Oxygenation

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Oxygenation

• OXYGEN -A PRESCRIBED DRUG
• Must be written legibly by the doctor
• Prescription should be dated by the doctor
• Doctor must indicate duration of O2 therapy
• The O2 concentration must be prescribed
• The flow rate must be prescribed

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Indication for Oxygen Therapy

• Acute Respiratory Failure
• Acute myocardial infarction (M.I.)
• Cardiac Failure
• Shock (bacteraemia, cardiogenic, haemorrhagic)
• Hypermetabolic state induced by trauma, burns or
  sepsis
• Anaemia
• Cyanide poisoning
• During CPR
• During anaesthesia for surgery

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0xygen Delivery Systems
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Basic Components of a oxygen delivery system

• Piped or portable cylinder oxygen supply
• A reduction gauge
• Flow meter (litres/ minute)
• Disposable tubing of varying diameter and width
• Mechanism for delivery (mask or cannula)
• Humidifier (to warm and moisten the O2)

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Methods of Administrating O2

• Simple semi-rigid masks
• Nasal cannula catheter
• Fixed performance masks or high-flow masks
  (Venturi)
• T-piece circuit
• Paediatric circuits - Headbox or hood
  
  
  - O2 tent/ cot
• Tracheostomy mask
• Mechanical ventilation
• Continuous Positive Airway Pressure (CPAP)

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Humidification of O2

• RATIONALE
• Normal air travelling through the airways is
  warmed, moistened and filtered by epithelial
  cells of the nasopharynx.
• The air entering the trachea will have a relative
  humidity of 90 and a temperature of between
  32-36c
• Oxygenation will cause dehydration of the mucus
  membranes and pulmonary secretions
• Humidity is essential for patients who
  endotracheal or tracheostomy tube.

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Humidification Requirements

• The inspired gas must be delivered to the trachea
  between 32-36c and have a water content of 33-43
  g/m
• The set temperature should remain constant
• Humidification and temp should not be affected by
  the flow rate
• Safety alarms should guard against overheating,
  over hydration and electric shock
• No increased resistance to respiration
• Wide bore tubing (elephant) should be used to
  allow sufficient formation of water vapour

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Health and Safety Issues with O2

• Medical gas cylinders have to conform to colour
  coding
• O2 is combustible
• Oil and grease around connections should be
  avoided
• Alcohol, ether and inflammatory liquids should be
  kept separate from O2
• No electrical device near O2 tent
• No smoking
• Fire extinguisher needs to be available
• Care with using defibrillator near high O2
  concentrations

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Potential problems

• CO2 narcosis
• CO2 level in the blood normally influences
  respiration.
• Patients who are hypercapnic (gtCO2) e.g chronic
  bronchitis, have their brain chemoreceptors no
  longer sensitive to gt levels of CO2
• Instead the lt PaO2 becomes the respiratory drive
  (hypoxic drive)
• High levels of supplementary O2 may lead to
  respiratory depression/ unconsciousness/ death

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Potential problems of O2

• Oxygen toxicity
• This follows after prolonged O2 therapy (gt 24
  hours)
• There is decreasing lung compliance from
  haemorrhagic interstitial and intra-alveolar
  oedema
• This ultimately leads to fibrosis of lung tissue
• gt 24 hours and gt 50 O2 therapy should be avoided

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Potential problems of O2

• Retro lental fibroplasia
• This is a disease affecting premature babies
  weighing under 1200g (28 weeks gestation)
• Immature babies exposed to high concentration of
  O2 within the first 3-4 weeks of life.
• O2 causes the immature blood vessels to
  vasoconstrict, resulting in neovascularisation,
  haemorrhaging and blindness

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Principles of Suctioning

• Three primary suctioning techniques are
  
• oropharyngeal and nasopharyngeal suctioning
• orotracheal and nasotracheal suctioning
• suctioning an artificial airway
• Where there is copious oral secretions, first
  remove with Yankaur suction device.
• Oropharynx and and trachea are considered
  sterile.
• The mouth is considered clean, therefore
  suctioning of oral secretions should be performed
  after suctioning of the oropharynx and trachea

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Principles of Suctioning

• Use nasal approach, perform tracheal suctioning
  before pharyngeal suctioning (the mouth and the
  pharynx contains more bacteria than the trachea).
  
• Frequency of suctioning is determined by
  continuous assessment
• secretions may be identified through inspection
  or auscultation techniques
• sputum is not produced continuously but occurs as
  a response to pathological conditions
• there is no rationale for suctioning a patient
  routinely every 1-2 hours

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Principles of Suctioning

• Oropharyngeal suctioning removes secretions from
  the the pharynx via a catheter placed through the
  mouth or nostrils.
• This type of suctioning is used when the patient
  is able to cough effectively but unable to clear
  secretions by expectorating or swallowing.
• Procedure is carried out after the patient has
  coughed.
• As the pulmonary secretions are reduced and there
  is less fatigue by the patient, the patient may
  then be able to expectorate or swallow the mucus

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Oropharyngeal Suctioning

• Measurements?
• Always use the smallest diameter suction catheter
  possible to remove the secretions
• For adults use catheters size 12-16 French gauge
• For children use 8-12 catheter gauge
• Insertion depth
• For nasopharyngeal suctioning
• measure the patients tip of nose or mouth to
  base of earlobe
• Adults- insert about 16cm
• Infants and young children- 4-8cm

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Oropharyngeal Suctioning

• Caution on patients with
• nasopharyngeal bleeding or CSF
• anticoagulant therapy or blood dyscrasia

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Oropharyngeal Suctioning

• Preparation
• Review blood gases and So2 levels
• Evaluate ability to cough
• Check history for deviated septum, nasal polyps,
  nasal obstruction, traumatic injury, epistaxis or
  mucosal swelling

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Oropharyngeal Suctioning

• Implementation
• Explain procedure
• Inform that suctioning may cause transient
  coughing and gagging
• Minimise anxiety and fear lt O2 consumption
• Position in semi-Fowler position to promote lung
  expansion

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Oropharyngeal Suctioning

• Implementation
• Turn on suction (80-120mmHg)
• Excessive pressure may cause trauma
• Occlude the end of connecting tube to check
  suction pressure.
• Aseptic technique
• Use lubricant if the catheter is passed through
  nasal passage

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Oropharyngeal Suctioning

• Implementation
• Use your dominant hand to control the catheter
• Use your other hand to control suction valve
• Patient to cough and breath deeply before
  suctioning.
• Coughing helps too loosen secretions
• Deep breathing helps to minimise hypoxia

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Oropharyngeal Suctioning

• Special consideration
• Alternate between nasal passages to minimise
  traumatic injury
• Where repeated suctioning is required, a
  pharyngeal airway will help with catheter
  insertion, reduce trauma and promote patent
  airway
• Rest patient after suctioning and observe

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Oropharyngeal Suctioning

• Complications
• Dyspnoea may increase owing to hypoxia and
  anxiety
• Bloody aspirate can result from prolonged or
  traumatic suctioning
• Water soluble lubricants can minimise traumatic
  injury

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Suctioning through an Oral Airway

• Oral airway prevents obstruction of the trachea
  by a the displacement of the patients tongue
  into the oropharynx in the unconscious patient.
• Incorrect insertion may force the patients
  tongue back into the oropharynx.
• Apply the same principles of oropharyngeal and
  orotracheal suctioning as mentioned before.

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Endotracheal Tube Suctioning

• This may be required in critical care settings.
• Patients sensitive to decreased O2 levels (head
  injuries or raising ICP) must be well ventilated
  and oxygenated prior to commencement of
  suctioning
• Patients should receive briefly and with
  increasing frequency

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Endotracheal/ Tracheostomy Tube Suctioning

• Measurement of catheter
• nasal trachea-measure from tip of nose to earlobe
  and along neck to thyroid cartilage
• oral trachea- measure from mouth to mid sternum
• Elevate head of bed with patient lying on their
  side or back
• Usually requires 2 nursing staff to undertake
  procedure, one to carry out whilst the other
  ventilates patient with suctioning oxygen
• Follow principles of nasorotracheal suctioning

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Oronasotracheal Suctioning

• Required when a patient with pulmonary secretions
  is unable to cough and does not have an
  artificial airway present.
• A catheter is passed through the mouth or nose
  into the trachea.
• The nose is the preferred route because the
  stimulation of the gag reflex is minimal
• The entire procedure should be kept to a minimum
  of 5 seconds because O2 does not reach the lungs
  during suctioning
• During rest periods, the supplemental O2 should
  be used on a patient

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Principles of Oronasotracheal Suctioning

• To remove secretions from the trachea and bronchi
  
• Insertion of a catheter is made through the
  mouth, nose, tracheal stoma, tracheostomy tube or
  endotracheal tube
• Tracheal suctioning stimulates the cough reflex

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Oronasotracheal Suctioning

• procedure promotes optimal exchange of O2 and Co2
• prevent pooling of secretions that could lead to
  pneumonia
• performed frequently as the condition warrants
• procedure requires strict aseptic technique

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Oronasotracheal Suctioning

• Measurements?
• Always use the smallest diameter suction catheter
  possible to remove the secretions
• For adults use catheters size 12-16 French gauge
• For children use 8-12 catheter gauge
• For nasotracheal suctioning
• Adults- insert catheter about 20 cm
• Older children- 14-20cm
• Young children and infants- 8-14cm

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Oronasotracheal Suctioning

• Positioning
• Place patient in Fowler or semi-Fowler position
  for conscious patient
• Turning patients head to right will help
  catheter advance to left main stem bronchus or
  vice versa.
• If resistance is felt after catheter insertion,
  the catheter has probably hit the carina. Pull
  catheter back 1 cm before applying suction.

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Lower Airway Suctioning

• Preparation
• Explanation to patient
• Collection of required materials
• Checking that suction equipment is in working
  order

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Lower Airway Suctioning

• Assess vital signs, breath sounds, general
  appearance to establish a baseline
• Review arterial and O2 sat levels
• Evaluate ability to cough and deep breath, this
  will help move secretions up the
  tracheo-bronchial tree

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Oronasotracheal Suctioning

• Nasotracheal suctioning requires an assessment
  for deviated septum, nasal polyps, nasal
  obstruction, nasal trauma, epistaxis or mucosal
  swelling
• Wash hands
• Explain procedure (including possibility of
  gagging and coughing to patient)

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Oronasotracheal Suctioning

• Reassure patient to reduce anxiety, promote
  relaxation and minimise O2 demand
• Place patient in a semi-Fowler position to
  promote lung expansion and productive coughing

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Oronasotracheal Suctioning

• Implementation
• Insert catheter aseptically, during inspiration
  and coughing by patient, the epiglottis will be
  open the passage into trachea
• Use your dominant hand, and roll the catheter
  between thumb/ forefinger
• Rotation prevents catheter from pulling tissues
  during exit

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Oronasotracheal Suctioning

• Apply intermittent suctioning on withdrawal of
  the catheter.
• Never suction for more than 5-10 seconds in order
  to prevent hypoxia
• Observe and allow patient to rest before next
  suctioning
• Always use a clean sterile catheter for each
  episode of suctioning

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Oronasotracheal Suctioning

• Encourage patient to cough between sessions
• Observe secretions, if thick, clear catheter by
  tipping into sterile saline solution with suction
• Observe for arrhythmias, if present, stop
  suctioning and ventilate patient

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Lower Airway Suctioning

• After Suctioning
• Hyper oxygenate patient who is on a ventilator
• Readjust FiO2
• Assess for upper airway suctioning
• Always change gloves and catheters before
  re-suctioning
• Auscultate lungs bilaterally, taking vital signs

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Lower Airway Suctioning

• Potential problems
• Hypoxaemia
• Dyspnoea
• Anxiety could change respiratory patterns
• Cardiac arrhythmias resulting from hypoxia, and
  vagal nerve stimulation in tracheo-bronchial tree
• Tracheal or bronchial trauma resulting from
  prolonged suctioning

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Lower Airway Suctioning

• Patients at Risk
• compromised cardiovascular or pulmonary status
• history of nasopharyngeal bleeding
• recent tracheostomy
• blood dyscrasias
• caution for ICP since it can lead to gt ICP

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Lower Airway Suctioning

• If patient has laryngospasm or bronchospasm
  during suctioning-
• disconnect the suction catheter to act as an
  AIRWAY

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Principles of Lower Airway Suctioning

• Evaluation
• Amount and colour of sputum
• Consistency and odour of secretions
• Complications
• Patients response to procedure

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Principles of suctioning
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REFERENCES

• Jean Smith-Temple and J.Y.Johnson (1998) Nurses
  Guide to Clinical Procedures (3rd edition)
  Lippincott Philadelphia,U.S.A
• Potter and Perry (2001) Fundamentals of Nursing
  (5th edition) MosbyU.S.A