Pulmonary Therapeutic Management

Chapter 21


Pulmonary Therapeutic Management


Kathleen M. Stacy



Oxygen Therapy


Normal cellular function depends on the delivery of an adequate supply of oxygen to the cells to meet their metabolic needs. The goal of oxygen therapy is to provide a sufficient concentration of inspired oxygen to permit full use of the oxygen-carrying capacity of the arterial blood; this ensures adequate cellular oxygenation, provided the cardiac output and hemoglobin concentration are adequate.1,2



Principles of Therapy


Oxygen is an atmospheric gas that must also be considered a medication because—like most other medications—it has detrimental as well as beneficial effects. Oxygen is one of the most commonly used and misused medications. As a medication, it must be administered for good reason and in a proper, safe manner. Oxygen is usually ordered in liters per minute (L/min), as a concentration of oxygen expressed as a percentage (e.g., 40%), or as a fraction of inspired oxygen (Fio2) such as 0.4.


The primary indication for oxygen therapy is hypoxemia.3 The amount of oxygen administered depends on the pathophysiologic mechanisms affecting the patient’s oxygenation status. In most cases, the amount required should provide an arterial partial pressure of oxygen (Pao2) of greater than 60 mm Hg or an arterial hemoglobin saturation (Sao2) of greater than 90% during rest and exercise.2 The concentration of oxygen given to an individual patient is a clinical judgment based on the many factors that influence oxygen transport such as hemoglobin concentration, cardiac output, and arterial oxygen tension.1,2


After oxygen therapy has begun, the patient is continuously assessed for level of oxygenation and the factors affecting it. The patient’s oxygenation status is evaluated several times daily until the desired oxygen level has been reached and has stabilized. If the desired response to the amount of oxygen delivered is not achieved, the oxygen supplementation is adjusted, and the patient’s condition is re-evaluated. It is important to use this dose-response method so that the lowest possible level of oxygen is administered that will still achieve a satisfactory Pao2 or Sao2.2,3



Methods of Delivery


Oxygen therapy can be delivered by many different devices (Table 21-1). Common problems with these devices include system leaks and obstructions, device displacement, and skin irritation. These devices are classified as low-flow, reservoir, or high-flow systems.3



TABLE 21-1


OXYGEN THERAPY SYSTEMS


























































































































CATEGORY DEVICE FLOW Fio2 RANGE (%) Fio2 STABILITY ADVANTAGES DISADVANTAGES BEST USE
Low-flow Nasal cannula 0.25-8 L/min (adults)
≤2 L/min (infants)
22-45 Variable Use on adults, children, infants; easy to apply; disposable, low cost; well tolerated Unstable, easily dislodged; high flows uncomfortable; can cause dryness or bleeding; polyps, deviated septum may block flow Stable patient needing low Fio2; home care patient requiring long-term therapy
  Nasal catheter 0.25-8 L/min 22-45 Variable Use on adults, children, infants; good stability; disposable, low cost Difficult to insert; high flows increase back pressure; needs regular changing; polyps, deviated septum may block insertion; may provoke gagging, air swallowing, aspiration Procedures in which cannula is difficult to use (bronchoscopy); long-term care for infants
  Transtracheal catheter 0.25-4 L/min 22-35 Variable Lower oxygen usage or cost; eliminates nasal/skin irritation; improved compliance; increased exercise tolerance; increased mobility; enhanced image High cost; surgical complications; infection; mucus plugging; lost tract Home care or ambulatory patients who need increased mobility or who do not accept nasal oxygen
Reservoir Reservoir cannula 0.25-4 L/min 22-35 Variable Lower oxygen usage/cost; increased mobility; less discomfort because of lower flows Unattractive, cumbersome; poor compliance; must be regularly replaced; breathing pattern affects performance Home care or ambulatory patients who need increased mobility
  Simple mask 5-12 L/min 35-50 Variable Use on adults, children, infants; quick, easy to apply; disposable, inexpensive Uncomfortable; must be removed for eating; prevents radiant heat loss; blocks vomitus in unconscious patients Emergencies, short-term therapy requiring moderate Fio2
  Partial rebreathing mask 6-10 L/min (prevent bag collapse on inspiration) 35-60 Variable Same as simple mask; moderate to high Fio2 Same as simple mask; potential suffocation hazard Emergencies, short-term therapy requiring moderate to high Fio2
  Nonrebreathing mask 6-10 L/min (prevent bag collapse on inspiration) 55-70 Variable Same as simple mask; high Fio2 Same as simple mask; potential suffocation hazard Emergencies, short-term therapy requiring high Fio2
  Nonrebreathing circuit (closed) 3 × VE (prevent bag collapse on inspiration) 21-100 Fixed Full range of Fio2 Potential suffocation hazard; requires 50 psi air or oxygen; blender failure common Patients requiring precise Fio2 at any level (21%–100%)
High-flow Air-entrainment mask (AEM) Varies; should provide output flow >60 L/min 24-50 Fixed Easy to apply; disposable, inexpensive; stable, precise Fio2 Limited to adult use; uncomfortable, noisy; must be removed for eating; Fio2 >0.40 not ensured; Fio2 varies with back-pressure Unstable patients requiring precise low Fio2
  Air-entrainment nebulizer 10-15 L/min input; should provide output flow of at least 60 L/min 28-100 Fixed Provides temperature control and extra humidification Fio2 <28% or >0.40 not ensured; Fio2 varies with back-pressure; high infection risk Patients with artificial airways requiring low to moderate Fio2
  Blending system (open) Should provide output flow of at least 60 L/min 21-100 Fixed Full range of Fio2 Requires 50 psi air + oxygen; blender failure or inaccuracy common Patient with high VE who need high Fio2
  High-flow cannula system Up to 40 L/min (depending on system) 35-90 Variable or fixed depending on system and input flow Wide range of Fio2 and relative or absolute humidity; use on adults, children, infants Fio2 not ensured depending on input flow and patient breathing pattern; infection risk Patients of all ages with high or variable VE who need supplemental oxygen, positive pressure, or humidity


image


FiO2, Fraction of inspired oxygen; VE, minute volume.


Modified from Heuer AJ. Medical gas therapy. In: Wilkins RL, et al, eds. Egan’s Fundamentals of Respiratory Care. 10th ed. St. Louis: Mosby; 2013.





High-Flow Systems


With a high-flow system, the oxygen flows out of the device and into the patient’s airways in an amount sufficient to meet all inspiratory volume requirements. This type of system is not affected by the patient’s ventilatory pattern. A high-flow system uses either an air-entrainment system or blending system to mix air and oxygen to achieve the desired Fio2. An air-entrainment mask is an example of a high-flow system that delivers precisely controlled oxygen at the lower Fio2 range.3


One of the newest high-flow systems is the high-flow nasal cannula. With this system, warmed and humidified oxygen is delivered to the patient via a nasal cannula using a blending system. This system has been shown to improve oxygenation and ventilation and decrease the work of breathing in the patient with acute lung failure. It also is more comfortable and better tolerated than similar therapies.4



Complications of Oxygen Therapy


Oxygen, like most medications, has adverse effects and complications resulting from its use. The adage, “If a little is good, a lot is better,” does not apply to oxygen. The lung is designed to handle a concentration of 21% oxygen, with some adaptability to higher concentrations, but adverse effects and oxygen toxicity can result if a high concentration is administered for too long.5



Oxygen Toxicity


The most detrimental effect of breathing a high concentration of oxygen is the development of oxygen toxicity. It can occur in any patient who breathes oxygen concentrations of greater than 50% for longer than 24 hours. Patients most likely to develop oxygen toxicity are those who require intubation, mechanical ventilation, and high oxygen concentrations for extended periods.3


Hyperoxia, or the administration of higher-than-normal oxygen concentrations, produces an overabundance of oxygen free radicals. These radicals are responsible for the initial damage to the alveolar–capillary membrane. Oxygen free radicals are toxic metabolites of oxygen metabolism. Normally, enzymes neutralize the radicals, preventing any damage from occurring. During the administration of high levels of oxygen, the large number of oxygen free radicals produced exhausts the supply of neutralizing enzymes. Damage to the lung parenchyma and vasculature occurs, resulting in the initiation of acute respiratory distress syndrome (ARDS).2,5


A number of clinical manifestations are associated with oxygen toxicity. The first symptom is substernal chest pain that is exacerbated by deep breathing. A dry cough and tracheal irritation follow. Eventually, definite pleuritic pain occurs on inhalation, followed by dyspnea. Upper airway changes may include a sensation of nasal stuffiness, sore throat, and eye and ear discomforts. Chest radiographs and pulmonary function tests show no abnormalities until symptoms are severe. Complete, rapid reversal of these symptoms occurs as soon as normal oxygen concentrations are restored.5



Carbon Dioxide Retention


In patients with severe chronic obstructive pulmonary disease (COPD), carbon dioxide (CO2) retention may occur as a result of administration of oxygen in high concentrations. A number of theories have been proposed for this phenomenon. One states that the normal stimulus to breathe (i.e., increasing CO2 levels) is muted in patients with COPD and that decreasing oxygen levels become the stimulus to breathe. If hypoxemia is corrected by the administration of oxygen, the stimulus to breathe is abolished; hypoventilation develops, resulting in a further increase in the arterial partial pressure of carbon dioxide (Paco2).2,3 Another theory is that the administration of oxygen abolishes the compensatory response of hypoxic pulmonary vasoconstriction. This results in an increase in perfusion of underventilated alveoli and the development of dead space, producing ventilation–perfusion mismatch. As alveolar dead space increases, so does the retention of CO2.2,3 One further theory states that the rise in CO2 is related to the ratio of deoxygenated to oxygenated hemoglobin (Haldane effect). Deoxygenated hemoglobin carries more CO2 compared with oxygenated hemoglobin. Administration of oxygen increases the proportion of oxygenated hemoglobin, which causes increased release of CO2 at the lung level.5 Because of the risk of CO2 accumulation, all patients who are chronically hypercapnic require careful low-flow oxygen administration.3




Nursing Management


Nursing management of the patient receiving oxygen is outlined in Box 21-1. Key nursing interventions include ensuring the oxygen is being administered as ordered and observing for complications of the therapy. Confirming that the oxygen therapy device is properly positioned and replacing it after removal is important. During meals, an oxygen mask should be changed to a nasal cannula if the patient can tolerate one. The patient receiving oxygen therapy should also be transported with the oxygen. In addition, oxygen saturation should be periodically monitored using a pulse oximeter.



image Box 21-1


NIC


Oxygen Therapy




Activities




• Clear oral, nasal, and tracheal secretions, as appropriate.


• Restrict smoking.


• Maintain airway patency.


• Set up oxygen equipment and administer through a heated, humidified system.


• Administer supplemental oxygen, as ordered.


• Monitor the oxygen liter flow.


• Monitor position of oxygen delivery device.


• Instruct patient about importance of leaving oxygen delivery device on.


• Periodically check oxygen delivery device to ensure that the prescribed concentration is being delivered.


• Monitor the effectiveness of oxygen therapy (e.g., pulse oximetry, arterial blood gases) as appropriate.


• Assure replacement of oxygen mask or cannula whenever the device is removed.


• Monitor patient’s ability to tolerate removal of oxygen while eating.


• Change oxygen delivery device from mask to nasal prongs during meals, as tolerated.


• Observe for signs of oxygen-induced hypoventilation.


• Monitor for signs of oxygen toxicity and absorption atelectasis.


• Monitor oxygen equipment to ensure that it is not interfering with the patient’s attempts to breathe.


• Monitor patient’s anxiety related to need for oxygen therapy.


• Monitor for skin breakdown from friction of oxygen device.


• Provide for oxygen when patient is transported.


• Instruct patient to obtain a supplementary oxygen prescription before air travel or trips to high altitude, as appropriate.


• Consult with other health care personnel about use of supplemental oxygen during activity, sleep, or both.


• Instruct patient and family about use of oxygen at home.


• Arrange for use of oxygen devices that facilitate mobility and teach patient accordingly.


• Convert to alternate oxygen delivery device to promote comfort, as appropriate.


From Bulechek GM, et al. Nursing Interventions Classification (NIC). 6th ed. St. Louis: Mosby; 2013.



Artificial Airways


Pharyngeal Airways


Pharyngeal airways are used to maintain airway patency by keeping the tongue from obstructing the upper airway. The two types of pharyngeal airways are oropharyngeal and nasopharyngeal airways. Complications of these airways include trauma to the oral or nasal cavity, obstruction of the airway, laryngospasm, gagging, and vomiting.6,7



Oropharyngeal Airway


An oropharyngeal airway is made of plastic and is available in various sizes. The proper size is selected by holding the airway against the side of the patient’s face and ensuring that it extends from the corner of the mouth to the angle of the jaw. If the airway is improperly sized, it will occlude the airway.6,7 An oral airway is placed by inserting a tongue depressor into the patient’s mouth to displace the tongue downward and then passing the airway into the patient’s mouth, slipping it over the patient’s tongue (Fig. 21-1).7 When properly placed, the tip of the airway lies above the epiglottis at the base of the tongue. It should be used only in an unconscious patient who has an absent or diminished gag reflex.6,7




Nasopharyngeal Airway


A nasopharyngeal airway is usually made of plastic or rubber and is available in various sizes. The proper size is selected by holding the airway against the side of the patient’s face and ensuring that it extends from the tip of the nose to the ear lobe.6,7 A nasal airway is placed by lubricating the tube and inserting it midline along the floor of the naris into the posterior pharynx.7 When properly placed, the tip of the airway lies above the epiglottis at the base of the tongue.6,7



Endotracheal Tubes


An endotracheal tube (ETT) is the most commonly used artificial airway for providing short-term airway management. Indications for endotracheal intubation include maintenance of airway patency, protection of the airway from aspiration, application of positive-pressure ventilation, facilitation of pulmonary toilet, and use of high oxygen concentrations.8 An ETT may be placed through the orotracheal or the nasotracheal route.9,10 In most situations involving emergency placement, the orotracheal route is used because it is simpler and allows the use of a larger-diameter ETT.10,11 Nasotracheal intubation provides greater patient comfort over time and is preferred in patients with a jaw fracture.9,11,12 The advantages of orotracheal and nasotracheal intubation are presented in Table 21-2.



ETTs are available in various sizes, which are based on the inner diameters of the tubes, and have a radiopaque marker that runs the length of the tube. On one end of the tube is a cuff that is inflated with the use of the pilot balloon. Because of the high incidence of cuff-related problems, low-pressure, high-volume cuffs are preferred. On the other end of the tube is a 15-mm adaptor that facilitates connection of the tube to a manual resuscitation bag (MRB), T-tube, or ventilator (Fig. 21-2).13




Rapid Sequence Intubation


Rapid sequence intubation (RSI) is a seven-step process that is often used to intubate the critically ill patient. It is considered safer for the patient as it decreases the risk of aspiration.14








Step 6—Placement of the Endotracheal Tube. 

Next, the ETT is inserted into the trachea (Fig. 21-3), and placement is confirmed.14 Each intubation attempt is limited to 30 seconds to prevent hypoxemia. After the ETT is inserted, the patient is assessed for bilateral breath sounds and chest movement. Absence of breath sounds is indicative of an esophageal intubation, whereas breath sounds heard over only one side is indicative of a main stem intubation. A disposable end-tidal CO2 detector (Fig. 21-4) is used to initially verify correct airway placement, after which the cuff of the tube is inflated and the tube is secured. Finally, a chest radiograph is obtained to confirm placement.911 The tip of the ETT should be approximately 3 to 4 cm above the carina when the patient’s head is in the neutral position.10






Complications


A number of complications can occur during the intubation procedure, including nasal and oral trauma, pharyngeal and hypopharyngeal trauma, vomiting with aspiration, and cardiac arrest.15 Tracheal rupture is a rare and often fatal complication that is associated with emergent intubation.16 Hypoxemia and hypercapnia can also occur, resulting in bradycardia, tachycardia, dysrhythmias, hypertension, and hypotension.8,12,15


Several complications can occur while the ETT is in place, including nasal and oral inflammation and ulceration, sinusitis and otitis, laryngeal and tracheal injuries, and tube obstruction and displacement. Other complications can occur days to weeks after the ETT is removed, including laryngeal and tracheal stenosis and a cricoid abscess (Table 21-3). Delayed complications usually require some form of surgical intervention.17,18



TABLE 21-3


COMPLICATIONS OF ENDOTRACHEAL TUBES

















































































































































































COMPLICATIONS CAUSES PREVENTION AND TREATMENT
Tube obstruction Patient biting tube Prevention:
  Tube kinking during repositioning Place bite block.
  Cuff herniation Sedate patient PRN.
  Dried secretions, blood, or lubricant Suction PRN.
  Tissue from tumor Humidify inspired gases.
  Trauma Treatment:
  Foreign body Replace tube.
Tube displacement Movement of patient’s head Prevention:
  Movement of tube by patient’s tongue
Traction on tube from ventilator tubing
Secure tube to upper lip.
Restrain patient’s hands as needed.
Sedate patient PRN.
  Self-extubation Ensure that only 2 inches of tube extend beyond lip.
    Support ventilator tubing.
    Treatment:
    Replace tube.
Sinusitis and nasal injury Obstruction of the paranasal sinus drainage Prevention:
Avoid nasal intubations.
  Pressure necrosis of nares Cushion nares from tube and tape or ties.
    Treatment:
    Remove all tubes from nasal passages.
    Administer antibiotics.
Tracheoesophageal fistula Pressure necrosis of posterior tracheal wall, resulting from overinflated cuff and rigid nasogastric tube Prevention:
Inflate cuff with minimal amount of air necessary.
Monitor cuff pressures every 8 hours.
    Treatment:
    Position cuff of tube distal to fistula.
    Place gastrostomy tube for enteral feedings.
    Place esophageal tube for secretion clearance proximal to fistula.
Mucosal lesions Pressure at tube and mucosal interface Prevention:
Inflate cuff with minimal amount of air necessary.
    Monitor cuff pressures every 8 hours.
    Use appropriate size tube.
    Treatment:
    May resolve spontaneously.
    Perform surgical intervention.
Laryngeal or tracheal stenosis Injury to area from end of tube or cuff, resulting in scar tissue formation and narrowing of airway Prevention:
Inflate cuff with minimal amount of air necessary.
Monitor cuff pressures every 8 hours.
    Suction area above cuff frequently.
    Treatment:
    Perform tracheostomy.
    Place laryngeal stent.
    Perform surgical repair.
Cricoid abscess Mucosal injury with bacterial invasion Prevention:
Inflate cuff with minimal amount of air necessary.
    Monitor cuff pressures every 8 hours.
    Suction area above cuff frequently.
    Treatment:
    Perform incision and drainage of area.
    Administer antibiotics.


image


PRN, As needed.



Tracheostomy Tubes


A tracheostomy tube is the preferred method of airway maintenance in the patient who requires long-term intubation. Although no ideal time to perform the procedure has been identified, it is commonly accepted that if a patient has been intubated or is anticipated to be intubated for longer than 7 to 10 days, a tracheostomy should be performed.19 A tracheostomy is also indicated in several other situations such as the presence of an upper airway obstruction due to trauma, tumors, or swelling and the need to facilitate airway clearance due to spinal cord injury, neuromuscular disease, or severe debilitation.20,21


A tracheostomy tube provides the best route for long-term airway maintenance because it avoids the oral, nasal, pharyngeal, and laryngeal complications associated with an ETT. The tube is shorter, of wider diameter, and less curved than an ETT; the resistance to air flow is less, and breathing is easier. Additional advantages of a tracheostomy tube include easier secretion removal, increased patient acceptance and comfort, capability of the patient to eat and talk if possible, and easier ventilator weaning.11,20 See Table 21-2 for a list of the advantages of a tracheostomy tube.


Tracheostomy tubes are made of plastic or metal and may have one or two lumens. Single-lumen tubes consist of the tube; a built-in cuff, which is connected to a pilot balloon for inflation purposes; and an obturator, which is used during tube insertion. The double-lumen tubes consist of the tube with the attached cuff, the obturator, and an inner cannula that can be removed for cleaning and then reinserted or, if disposable, replaced by a new sterile inner cannula. The inner cannula can quickly be removed if it becomes obstructed, making the system safer for patients with significant secretion problems. Single-lumen tubes provide a larger internal diameter for airflow, so airflow resistance is reduced, and the patient can ventilate through the tube with greater ease. Plastic tracheostomy tubes also have a 15-mm adaptor on the end (Fig. 21-6).20,21





Complications


A number of complications can occur during the tracheostomy procedure, including misplacement of the tracheal tube, hemorrhage, laryngeal nerve injury, pneumothorax, pneumomediastinum, and cardiac arrest.17,21,22 Several complications can occur while the tracheostomy tube is in place, including stomal infection, hemorrhage, tracheomalacia, tracheoesophageal fistula, tracheoinnominate artery fistula, and tube obstruction and displacement.21,22 A number of complications can occur days to weeks after the tracheostomy tube is removed, including tracheal stenosis and tracheocutaneous fistula (Table 21-4). Delayed complications usually require some form of surgical intervention.21



TABLE 21-4


COMPLICATIONS OF TRACHEOSTOMY TUBES
























































































































































































COMPLICATIONS CAUSES PREVENTION AND TREATMENT
Hemorrhage Vessel opening after surgery Prevention:
  Vessel erosion caused by tube Use appropriate size tube.
    Treat local infection.
    Suction gently.
    Humidify inspired gases.
    Position tracheal window not lower than third tracheal ring.
    Treatment:
    Pack lightly.
    Perform surgical intervention.
Wound infection Colonization of stoma with hospital flora Prevention:
Perform routine stoma care.
    Treatment:
    Remove tube, if necessary.
    Perform aggressive wound care and débridement.
    Administer antibiotics.
Subcutaneous emphysema Positive-pressure ventilation Prevention:
Coughing against a tight, occlusive dressing or sutured or packed wound Avoid suturing or packing wound closed around tube.
Treatment:
    Remove any sutures or packing, if present.
Tube obstruction Dried blood or secretions Prevention:
  False passage into soft tissues Suction PRN.
  Opening of cannula positioned against tracheal wall Humidify inspired gases.
Use a tube with a removable inner cannula.
  Foreign body
Tissue from tumor
Position tube so that opening does not press against tracheal wall.
    Treatment:
    Remove or replace inner cannula.
    Replace tube.
Tube displacement Patient movement Prevention:
  Coughing Use commercial tube holder.
  Traction on ventilatory tubing Use tubes with adjustable neck plates for patients with short necks.
    Support ventilatory tubing.
    Sedate patient PRN.
    Restrain patient, as needed.
    Treatment:
    Cover stoma and manually ventilate patient by mouth.
    Replace tube.
Tracheal stenosis Injury to area from end of tube or cuff, resulting in scar tissue formation and narrowing of airway Prevention:
Inflate cuff with minimal amount of air necessary.
Monitor cuff pressures every 8 hours.
    Treatment:
    Perform surgical repair.
Tracheoesophageal fistula Pressure necrosis of posterior tracheal wall, resulting from overinflated cuff and rigid nasogastric tube Prevention:
Inflate cuff with minimal amount of air necessary.
Monitor cuff pressures every 8 hours.
    Treatment:
    Perform surgical repair.
Tracheoinnominate artery fistula Direct pressure from the elbow of the cannula against the innominate artery Prevention:
Position tracheal window not lower than third tracheal ring.
  Placement of tracheal stoma below fourth tracheal ring Treatment:
Hyperinflate cuff to control bleeding.
  Downward migration of the tracheal stoma, resulting from traction on tube Remove tube and replace with endotracheal tube, and apply digital pressure through stoma against the sternum.
  High-lying innominate artery Perform surgical repair.
Tracheocutaneous fistula Failure of stoma to close after removal of tube Treatment:
Perform surgical repair.


image


PRN, As needed.



Nursing Management


Nursing management of the patient with an endotracheal or tracheostomy tube requires some additional measures to address the effects associated with tube placement on the respiratory and other body systems (Box 21-2). Nursing interventions for the patient with an artificial airway include providing humidification, managing the cuff, suctioning, establishing a method of communication, and providing oral hygiene. Because the tube bypasses the upper airway system, warming and humidifying of air must be performed by external means. Because the cuff of the tube can cause damage to the walls of the trachea, proper cuff inflation and management are imperative. In addition, the normal defense mechanisms are impaired and secretions may accumulate; thus, suctioning may be needed to promote secretion clearance. Because the tube does not allow air flow over the vocal cords, developing a method of communication is also very important. Last, observing the patient to ensure proper placement of the tube and patency of the airway is essential.



image Box 21-2


NIC


Artificial Airway Management




Activities




• Perform hand hygiene.


• Use universal precautions.


• Use personal protective equipment (gloves, goggles, and mask), as appropriate.


• Provide an oropharyngeal airway or bite block to prevent biting on the endotracheal tube, as appropriate.


• Provide 100% humidification of inspired air, oxygen, or gas.


• Provide adequate systemic hydration via oral or intravenous fluid administration.


• Inflate endotracheal or tracheostoma cuff using minimal occlusive volume (MOV) technique or minimal leak technique (MLT).


• Maintain inflation of the endotracheal or tracheostoma cuff at 15 to 25 mm Hg during mechanical ventilation and during and after feeding.


• Monitor cuff pressures every 4 to 8 hours during expiration using a three-way stopcock, calibrated syringe, and manometer.


• Check cuff pressure immediately after delivery of any general anesthesia or manipulation of endotracheal tube.


• Institute endotracheal suctioning, as appropriate.


• Suction the oropharnyx and secretions from the top of the tube cuff before deflating cuff.


• Change endotracheal tapes or ties every 24 hours, inspect the skin and oral mucosa, and reposition ET to the other side of the mouth.


• Loosen commercial endotracheal tube holders at least once a day, and provide skin care.


• Auscultate for presence of lung sounds bilaterally after insertion and after changing endotracheal or tracheostomy ties.


• Note the centimeter reference marking on endotracheal tube to monitor for possible displacement.


• Assist with chest radiographic examination, as needed, to monitor position of tube.


• Minimize leverage and traction on the artificial airway by suspending ventilator tubing from overhead supports, using flexible catheter mounts and swivels, and supporting tubes during turning, suctioning, and ventilator disconnection and reconnection.


• Monitor for presence of crackles and rhonchi over large airways.


• Monitor secretions: color, amount, and consistency.


• Perform oral care (i.e., use toothbrush, swabs, mouth and lip moisturizer), as needed.


• Monitor for decrease in exhale volume and increase in inspiratory pressure in patients receiving mechanical ventilation.


• Institute measures to prevent spontaneous decannulation (i.e., secure artificial airway with tape or ties, administer sedation and muscle paralyzing agent, use arm restraints), as appropriate.


• Provide additional intubation equipment and Ambu bag in a readily available location.


• Provide trachea care every 4 to 8 hours, as appropriate: clean the inner cannula, clean and dry the area around the stoma, and change tracheostomy ties.


• Inspect skin around tracheal stoma for drainage, redness, irritation and bleeding.


• Inspect and palpate for air under skin every 8 hours.


• Monitor for presence of pain.


• Maintain sterile technique when suctioning and providing tracheostomy care.


• Shield the tracheostomy from water.


• Tape the tracheostomy obturator to head of bed.


• Tape a second tracheostomy (same type and size) and forceps to head of bed.


• Institute chest physiotherapy, as appropriate.


• Ensure that endotracheal or tracheostomy cuff is inflated during feedings, as appropriate.


• Elevate head of the bed 30 degrees or more, or assist patient to a sitting position in a chair during feedings, as appropriate.


From Bulechek GM, et al. Nursing Interventions Classification (NIC), 6th ed. St. Louis: Mosby; 2013.


Patient safety is critically important when caring for a patient with an artificial airway, as loss of the tube can result in loss of the patient’s airway. In the event of unintentional extubation or decannulation, the patient’s airway should be opened with the head tilt–chin lift maneuver and maintained with an oropharyngeal or nasopharyngeal airway. If the patient is not breathing, he or she should be manually ventilated with a manual resuscitation bag and face mask with 100% oxygen. In the case of a tracheostomy, the stoma should be covered to prevent air from escaping through it. If the tracheostomy remains open then consideration should be given to ventilating the patient through the stoma instead of the mouth.


One recent study examined patients’ perception of endotracheal tube–related discomforts. Forty-six percent of the patients reported remembering having the endotracheal tube while in the critical care unit. The majority of these patients found the discomfort associated with the ETT and the inability to speak very stressful. In addition, some of the patient’s continued to have problems with hoarseness, sore throat, and voice changes days to months later.24




Cuff Management


Because the cuff of the ETT or tracheostomy tube is a major source of the complications associated with artificial airways, proper cuff management is essential. To prevent the complications associated with cuff design, only low-pressure, high-volume cuffed tubes are used in clinical practice.13,28 Even with these tubes, cuff pressures can be generated that are high enough to lead to tracheal ischemia and injury. Proper cuff inflation techniques and cuff pressure monitoring are critical components of the care of the patient with an artificial airway.10,28 Figure 21-7 is an example of a one device used to measure cuff pressures.




Cuff Inflation Techniques. 

Two cuff inflation techniques are used: 1) the minimal leak (ML) technique and 2) the minimal occlusion volume (MOV) technique. The ML technique consists of injecting air into the cuff until no leak is heard and then withdrawing the air until a small leak is heard on inspiration. Problems with this technique include difficulty maintaining positive end-expiratory pressure (PEEP) and aspiration around the cuff. The MOV technique consists of injecting air into the cuff until no leak is heard at peak inspiration. This technique generates higher cuff pressures than does the ML technique. The selection of one technique over the other is determined by individual patient needs. If the patient needs a seal to provide adequate ventilation or is at high risk for aspiration, the MOV technique is used. If these are not concerns, usually the ML technique is used.10,11,28




Foam Cuff Tracheostomy Tubes. 

One tracheostomy tube on the market has a cuff made of foam that is self-inflating (Fig. 21-8). It is deflated during insertion, after which the pilot port is opened to atmospheric pressure (room air), and the cuff self-inflates. After inflation, the foam cuff conforms to the size and shape of the patient’s trachea, thereby reducing the pressure against the tracheal wall. The pilot port can be left open to atmospheric pressure or attached to the mechanical ventilator tubing, allowing the cuff to inflate and deflate with the cycling of the ventilator. Routine maintenance of a foam cuff tracheostomy tube includes aspirating the pilot port every 8 hours to measure cuff volume, to remove any condensation from the cuff area, and to assess the integrity of the cuff. Removal is accomplished by deflating the cuff; this can be complicated if the plastic sheath covering the foam is perforated. If perforation occurs, the foam may not be deflatable because the air cannot be totally aspirated.21




Subglottic Secretion Removal. 

The cuff has also been implicated in the development of ventilator-associated pneumonia. Fluids can leak around the cuff into the airway, resulting in microaspiration. Bacteria-laden oral secretions trickle down the larynx and pool above the cuff of the artificial airway. These secretions are referred to as subglottic secretions. Subglottic secretions can then leak into the lower airways around the cuff via the longitudinal folds in that form in the cuff as it accommodates for the shape of the airway, an underinflated cuff that fails to form a proper seal in the airway, or inadvertent movement of the endotracheal tube within airway. Thus, the use of established cuff inflation techniques, monitoring of cuff pressures, using an appropriate method of tube stabilization, and oral hygiene are important interventions for preventing this problem.29 Deep oropharyngeal suctioning to remove subglottic secretions should be performed at least every 12 hours and prior to deflating the cuff or moving the tube.30


Specialized tubes are available to allow for the continuous removal of subglottic secretions. These tubes have an additional lumen, with an opening above the cuff, which is connected to continuous (–20 to –30 cm H2O) suction (Fig. 21-9).11 These tubes are recommended for patients who are expected to be intubated for longer than 72 hours.31 One issue with these tubes is that the aspiration lumen can become clogged and, thus, requires a small amount of air to be injected into the aspiration port every 4 hours.




Suctioning


Suctioning is often required to maintain a patent airway in the patient with an ETT or tracheostomy tube. Suctioning is a sterile procedure that is performed only when the patient needs it and not on a routine schedule.10,32,33 Indications for suctioning include coughing, secretions in the airway, respiratory distress, presence of rhonchi on auscultation, increased peak airway pressures on the ventilator, and decreasing oxygenation saturation.11 Complications associated with suctioning include hypoxemia, atelectasis, bronchospasms, dysrhythmias, increased intracranial pressure, and airway trauma.11,32




Suctioning Protocol. 

A number of protocols regarding suctioning have been developed. Several practices have been found helpful in limiting the complications of suctioning. Hypoxemia can be minimized by giving the patient three hyperoxygenation breaths (breaths at 100% Fio2) with the ventilator before the procedure begins and again after each pass of the suction catheter.10,33,34 If the patient exhibits signs of desaturation, hyperinflation (breaths at 150% tidal volume) should be added to the procedure.10 Atelectasis can be avoided by using a suction catheter with an external diameter of less than one half of the internal diameter of the ETT.32,33 Using no greater than 120 mm Hg of suction decreases the chances of hypoxemia, atelectasis, and airway trauma.10,33 Limiting the duration of each suction pass to 10 to 15 seconds;10,32,33 and the number of passes to a maximum of three also helps minimize hypoxemia, airway trauma, and cardiac dysrhythmias.35 The process of applying intermittent (instead of continuous) suction has been shown to be of no benefit.33,36 The instillation of normal saline to help remove secretions has not proved to be of any benefit;32,33,37 and it may actually contribute to the development of hypoxemia, as well as lower airway colonization, resulting in ventilator-associated pneumonia (VAP).10,38,39



Closed Tracheal Suction System. 

One device to facilitate the suctioning of a patient on a ventilator is the closed tracheal suction system (CTSS) (Fig. 21-10). This device consists of a suction catheter in a plastic sleeve that attaches directly to the ventilator tubing. It allows the patient to be suctioned while remaining on the ventilator. Advantages of the CTSS include maintenance of oxygenation and PEEP during suctioning, reduction of hypoxemia-related complications, and protection of staff members from the patient’s secretions. The CTSS is convenient to use, requiring only one person to perform the procedure.11



Concerns related to the CTSS include autocontamination, inadequate removal of secretions, and increased risk of unintentional extubation resulting from the extra weight of the system on the ventilator tubing. Autocontamination has been shown not to be an issue if the catheter is cleaned properly after every use. Inadequate removal of secretions may or may not be a problem, and further investigation is required to settle this issue.11 Although recommendations for changing the catheter vary, one study indicated that the catheter could be changed on an as-needed basis without increasing the incidence of VAP.40 Once recent study found that suctioning with the CTSS caused massive aspiration of fluid around the tracheal tube cuff as a result of a significant drop in airway pressure.41



Communication


One of the major stressors for the patient with an artificial airway is impaired communication. This is related to the inability to speak, insufficient explanations from staff members, inadequate understanding, fear of being unable to communicate, and difficulty with communication methods.42 A number of interventions can facilitate communication in the patient with an ETT or tracheostomy tube. These include establishing an environment that fosters communication, performing a complete assessment of the patient’s ability to communicate, anticipating the patient’s needs, teaching the patient and family how to communicate, using a variety of methods to communicate, and facilitating the patient’s ability to communicate by providing the patient with his or her eyeglasses or hearing aid.43


Methods to facilitate communication in this patient population include the use of verbal and nonverbal language and a variety of devices to assist the patient on short-term and long-term ventilator assistance. Nonverbal communication may include the use of sign language, gestures, lip reading, pointing, facial expressions, or eye blinking. Simple devices available include pencil and paper; Magic Slates; magnetic boards with plastic letters; picture, alphabet, or symbol boards; and flash cards. More sophisticated devices include typewriters, computers, talking ETT and tracheostomy tubes, and external handheld vibrators. Regardless of the method selected, the patient must be taught how to use the device.10,43



Passy-Muir Valve. 

One device used to assist the mechanically ventilated patient with a tracheostomy to speak is the Passy-Muir valve. This one-way valve opens on inhalation, allowing air to enter the lungs through the tracheostomy tube, and closes on exhalation, forcing air over the vocal cords and out the mouth, permitting the patient to speak (Fig. 21-11). Before the valve can be placed on a tracheostomy tube, the cuff must be deflated to allow air to pass around the tube, and the tidal volume of the ventilator must be increased to compensate for the air leak. In addition to aiding communication, the Passy-Muir valve can assist the ventilator-dependent patient with relearning normal breathing patterns. The valve is contraindicated in patients with laryngeal or pharyngeal dysfunction, excessive secretions, or poor lung compliance.43


Oct 29, 2016 | Posted by in NURSING | Comments Off on Pulmonary Therapeutic Management
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