7/7/14

Troubleshooting Tracheostomies

Troubleshooting Tracheostomies

Neuro: Anxiety, restlessness
Resp: Respiratory distress, gasping, airway obstruction
CV:Tachycardia, hypertension
Skin: Cool, pale, cyanotic, diaphoretic
Note: Pt may be asymptomatic (with established stomas)

Tracheostomy Dislodgement
■ If tracheostomy is less than 4 days old, STAT intervention is required
because tract can collapse suddenly.
■ Notify physician and RT STAT. Only trained personnel should replace
new tracheostomy tube.
■ Open tracheostomy with a sterile hemostat, suction catheter, or sterile
gloved finger to maintain airway and to keep the edges of the
tracheostomy from collapsing.
■ If Pt cannot breathe, ventilate using BVM.

■ If you cannot be sure that someone clinically prepared to reinsert
tracheostomy tube will arrive within 1 minute, call Code.
■ If tracheostomy is more than 4 days old, tract will be well formed and will
not close quickly.
■ Notify physician and RT that tube needs to be replaced.
■ Obtain replacement tube, if not already at Pt’s bedside.
■ Stay with Pt and prepare for insertion of new tube.
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Suctioning a Patient on a Ventilator

Suctioning a Patient on a Ventilator

Preparation:
■ Prepare Pt: Explain procedure and offer reassurance.
■ Gather supplies: Sterile gloves, sterile suction catheter and tubing, sterile normal saline, sterile basin, bag-valve mask connected to a supplemental oxygen source, suction source.
■ Equipment: Ensure that wall or portable suction is turned on (no higher than 120 mm Hg), and position supplies and suction tubing so that they are easily accessible.
■ Wash hands: Follow standard precautions.

Preprocedure:
■ Setup: Using sterile technique, open and position supplies so that they are within easy reach. Fill sterile basin with sterile normal saline, and open sterile
gloves close by so that they are easy to reach.
■ Position yourself: Stand at Pt’s bedside so that your nondominant hand is toward Pt’s head.
■ Preoxygenate: Manually ventilate Pt with 100% O2 for several deep breaths.

Technique:
■ Don sterile gloves.
■ Wrap sterile suction catheter around your dominant hand and connect it to the suction tubing. Wrapping catheter around your hand prevents it from dangling and minimizes risk of contamination. Be careful not to touch your dominant hand with the end of suction tubing.
■ Note:Your nondominant hand is no longer sterile and must not touch any part of the catheter or your dominant hand.
■ Insert suction catheter just far enough to stimulate cough reflex.
■ Apply intermittent suction while withdrawing catheter and rotating 360 degrees for no longer than 10–15 seconds to prevent hypoxia.
■ Ventilate with 100% O2 for several deep breaths.
■ Repeat until Pt’s airway is clear.
■ Suction oropharynx after suctioning of airway is complete.
■ Rinse catheter in basin with sterile saline in between suction attempts (apply suction while holding tip in the saline).
■ Rinse suction tubing when done and discard soiled supplies.
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Pulse Oximeters

Pulse Oximeters
Finding
Intervention
SpO2 >95%
■ Considered normal and requires no intervention.
■ Continue routine monitoring of Pt.
SpO2 91%–94%
■ Considered acceptable.
■ Assess probe placement and adjust if necessary.
■ Continue to monitor Pt.
SpO2 85%–90%
■ Raise HOB and stimulate Pt to breathe deeply.
■ Assess airway and encourage coughing
■ Suction airway if needed.
■ Administer oxygen and titrate to SpO2 >90%.
■ Notify physician and RT if SpO2 fails to improve after
a few minutes.
SpO2 <85%
■ Administer 100% oxygen, position Pt to facilitate
breathing, suction airway if needed, and notify
physician and RT immediately.
■ Check medication record and consider naloxone or
flumazenil for medication-induced respiratory
depression.
■ Be prepared to manually ventilate or aid in intubation
if condition worsens or fails to improve.

Caution: 
Consider readings within overall context of Pt’s medical history and physical exam. Reliability of pulse oximeters is sometimes questionable, and many conditions can produce false readings. Assess Pt’s skin signs, RR, and HR. Ask how Pt is feeling. Repositioning probe to a different location (ears, toes, or
different finger) may help correct suspected false reading. Note: readings > 90% may be considered normal to acceptable in Pts who normally live at higher altitudes.

Conditions That May Produce False Readings
Alkalosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . false high
Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . false high
Carbon monoxide (CO) poisoning . . . . . . . . . . false high
Hypovolemia . . . . . . . . . . . . . . . . . . . . . . . . . . false high
Pt movement . . . . . . . . . . . . . . . . . . . . . . . . . . erratic readings
Cool extremities . . . . . . . . . . . . . . . . . . . . . . . . false low
Dark pigment . . . . . . . . . . . . . . . . . . . . . . . . . . false low
Nail polish or nail infections . . . . . . . . . . . . . . false low
Medication (peripheral vasoconstrictors) . . . . false low
Poor peripheral circulation . . . . . . . . . . . . . . . false low
Raynaud’s disease . . . . . . . . . . . . . . . . . . . . . . false low
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Laryngeal Mask Airway (LMA)

Oxygen Delivery Equipment
Laryngeal Mask Airway (LMA)

■ Often used in noncomplicated surgical procedures and by EMS.

■ Direct visualization not needed for proper placement.

■ When cuff is inflated, mask conforms to hypopharynx, occludes esophagus, and protects glottic opening.
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Endotracheal Tube (ETT)

Oxygen Delivery Equipment
Endotracheal Tube (ETT)

■ Indicated for apnea, airway obstruction, respiratory failure, risk of aspiration, or therapeutic hyperventilation.

■ Can be inserted through mouth or nose.

■ Inflated cuff protects Pt from aspiration.
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Nasopharyngeal Airway (NPA)

Oxygen Delivery Equipment
Nasopharyngeal Airway (NPA)

■ Indicated for Pts with a gag reflex or for comatose Pts with spontaneous respirations.

■ Measure from tip of Pt’s nose to earlobe.

■ Diameter should match Pt’s smallest finger.

■ NEVER insert in presence of facial trauma!

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Oropharyngeal Airway (OPA)

Oxygen Delivery Equipment
Oropharyngeal Airway (OPA)

■ Indicated for unconscious Pts who have no gag reflex.

■ Measure from corner of Pt’s mouth to the earlobe.

■ Insertion method # 1 (do not use for small child): Insert upside down and rotate 180 degrees as it passes crest of tongue. Be careful not to injure hard or soft palate, to minimize risk of bleeding.

■ Insertion method # 2 (all ages): Displace tongue with tongue depressor and insert airway (right side up) posteriorly, following normal curve of oral cavity.
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Transtracheal Oxygenation

Oxygen Delivery Equipment
Transtracheal Oxygenation

■ Indicated for Pts with tracheostomy who require long-term O2 therapy and/or intermittent, transtracheal aerosol treatment.

■ Ensure proper placement (over stoma, tracheal tube).

■ Assess for and clear secretions as needed.

■ Assess skin for irritation.

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Humidified Systems

Oxygen Delivery Equipment
Humidified Systems

■ Indicated for Pts requiring longterm O2 therapy to prevent drying of mucous membranes.

■ Setup may vary among brands. Fill canister with sterile water to recommended level, attach to O2 source, and attach mask or cannula to humidifier. Adjust flow rate.
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Bag-Valve Mask (BVM)

Oxygen Delivery Equipment

 Bag-Valve Mask (BVM)

■ Indicated for manual ventilation of a Pt who has no or ineffective respirations.

■ Can deliver up to 100% O2 when it is connected to O2 source.

■ Appropriate mask size and fit are essential to create a good seal.

■ To create seal, hold mask with thumb and index finger and grasp underneath the ridge of the jaw with remaining three fingers.
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Venturi Mask (Ventimask)

Oxygen Delivery Equipment
Venturi Mask (Ventimask)

■ Indicated for precise titration of percentage of O2.

■ Flow rate of 4–8 L/min.

■ Delivers 24%–40% O2.

■ Accurate delivery of O2 is accomplished with a graduated dial that is set to desired percentage of O2 to be delivered.
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Nonrebreather Mask

Oxygen Delivery Equipment
Nonrebreather Mask

■ Indicated for high percentage supplemental O2.

■ Flow rate of up to 15 L/min.

■ Delivers up to 100% O2.

■ One-way flaps open and close with respiration and result in a high concentration of delivered O2 and minimal to no CO2 rebreathed by Pt.

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Simple Face Mask

Oxygen Delivery Equipment
Simple Face Mask

■ Indicated for higher percentage supplemental O2.

■ Flow rate of 6–10 L/min.

■ Delivers 35%–60% O2.

■ Lateral perforations permit exhaled CO2 to escape.

■ Permits humidification.
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Nasal Cannula

Oxygen Delivery Equipment
Nasal Cannula

■ Indicated for low flow, low percentage supplemental O2.

■ Flow rate of 1–6 L/min.

■ Delivers 22%–44% O2.

■ Pt can eat, drink, and talk.

■ Extended use can be very drying; use with a humidifier.
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2/3/14

Artificial respiration (rescue breathing)

Artificial respiration (rescue breathing) - In clients who have stopped breathing it is essential to give mouth-tomouth, mouth-to-nose, or mouth-to-mouth-and-nose ventilation until normal respiratory function is restored. If the client’s breathing and pulse have stopped cardiopulmonary resuscitation (CPR) must be initiated immediately. The procedures and rationales are given below.

ADULT

Procedure
Rationale
Check airway is clear as previously
described and remove any obvious
obstruction
To facilitate respirations
Check for breathing
It is dangerous to perform artificial ventilation on someone who has normal respiratory function
Look for chest movements
Absence of a rise and fall of the chest indicates absence of respiratory function
Listen for breath sounds
Absence indicates absence of respiratory function
Feel for breath on your cheek
Absence of warm blowing from the mouth indicates absence of respiratory function
Look, listen and feel for no more than 10 seconds. If the client is not breathing get help, then:
To ensure that respiration has ceased
Lie client flat on their back (supine)
To facilitate access to airways
Tilt head and lift chin (see Figure 1.1a)
To ensure tongue is lifted away from the throat, ensuring a clear airway
Pinch the client’s nose
To ensure exhaled air is forced into the lungs and not out of the nasal passages
Take a deep breath
To ensure lungs are expanded with sufficient air to ventilate the client
Place your lips securely around the client’s mouth
To ensure a good seal and prevent leakage of air
Blow into the client’s mouth for approximately 2 seconds, watching for the chest rising
Expelled air will enter client’s lung fields, providing
some oxygen. The chest rising indicates that air
has entered the lung fields and not the stomach
If chest fails to rise recheck position and airway
Air may be entering the stomach as opposed to
the lung fields
Remove your lips from the client’s mouth and allow the chest to fall
To facilitate exhalation
Repeat at a rate of 10 breaths per minute until the client starts to breathe on their own
To sustain respiratory function
Place client in recovery position once normal respiratory function is restored
To maintain client safety
Seek assistance
To enable investigation and treatment of cause


CHILD

Procedure
Rationale
Check airway is clear as described above
To facilitate respirations
Check for breathing
It is dangerous to perform artificial ventilation on
someone who has normal respiratory function
Look for chest movements
Absence of a rise and fall of the chest indicates
absence of respiratory function
Listen for breath sounds
Absence indicates absence of respiratory function
Feel for breath on your cheek
Absence of warm blowing from the mouth indicates absence of respiratory function
Look, listen and feel for no more than 10 seconds. If the client is not breathing get help, then:
To ensure that respiration has ceased
Lie client flat on their back
To facilitate access to airways
Tilt head and lift chin into ‘sniffing’ position (see Figure 1.2a)
To ensure tongue is lifted away from the throat,
ensuring a clear airway
Pinch the child’s nose (unless mouth-to-mouth-and-nose
ventilation is to be used)
To ensure exhaled air is forced into the lungs and
not out of the nasal passages
Place your lips securely around the child’s mouth (or mouth and nose in a small child)
To ensure a good seal and prevent leakage of air
Blow into the child’s mouth for approximately 1–1.5 seconds, watching for the chest rising
Expelled air will enter child’s lung fields, providing
some oxygen. The chest rising indicates that air
has entered the lung fields and not the stomach
If chest fails to rise recheck position and airway
Air may be entering the stomach as opposed to
the lung fields
Remove your lips from the child’s mouth and allow the chest to fall
To facilitate exhalation
Repeat at a rate of 20 breaths per minute until the child starts to breathe on their own
To sustain respiratory function
Assist the child to find a comfortable position once normal
respiratory function is restored
A child will often find the best position to maintain
their airway and should not be forced into
position which is less than comfortable
Seek assistance
To enable investigation and treatment of cause
INFANT

Procedure
Rationale
Check airway is clear as described above
To facilitate respirations
Check for breathing
It is dangerous to perform artificial ventilation on
someone who has normal respiratory function
Look for chest movements
Absence of a rise and fall of the chest indicates
absence of respiratory function
Listen for breath sounds
Absence indicates absence of respiratory function
Feel for breath on your cheek
Absence of warm blowing from the mouth indicates
absence of respiratory function
Look, listen and feel for no more than 10 seconds. If the client is not breathing get help, then:
To ensure that respiration has ceased
Lie infant flat on their back
To facilitate access to airways
Tilt head and lift chin into neutral position (see Figure 1.3)
To ensure a clear airway
Place your lips securely around the infant’s mouth and nose
To ensure a good seal and prevent leakage of air
Blow into the infant’s mouth for approximately 1–1.5 seconds, watching for the chest rising
Expelled air will enter infant’s lung fields, providing
some oxygen. The chest rising indicates that air
has entered the lung fields and not the stomach
If chest fails to rise recheck position and airway
Air may be entering the stomach as opposed to
the lung fields
Remove your lips from the infant’s mouth and allow the chest to fall
To facilitate exhalation
Repeat at a rate of 20 breaths per minute until the infant starts to breathe on their own
To sustain respiratory function
Assist the infant to find a comfortable position once normal
respiratory function is restored
An infant will often find the best position to maintain
their airway and should not be forced into
position which is less than comfortable
Seek assistance
To enable investigation and treatment of cause

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Methods of humidification

There are many devices that can be used to supply humidification (see Table 1.2). The best of these will fulfil the following requirements:

1 The inspired gas must be delivered to the trachea at a room temperature of 32–36ºC and should have a water content of 33–43 g/M3.
2 The set temperature should remain constant; large ranges of flow should not affect humidification and temperature.
3 The device should have a safety and alarm system to guard against overheating, over-hydration and electric shocks.
4 It is important that the appliance should not increase resistance or affect the compliance to respiration.
5 It is essential that whichever device is selected, wide-bore tubing, that is, tubing with a wide internal diameter (sometimes referred to as elephant tubing), must be used.

General considerations of oxygen administration
1 Oxygen is an odourless, tasteless, colourless, transparent gas that is slightly heavier than air.
2 Oxygen supports combustion, therefore there is always a danger of fire when oxygen is being used.

The following safety measures should be remembered:
(a) Oil or grease around oxygen connections should be avoided.
(b) Alcohol, ether and other inflammatory liquids should be used with caution in the vicinity of oxygen.
(c) No electrical device must be used in or near an oxygen tent.
(d) Oxygen cylinders should be kept secure in an upright position and away from heat.
(e) There must be no smoking in the vicinity of oxygen.
(f) A fire extinguisher should be readily available and all staff have a responsibility to be competent in its use.

Table 1.2 Devices for humidification

Device
Use
Benefits
Problems
Condensers
(Swedish nose)
Perform function of
nasopharynx
Retain heat and water
from expired air and
return to inspired air
Heated humidifiers
may be preferable for
long-term use
Cold water bubble
humidifiers
Deliver partially humidified
oxygen
Achieve about 50%
humidity
Inefficient
Water bath
humidifiers
Deliver adequately
humidified oxygen
Achieve about 100%
humidity
Overheating may
damage trachea.
Efficiency can alter
with flow rate/surface
area and water
temperature.
Condensation and
collection of water in
delivery tubes.
Micro-contamination
of stagnant water
possible
Aerosol generators
Provide micro-droplets
of water suspended in
the gas
Can achieve highly
saturated gas.
Device not governed
by temperature

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