Tracheostomy Care: Post-Operative Management

Interpreting ABG's and ODC

• Analysing arterial blood gas samples allows for the analysis of health data.
• Arterial blood gas interpretation is fundamental to identifying respiratory acidosis/alkalosis, metabolic acidosis/alkalosis, mixed, compensated and partly compensated gases.
• Understanding if a patient is acidotic or alkalotic is important.
• A patient's acidotic or alkalotic state affects the oxyhaemoglobin dissociation curve.
• Normal pH is between 7.35 to 7.45; a pH below 7.35 indicates acidity, while a pH above 7.45 suggests a base.
• Normal PaO2 levels are 70-100 mmHg.
• Normal PaCO2 levels range from is 35-45mmHg; above and below indicates respiratory, Acid
• Normal HCO3- is 22-26mmol/L. Kidney–metabolic, Base
• In respiratory acidosis with hypoxaemia the Acid has a low PH, normal HCO3, with a PCO2

Compensation

• No compensation: pH remains abnormal; the value that is not the cause of the problem will remain normal or has not made an attempt to help normalise the pH.
• Partial compensation: pH is still abnormal, but the value that is not the cause of the problem is abnormal and has begun to help normalise the pH.
• Full compensation: pH is normal, and the value that is not the cause of the problem is abnormal and has been successful in normalising the pH.

Oxyhaemoglobin Dissociation Curve

• Alterations impacts oxygen affinity.
• A left shift in the curve indicates increased oxygen affinity.
• Increases in pH, decreased temperature, decreased 2,3-DPG, and decreased PCO2 all contribute to a left shift.
• A right shift indicates a decreased oxygen affinity.
• Decreases in pH, increased temperature, increased 2,3-DPG, and increased PCO2 all contribute to a right shift.

HFNP CPAP BiPAP and Invasive Mechanical Ventilation Lecture

• High flow assist devices:
• Including high flow nasal prongs (HFNP)
• Continuous positive airway pressure (CPAP)
• Bi-level positive airway pressure (BiPAP)
• Invasive ventilation basics
• Key ventilator terminology.
• Crucial nursing management considerations.

High Flow Nasal Cannulae (HFNP)

• Large prongs facilitate oxygen flow up to 60L/min.
• HFNP can generate low levels of PEEP.
• HFNP can reduce tachypnoea and work of breathing (WOB).
• They prevent CO2 rebreathing, decreasing PaCO2.
• Must be used with humidification.
• HFNP is generally well-tolerated.
• Oxygen Delivery Systems Comparison:
• Nasal cannula: 1-6 L/min, 24-40% FiO2, comfortable, nose breathing.
• Face mask: 6-10 L/min, 35-60% FiO2, moderate comfort, mouth breathing.
• Venturi mask: 2-15 L/min, 24-50% FiO2, moderate comfort, mouth breathing.
• Non-rebreather: 10-15 L/min, 50-90% FiO2, not comfortable, mouth breathing.
• HFNP: 15-60 L/min, 30-100% FiO2, moderate comfort, nose breathing.

Ventilator Terminology

• FiO2 is the fraction of inspired oxygen or O2 concentration, usually between 30-100%.
• Respiratory Rate (RR) indicates the number of breaths per minute.
• Tidal Volume (Vt) is the volume of gas moved into or out of the lungs in a single normal inspiration and expiration.
• Minute Volume (Ve) is the volume of gas moved in and out of the lungs in one minute.
• Positive End Expiratory Pressure (PEEP), or End Expiratory Positive Airway Pressure (EPAP), is the amount of pressure still in the lungs/alveoli at the end of expiration.
• Pressure Support (PS) provides a push of air to help the Patient with each spontaneous breath.
• Peak Inspiratory Pressure (PIP) is the maximum amount of pressure during inspiration.

Non-Invasive Ventilation (NIV)

• CPAP and BiPAP are two versions of NIV, also known as non-invasive positive pressure ventilation (NPPV).
• Both CPAP and BiPAP require the patient to trigger breathing, indicating a patent airway and adequate level of consciousness.
• Both CPAP and BiPAP preserves the patient's ability to speak, swallow, cough, and clear secretions while decreasing risks associated with endotracheal intubation.
• May have increased FiO2 or may just have pressure controls.

Continuous Positive Airway Pressure (CPAP)

• CPAP is indicated for ARDS, cardiac pulmonary oedema (HF), bilateral, diffuse pneumonia, Type 1 respiratory failure (PaO2<60mmHg), and OSA.
• Benefits of CPAP include positive end expiratory pressure (PEEP) that reduces the work of breathing (WOB) required during inspiration and facilitates alveoli recruitment, which helps prevent collapse.
• CPAP adds to respiratory reserve volume.
• For heart failure patients, CPAP may also improve cardiac performance by reducing ventricular preload and left ventricular afterload, therefore reducing pulmonary oedema

Biphasic Positive Airway Pressure (BIPAP)

• BIPAP involves two pressure levels: inspiratory (IPAP) and expiratory (EPAP/PEEP).
• BIPAP is indicated for COPD, Type 2 (hypercapnic) respiratory failure (PaCO2 > 60mmHg), and obesity hypoventilation.
• Shares same benefits as CPAP, added benefit of pressure support on inspiration which significantly decreasing the work of breathing required.
• Avoid inspiratory muscle fatigue through the addition of inspiratory positive pressure thus reducing dyspnoea.
• It increases tidal volume, which in turn increases the elimination of CO2 and reverses acidaemia.
• PEEP (EPAP) determines baseline pressure. For example, 5cm H2O
• PS (IPAP) adds additional inspiratory support. For example, 7cm H2
• Peak inspiratory pressure (PIP) is the sum of PEEP + IPAP. For example, 5 + 7 = 12cmH2O

Nursing Monitoring Requirements

• Patient education on the rationale for intervention
• Ensure mask fits face and provides good seal and monitor for presence of air leaks
• Full MEWS and NIV observations are completed, on both the NIV and MEWS charts, half hourly for the first four hours, then hourly for the first 24 hours recording:
• Patient’s respiratory and haemodynamic stability (Oxygen saturation + cardiovascular observations)
• Flow rate of supplemental oxygen
• NIV settings and elapsed time on and off machine
• Patient comfort (claustrophobia or agitation) and assessment of accessory muscle use
• Coordination of respiratory effort with the ventilator
• Fluid balance chart completed accurately
• Pressure areas I.e. bridge of nose, tips of ears
• Nasal congestion or nasal dryness

Invasive Ventilation - Intubated Patients

• Synchronised Intermittent Mandatory Ventilation.
• Pressure Regulated Volume Control
• Set: RR, FiO2, PEEP, Vt, PS + other settings
• Synchronised with patients own intrinsic breathing
• Patient triggered breath
• Pressure supported
• Is same as BiPAP
• Mandatory ventilation: only when required if patient doesn't initiate breath.
• Volume control: controls volume of mandatory breaths only.
• Pressure regulated: pressure is regulated to prevent barotrauma, usually set to 35cm H2O as an alarm, cutting off if too high (40cmH2O).
• Pressure Support Ventilation (PSV) is a weaning mode, providing a pressure boost. Set: FiO2, PEEP and PS
• No RR is set - Patient must trigger every breath.
• A ventilator provides pressure boost to the patient's breath.
• Exactly the same as BiPAP only not via a mask is via a ETT or trachy
• Pressure Support Ventilation

Nursing Monitoring Requirements

• Assessing and maintaining airway. (ETT or Tracheostomy)
• Suctioning equipment and adjuncts.
• Check circuits Humidified.
• Coordinate respiratory effort with ventilator including ventilator settings and alarms
• Monitor waveforms and capnography.
• Assess patient respiratory and haemodynamic stability
• Check skin integrity
• Ensure all equipment used on the patient is cleaned in the correct manner as per the manufactures instructions.

Intubation

• ETT and tracheostomy, including indications, risks, and checking correct placement.
• Assessing artificial airways
• Nursing responsibilities
• Emergency equipment check.
• Airway suctioning.

When to Intubate

• Impending cardiorespiratory arrest
• Multi organ failure requiring extensive monitoring.
• Haemodynamic instability or unstable cardiac arrhythmia
• Untreated pneumothorax.
• Pneumonia in immunocompromised patients.
• Reduced level of consciousness and inability to protect airways.
• Confusion requiring sedative medications to apply NIV.
• Vomiting or haematemesis.
• Recent facial trauma.
• Acute burn
• Barotrauma.
• Allergic reaction of face

Induction Medications

• Sedative (Midazolam, Propofol)
• Paralytic (Succinycholine, Vecuronium, Rocuronium)
• Analgesic (Fentanyl, Morphine)

Intubation

• ETT has routes via orotracheal and nasotracheal
• Size (internal diameter in mms) 2.0-12.0 (0.5 increments)
• Length
• Radiopaque line
• Inflated cuff and Pilot tube
• Connector (standard 15mm)
• Subglottic suction

Risk of Intubation

• Infection – pneumonia or VAP
• Bleeding
• Perforation oropharynx
• Oesophageal placement
• Vocal cord damage
• Tracheal mucosa ischaemia. Therefor increased cuff inflations.

Indicators for a Tracheostomy

• To bypass upper airway obstruction
• Uncontrolled aspiration
• Prolonged intubation
• To facilitate long term ventilator support/airway management
• Assist facilitator weaning support

Assessing an Artificial Airway

• Type
• Size
• Length
• Cuff pressure
• Assess securing device
• Suctioning
• +/– Dressing
• check pressure
• Ventilator setting is a function of breathing

Assessing an Artificial Airway: Checking Correct Placement

• Auscultate _ End Tidal
• CXR
• 2 cm above carina

Document Artificial Airway

• Assumed care of patient airway via size in teeth.
• Cuff pressure, secured with (material), suctioned (hourly rate) and oral cares.
• Portex trachy, secured with ribbon, strong coughing, trachy is clean

Bedside Emergency Equipment Check

• All different size ETT or tachy's available.
• Bag valve mask with out face mask attached + face mask
• Cuff monitor device (manometer) and 10ml syringe
• Trachy dressing + Securing
• Suctioning equipment

Nursing Responsibilities

• Tracheostomy dressings/ strappits change in 24 hours
• A second nurse must assist
• Daily cares

Suctioning via ETT Tracheostomy

• Audible/ upper respiratory tract noises
• Deterioration of ABGs SO
• Suspected aspiration
• Clinically apparent increased work of breathing
• CXR changes consistent with sputum retention

Explore key aspects of post-operative tracheostomy care, including delayed dressing changes, airway stabilization techniques and essential emergency equipment. Learn about suctioning with sterile normal saline and recognizing complications. Understand nursing interventions and assessments to maintain airway patency and prevent infection.