive materials

  • Malignancies/cancer of the neck

  • Chronic lung disease / COPD

  • Coma

  • Diaphragm dysfunction

  • Facial burns or extensive facial trauma/surgery

  • Severe throat/neck infections

  • Laryngeal trauma or laryngectomy

  • Chest wall injuries

Tracheostomy Tube Anatomy, Components, and Device Variations

• Three Primary Parts of a Tracheostomy Tube:

  1. Obturator: A firm, smooth guide inserted into the outer cannula to facilitate smooth placement of the trach tube into the stoma without damaging tracheal tissues. Must be removed immediately after tube insertion. Safety Rule: The obturator must always remain taped or positioned at the patient's bedside for emergency re-insertion

  2. Outer Cannula: The outer structural tube that remains in the trachea. Contains a plastic neck plate/flange resting against the skin of the neck to hold the tube in place

  3. Inner Cannula: Fits inside the outer cannula and locks securely into position. Can be removed for routine cleaning or disposed of (disposable inner cannulas, commonly sized $12-16\,\text{Fr}$)

• Cuffed vs. Cuffless Tracheostomy Tubes:

  • Cuffed Tube:

  • Features an inflatable balloon cuff located near the distal tip

  • Function: Creates a seal between the tracheal wall and cuff to prevent air leaks during mechanical ventilation, ensures delivery of a set tidal volume, and protects against aspiration when eating

  • Management: Cuff should be inflated just enough to allow a minimal air leak. Check cuff pressure twice daily. Deflate the cuff if the patient uses a speaking valve

  • Inner cannula is disposable

  • Complications of Over-inflated Cuff:

    • Increased risk of tracheal mucosal ischemia and injury

    • Tracheal stenosis

    • Granuloma formation

    • Diminished upper airway use leading to muscle atrophy

    • Restriction of laryngeal movement, severely impacting swallowing     

      

  • Cuffless Tube:

  • Lacks an inflatable balloon cuff

  • Used for patients with long-term tracheal problems, those ready for decannulation, or patients who can eat and communicate without aspiration risk

  • Allows secretion clearance but offers no protection against aspiration

  • Retain the decannulation plug if the patient is preparing for decannulation

• Fenestrated vs. Non-Fenestrated Tubes:

  • Fenestrated: Contains an opening (fenestration) in the outer cannula wall, allowing air to pass up through the vocal cords to enable talking

  • Non-Fenestrated: Lacks openings in the outer cannula wall

• Communication and Speaking Valves:

  • Tracheostomy compromises verbal communication unless a Passy-Muir speaking valve is attached

  • Prior to applying a Passy-Muir valve, the tracheostomy cuff must be fully deflated

  • Establish alternative non-verbal communication methods (paper and pencil, communication boards) for all tracheostomy patients

• Humidification Supply Devices:

  • Tracheostomy Collar / Mask: Fits loosely over the tracheostomy tube to deliver humidified oxygen or air

  • T-Piece (Briggs Adapter): Attaches directly to the tracheostomy tube to supply humidified oxygen

  • Transtracheal Oxygen Delivery: Delivers oxygen directly into the trachea throughout the entire respiratory cycle; especially suited for home care

Emergency Bedside Equipment for Tracheostomy Patients

• The following emergency items must be kept present at the bedside at all times for any patient with a fresh or existing tracheostomy:

  • Spare tracheostomy kit (same size as inserted tube, plus one size smaller)

  • Obturator (taped to head of bed or easily accessible)

  • Sterile suction catheters

  • Humidified tracheostomy collar setup

  • Hemostat (used to hold open the tracheostomy stoma if the tube is accidentally expelled)

  • Pulse oximeter

  • Manual resuscitation bag (Ambu bag) with appropriate mask

Skill 14.2: Tracheostomy Care and Maintenance Protocols

• Primary Nursing Responsibilities:

  1. Maintain airway patency (Priority #1)

  2. Clean the tracheostomy tube and inner cannula at least once per shift (every $8\,\text{hours}$ at minimum)

  3. Prevent skin breakdown and tissue impairment surrounding the stoma

  4. Establish and maintain effective non-verbal communication

• Tracheostomy Care Step-by-Step Procedure:

  • Verify physician orders and identify the patient

  • Assess patient respiratory status and perform airway suctioning prior to cleaning if secretions are present

  • Position patient in Semi-Fowler's position

  • Perform hand hygiene; open disposable tracheostomy kit using aseptic sterile technique

  • Don clean gloves

  • With non-dominant hand, unlock and remove inner cannula; soak reusable inner cannula in hydrogen peroxide solution

  • Don second pair of gloves (sterile gloves)

  • Clean inner cannula thoroughly using a tube brush or pipe cleaners, rinse with sterile normal saline, and inspect outer and inner cannula integrity

  • Reinsert inner cannula in direction of tracheostomy curve and lock securely into position

  • Clean stoma and outer flange using sterile normal saline; dry peristomal skin completely

  • Apply a pre-split sterile $4 \times 4\,\text{inch}$ drainage sponge around the tracheostomy flange (Note: Never cut standard gauze sponges, as loose fibers can enter the stoma and cause aspiration/foreign body reaction)

  • Change Tracheostomy Ties:

  • CRITICAL SAFETY RULE: Always secure new ties completely before removing old ties, or maintain a second assistant holding the trach tube securely in place. Removing old ties first creates a high Risk for Injury from accidental tube decannulation

  • Tension Check: Adjust ties so that two fingers can fit comfortably underneath the tie against the neck     

    

  • Auscultate lung sounds and provide thorough oral hygiene

  • Remove any condensed water accumulation from respiratory tubing

  • Position call light, paper, and pencil within easy reach

• Required Documentation:

  • Date and time care was performed

  • Type of tracheostomy care rendered

  • Patient tolerance and evaluation of respiratory status

  • Stoma site appearance and peristomal skin condition

  • Oxygen flow rate and delivery method utilized

  • Patient teaching provided

• Physician Notification Criteria:

  • Tracheostomy tube becomes dislodged or displaced and cannot be easily re-inserted

  • Patient experiences acute respiratory distress or dyspnea

  • Tracheal secretions become markedly increased, thick, foul-smelling, or blood-tinged

  • Presence of dry, crusted secretions (mucus plugs) obstructing airway

  • Patient reports chest discomfort

  • Patient develops fever or systemic signs of infection

  • Open skin sores, severe breakdown, or expanding erythema around stoma

Airway Suctioning Procedures and Protocols

• Priority and Indications for Suctioning:

  • The nurse's primary priority is evaluating airway patency and patient response to suctioning

  • Perform suctioning as needed based on assessment, not on a fixed routine schedule

  • Indications: Audible or visible gurgling respirations, restlessness, decreased oxygen saturation, drooling, or vomitus in mouth

• Suction Equipment Settings and Sizing:

  • Adult Wall Suction Pressure: Set between $120-150\,\text{mmHg}$

  • Common Adult Suction Catheter Size: $12-14\,\text{Fr}$

• Tracheostomy Suctioning Protocol (Skill 14.2):

  • Assemble suction kit, catheter, sterile saline, and pulse oximeter

  • Position conscious patient in Semi-Fowler's position

  • POSITIONING UNCONSCIOUS PATIENT: Place an unconscious patient in a side-lying position during suctioning to prevent aspiration

  • Place pulse oximeter on patient for continuous $\text{SpO}_2$ monitoring during suctioning

  • Perform hand hygiene and don clean gloves/sterile gloves per sterile protocol

  • Pre-oxygenate patient with $100\%\,\text{O}_2$ prior to inserting suction catheter

  • Dip catheter tip into sterile saline solution to lubricate

  • Advance catheter gently into tracheostomy tube $1-2\,\text{inches}$ without applying suction (keep thumb off suction control vent)

  • Apply intermittent suctioning while rotating catheter during withdrawal

  • MAXIMUM SUCTION DURATION: Apply suction for a maximum of $10\,\text{seconds}$ per pass to prevent hypoxia and tissue injury

  • Rinse catheter with sterile solution; allow patient time to rest between suction passes

  • Single-Use Rule: Catheter must be discarded after each procedure

  • Handling Bloody Secretions: If intermittent bloody secretions appear during suctioning, complete the suctioning pass, evaluate patient response, and assess for mucosal damage

• Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning:

  • Oropharyngeal Suctioning: Performed using a rigid Yankauer (tonsillar tip) catheter to clear oral secretions

  • Nasopharyngeal / Nasotracheal Suctioning: Requires strict sterile technique when inserting catheter through nares into pharynx or trachea