Interventions for Clients Interventions for Clients Requiring Oxygen Requiring Oxygen

Therapy or Therapy or TracheostomyTracheostomy

Therapeutic oxygen is used for both acute and Therapeutic oxygen is used for both acute and chronic respiratory conditions associated with chronic respiratory conditions associated with decreased blood and tissue oxygen levels as decreased blood and tissue oxygen levels as indicated by decreased partial pressure of arterial indicated by decreased partial pressure of arterial oxygen (PaO2) levels or by decreased arterial oxygen (PaO2) levels or by decreased arterial oxygen saturation (SaO2). oxygen saturation (SaO2).

Conditions outside the respiratory system that Conditions outside the respiratory system that increase oxygen demand, decrease oxygen-increase oxygen demand, decrease oxygen-carrying capability of the blood, or decrease carrying capability of the blood, or decrease cardiac output also are indications for oxygen cardiac output also are indications for oxygen therapy. Such conditions include sepsis, fever, therapy. Such conditions include sepsis, fever, and decreased hemoglobin levels or poor and decreased hemoglobin levels or poor hemoglobin qualityhemoglobin quality

The goal of oxygen therapy is to use the lowest The goal of oxygen therapy is to use the lowest fraction of inspired oxygen fraction of inspired oxygen (FiO2) to obtain the (FiO2) to obtain the most acceptable oxygenation without causing the most acceptable oxygenation without causing the development of harmful side effectsdevelopment of harmful side effects

The average client requires an oxygen flow of The average client requires an oxygen flow of 2 2 to to 4 4 L/min via nasal cannula or up to L/min via nasal cannula or up to 40% 40% via Venturi via Venturi mask. mask.

The client who is hypoxemic and also has chronic The client who is hypoxemic and also has chronic hypercarbia hypercarbia (increased partial(increased partial pressure of arterial pressure of arterial carbon dioxide [PaCO2] levels) requires lower levels carbon dioxide [PaCO2] levels) requires lower levels of oxygen delivery, usually of oxygen delivery, usually 1 1 to to 2 2 L/min via nasal L/min via nasal cannula, to prevent decreased respiratory effort. (A cannula, to prevent decreased respiratory effort. (A low PaO2 level is this client's primary drive for low PaO2 level is this client's primary drive for breathing.breathing.

Hazards and ComplicationsHazards and Complications of Oxygen of Oxygen Therapy Therapy

CombustionCombustion Oxygen-induced hypoventilationOxygen-induced hypoventilation

– The central chemoreceptors in the brain (medulla) are normally The central chemoreceptors in the brain (medulla) are normally sensitive to increased Paco2 levels, which stimulate breathing and sensitive to increased Paco2 levels, which stimulate breathing and cause an increased respiratory rate. When the Paco2 increases cause an increased respiratory rate. When the Paco2 increases over time to above over time to above 60 60 to to 65 65 mm Hg, this normal mechanism shuts mm Hg, this normal mechanism shuts off. The central chemoreceptors lose their sensitivity to increased off. The central chemoreceptors lose their sensitivity to increased levels of Paco2 and no longer respond by increasing the rate and levels of Paco2 and no longer respond by increasing the rate and depth of respiration, a condition called depth of respiration, a condition called CO2 narcosisCO2 narcosis. . For these For these clients, the stimulus to breathe is a decreased arterial oxygen clients, the stimulus to breathe is a decreased arterial oxygen concentration as sensed by peripheral chemoreceptors found in concentration as sensed by peripheral chemoreceptors found in the carotid sinus areas and aortic arch. When partial pressure of the carotid sinus areas and aortic arch. When partial pressure of arterial oxygen (Pao2) levels drop (hypoxemia), these receptors arterial oxygen (Pao2) levels drop (hypoxemia), these receptors signal the brain to increase the respiratory rate and depth signal the brain to increase the respiratory rate and depth —— the the hypoxic drive hypoxic drive to breathe.to breathe.

– The hypoxic drive occurs only in the presence of severely elevated The hypoxic drive occurs only in the presence of severely elevated PaCO2 levels (i.e., in the client who has hypoxemia and PaCO2 levels (i.e., in the client who has hypoxemia and hypercarbia). hypercarbia). When the client with low Pao2 levels and high Paco2 When the client with low Pao2 levels and high Paco2 levels receives oxygen therapy, the Pao2 level increases, levels receives oxygen therapy, the Pao2 level increases, removing the stimulation for breathing, and the client experiences removing the stimulation for breathing, and the client experiences respiratory depression. (The client being ventilated mechanically respiratory depression. (The client being ventilated mechanically is not at risk for this complication.is not at risk for this complication.

Hazards and ComplicationsHazards and Complications of Oxygen of Oxygen TherapyTherapy

Oxygen toxicityOxygen toxicity – High concentrations of oxygen are avoided unless absolutely High concentrations of oxygen are avoided unless absolutely

necessary. The addition of necessary. The addition of continuous positive airway continuous positive airway pressure (CPAP) pressure (CPAP) with an oxygen mask, with an oxygen mask, bilevel positive bilevel positive airway pressure (Bi-PAP), airway pressure (Bi-PAP), or or positive end-expiratory positive end-expiratory pressure (PEEP) pressure (PEEP) on the mechanical ventilatoron the mechanical ventilator may reduce the may reduce the amount of oxygen needed. As soon as the client's clinical amount of oxygen needed. As soon as the client's clinical condition allows, the physician decreases the prescribed amount condition allows, the physician decreases the prescribed amount of oxygenof oxygen

Absorption atelectasisAbsorption atelectasis – Nitrogen normally plays a large role in the maintenance of Nitrogen normally plays a large role in the maintenance of

patent airways and alveoli. Making up patent airways and alveoli. Making up 79% 79% of room air, nitrogen of room air, nitrogen prevents alveolar collapse. When high concentrations of oxygen prevents alveolar collapse. When high concentrations of oxygen are delivered, nitrogen is diluted, oxygen diffuses from the are delivered, nitrogen is diluted, oxygen diffuses from the alveoli into the pulmonary circulation, and the alveoli collapse. alveoli into the pulmonary circulation, and the alveoli collapse. Collapsed alveoli cause atelectasis (called Collapsed alveoli cause atelectasis (called absorption absorption atelectasis), atelectasis), which is detected by auscultationwhich is detected by auscultation

Drying of the mucous membranesDrying of the mucous membranes InfectionInfection

A bubble humidifier bottle used with oxygen therapy

Oxygen Delivery SystemsOxygen Delivery Systems Oxygen delivery systems are classified according to the rate at Oxygen delivery systems are classified according to the rate at

which oxygen is delivered. There are two systems: which oxygen is delivered. There are two systems: low-flow low-flow systemssystems and and high-flow systemshigh-flow systems. .

Low-flow systems do not provide enough flow of oxygen to meet Low-flow systems do not provide enough flow of oxygen to meet the total inspiratory effort of the client. Part of the tidal volume is the total inspiratory effort of the client. Part of the tidal volume is supplied by inspiring room air. The total concentration of oxygen supplied by inspiring room air. The total concentration of oxygen received dependsreceived depends on the respiratory rate and tidal volume. on the respiratory rate and tidal volume.

In contrast, high-flow systems provide a flow rate that is adequate In contrast, high-flow systems provide a flow rate that is adequate to meet the entire inspiratory effort and tidal volume of the client to meet the entire inspiratory effort and tidal volume of the client regardless of the respiratory pattern. High-flow systems are used regardless of the respiratory pattern. High-flow systems are used for critically ill clients and when it is particularly important to know for critically ill clients and when it is particularly important to know the precise concentration of oxygen being delivered.the precise concentration of oxygen being delivered.

If the client requires a mask but is able to eat, the nurse requests If the client requires a mask but is able to eat, the nurse requests an order for a nasal cannula at an appropriate liter flow for an order for a nasal cannula at an appropriate liter flow for mealtimes only. The mask is replaced after the meal is completed. mealtimes only. The mask is replaced after the meal is completed.

To increase mobility, up to To increase mobility, up to 50 50 feet of connecting tubing can be feet of connecting tubing can be used with proper connecting pieces.used with proper connecting pieces.

Low-flow oxygen delivery systemsLow-flow oxygen delivery systems

NASAL CANNULA. NASAL CANNULA. The The nasal cannula, or nasal nasal cannula, or nasal prongsprongs, , is used at flow is used at flow rates of rates of 1 1 to to 6 6 L/min. L/min. Approximate oxygen Approximate oxygen concentrations of concentrations of 24% 24% (at (at 1 1 L/min) to L/min) to 44% 44% (at (at 6 6 L/min) L/min) can be achieved. can be achieved.

The nasal cannula is The nasal cannula is frequently used for chronic frequently used for chronic lung disease and for long-lung disease and for long-term maintenance of term maintenance of clients with other illnesses. clients with other illnesses. The nurse places the nasal The nurse places the nasal prongs in the nostrils, with prongs in the nostrils, with the openings facing the the openings facing the clientclient

Low-flow oxygen delivery Low-flow oxygen delivery systemssystems

SIMPLE FACE MASK. SIMPLE FACE MASK. A A simple face mask is used to simple face mask is used to deliver oxygen deliver oxygen concentrations of concentrations of 40% 40% to to 60% 60% for short-term oxygen for short-term oxygen therapy or in an therapy or in an emergencyemergency. . A minimum A minimum flow rate of flow rate of 5 5 L/min is L/min is needed to prevent the needed to prevent the rebreathing of exhaled air. rebreathing of exhaled air. The nurse gives special The nurse gives special attention to skin care and attention to skin care and to the proper fitting of the to the proper fitting of the mask so that inspired mask so that inspired oxygen concentration is oxygen concentration is maintainedmaintained

Low-flow oxygen delivery Low-flow oxygen delivery systemssystems

PARTIAL REBREATHER PARTIAL REBREATHER MASK. MASK. A partial rebreather A partial rebreather mask provides oxygen mask provides oxygen concentrations of concentrations of 60% 60% to to 75%, 75%, with flow rates of with flow rates of 6 6 to to 11 11 L/min. It consists of a mask L/min. It consists of a mask with a reservoir bag but no with a reservoir bag but no flapsflaps. . The client first The client first rebreathes one third of the rebreathes one third of the exhaled tidal volume, which is exhaled tidal volume, which is high in oxygen, thus providing high in oxygen, thus providing a high fraction of inspired a high fraction of inspired oxygen (Fio2). oxygen (Fio2).

The nurse ensures that the The nurse ensures that the bag remains slightly inflated at bag remains slightly inflated at the end of inspiration; the end of inspiration; otherwise, the client will not otherwise, the client will not be getting the desired oxygen be getting the desired oxygen prescription. If needed, the prescription. If needed, the nurse calls the respiratory nurse calls the respiratory therapist for assistancetherapist for assistance

Low-flow oxygen delivery Low-flow oxygen delivery systemssystems

NON-REBREATHER MASK. NON-REBREATHER MASK. A non-A non-rebreather mask provides the rebreather mask provides the highest concentration of the low-highest concentration of the low-flow systems and can deliver an flow systems and can deliver an Fio2 greater than Fio2 greater than 90%, 90%, depending depending on the client's breathing pattern. on the client's breathing pattern. The non-rebreather mask is used The non-rebreather mask is used most often with deteriorating most often with deteriorating respiratory status who might soon respiratory status who might soon require intubation.require intubation.

The non-rebreather mask has a The non-rebreather mask has a one-way valve between the mask one-way valve between the mask and the reservoir and two flaps and the reservoir and two flaps over the exhalation portsover the exhalation ports. . The The valve allows the client to draw all valve allows the client to draw all needed oxygen from the reservoir needed oxygen from the reservoir bag, and the flaps prevent room air bag, and the flaps prevent room air from entering through the from entering through the exhalation ports. During exhalation, exhalation ports. During exhalation, air leaves through these exhalation air leaves through these exhalation ports while the one-way valve ports while the one-way valve prevents exhaled air from re-prevents exhaled air from re-entering the reservoir bag. entering the reservoir bag.

High-flow oxygen delivery systemsHigh-flow oxygen delivery systems VENTURI MASK. VENTURI MASK. The Venturi mask The Venturi mask

(commonly called Venti mask) (commonly called Venti mask) delivers the most accurate oxygen delivers the most accurate oxygen concentration. Its operation is based concentration. Its operation is based on a mechanism that pulls in a on a mechanism that pulls in a specific proportional amount of room specific proportional amount of room air for each liter flow of oxygen. An air for each liter flow of oxygen. An adaptor is located between the adaptor is located between the bottom of the mask and the oxygen bottom of the mask and the oxygen sourcesource. . Adaptors with holes of Adaptors with holes of different sizesdifferent sizes allow only specific allow only specific amounts of air to mix with the amounts of air to mix with the oxygen. Precise delivery of oxygen oxygen. Precise delivery of oxygen results. Each adaptor also specifies results. Each adaptor also specifies the flow rate to be used; for the flow rate to be used; for example, to deliver example, to deliver 24% 24% of oxygen, of oxygen, the flow rate must be the flow rate must be 4 4 L/min. L/min. Another type of Venturi mask has Another type of Venturi mask has one adaptor with a dial that the one adaptor with a dial that the nurse uses to select the amount of nurse uses to select the amount of oxygen desired. Humidification is not oxygen desired. Humidification is not necessary with the Venturi mask. necessary with the Venturi mask. The Venturi system is best for the The Venturi system is best for the client with chronic lung disease client with chronic lung disease because it delivers a precise oxygen because it delivers a precise oxygen concentrationconcentration

High-flow oxygen delivery High-flow oxygen delivery systemssystems

OTHER HIGH-FLOW SYSTEMS. OTHER HIGH-FLOW SYSTEMS. The face tent, aerosol The face tent, aerosol mask, tracheostomy collar, and T-piece are often used to mask, tracheostomy collar, and T-piece are often used to administer high humidity. A dial on the humidification source administer high humidity. A dial on the humidification source regulates the oxygen concentration being delivered. regulates the oxygen concentration being delivered.

A face tent fits over the chin, with the top extending halfway A face tent fits over the chin, with the top extending halfway across the face. The oxygen concentration varies, but the across the face. The oxygen concentration varies, but the face tent, instead of a tight-fitting mask, is useful for facial face tent, instead of a tight-fitting mask, is useful for facial trauma or burns. trauma or burns.

An aerosol mask is used when high humidity is required after An aerosol mask is used when high humidity is required after extubation or upper airway surgery or for thick secretions. extubation or upper airway surgery or for thick secretions.

The tracheostomy collar can be used to deliver high humidity The tracheostomy collar can be used to deliver high humidity and the desired oxygen to the client with a tracheostomy. and the desired oxygen to the client with a tracheostomy.

A special adaptor, called the T-piece, can be used to deliver A special adaptor, called the T-piece, can be used to deliver any desired Fio2 to the client with a tracheostomy, any desired Fio2 to the client with a tracheostomy, laryngectomy, or endotracheal tubelaryngectomy, or endotracheal tube. . The flow rate is The flow rate is regulated so that the aerosol does not disappear on the regulated so that the aerosol does not disappear on the exhalation side of the T-pieceexhalation side of the T-piece

Example of transtracheal oxygen delivery.

A T-piece apparatus for attachment to an endotracheal or tracheostomy tube.

Noninvasive positive-pressure Noninvasive positive-pressure ventilationventilation

Noninvasive positive-pressure ventilation (NPPV)Noninvasive positive-pressure ventilation (NPPV) is a newer is a newer technique using positive pressure to keep alveoli open and technique using positive pressure to keep alveoli open and improve gas exchange without the need for airway intubationimprove gas exchange without the need for airway intubation. .

This type of ventilation can deliver oxygen or may just use room This type of ventilation can deliver oxygen or may just use room air. Essentially, a nasal mask or full-face mask delivery system air. Essentially, a nasal mask or full-face mask delivery system allows mechanical delivery of either bilevel positive airway allows mechanical delivery of either bilevel positive airway pressure (BiPAP) or continuous nasal positive airway pressure.pressure (BiPAP) or continuous nasal positive airway pressure.

For BiPAP, a cycling machine delivers a set inspiratory positive For BiPAP, a cycling machine delivers a set inspiratory positive airway pressure each time the client begins to inspire. As the airway pressure each time the client begins to inspire. As the client begins to exhale, the machine delivers a lower set end client begins to exhale, the machine delivers a lower set end expiratory pressure. Together, these two pressures improve tidal expiratory pressure. Together, these two pressures improve tidal volume.volume.

Nasal continuous positive airway pressure delivers a set positive Nasal continuous positive airway pressure delivers a set positive airway pressure continually throughout each cycle of inhalation airway pressure continually throughout each cycle of inhalation and exhalation. The effect is to open collapsed alveoli. Clients who and exhalation. The effect is to open collapsed alveoli. Clients who might benefit from this form of oxygen or air delivery include might benefit from this form of oxygen or air delivery include those with postoperative atelectasis or cardiac-induced pulmonary those with postoperative atelectasis or cardiac-induced pulmonary edema. This technique is also used for sleep apnea. The effect of edema. This technique is also used for sleep apnea. The effect of this use is to hold open the upper airwaysthis use is to hold open the upper airways

Transtracheal oxygen therapyTranstracheal oxygen therapy

Transtracheal oxygen (TTO) is a long-term method Transtracheal oxygen (TTO) is a long-term method of delivering oxygen directly into the lungs. The of delivering oxygen directly into the lungs. The physician passes a small, flexible catheter into the physician passes a small, flexible catheter into the trachea via a small incisiontrachea via a small incision with the use of local with the use of local anesthesia. anesthesia.

TTO allows better compliance and avoids the TTO allows better compliance and avoids the irritation that nasal prongs cause. Clients also report irritation that nasal prongs cause. Clients also report it to be more cosmetically acceptable. it to be more cosmetically acceptable.

A TTO team provides formal client education, A TTO team provides formal client education, including the purpose of TTO and care of the including the purpose of TTO and care of the catheter. The physiciancatheter. The physician prescribes a TTO flow rate prescribes a TTO flow rate for rest and for activity and a flow rate for the nasal for rest and for activity and a flow rate for the nasal cannula, to be used when the TTO catheter is being cannula, to be used when the TTO catheter is being cleaned. The average client will have a cleaned. The average client will have a 55% 55% reduction in required oxygen flow at rest and a reduction in required oxygen flow at rest and a 30% 30% decrease with activitydecrease with activity

Home care managementHome care management

CRITERIA FOR HOME OXYGEN THERAPY CRITERIA FOR HOME OXYGEN THERAPY The client must be clinically stable and optimally The client must be clinically stable and optimally

treated before the need for home oxygen is treated before the need for home oxygen is considered. considered.

For Medicare to cover the cost of continuous oxygen For Medicare to cover the cost of continuous oxygen therapy, the client must have severe hypoxemia. therapy, the client must have severe hypoxemia.

For reimbursement purposes, severe hypoxemia is For reimbursement purposes, severe hypoxemia is generally defined as a partial pressure of arterial generally defined as a partial pressure of arterial oxygen (Pao2) level of less than oxygen (Pao2) level of less than 55 55 mm Hg or an mm Hg or an arterial oxygen saturation (Sao2) of less than arterial oxygen saturation (Sao2) of less than 88% 88% on room air and at rest. on room air and at rest.

The criteria are variable when hypoxemia is caused The criteria are variable when hypoxemia is caused by cardiac rather than pulmonary problems, or by cardiac rather than pulmonary problems, or when oxygen is needed only at night or with when oxygen is needed only at night or with exerciseexercise

Home care managementHome care managementCLIENT EDUCATION After the need for home oxygen therapy is verified, the

nurse begins a teaching plan about oxygen therapy. The client, with the nurse's assistance, selects a durable medical equipment (DME) company to deliver oxygen equipment and a community health nursing agency for follow-up care in the home. The physician re-evaluates the need for oxygen therapy approximately 6 months after discharge from the health care facility and yearly thereafter.

While providing discharge planning and teaching, the nurse is sensitive to the client's psychologic adjustment to oxygen therapy. The nurse encourages the client to share feelings and concerns. The client may be concerned about social acceptance and misconceptions of friends. The nurse helps him or her realize that compliance with oxygen therapy is important so that normal activities of daily living (ADLs) and events that bring enjoyment can be continued

TRACHEOSTOMYTRACHEOSTOMY Tracheotomy Tracheotomy is the is the

surgical incision into the surgical incision into the trachea for the purpose trachea for the purpose of establishing an of establishing an airway. airway.

Tracheostomy Tracheostomy is the is the (tracheal) stoma, or (tracheal) stoma, or opening, that results opening, that results from the tracheotomy. from the tracheotomy. A tracheostomy can be A tracheostomy can be performed as an performed as an emergency procedure emergency procedure or as a scheduled or as a scheduled surgical procedure and surgical procedure and can be temporary or can be temporary or permanentpermanent

Indications for tracheostomy

ComplicationsComplications

Tube obstructionTube obstruction Tube dislodgment or accidental Tube dislodgment or accidental

decannulationdecannulation PneumothoraxPneumothorax Subcutaneous emphysemaSubcutaneous emphysema BleedingBleeding InfectionInfection

Tracheostomy tubesTracheostomy tubes

Double-lumen tubeDouble-lumen tube Single-lumen tubeSingle-lumen tube Cuffed tubeCuffed tube Cuffless tubeCuffless tube Fenestrated tubeFenestrated tube Cuffed fenestrated tubeCuffed fenestrated tube Metal tracheostomy tubeMetal tracheostomy tube Talking tracheostomy tubeTalking tracheostomy tube

Dual-lumen cuffed tracheostomy tube with disposable inner cannula

Single-lumen cannula cuffed tracheostomy tube

Dual-lumen cannula cuffed fenestrated tracheostomy tube

Care Issues for the Tracheostomy ClientCare Issues for the Tracheostomy Client

Prevention of tissue damagePrevention of tissue damage– Cuff pressure can cause mucosal Cuff pressure can cause mucosal

ischemia.ischemia.– Use minimal leak technique and Use minimal leak technique and

occlusive technique.occlusive technique.– Check cuff pressure often.Check cuff pressure often.– Prevent tube friction and movement.Prevent tube friction and movement.– Prevent and treat malnutrition, Prevent and treat malnutrition,

hemodynamic instability, or hypoxia.hemodynamic instability, or hypoxia.

Air Warming and HumidificationAir Warming and Humidification

The tracheostomy tube bypasses the nose The tracheostomy tube bypasses the nose and mouth, which normally humidify, and mouth, which normally humidify, warm, and filter the air.warm, and filter the air.

Air must be humidified.Air must be humidified.

Maintain proper temperature.Maintain proper temperature.

Ensure adequate hydration.Ensure adequate hydration.

Suctioning Suctioning

Suctioning maintains a patent airway and Suctioning maintains a patent airway and promotes gas exchange.promotes gas exchange.

Assess need for suctioning from the client who Assess need for suctioning from the client who cannot cough adequately.cannot cough adequately.

Suctioning is done through the nose or the Suctioning is done through the nose or the mouth.mouth.

Suctioning can cause:Suctioning can cause:– Hypoxia (see causes to follow)Hypoxia (see causes to follow)– Tissue (mucosal) traumaTissue (mucosal) trauma– InfectionInfection– Vagal stimulation and bronchospasmVagal stimulation and bronchospasm– Cardiac dysrhythmias from hypoxia caused by Cardiac dysrhythmias from hypoxia caused by

suctioningsuctioning

Causes of Hypoxia in the Causes of Hypoxia in the TracheostomyTracheostomy

Ineffective oxygenation before, Ineffective oxygenation before, during, and after suctioningduring, and after suctioning

Use of a catheter that is too large for Use of a catheter that is too large for the artificial airwaythe artificial airway

Prolonged suctioning timeProlonged suctioning time Excessive suction pressureExcessive suction pressure Too frequent suctioningToo frequent suctioning

Possible Complications of Possible Complications of SuctioningSuctioning

Tissue traumaTissue trauma Infection of lungs by bacteria from Infection of lungs by bacteria from

the mouththe mouth Vagal stimulation: stop suctioning Vagal stimulation: stop suctioning

immediately and oxygenate client immediately and oxygenate client manually with 100% oxygenmanually with 100% oxygen

Bronchospasm: may require a Bronchospasm: may require a bronchodilatorbronchodilator

Tracheostomy CareTracheostomy Care

Assessment of the clientAssessment of the client Secure tracheostomy tubes in placeSecure tracheostomy tubes in place Prevent accidental decannulationPrevent accidental decannulation

Bronchial and Oral HygieneBronchial and Oral Hygiene

Turn and reposition every 1 to 2 hours, Turn and reposition every 1 to 2 hours, support out-of-bed activities, encourage support out-of-bed activities, encourage early ambulation.early ambulation.

Coughing and deep breathing, chest Coughing and deep breathing, chest percussion, vibration, and postural percussion, vibration, and postural drainage promote pulmonary cure.drainage promote pulmonary cure.

Oral hygiene—avoid glycerine swabs or Oral hygiene—avoid glycerine swabs or mouthwash that contains alcohol; assess mouthwash that contains alcohol; assess mouth for ulcers, bacterial or fungal mouth for ulcers, bacterial or fungal growth, or infections.growth, or infections.

Nutrition Nutrition

Swallowing can be a major problem for the Swallowing can be a major problem for the client with a tracheostomy tube in place.client with a tracheostomy tube in place.

If balloon is inflated, it can interfere with If balloon is inflated, it can interfere with the passage of food through the esophagus.the passage of food through the esophagus.

Elevate head of bed for at least 30 minutes Elevate head of bed for at least 30 minutes after client eats to prevent aspiration during after client eats to prevent aspiration during swallowing.swallowing.

Speech and CommunicationSpeech and Communication

Client can speak with a cuffless tube, fenestrated Client can speak with a cuffless tube, fenestrated tube, or cuffed fenestrated tube that is capped or tube, or cuffed fenestrated tube that is capped or covered.covered.

Client can write.Client can write.

Phrase questions to client for “Phrase questions to client for “yes”yes” or “ or “no”no” answers.answers.

A one-way valve that fits over the tube and A one-way valve that fits over the tube and replaces the need for finger occlusion can be replaces the need for finger occlusion can be used to assist with speech.used to assist with speech.

Weaning from a Tracheostomy Weaning from a Tracheostomy TubeTube

Weaning is a gradual decrease in the tube size Weaning is a gradual decrease in the tube size and ultimate removal of the tube.and ultimate removal of the tube.

Cuff is deflated as soon as the client can manage Cuff is deflated as soon as the client can manage secretions and does not need assisted ventilation.secretions and does not need assisted ventilation.

Change from a cuffed to an uncuffed tube. Change from a cuffed to an uncuffed tube.

Size of tube is decreased by capping; use a Size of tube is decreased by capping; use a smaller fenestrated tube.smaller fenestrated tube.

Tracheostomy button has a potential danger of Tracheostomy button has a potential danger of getting dislodged.getting dislodged.