This chapter reviews one procedure and five skills: applying an oxygen-delivery mask, administering oxygen therapy to a patient with an artificial airway, using incentive spirometry, care of a patient receiving noninvasive positive-pressure ventilation, use of a peak flowmeter, and care of a patient on a mechanical ventilator.
Special care is required for each of the separate delivery devices.
Oxygen therapy is used in a variety of conditions to treat hypoxia, which is a condition in which there is insufficient oxygen to meet the metabolic demands of the tissues and cells.
[Review Box 23-1 with students: Signs and Symptoms Associated with Acute Hypoxia]
Hemoglobin is the carrier of respiratory gases, oxygen, and carbon dioxide (CO2). It combines with a gas to carry it to and from the cells.
Hemoglobin levels and acid-base status directly affect oxygenation. Acidemia increases the ability of hemoglobin to release oxygen to the tissues. Alkalemia decreases the ability of hemoglobin to release oxygen to the tissues.
Pain and anxiety affect patient oxygenation. Therefore, assess patient’s pain, pulse oximetry (SpO2) values, level of consciousness, developmental level, and observed behaviors.
As with any drug, continuously monitor the dosage or concentration of oxygen and routinely check the health care provider’s orders to verify that the patient is receiving the prescribed oxygen concentration. Follow the six rights of medication administration when administering oxygen.
[Ask students: what kind of cultural practices might affect oxygen therapy? Discuss: some cultures sometimes burn incense, which does not have a flame, to promote healing of ill members. When oxygen is used in the home, designate areas where patients can safely burn incense and encourage family members to bring the ashes to the bedside. Some cultures light candles to celebrate or honor holidays and may accept the use of battery-operated candles while in the hospital. Collaborate with family members and religious leaders on how to accommodate these practices during illness and recovery.]
High-flow nasal cannula may also be used instead of bag-valve mask ventilation when preoxygenating patients immediately prior to intubation.
[Review Box 23-2 with students: Care Bundle for Ventilator-Associated Pneumonia]
There are significant issues in regard to defining ventilator-associated pneumonia (VAP) and ventilator-associated events (VAE). The CDC (2016) developed a lengthy algorithm for clinicians to use in order to accurately diagnose these complications.
The key points in the definition of VAE are the “deterioration in respiratory status after a period of stability or improvement on the ventilator, evidence of infection or inflammation, and laboratory evidence of respiratory infection…Patients must be mechanically ventilated for more than 2 calendar days to be eligible for VAE.”
The Institute for Healthcare Improvement created the five step “Ventilator Bundle.” See skill 23-5.
Adult patients who have received mechanical ventilation reported several feelings during their experience, including:
Fear due to dependence on ventilator and loss of control of their life.
Disconnection from reality.
Impaired sense of body image.
Development of adaptation patterns, including maintaining a strong belief and developing communication methods.
Feeling concern and caring from others, including health care professionals, helped patients’ sense of security.
Hypoxia affects a patient’s vital signs and pulse oximetry (SpO2) values.
Patients with chronic respiratory diseases have difficulty maintaining optimal oxygen levels in polluted environments. If a patient is to receive home oxygen therapy, complete an environmental assessment to determine respiratory hazards in the home such as the use of gas stoves or kerosene space heaters, or the presence of smokers in the home.
If a patient is to receive home oxygen therapy, complete an environmental assessment to determine respiratory hazards in the home such as the use of gas stoves or kerosene space heaters or the presence of smokers in the home.
Smoking damages the mucociliary clearance mechanism of the lungs and paralyzes the ciliary action, resulting in a decreased ability to clear mucus from the airways. Chronic bronchitis is caused primarily by smoking and results in pooling of mucus in the airways, creating an environment for the development of infection. Long-term chronic bronchitis ultimately results in hypoxia.
[Review where in the file past and current arterial blood gas (ABG) values can be found.]
Increasing the oxygen liter flow rate for shortness of breath is similar to doubling heart, asthma, or other medications.
Be sure the patient and family understand proper use of the equipment. Safety measures for oxygen use are very important (see Chapter 42).
[Review with students Box 23-3, Oxygen Safety Guidelines.]
Have suction machine equipment available to assist in clearing airway secretions, particularly in patients with artificial airways such as an endotracheal tube or tracheostomy.
Most facilities require that a self-inflating resuscitation bag and appropriate sized mask should be available in patient rooms, particularly in patients requiring mechanical ventilation.
Oxygen-delivery devices fall into one of two categories, high flow or low flow, depending on their ability to provide enough flow to match the patient’s spontaneous minute volume.
Matching a patient’s spontaneous minute volume is imperative for patient comfort and adequate oxygen delivery.
High-flow devices discourage entraining room air, which dilutes the inspired oxygen percentage (FiO2).
A newer type of high-flow device is the high-flow nasal cannula.
Low-flow devices deliver set percentages of oxygen and each one has advantages and disadvantages. You can estimate approximate FiO2 by the flow rate.
[Review Table 23-1 with the students: Oxygen-Delivery Systems.]
An oxygen flowmeter regulates the flow rate in liters per minute.
Oxygen cylinders used in hospital and institutional care settings include large H cylinders and smaller E cylinders.
In addition, still smaller, easily transported cylinders are available for use in the home. Patients using home oxygen commonly use concentrators, some of which are portable.
Nasal cannulas are easily accepted by most patients.
[Shown is Figure 23-3: Nasal cannula adjusted for proper fit.]
The two tips of the cannula, about 1.5 cm (1/2 inch) long, protrude from the center of a disposable tube and are inserted into the nostrils.
Flow rates less than 4 L/min do not require humidification. Those greater than 4 L/min need humidification to prevent drying of nasal and oral mucous membranes.
You can estimate approximate inspired oxygen concentration (FiO2) from the flow rate.
A high-flow nasal cannula (HFNC) consists of an air-oxygen blender that has an adjustable FiO2.
It is used in patients prone to severe oxygen desaturation and is currently recommended for use in critical care settings.
This system can deliver heated and humidified air/oxygen mixture at high flows, up to 60 L/min.
The oxygen gas is then delivered to the patient via wide-bore nasal prongs.
HFNC has been used in the neonatal population and there is increasing evidence to support its use in adults with acute respiratory failure.
An oxygen conserving cannula is indicated for those patients who require higher oxygen concentrations than what can be provided via traditional nasal cannula.
The cannula possess a built-in reservoir that allows for increasing oxygen concentration at a lower flow rate, which can increase patient comfort.
The simple face mask is used for short-term oxygen therapy. It fits loosely and delivers oxygen concentrations from 35% to 60%.
[Shown is Figure 23-4: Simple face mask.]
A plastic face mask with a reservoir bag and a Venturi mask deliver higher concentrations of oxygen. When used as a nonrebreather, the plastic face mask with a reservoir bag delivers 60% to 90% oxygen at appropriate flow rates. Frequently inspect the bag to make sure that it is fully inflated. If it is not fully inflated, the patient may breathe in large amounts of exhaled carbon dioxide.
[Review with students Figure 23-5: Plastic face mask with reservoir bag.]
A Venturi mask is a cone-shaped high-flow device with entrainment ports of various sizes at the base of the mask. The entrainment ports adjust to permit regulation of FiO2 from 24% to 50%.
The face tent is a shieldlike device that fits under a patient’s chin and sweeps around the face. It is used primarily for humidification and is used for oxygen only when a patient cannot or will not tolerate a tight-fitting mask. Because it is so close to a patient’s face, there is no way to estimate how much oxygen is delivered to him or her.
[Review with students Figure 23-10: Face tent for oxygen delivery.]
Oxygen hoods and tents are commonly used in the pediatric setting. These devices are able to provide high concentrations of humidified oxygen. This is particularly useful in the child with airway inflammation, epiglottitis (croup), or other respiratory tract infections.
The nurse is responsible for assessing the patient’s respiratory system and response to oxygen therapy, as well as setup of oxygen therapy and liter flow, including adjustment of oxygen flow rate
[Ask students: what changes in patient condition could be related to the nasal cannula? Discuss: any changes in vital signs; changes in level of consciousness (LOC); skin irritation from the cannula, mask, or straps; or patient complaints of pain or breathlessness.]
[Ask students: what are the signs of oxygen toxicity and carbon dioxide retention? Discuss: confusion, headache, decreased LOC, somnolence, carbon dioxide narcosis, respiratory arrest.]
Pediatric
Some infants and small children are able to tolerate a nasal cannula. Secure the prongs of the cannula with Dermiclear tape or strips of transparent dressing over the child’s cheek.
Typically infants receive oxygen therapy via an oxygen hood. Place the hood over the patient’s head, leaving sufficient room to allow carbon dioxide to escape.
Inspect toys placed in the tent for safety and suitability. Any source of sparks (e.g., from mechanical or electrical toys) is a potential fire hazard.
Make sure that the child is able to see someone nearby.
Gerontological
Because of the fragility of older adults’ skin and mucous membranes, offer oral hygiene and skin care more frequently.
Water-based gels such as Aquagel are useful but also dry quickly and need more frequent application.
Home care
Obtain appropriate referrals to determine whether patient meets the standards for third-party reimbursement (e.g., arterial oxygen [PaO2] 55 mm Hg or less during sleep or exercise). If patients have dependent edema, pulmonary hypertension, or hematocrit greater than 56%, they are eligible with a PaO2 of 56 to 59 mm Hg.
Oxygen tubing in the home setting is available in lengths of 15 m (50 feet).
Provide information about a reliable oxygen therapy equipment vendor within the community to determine whether patient and family are able to use a home-fill system with an oxygen concentrator, which provides patient opportunity to fill portable canister as needed.
Consider using oxygen-conserving devices (e.g., Oxymizer) that administer oxygen in a pulse-dosed flow during inhalation only. These reduce the use and cost of long-term oxygen therapy.
Patients with an artificial airway require constant humidification to the airway.
The T tube, also called a Briggs adaptor, is a T-shaped device with a 15-mm connection that connects an oxygen source to an artificial airway such as an endotracheal (ET) tube or tracheostomy
[Shown is Figure 23-12: T tube.]
A tracheostomy mask is a curved device with an adjustable strap that fits around a patient’s neck.
[Ask students: what are some patient-specific variations for application or adjustment of the T tube or tracheostomy collar? Discuss: methods to avoid pressure or pulling on the artificial airway, methods for handling accumulated secretions in devices.]
[Discuss some possible descriptors of a tracheal stoma.]
Home care
Some patients who are at home have both a permanent tracheostomy and a T tube or a tracheostomy collar. The patient or caregiver needs to be physically able to perform tracheostomy care and suctioning techniques, as well as understand how to manage oxygen (see Chapter 25).
The use of an incentive spirometer (IS) alone is not recommended in order to prevent postoperative pulmonary complications. It should be used in combination with other pulmonary maneuvers such as deep breathing and coughing, early mobilization of the patient, and directed coughing.
Studies demonstrate that use of an IS in combination with coughing and other methods of lung expansion lowers rates of postoperative pneumonia
The two types of ISs are flow-oriented and volume-oriented.
Flow-oriented ISs have one or more plastic chambers with freely movable, colored balls. As a patient inhales slowly, the balls are elevated to a premarked area.
Volume-oriented devices use a bellows that a patient must raise to a predetermined volume by inhaling slowly. The advantage of the volume-oriented IS is that a patient can achieve a known inspiratory volume and measure it with each breath.
[Shown is Figure 23-14: Flow-oriented incentive spirometer.]
[Review with students Figure 23-15: Volume-oriented incentive spirometer.]
The nurse is responsible for patient assessment and monitoring, and for evaluating the patient response.
The nurse is responsible for educating the patient about the proper use of the IS and evaluating that education.
Teaching
Do not let patient use the device if he or she cannot understand or demonstrate proper use.
Teach patient to examine sputum for consistency, amount, and color changes.
Pediatric
Incentive spirometry is not typically used in pediatrics except for school-age children; a pediatric patient needs the fine-motor skills and ability to follow instructions to effectively use an IS.
Allowing a child to play with and try out the IS helps to decrease his or her anxiety and encourages participation in care.
Use games or bubbles and pinwheels to encourage small children to take deep breaths. These activities help achieve the same goals as incentive spirometry in some children.
[Ask students: why does it take an older adult longer to achieve target volume? Discuss: weakened respiratory muscles and decreased elastic recoil properties of the lungs affect a patient’s ability to cough and deep-breathe.]
Correct answer: A
Rationale: Incentive spirometry assists the patient in deep breathing; a child admitted in acute sickle cell crisis is in pain and may be less apt to perform deep breathing. According to a recent study, mandatory IS for a sickle cell patient admitted without respiratory complaints reduces transfusions and acute chest syndrome.
Noninvasive positive-pressure ventilation (NIPPV) maintains positive airway pressure and improves alveolar ventilation without the need for an artificial airway
BiPAP and CPAP are usually applied via a mask covering the nose or both the mouth and nose, but those who require home CPAP may wear nasal prongs instead.
NIPPV is used in both acute care settings and increasingly more in home care settings to treat a variety of conditions including obstructive sleep apnea (OSA), COPD, cardiogenic pulmonary edema, respiratory failure, and neuromuscular disorders.
It should not be used in patients who cannot protect their airway or in patients with an inadequate respiratory drive or apnea and should be used with caution in patients with facial injuries, uncooperative patients, or hemodynamically unstable patients.
The advantages of this type of ventilation versus invasive ventilation include an increased ability to communicate with caregivers and family, better ability to cough and clear secretions, and allowing for eating and drinking.
Disadvantages: The mask must be tight fitting and have a good seal in order to prevent air from leaking. This pressure can cause feelings of claustrophobia and intolerance in patients which can lead to issues with adherence to therapy. This tight-fitting mask can also lead to skin breakdown, particularly on the bridge of the nose.
[Shown is Figure 23-17: CPAP mask.]
[Review with students Table 23-2, Problems Associated with Continuous Positive Airway Pressure and Bi-level Positive Airway Pressure.]
[Ask students: what are some of the changes in patient status that should be reported? Discuss: patient’s vital signs, oxygen saturation, mental status, or skin color.]
The nurse collaborates with the respiratory therapist when providing care for the patient. However, the skills of patient positioning, therapeutic coughing, and CPAP/BiPAP mask application can be delegated to NAP.
The nurse directs the NAP by:
Informing about the need to immediately report to the nurse any changes in patient’s vital signs, oxygen saturation, mental status, skin color, or skin abrasions, bruising, or blistering around mask area.
Informing about the need to immediately report to the nurse any ventilator or CPAP/BiPAP machine alarms or patient monitor alarms.
Instructing on how to modify care such as how long the mask can be removed, oral care, or any special skin-care needs.
Informing about the prescribed settings on the NIPPV equipment and instructing personnel to immediately notify the nurse of any change in settings or patient comfort.
Teaching
Instruct family to bring the machine, along with a list of correct settings, to the hospital any time patient is admitted.
Home care
When patients require home NIPPV, instruct in complete care of the CPAP/BiPAP system. Skills include assembling the system, cleaning it, and daily equipment maintenance.
The durable medical equipment provider, the home care nurse, and the primary care nurse develop a teaching plan to ensure that patient and family have working knowledge of the system before discharge.
[Discuss what to do in case of power loss.]
Use these measurements as an objective indicator of a patient’s current status or the effectiveness of treatment.
Normal peak expiratory flow rate (PEFR) values vary according to a person’s age, gender, and size.
Decreased PEFR may indicate the need for further interventions such as increased doses of bronchodilators or antiinflammatory medications.
Patients with asthma perform PEFR measures in the home to monitor the status of their airways.
Health care providers usually recommend that patients measure their PEFR during the following times: every morning, before taking asthma medicines, during asthma symptoms or an asthma attack, after taking medicine for an asthma attack, and at other times recommended by their health care provider.
Correct answer: B
Rationale: The patient will perform three measurements. The highest number is what is to be recorded in the chart or the patient’s diary. This reading is the peak expiratory flow (PEF).
Mechanical ventilation is a lifesaving therapy used for patients who have an inability to protect their airway or who have an illness that leads to respiratory failure.
The nurse must collaborate with the respiratory therapist when caring for patients receiving mechanical ventilation.
An artificial airway such as an endotracheal (ET) tube or tracheostomy tube is necessary for mechanical ventilation.
Two types of mechanical ventilation may be used: positive pressure and negative pressure.
Positive-pressure ventilation is the usual method of ventilation that delivers positive pressure to inflate the lungs. Multiple complications are associated with positive-pressure ventilation including decreased cardiac output, aspiration, barotrauma, and ventilator-associated events (VAE) such as ventilator-associated pneumonia.
A patient using negative-pressure ventilation does not need an artificial airway. Air is removed from between the patient’s chest wall and the interior wall of the poncho or shell, causing the patient to inhale. It is used for the chronic management of patients with primary neuromuscular illnesses that interfere with normal respiratory muscle function such as multiple sclerosis and muscular dystrophy.
The task described in this chapter focuses on positive-pressure mechanical ventilation, which is frequently used in acute, subacute, and some selective home care settings.
[Shown is Figure 23-20: Positive-Pressure Ventilator.]
Many different modes of mechanical ventilation can be used to support different conditions and physiological processes.
Mechanical ventilation controls or assists a patient’s respirations when he or she is unable to maintain adequate gas exchange because of respiratory or ventilatory failure.
The ventilator takes over the physical work of moving air into and out of the lungs, but it does not replace or alter the physiological function of the lung.
Mechanical ventilation maintains or improves ventilation, oxygenation, and breathing pattern.
Caring for a patient on mechanical ventilation and weaning from it require interdisciplinary collaboration. Nursing care includes providing emotional support, preventing complications, promoting optimal respiratory gas exchange, and monitoring for equipment failure.
[Review with students Table 23-3, Modes of Mechanical Ventilation.]
The mechanical ventilator has a number of settings to adjust the amount of oxygen delivered, the number of breaths per minute, the amount of tidal volume, the times for inspiration and expiration, and the pressure at which each breath is delivered.
[Ask students: what is the tidal volume? Discuss: the amount of air per breath.]
The goal of providing oxygenation is to maintain a PaO2 of greater than 60 mm Hg using an FiO2 of 40% or less.
The two most frequent alarms are the high-pressure and low-pressure alarms. The high-pressure alarm is usually set at 10 to 20 cm greater than the peak airway pressure.
When this alarm sounds, it indicates that the ventilator has met resistance to delivering the tidal volume and requires more pressure to inflate the lungs.
The low-pressure alarm sounds when the ventilator has no resistance to inflating the lung.
All ventilator alarms require immediate nursing intervention in order to prevent patient harm.
[Review with students Table 23-4, Ventilator Parameters.]
The simplified way to identify a VAP includes observing a deterioration in the patient’s respiratory status after a period of stability while on the ventilator, objective evidence of inflammation or infection, and laboratory evidence of respiratory infection.
The Institute for Healthcare Improvement (IHI) developed a Ventilator Bundle that includes the following elements of care:
Elevation of the HOB between 30 and 45 degrees
Daily interruption of sedation and daily assessment of patient’s readiness to extubate
Peptic ulcer disease prophylaxis
Deep venous thrombosis prophylaxis (unless contraindicated)
Daily oral care with chlorhexidine
Another care practice that is implemented for patients receiving mechanical ventilation is the ABCDE bundle. This bundle includes awakening and breathing coordination, delirium monitoring and management, and early exercise and mobility. This care bundle, while not utilized in practice for very long, has some evidence demonstrating that there is a decreased amount of time spent on the ventilator, decreased amount of delirium, and lower mortality when it is used.
One of these interventions is to maintain the ET tube cuff pressure at least 20 cm H2O pressure in order to decrease the risk of microaspiration of oral secretions or gastric contents. Refer to Skill 25-5 for directions for this procedure.
Other interventions include specially coated ET tubes and the use of ET tubes that allow for drainage of subglottic secretions and turning and repositioning the patient every 2 hours.
The nurse will collaborate with a respiratory therapist when caring for this patient.
NAP should immediately report to the nurse any change in the patient’s status, including respiratory status, vital signs, oxygen saturation, and whether the patient indicates breathlessness.
Record the following on the appropriate flow sheet in nurses’ notes in EHR or chart: respiratory assessment findings; mode of mechanical ventilation; oxygen level; actual patient tidal volume; actual patient respiratory rate peak inspiratory pressure; vital signs; size and level of the ET tube, ABG results (if performed as a point of care test); patient level of comfort; sedation level scores (if sedation is used); and degree of bed elevation.
Record on flow sheet or nurses’ notes in EHR or chart any nursing interventions that are performed, including oral care, repositioning, range of motion exercises, medications that were administered, and suctioning.
Record patient or family’s understanding through teach-back about the reason for mechanical ventilation.
Report to nurse in charge or health care provider: sudden change in patient’s respiratory status, ventilator-associated problems, or adverse reactions or side effects.
Pediatric
Increasing numbers of children are on home mechanical ventilation. For this reason, it is important to include the parent in the child’s care as appropriate. Parents also need to be prepared that, when a readmission to the hospital occurs, because of the chronic nature of the illness the child may not be readmitted to an intensive care unit, but rather may remain in the general medical or surgical area.
Once the child is stable on the mechanical ventilator, promote normal or near-normal activities as the child’s condition warrants (e.g., promote play, resume school activities, encourage mobility).
Gerontological
Presence of underlying chronic illnesses increases patient’s risk for longer intensive care hospital stays.
Older adults usually are not able to tolerate the usual sedative, antianxiety medications ordered. The prescribed dose is based on patient’s baseline kidney and liver functions.
Home care
Planning for home ventilation is performed by a multidisciplinary team, including representatives of nursing, respiratory, dietary service, and social services; the home care nurse; the home care durable medical equipment company; and the patient’s insurance company/health care payer.
Patients requiring home mechanical ventilation need to be assessed for acceptance of ventilator dependence and the ability to understand and demonstrate daily care of the artificial airway, ventilator, and ventilator circuit.
Patients requiring home mechanical ventilation will need their home environment, personal and monetary resources, and availability of home care nurses or staff assessed. Availability of community resources should also be assessed. The home electricity may need to be updated in order to support the equipment required to care for them.
Evaluate the following areas during each visit: oxygen flow, alarm system, inspiratory pressure, high-pressure alarm, tidal volume setting, humidifier, respiratory rate, tubing, temperature, resuscitation bag, tracheostomy care, breath sounds, suctioning, and tubing changes.
Teach patient and family caregiver what to do in case of respiratory distress or power failure. Check to determine availability of emergency batteries.
Correct answer: C
Rationale: Continuous positive airway pressure (CPAP) keeps the terminal airways (alveoli) partially inflated, reducing the risk for atelectasis; if atelectasis has occurred, positive pressure assists in reinflation. This is very beneficial in patients who retain carbon dioxide, such as those with obstructive sleep apnea (OSA) or acute exacerbations of COPD. CPAP keeps the airway open and prevents upper airway collapse. As a result of CPAP therapy, the patient breathes more normally, sleeps better, and has markedly reduced snoring.
