Pulse Oximetry and Oxygen Therapy

• Efficient airway management includes respiratory evaluations, vital sign measurements, pulse oximetry, and oxygen administration.
• Oxygen administration aids in maintaining sufficient cellular oxygenation, especially for those with respiratory issues or at risk of hypoxia.
• Nursing priority involves maintaining a clear airway via secretion mobilization, airway suctioning, and managing artificial airways.

Pulse Oximetry and Oxygen Therapy

• Pulse oximeters use a sensor probe attached to a finger, toe, nose bridge, earlobe, or forehead.
• Pulse oximeters measure pulse saturation (SpO2) with infrared light, gauging absorption by oxygenated/deoxygenated hemoglobin in arterial blood.
• SpO2 mirrors hemoglobin saturation (SaO2) percentage accurately when SaO2 exceeds 70%.
• Oxygen, a tasteless and colorless gas, makes up 21% of the atmosphere.
• Oxygen flow rates must be adjusted to maintain SpO2 between 95% and 100% using the minimal amount required to avoid complications.
• FiO2, or fraction of inspired oxygen, is the oxygen percentage a client receives.
• Pulse oximetry is a noninvasive method of measuring blood oxygen saturation for monitoring respiratory status.
• Assessment indications for pulse oximetry include increased work of breathing, wheezing, coughing, cyanosis, changes in respiratory rate/rhythm, adventitious breath sounds, restlessness, irritability, confusion, dyspnea, and orthopnea.
• Probe placement should be confirmed when readings fall below 90%, suggesting hypoxemia.
• It's important to confirm proper functioning and prescribed oxygen levels of the oxygen delivery system.
• The client should be placed in semi-Fowler's or Fowler's position to promote chest expansion, improve ventilation, and encourage deep breathing.
• Reducing anxiety involves emotional support.
• Reference SpO2 range typically spans 95% to 100%, with illness sometimes allowing 85% to 89%; readings below 90% denote hypoxemia.
• SpO2 readings may be naturally lower in older adults and individuals with darker skin tones.
• Hypothermia, poor blood flow, excessive light, low hemoglobin, jaundice, movement, edema, and nail products can cause artificially low readings
• Oxygen serves as a therapeutic intervention for hypoxemia; administration dictates a prescription accompanied by precise adjustment.

Manifestations of Hypoxia

• Early signs of hypoxia include tachypnea, tachycardia, restlessness, anxiety, confusion, pale skin/mucous membranes, elevated BP, use of accessory muscles, nasal flaring, and adventitious lung sounds.
• Late signs of hypoxia include stupor, cyanotic skin/mucous membranes, bradypnea, bradycardia, hypotension, and cardiac dysrhythmias.
• Nursing actions against hypoxia consist of monitoring respiratory parameters, administering oxygen, ensuring mask seal, assessing for hypercarbia, auscultating lung sounds, monitoring oxygenation, etc.
• Further nursing interventions consist of promoting oral hygiene, encouraging deep breathing exercises, promoting rest, providing emotional support, assessing nutritional status, ensuring skin integrity, documenting therapy response, titrating oxygen, gradually ceasing oxygenation, monitoring for respiratory depression.
• Low-flow delivery systems provide varied oxygen levels depending on their breathing style.
• Priority action within the ABC approach is relieving dyspnea, facilitated by Fowler's position

Low-Flow Oxygen Delivery Systems

• Nasal cannulas deliver an FiO2 of 24% to 44% at a flow rate of 1 to 6 L/min via tubing with two small prongs inserted into the nares.
• A cannula is advantageous due to its safety, comfort, and ability to allow clients to eat, talk, and move around.
• Canulas are disadvantageous as the FiO2 varies and extended use may cause skin or membrane damages
• Patency must be ensured, prongs properly fitted, with use of water-soluble gels, and humidification at 4+ L/min to prevent nares from drying.
• Simple face masks deliver an FiO2 of 35% to 60% at flow rates of 5 to 10 L/min and must have a minimim flow of 5 L/min to prevent excess CO2
• A face mask is advantageous due to how simple and comfortable it can be in comparison to canulas, and the humidified pressure it provides.
• Face masks can be disadvantageous due to issues with claustrophobia, rebreathing, speaking, and skin breakdown.
• Face masks require caution of assessing proper fit/seal, utilizing nasal cannula during meals, and monitoring skin breakdown.
• Partial rebreather masks provide easier humidification by use of a reservoir bag but can be disadvantageous due to causing a CO2 buildup.
• The non-rebreather mask gives the highest O2 concentration, using a one-way valve system between the mask/reservoir.
• Hourly assessments should be performed in order to assess vlave and flap.

High-Flow Oxygen Delivery Systems

• Venturi masks can deliver precise oxygen concentrations with added humidity while being advantageous for those with lung disease.
• Venturi masks are disadvantageous as they are expensive, and impair daily actions such as eating, but proper fit with free tubing are crucial.
• Aerosol masks/face tents deliver an FiO2 of of 24%-100% and are useful for clients who cannot wear masks, and those who have facial burns and thick secretions.
• Water accumulations should be drained, adequate water must be available, and mist should be leaving vents with the tubing out of the way.

Complications of Oxygen Therapy

• Oxygen toxicity can occur from high oxygen concentrations (over 50%), prolonged therapy (24-48hr), and severity of lung disease.
• Appropriate measure against oxygen toxicity include using the lowest level necessary, monitoring ABGs and decreasing FiO2 as SpO2 improves.
• Oxygen-induced hypoventilation may manifest in clients prone to alveolar hypoventilation and requires careful monitoring of respiratory parameters, lowest possible oxygen flow, and use of Venturi masks
• Oxygen is combustible, thus precautions such as posting "No Smoking" signs, locating extinguishers, educating on fire hazards, using cotton gowns, ensuring functional electrical devices, grounding machinery, and avoiding flammable materials.

Airway Clearance

• Airway clearance addresses potential obstructions from mucosal buildup or aspiration.
• Adequate hydration alongside coughing efforts aids in airway maintenance.
• Nursing interventions include assisting with coughing, chest physiotherapy, hydration, positioning, humidification, nebulizer therapy, and suctioning.
• The previously stated interventions promote effective gas exchange and lung expansion.

Airway Clearance Indication

• The following clients are especially vulnerable to airway compromise, infants, those with neuromuscular disorders, quadriplegics, and those with cystic fibrosis.
• Hypoxia, restlessness, tachypnea, cyanosis, adventitious breath sounds, visible secretions, and absence of spontaneous cough all point to a need for enhanced airway assistance.
• Humidification of oxygen may loosen secretions, with nebulization and chest physiotherapy also important.
• Coughing is more effective than any suctioning method

Sputum Specimen Collection

• Sputum collection indications consist of identifying cancer, or identifying microorganisms and the correct antibiotic against them.
• Acid-fast bacilli should be identified to test for tuberculosis.
• Early morning appointments are preferred and waiting 1-2hr post meal is necessary to prevent emesis/aspiration.
• Always use a sterile container, appropriate biohazard bags and clean gloves for the specimen.
• Suctioning should be used by clients who cannot cough effectively.

Chest Physiotherapy

• Chest physiotherapy loosens respiratory secretions for removal, using techniques such as percussion, vibration, and postural drainage.
• The contraindications for this therapy include pregnancy, chest trauma, intracranial pressure, recent abdominal surgery, pulmonary embolism, or bleeding disorders.
• Treatments should be scheduled separate from meals to prevent vomiting, and bronchodilators could be administered before treatment.
• If dizziness/faintness occurs, immediately stop treatment.
• The Older clients may require more frequent repositioning.
• Positioned for certain lobes include high Fowler for all lobes, or supine elevation, and Trendelenburg related treatments

Suctioning

• Hypoxemia warrants suctioning interventions for various patients.
• Proper PPE should be donned when beginning
• Encourage the client to breathe deeply and cough to attempt to dislodge secretions
• Maintain baseline vital signs prior to beginning including the SpO2
• For oropharyngeal, nasphyaryngeal and nastotracheal suction use a Yankauer, flexible, and lubricated catheter respectively
• Perform endotracheal suctioning by removing the BVM or ventilating client, inserting the catheter (avoid excessive depths into the carina), then pulling it back 1cm to reduce mucosal injury.
• All tracheal and other forms of suctioning must use surgical techniques
• Suction force should never passed 120-150 mm Hg.
• All other types of suctioning warrant sterile practices.
• Each suction must be limited to only 10 to 15 seconds with a limit of 5 minutes.
• Always insert the catheter during inhalation and advance 15-20cm, or 6-8 inches.
• Cover the port intermittently during withdraw

Tracheostomy

• A tracheotomy involves a surgical incision into the trachea to create an airway, performed in emergencies or scheduled.
• A tracheostomy is the resulting stoma that secures a clear airway.

Tracheostomy Tubes

• Tracheostomy tubes show diversity in shape, composition, size, number of components, etc.
• Tubes can be orotracheal, nasotracheal or other locations.
• The outside cannula connects a neck plate to secure the tube.
• Cuffed tubes prevent speech whereas undercuffed tubes allow such.
• Indications for usage of tracheostomy tubes may vary for an array of reasons.

Artificial Airway Tube Types

• Single lumen: Long tubes best suited for those with thick necks, yet not to be used on clients with excessive secretions.
• Double lumen: Outer tubes always fit the stoma, with inner ones snugly inside.
• These require a obturator to guide the tube in, as they are useful for clients with excessive secretions.
• Cuffed Tubes: Allows no speech, is indicated for mechanical ventilation as well as those with no aspiration risk.
• Cuffs are not suitable for children.
• Fenestrated Tubes: Allows speech with the outer cannula housing posterior fenestrations.

Nursing Actions

• Airway tubes require 2 additional sizes bedside.
• Methods to communicate and call should be given to a client, as hydration and oral care is a necessity.
• Aseptic techniques should be performed to remove all secretions.
• Tubes must be changed every 8 weeks, minimize the dust and shake the bedding within the room
• Changing frequency should be every 6-8 weeks; changing client position, minimizing dust, and assisting with meals are also necessary depending on what is needed.
• When providing care to a client that has a tracheostomy, provide supplemental oxygen, remove and clean the inner cannula, clean the outer cannula and replace the ties.

Complications of Tracheastomy Tubes

• Decannulation demands immediate care to ventilate with a BVM, call for assistance and keep an obturator beside the bed.
• After 72 hours, the tube should be slightly hyper extended.
• Check cuff levels bi-hourly.
• Stenosis occurs when tracheal damage happens, which could eventually lead to necrosis.