Chapter 25: Concepts of Care for Patients Requiring Oxygen Therapy or Tracheostomy

Welcome to Last Minute Lecture.

This free chapter overview is designed to help students review and understand key concepts.

These summaries supplement not replaced the original textbook and may not be redistributed or resold.

For complete coverage, always consult the official text.

Welcome to the Deep Dive.

We're here to cut through the noise, get right into the core stuff you need from those dense medical texts.

Today we are tackling critical respiratory support.

Think oxygen therapy, think tracheostomy care.

We're pulling straight from the essentials in medical surgical nursing, our mission, a fast focused review, principles, safety rules you just can't ignore, and you know the practical management.

And it all comes back to one main priority concept, gas exchange.

Everything else like skin breakdown or infection risk connects back to tissue integrity and infection.

Makes sense.

That framework is perfect.

Yeah because you can't fix something if you don't know exactly what's broken.

So first things first, you've got to nail the difference between these three key terms.

Hypoxemia, that's low oxygen specifically in the blood.

Okay.

Hypoxia is what happens next, decreased oxygen getting to the tissues.

Got it, tissue level.

And hypercarbia, well that's too much carbon dioxide in the arterial blood often because the patient just can't breathe it off effectively.

And the stakes are high when we intervene.

We have to remember oxygen isn't just you know plain air, it's actually a prescribed drug.

Obviously for respiratory issues but the source points out it's also for things like sepsis or fever, even anemia.

Exactly.

Conditions where the body's demand for oxygen skyrockets or maybe its ability to carry oxygen is down.

So the body's just working overtime.

Right.

Even if the lungs seem okay initially, the tissues might still need that extra boost.

So how do we know when it's actually time to give that drug the oxygen?

What's the definitive sign?

Well the gold standard, the most accurate measure is still the arterial blood gas analysis, your ABG.

Right.

But you know moment to moment at the bedside we're heavily relying on non -invasive things like pulse oximetry, maybe capnography to get the immediate picture.

And generally we're shooting for what like 95 % saturation or higher?

Usually yes.

At least 95%.

But, and this is really crucial, one of those details that Mark's experienced for patients who are both hypoxemic and have chronic hypercarbia, I think classic COPD, if you push their oxygen levels too high, you actually risk knocking out their main drive to breathe.

Wait, really?

So the treatment itself could like shut down their breathing?

It absolutely can.

The source material is very clear here.

For these specific patients, the target range is actually lower.

You're often aiming for 88 % to 92 % saturation.

Ah, okay.

You want to correct the low oxygen just enough, but without causing that dangerous respiratory depression.

It's a really That makes a lot of sense.

Okay, so once we start the oxygen, safety becomes the absolute priority.

The source flags four big hazards we need to be watching for.

Let's start with the one everyone thinks about first, combustion, fire risk.

Right.

Oxygen itself doesn't burn or explode, but it makes other things burn much more intensely.

Like normal air is 21 % oxygen.

If you bump that up to say 50%, a tiny spark or a cigarette ember can just flare up.

Okay, so practically?

Practically, you need those oxygen and use signs posted clearly.

Absolutely no smoking, no candles, no open flames nearby.

And this one gets missed sometimes.

Always use grounded electrical equipment.

That means the three pronged plugs prevent sparks.

What about things like petroleum jelly?

People sometimes use it for dry noses with cannulas at home.

Is that still a real risk?

It is.

Yeah.

The source specifically warns against it.

Petroleum products can support combustion.

Wow.

That's why best practice is to use a non -petroleum -based cream or lubricant for the lips or nostrils.

Definitely ditch the petroleum jelly.

Good to know.

Okay, hazard number two, oxygen toxicity.

This sounds serious.

It's about too much for too long.

Exactly.

It's all about the concentration and the duration.

The key threshold is giving oxygen at a concentration greater than 50 % for more than 44 to 48 hours continuously.

And that causes lung injury.

Yes, serious lung injury.

That high O2 level creates these damaging molecules, reactive oxygen species that attack lung cells.

The symptoms can actually look a lot like ARDS, acute respiratory distress syndrome.

So shortness of breath, maybe a cough that's not producing anything, chest pain,

new crackles on auscultation.

Precisely.

So prevention is key.

Always, always use the lowest effective FIO2, the lowest concentration that gets the job done.

And what's the warning You need to watch those ABGs closely.

If the PO2 level climbs above 90 millimeter Hg, you need to flag that for the provider.

That's your signal.

You might be overdoing it.

Okay.

The third hazard.

This one always felt a bit weird to me.

Absorptive atelectasis.

How can oxygen cause lung collapse?

Yeah, it seems backward, doesn't it?

But it's about the other gases in the air, mainly nitrogen.

Room air is about 79 % nitrogen.

Right.

Nitrogen doesn't easily cross into the blood.

So it kind of acts like a scaffold holding the little air sacks, the alveoli open.

Okay.

Like a structural support.

Exactly.

Now if you flood the lungs with high concentrations of oxygen, you wash out that nitrogen, the oxygen gets absorbed really quickly into the blood.

Leaving nothing behind to keep the alveoli open.

Pretty much.

It can collapse.

That's atelectasis caused by oxygen absorption.

So clinically, we're listening for new crackles, maybe diminished breath sounds.

That's it.

And you should be assessing for those, say, every one to two hours, especially when you first start high -concentration oxygen therapy.

Okay.

And the last hazard ties into basic care.

Drying and infection.

Right.

If the oxygen flow rate is four liters per minute or higher, it's going to dry out the nasal passages, the mucus membranes.

So you absolutely need to add humidification.

Makes sense.

Protects the tissue.

But that humidification system itself can become a source of infection.

Humidifiers, nebulizers, they can grow bacteria, fungus if not maintained properly.

So infection control is key here.

Huge.

And here's a critical safety point.

Condensation often collects in the oxygen tubing.

You see that water.

Never drain it back into the humidifier bottle.

Dispose of it.

Draining it back just feeds potential bacteria.

Got it.

Dispose, don't return.

And speaking of protecting tissues, tissue integrity, we mentioned the non -patrolling cream.

What else?

Meticulous skin checks.

You need be looking at the skin around the ears, back of the neck, the face,

anywhere the cannula or mask touches.

Check every four to eight hours for redness.

Breakdown, those pressure points.

And mouth care too.

Definitely.

Mouth care at least every eight hours.

Check for dryness, cracks.

These basic comfort measures prevent bigger problems like skin breakdown or infections.

Absolutely.

Those little things add up.

Okay.

That covers the hazards.

Let's talk about the gear, the delivery systems.

How do we choose?

It really comes down to how precise we need the oxygen delivery to be.

We basically group them into low flow and high flow systems.

Low flow versus high flow.

Yeah.

Low flow systems like your standard nasal cannula or simple mask, they deliver oxygen, but it gets diluted by the room air the patient is also breathing in.

So the actual amount of oxygen they get, the 502, it can vary quite a bit depending on their breathing pattern.

Fast, slow, deep, shallow.

So less precise.

It's precise.

High flow systems, on the other hand, are designed to deliver the patient's entire breath, the total volume they inhale, at a specific controlled FiO2.

Much more precise, which is vital for really sick or unstable patients.

Okay.

Let's start with the common low flow ones.

The nasal cannula.

Good for one to six liters per minute, right?

Correct.

That gives you roughly 24 % to 44 % IO2.

And here's a key detail the source points out.

Going above six liters per minute on a standard cannula doesn't actually boost gas exchange effectively.

Why is that?

Because the anatomic dead space, you know, the nose, pharynx, trachea, where air sits, but no gas exchange happens, it gets filled up.

Pushing more flow beyond six lemon mainly just irritates the nose and doesn't deliver much more usable oxygen.

Okay.

Good point.

Next up, the simple face mask.

Why does it need a minimum flow of five lemon?

That flow rate is crucial to slush the patient's exhaled carbon dioxide out of the mask.

If the flow is too low, say three or four liters, they start rebreathing their own CO2, which can build up inside the mask and lead to hypercarbia.

Okay.

So five liters is the minimum safety flow.

Exactly.

It delivers about 40 % to 60 % IO2.

And then the heavy hitter for low flow, the non -rebreather mask.

This gives the highest oxygen concentration, right?

Over 90%.

Yes, potentially over 90 % IO2.

This is for patients who are seriously hypoxic in acute distress.

And there's one check you absolutely cannot miss with this mask.

What's that?

The one -way valves.

They're usually one between the mask and the reservoir bag, and sometimes flaps over the exhalation ports on the side.

They must be working correctly with every single breath.

Even more critical, that reservoir bag.

It must stay at least two thirds inflated throughout both inhalation and exhalation.

What happens if it collapses?

If that bag fully deflates when the patient inhales, they aren't getting the high oxygen concentration they need.

And worse, they could be rebreathing CO2 or even

It's a critical failure.

Treat it like an emergency.

Okay, that's a huge safety point.

Got it.

Let's shift to HIFLAS systems, the ones for precision, the Venturi mask or VentMask.

That's the most accurate one without intubation.

That's the one.

It uses these color -coded adapters, the Venturi devices.

Each adapter is engineered to pull in a very specific amount of room air to mix with the pure oxygen flow.

This allows you to deliver really precise, predictable FIO2.

So the key nursing action?

Simple, but vital.

Make sure the little air entrainment ports on the Venturi adapter, those little holes, are kept open and aren't covered by blankets or clothing or anything.

If you block those ports, you mess up the air mix and the FIO2 becomes unknown.

Makes sense.

Now, what about the high flow nasal cannula, HFNC?

Seems like we're seeing this more and more.

What are the advantages?

HFNC is pretty impressive.

It can deliver very high flows like 30, 40, even up to 60 liters per minute, also with a precise FIO2.

But a big plus is comfort and tissue integrity.

It delivers air that's warmed and humidified, which is much gentler on the nasal mucosa, less drying and irritation than traditional HIFLAS.

And it does something else too.

Yeah, that high flow generates a little bit of positive pressure in the airway, kind of like a very gentle CPAP.

It can help keep small airways open, improve oxygenation that way too.

Plus, patients can usually talk and eat more easily than with a tight mask.

Okay.

And that leads us to the actual masks that deliver positive pressure non -invasively

MPPV, things like CPAP or BiPAP.

Right.

These use a tight -fitting mask over the nose or face to deliver pressurized air, helping to keep alveoli open.

Great for things like COPD flare -ups or maybe pulmonary edema.

Avoids intubation sometimes.

But there are downsides.

You mentioned tissue integrity.

Definitely.

Because those masks have to seal really tightly to maintain the pressure.

There's the significant risk of skin breakdown on the bridge of the nose, cheeks, wherever the mask presses.

Big tissue integrity concern.

And another risk?

Aspiration.

Because the mask is sealed and delivering pressure, if the patient vomits or has excessive secretions, it's harder for them to clear their airway.

So MPPV is generally only safe for patients who are alert, cooperative, and can protect their own airway.

If their level of consciousness drops, the risk goes way up.

That's a really important point.

Okay, that actually provides a good transition.

We've talked about supporting the airway from the outside.

What happens when we need to bypass the upper airway entirely?

Let's talk tracheostomy.

Okay, shifting gears.

First, just the terms.

Tracheotomy is the actual surgical incision into the trachea.

Tracheostomy refers to the stoma, the opening that results from that surgery.

And why would someone need one?

Common reasons include, well, an acute airway obstruction, maybe facial trauma or burns where swelling is a concern.

Also, needing long -term airway protection, perhaps in someone unconscious.

Or if a patient needs prolonged mechanical ventilation and can't be weaned off easily.

After the surgery, what's the number one immediate priority?

Airway patency.

Absolutely critical.

You need to be checking for clear bilateral breath sounds, usually hourly right after surgery, making sure that airway is functioning.

And complications.

When they happen with a track, they can be severe.

They really can.

The two big mechanical ones are tube obstruction getting plugged, usually with thick secretions and tube dislodgement, or accidental decannulation, meaning the tube comes out.

Ah, yes.

The 72 -hour rule.

This always makes me nervous.

It should.

It highlights a critical period.

If that track tube accidentally comes out within the first 72 hours after surgery, that's a major emergency.

Why

72 hours?

Because the track, the tunnel from the skin down to the trachea isn't mature yet.

It hasn't healed and firmed up.

If the tube comes out and you try to just shove it back in, it might not go into the trachea.

Exactly.

It's very likely to go into the surrounding soft tissue of the neck, creating what's called a false passage.

You're ventilating the neck tissue, not the lungs.

It's dangerous.

So what do you do?

Critical rescue situation.

Immediate action.

Forget trying to oxygen and start ventilating the patient using a face mask over their mouth and nose, just like regular CPR.

While you're doing that, call for help.

The rapid response team, the surgical service, whoever your protocol dictates, it's a surgical emergency.

Okay.

But what if it happens after 72 hours?

The tube comes out on, say, day five.

After 72 hours, the tract is usually considered mature enough that you can attempt reinsertion carefully.

The standard procedure is to slightly extend the patient's neck, use a sterile curved Kelly clamp to gently hold the stoma open,

insert the obturator into the spare tract tube.

The obturator provides that smooth rounded tip for insertion.

Right.

You insert the tract tube with the obturator, then immediately remove the obturator so the patient can breathe through the tube,

then secure it and check placement.

Okay.

Another complication.

Subcutaneous emphysema, air in the neck tissue.

Yeah, air escapes from around the tract site and gets trapped under the skin in the neck.

Sometimes the face or chest.

It often happens if the tube fit isn't quite right or if there's been some trauma.

How do you spot it?

Your assessment is key.

You'll see puffiness, swelling, and when you gently press on the skin, you'll feel this distinctive crackling sensation under your fingers.

It's called crepitus.

It feels like Rice Krispies.

And if you feel that, notify the surgeon or provider immediately.

It needs evaluation.

Okay.

Let's bring back tissue integrity again, this time related to the track cuff.

The source calls cuff -related tracheal injury a never event.

That's serious.

It is.

Means it's considered entirely preventable with proper care.

Excessive pressure from that inflated cuff can cut off blood flow to the trachea lining, leading to ischemia, necrosis, long -term damage like stenosis, or tracheal malacia.

So managing that pressure is non -negotiable.

What are the numbers?

You have to keep the cuff pressure within a very specific narrow range,

typically between 14 and 20 millimeters of mercury, millimeter Hg.

Some sources use centimeters of water, where the ideal is 20 to 30 centimeters H2O, ideally aiming for 25 centimeters H2O or less.

And checking it regularly.

Absolutely.

Right.

At least once per shift, sometimes more often using a calibrated cuff manometer.

Keeping it in that range prevents injury, but still provides an adequate seal for ventilation if needed.

Okay.

Moving to routine trache care.

Since the track bypasses the nose and mouth, which normally warm and humidify air, we need to do that artificially, right?

Yes.

Absolutely essential.

Without added humidity, secretions become thick, dry, hard to clear, and can damage the trachea.

You need heated humidification.

What's the target temperature for that humidified air?

Should be kept right around body temperature between 98 .6 degrees air and 100 .4 degrees air, which is 37 degrees C to 38 degrees C.

Two cold thickened secretions.

Two hot can cause burns.

And then suctioning.

The source is clear.

Only suction when you need to, not on a fixed schedule.

Correct.

Indications would be things like noisy rattling secretions you can hear,

visible secretions in the tube, maybe increased respiratory rate or heart rate,

restlessness signs the patient is struggling to clear the airway, or if you hear crackles or raunchy on auscultation.

And the procedure itself has very specific safety steps.

They're very specific and you need to follow them precisely every time.

First, pre -oxygenate the patient with 100 % oxygen for at least 30 seconds, maybe up to three minutes.

Okay.

Before you get the reserves up.

Exactly.

Keep the suction pressure safe, generally 80 to 120 millimeter Hg for adults.

Too high can damage the mucosa.

Then insert the catheter.

Insert quickly but gently without applying suction until you meet resistance or the patient coughs.

Then pull back slightly, about one to two centimeters, before you start suctioning.

And apply suction while withdrawing.

Yes.

Apply continuous suction while withdrawing the catheter using a gentle twirling motion.

This helps remove secretions from all sides.

And the time limit.

This is crucial.

Absolutely crucial.

The total time from inserting the catheter to finishing suctioning should never be longer than 10 to 15 seconds.

Any longer risks significant hypoxemia.

Okay.

10 to 15 seconds max.

And watch

Vagal stimulation.

Suctioning can sometimes trigger the vagus nerve, causing sudden breaded cardio,

sometimes hypotension, even dysrhythmias.

If you see that happen, stop suctioning immediately.

Pull the catheter out and manually ventilate the patient with 100 % oxygen.

And one more infection control point related to suction.

Super important.

Never use the same suction equipment you use for the mouth, oral suction, to suction the artificial airway.

Use separate sterile equipment for the

lungs.

Make perfect sense.

Let's wrap up with some holistic care aspects.

Quality of life is huge for these patients.

Swallowing can be tricky.

Very tricky.

The track tube anchors the larynx, making it harder for it to elevate properly during a swallow, which increases aspiration risk.

So what strategies can help prevent aspiration during eating?

The source lists several best practices.

Things like smaller, more frequent meals.

Ficketing all liquids is often necessary.

Teaching the patient the chin tech maneuver can help protect the airway, and a really key one.

If it's safe for the patient based on their ventilation needs, you should completely or partially deflate the cuff during meals.

Why deflate the cuff?

Deflating it allows the larynx to move a bit more freely, improving the mechanics of the swallow.

Of course, you need to suction well before and after deflating green -flating.

Also, encouraging patients to double swallow.

Each bite can help clear residue.

Communication is another huge factor.

Not being able to speak is incredibly stressful.

Absolutely.

It's a major stressor recognized by the Joint Commission as a patient safety issue.

We need to provide communication tools, whiteboards, apps, picture boards.

And for patients who are medically stable enough, there are options like fenestrated track tubes, tubes with holes in them, or using a one -way speaking valve.

How do those work?

They allow air to pass up through the vocal cords on exhalation, enabling speech.

But critically, these only work if the track cuff is deflated.

You can't speak with the cuff up using these devices.

Got it.

Cuff down for speaking valves.

Finally, transitioning home.

What are the key safety points for patients and families?

They need to know how to keep the stoma clean and protected.

Usually covering it loosely with something like a cotton cloth or a special track cover helps filter air and retain some humidity.

They need a shower shield to keep water out of the airway during bathing.

And definitely wear a medical alert bracelet indicating they have a tracheostomy.

And if they go home on oxygen?

All the same oxygen safety rules apply rigorously at home.

Secure any tanks so they can't fall.

Keep oxygen away from any open flames.

No smoking.

No candles.

Be careful with gas stoves.

Whether they have tanks, liquid oxygen, or an oxygen concentrator, safety is paramount.

That was a fantastic, really practical run through.

So to quickly recap for everyone listening, oxygen is a drug.

Manage it carefully using ABGs and pulse ox.

Know those four big hazards.

Combustion, toxicity, atelectasis, infection.

Right.

And for tracheostomy care, it's all about keeping that airway patent.

Using strict sterile technique for suctioning.

Protecting tissue integrity by managing that cuff pressure religiously.

Remember 14 to 20 millimeter Hg.

And don't forget the quality of life supporting communication.

Making swallowing as safe as possible.

Exactly.

And we kind of pull back and look at the bigger picture from all this.

Yeah.

It raises an interesting clinical question, doesn't it?

We talked about how high flow nasal cannulas seem to offer similar outcomes to non -invasive masks like biopanderol for preventing breathing problems after extubation.

But maybe with better comfort, better tissue integrity.

Right.

Potentially fewer complications like skin breakdown.

So the provocative thought for you to consider is this.

In your own practice, when you have these different respiratory support options, how do you really weigh the factors?

How do you balance the pure clinical efficacy against things like patient comfort, the risk of invasiveness or maintaining tissue integrity?

It's often not just about the numbers, it's about the whole patient.

Something to think about.

That's a great point to reflect on as you put these concepts into action.

A huge thank you for joining us on this deep dive.

Definitely review these safety points and care strategies.

And from all of us here on the Last Minute Lecture Team, thanks for listening and we hope to have you with us for the next deep dive.