Tracheostomy Oxygen Devices User Guide

Tracheostomy & Oxygen
Device Guide

Oxygen Devices:

1. Low Flow Nasal Cannula: “An oxygen delivery device delivering flow rates of 1-6LPM and FiO2 ranging from 24%-45%”

2. Pediatric High Flow Nasal Cannula – An oxygen delivery device delivering flow rates of 1-50L (depending on the interface) and FiO2 range from 21-100%. If any pediatric patent requires >15 LPM and 50% FiO2 on this specific device they must be admitted to PICU.

3. Green High Flow Nasal Cannula – An oxygen delivery device delivering flow rates of 615LPM and Fi02 range from 45%-80%.
   Allows for increased Fi02 for stable patients who want to eat, drink, talk, and take oral medications.

4. Venturi Mask – Delivers a flow range from 4-10 LPM, FiO2 35-50%. Device is used by turing the arrow to the FiO2 that you want to deliver, then matching the corresponding LPM printed above the setting to achieve FiO2.

5. Non-rebreather Face Mask- delivers higher concentrations of O2 due to the one way valve in the mask. The minimum flow rate for the mask is 10L/min, which delivers 60% FiO2. Flow rate can be increased to 15L/min, which may deliver 90% FiO2.

6. Trach Collar: RCS to set up humidified O2. RN to select the appropriate FiO2.

7. High Oxygen Requirement: Need for ≥ 50% fraction of inspired oxygen (FIO2) to maintain adequate oxygen saturation per provider order (Policy PC 48)
   • Floor patients:
   • In an emergency, a nurse, respiratory care practitioner may place a patient on oxygen by nasal cannula or face mask, as needed, to provide immediate respiratory support without an order, provided the licensed independent
   provider (LIP) is notified, an order is entered in the medical record within 30 minutes of the application of oxygen therapy, and the clinical indication for emergency application of oxygen is documented in a note.
   • An emergency is defined as a new or worsening pulse oximetry reading of <90%, in the setting of a dependable waveform, or any clinical evidence of hypoxemia or respiratory distress, such as cyanotic nail beds or lips, chest retractions, nasal flaring, or tripoding, in the absence of a dependable pulse oximetry waveform.
   • Subjective shortness of breath without any clinical indication of hypoxemia or respiratory distress does not constitute an emergency.
   • The LIP should be contacted for any new or worsening symptoms, regardless whether the criteria for emergency application of oxygen are met. In addition, the Rapid Response Team or Pediatric Emergency Team should be activated.

Additional Resources:

• UCM Policy PC48 Managing of New or Worsening Respiratory Insufficiency
• UCM Oxygen Devices Video
• High Flow Quick Video
• Elsevier Skill Noninvasive CPAP BiPAP

Tracheostomy:

1. Components:
   a. Trach and how to identify what size it is
   b. Obturator & its purpose
   i. Used in initial insertion and for emergency reinsertion
   c. Inner cannula
   i. Note difference between disposable and reusable
   d. Trach collar
   i. The first tracheostomy tube and tie change must be performed by the primary surgical service or their designees.
   e. Difference between cuffed and non-cuffed trachs
   i. Cuffed- facilitates ventilator support and protection from aspiration
   ii. Non-cuffed- for spontaneously breathing patients and can aid in weaning
   f. Difference between tracheostomy and laryngectomy
   i. Tracheostomy- Breathing hole in neck. Upper airway intact. Can intubate although may be difficult.
   ii. Obligate Trach/Laryngectomy- Upper airway removed. Stoma is the only airway for the patient! Cannot be intubated or have oxygen given by mouth!!

2. Emergency equipment list to have at bedside. This equipment is needed in addition to equipment needed for daily care
   a. Oxygen- Set up
   b. Appropriate-sized resuscitation bag and mask
   c. Suction equipment and catheters
   d. Spare tracheostomy tube of same size and brand or similar size/brand, if available
   e. Step down tracheostomy tube of same or similar size/brand, if available, template of the custom tracheostomy tube, individualized alternative airway device
   f. Obturator for current tracheostomy tube
   g. Water-based lubricant
   h. Scissors
   i. Tracheostomy ties
   j. Syringe, if cuffed tracheostomy present

3. Mucus Plug
   a. Presents as poor ventilation
   b. Attempt to pass suction catheter
   i. If able to pass suction catheter
   1. Suction and then change inner cannula
   2. Reassess
   ii. If unable to pass suction catheter
   1. Prepare to replace trach tube
   2. Escalate to appropriate team based on patient’s presenting condition
   c. Prevent mucous plugs through good trach care: suctioning, humidity, nebulizers, and Chest PT

4. Trach decannulation: This protocol is in development for all inpatient areas.
   • Assess:
   1. Is the patient in distress?
   a. No—initiate RRT for reinsertion
   i. Sit patient up >45 degrees
   ii. Gather and prep emergency equipment for RRT or Respiratory Care Services
   iii. Oxygenate via mouth (with stoma occluded) or via stoma (obligate trach) as appropriate
   *Pediatric RNs are expected to change the trach routinely on Fridays q week and also during emergencies/distress. Always with 2 trained providers (RNs, RTs, or Caregivers).
   b. Yes- Call Dr. Cart or Anesthesia as appropriate
   i. Sit patient up >45 degrees
   ii. Ventilate mouth vs. stoma as appropriate.
   iii. Known difficult airway can be escalated to a Dr. Airway
   iv. Gather and prep emergency equipment

5. Trach Care
   a. Clean stoma site and surrounding skin on neck with soap and water Q shift and PRN. Avoid allowing soap to enter the airway. Rinse and pat dry.
   b. Replace dressing (split gauze) q shift and PRN
   c. Change Inner Cannula: Have staff members demonstrate
   a. If disposable inner cannula present, change Q shift
   b. If non-disposable inner cannula present, cleanse Q shift and PRN with sterile water
   d. Tracheostomy ties should be changed at least every 48 hours and PRN for adult patients. Tracheostomy ties should be changed at least every 24 hours and PRN for pediatric patients.
   e. Suction patient PRN: Have staff member demonstrate
   i. Ensure the suction vacuum regulator is less than 150 mm Hg
   ii. Do not apply suction during insertion.
   iii. Ensure that each suction pass does not last longer than 15 seconds to minimize decreases in oxygen saturation.
   iv. Perform one additional pass of the suction catheter if secretions remain in the airway and the patient is tolerating the procedure. Allow a minimum of 60 seconds between passes for the patient to recover before the next pass.
   v. Consider administering 100% oxygen to the patient between each pass of the suction catheter. At the completion of the suctioning procedure, consider administering 100% oxygen for 60 seconds.
   vi. Return supplemental oxygen to the baseline level.
   f. Respiratory Therapist (or RN in pediatrics) will change tracheostomy tube as ordered.

6. Speaking Valve
   a. Speech and swallow should be consulted if a TSV is ordered.
   b. When a patient uses a TSV, the tracheostomy cuff must be deflated.
   c. TSVs should not be worn while the patient is sleeping or if the patient is short of breath. Patients who tolerate wearing a TSV should wear the TSV while eating. If the patient is allowed to eat per medical order, the tracheostomy cuff should be deflated (unless otherwise ordered).

Additional Resources:

• Tracheostomy Inservice Video

Trach Care: Prevention and Management of Common Skin Conditions and Pressure Injuries

Moisture Associated Skin Damage (MASD): moisture on the skin from any source, including mucous secretions from trachs, can lead to MASD. MASD can result superficial erythema or lead to partial – or full-thickness skin loss.
Prevention includes limiting the exposure of the skin to moisture. For copious secretions or when humidity is needed, more frequent care of the trach (including dressing changes) may be necessary.
Management: Taking care to avoid trach opening, protective dressings or a thin layer of clear zinc could be applied below the trach opening. With every shift trach care, the secretions would be cleansed and apply new dressing.
Medical Device Related Pressure Injury (MDRPI): occur secondary to pressure from a device, risk is increased in the presence of MASD.
Prevention includes ensuring the trach ties are secure enough to protect the airway, but not so tight as to create intense pressure. In most cases, you should be able to insert a finger between the tie and skin.
The trach plate is another concern for MDRPI, particularly if facial/neck edema. A non-adhesive foam dressing can be cut to mimic split gauze dressings and used to reduce pressure.
Management: Initiate wound care according to UCM guidelines, a wound care nurse consult is also advised for any pressure injury. Refer to PC 159. Sutures: newly created tracheostomies are sutured into place. Typically these sutures are removed by ENT/service in 7 days. If you note sutures in longer than 7 days, please page provider to request removal. Prolonged suture use can limit the ability to provide interventions and increase MDRPI

Routine Trach Care

1. Clean the site and stoma and non-disposable inner cannula, if present, of a tracheostomy with sterile water (unless otherwise ordered) using aseptic technique every shift and PRN. If inner cannula is disposable, change out every shift and PRN. Dry the peri-stoma area.
2. Change the dressing every shift and PRN (if frequent secretions). Trach ties are changed every 48 hours and PRN.
3. Ensure the trach ties are secure but not overly tight.

Refer to Elsevier Skills for additional information regarding trach care, if needed.

UCM Nursing Tip Sheet: Respironics V60 BiPAP/CPAP

To activate Standby

1. Press the Standby tab. The Entering Standby window appears.
2. Disconnect the patient from the ventilator.

The ventilator will not enter Standby until the patient is disconnected. It continues ventilation while waiting for the patient to be disconnected. The Standby mode gives the clinician up to 60 seconds to disconnect the patient from the ventilator. If after 60 seconds no disconnection is detected, the Standby mode cancels.

Interface

Apply “two-finger”’ rule to Inte rfaces application of the straps.
Ensure a good seal is achieved without applying excessive pressure to skin. (a slight leak is preferred).

Contraindications for NPPV for Acute Respiratory Failure
ALOC (cannot remove mask independently)
RESTRAINTS
Inability to protect airway
Copious secretions
Respiratory arrest
Recent upper airway/ upper Gl surgery

UCM Nursing Tip Sheet: Heated and Humidified High Flow Oxygen Therapy

• Interface comes in S,M and L
• For sizing, nasal prongs should occlude approx. 50% of nare
• Straps should sit on crown of head to avoid pressure injuries on or around ears

The University of Chicago Medical Center Policy and Procedure Manual

Policy: PC 48 Management of New or Worsening Respiratory Insufficiency Outside an ICU
Issued: October 2000
Revised: November 2022
Policy:
It is the policy of the Medical Center and Medical Staff that the following be implemented as it relates to the management of new or worsening respiratory insufficiency outside of the intensive care unit (ICU):

• A medical order must be entered for all patients requiring oxygen therapy.
• Patients with new or worsening respiratory insufficiency requiring positive pressure ventilation, to maintain adequate ventilation and/or oxygenation must be managed in a critical care area.
• Pediatric patients should be managed in a critical care area if:
  1. Requiring FiO2>50% and/or
  2. Above the recommended initial flow rate for pediatric High Flow Nasal Cannula (HFNC), calculated as 1L/kg/min, to a maximum of 15L/min.

Refer to pediatric guidelines and Agile MD pathways for details on pediatric management.

Definitions:

1. Non-invasive positive pressure ventilation (NIPPV): Continuous positive airway pressure (CPAP) or bi-level positive airway pressure (e.g. BiPAP) delivered via face mask, nasal mask, or other device that ensures delivery of positive end-expiratory pressure

2. Low Flow Nasal Cannula: “An oxygen delivery device delivering flow rates of 1-6LPM and FiO2 ranging from 24%-45%”

3. Green High Flow Nasal Cannula – An oxygen delivery device delivering flow rates of 6-15LPM and Fi02 range from 45%-80%. Allows for increased Fi02 for stable patients who want to eat, drink, talk, take oral medications

4. High Flow Nasal Cannula (HFNC): an alternative means of non-invasive positive pressure respiratory support. The apparatus comprises an air/oxygen blender, an active heated humidifier, a single limbed heated circuit, and a nasal cannula specifically designed for high flow therapy (See appendix A)
   Adult flow rates: 10-60L/min
   Pediatric flow rates: Up to 2L/kg/min

5. High Oxygen Requirement:
   • Need for ≥ 50% fraction of inspired oxygen (FIO2) to maintain adequate oxygen saturation per provider order

6. Critical Care Area: All Intensive Care Units and Emergency Departments

Procedure:

1. Stable patients that may be managed in the general care areas include:
   • Adult and Pediatric patients with high oxygen requirements receiving comfort care
   • Pediatric patients on Comer 5 receiving HFNC at 1 L/kg/min, to a maximum of 15L/min of HFNC and/or </=FiO2 0.5
   • Adult patients with an established program of CPAP or NIPPV for obstructive sleep apnea
   • Adult patients being evaluated for obstructive sleep apnea with an auto- titrating NIPPV device
   • Adult patients with chronic high oxygen requirements responsive to titration per provider’s orders.
   • Adult patients with stable or decreasing levels of oxygen administration by nasal cannula, Venturi mask, face mask, non-rebreather mask, trach collar or HFNC.

2. In an emergency, a nurse, respiratory care practitioner may place a patient on oxygen by nasal cannula or face mask, as needed, to provide immediate respiratory support without an order, provided the licensed independent provider (LIP) is notified, an order is entered in the medical record within 30 minutes of the application of oxygen therapy, and the clinical indication for emergency application of oxygen is documented in a note.
   • An emergency is defined as a new or worsening pulse oximetry reading of <90%, in the setting of a dependable waveform, or any clinical evidence of hypoxemia or respiratory distress, such as cyanotic nail beds or lips, chest retractions, nasal flaring, or tripoding, in the absence of a dependable pulse oximetry waveform.
   • Subjective shortness of breath without any clinical indication of hypoxemia or respiratory distress does not constitute an emergency.
   • The LIP should be contacted for any new or worsening symptoms, regardless whether the criteria for emergency application of oxygen are met. In addition, the Rapid Response Team or Pediatric Emergency Team should be activated.

3. A patient with new or worsening respiratory insufficiency requiring NIPPV must have an order for transfer to a critical care area (e.g. ICU).

4. A patient with new or worsening respiratory insufficiency outside a critical care area who requires NIPPV must have 1:1 care by an appropriately educated and competent staff member (critical care nurse, licensed independent provider or respiratory therapist) until transferred to a critical care area.

5. Stable patients with high oxygen requirements, HFNC or NIPPV (see definition # 5) maybe managed on a general floor with continuous pulse oximetry monitoring. Medical orders are required to clarify patient specific oxygen requirements and goals of therapy. See noted limitations for pediatric patients on Comer 5 indicated above.

6. Deviations from the policy must be approved by physicians with privileges in Critical Care

Medicine and documented in the patient’s medical record.
The placement of chronic ventilated patients on a general medical floor is not permitted.
Anyexception to this policy requires nursing executive director approval.
Interpretation, Implementation and Revision:
The Departments of Nursing, Critical Care Medicine, and Respiratory Care are responsible for the interpretation, implementation and revision of this policy.

Attachments:
Attachment A: High Flow Nasal Cannula Apparatus
Attachment B: Supplemental Oxygen Mask Devices
Attachment C: Oxygen Tank Flow Rate and Capacity

Cross References:
Pediatric Acute Inpatient Bronchiolitis Guidelines, non-ICU
Pediatric High Flow Nasal Cannula Guideline
Agile MD Pathway, Comer Emergency Department/Comer 5, High Flow Nasal Cannula Initiation for Non-ICU Settings
Agile MD Pathway, Comer Inpatient High Flow Nasal Cannula Maintenance and Weaning

References:

1. Lee JH, Rehder JK, Williford L, Cheifetz IM, Turner DA. Use of high flow nasal cannula in critically ill infants, children, and adults: a critical review of the literature. Intensive Care Med 2013:39;247-257
2. Kernick J., & Magarey, J. (2010). What is the evidence for the use of high flow nasalcannula oxygen in adult patients admitted to critical care units? A systemic review. Australian Critical Care. 23,(2), 53-70.
3. Nishimura, Masaji. “High-flow nasal cannula oxygen therapy in adults.” Journal of intensive care 3.1 (2015): 1.
4. Roca, O., Torres, F., & Mascians, J.R. (2010). High flow oxygen therapy in acute respiratory failure. Respiratory Care. 55,(4), 408-413.
5. Boyer, A., Vargas, F., Delacre, M., Saint-Leger, M., Clouzeau, B., Hilbert, G., & Gruson, D.(2010). Prognostic impact of high flow nasal cannula oxygen supply in an ICU patient with pulmonary fibrosis complicated by acute respiratory failure. Intensive Care Medicine, Sept 18, 2010.
6. Walsh, B. K., Czervinske, M. P., & DiBlasi, R. M. (2010). Perinatal and Pediatric Respiratory Care, 3rd Ed. St. Louis, MS: Saunders Elsevier.

Applicable Elsevier Skills:
High-Flow Nasal Oxygen Therapy (Respiratory Therapy)
Ventilation: CPAP, NIPPV, and HFNC (Neonatal)- CE
Oxygen Therapy and Oxygen Delivery (Pediatric)- CE

Attachment A: High Flow Nasal Cannula Apparatus
Attachment B: Supplemental Oxygen Devices

**DEVICE| ****FiO2| O2 FLOW RANG| ****COMMENTS| CURRENTLY AVAILABLE?
---|---|---|---|---
****ADULT| ****PEDIATRIC**
LOW FLOW NASAL CANNULA| 24-

44%

| 1-6 LPM| Can use Bubble Humidifier for flows > 4 lpm; no supporting studies

for bubble humidifier use; HAPU on ears, nares; widely variedFiO2

delivered, depending on inspiratory demand

| YES| YES
HIGH FLOW – GREEN| 45-

80%

| 6-15 LPM| High Flow cannula allowing for up to 15 liters of flow and the ability to talk, eat, drink, and take medications.| **YES| ****NO**
HIGH FLOW NASAL CANNULA

See attachment A for image

| 21%-

100%

| 1-60 LPM| High Flow Nasal Cannula(HFNC): the administration of air (=/- supplemental oxygen) at flow rates that exceed the inspiratory

demand of the patient. The air is heated (37⁰C) and humidified (100%)

| YES| YES
SIMPLE MASK| 35- 50%| 5-10 LPM| Fit dependent; Rebreathing of exhaled CO2 at flowrates < 10LPM; May build mask from 3-in-1 mask; closed mask causes feelings of claustrophobia leading to poor compliance; must be removed to drink, eat, talk, take pills; risk of aspiration of emesis.| **YES| YES-ONLY PEDIATRIC SIZE**
PARTIAL-
REBREATHER FACEMASK| 40- 70%| 6-10 LPM| Fit dependent; Rebreathing of exhaled CO2 at flowrates < 10LPM;

Must build mask by removing valve-flaps on Non-Rebreather mask;

closed mask causes feelings of claustrophobia leading to poor compliance; must be removed to drink, eat, talk, take pills; risk of aspiration of emesis; Regulate flow to keep reservoir bag 1/3 to 1/2 full.

| **YES| YES-ONLY PEDIATRIC SIZE
NON-REBREATHER
FACEMASK| 60- 100%| 10-15 LPM| Fit dependent; Rebreathing of exhaled CO2 at flowrates < 10LPM;
Closed mask causes feelings of claustrophobia leading to poor compliance; must be removed to drink, eat, talk, take pills; risk of aspiration of emesis; Regulate flow to keep reservoir bag full. May provide minimal positive- pressure at high flows.| YES| YES-ONLY**

PEDIATRIC SIZE

VENTURI MASK

| 24-31%; 30- 55%| 2-4 LPM; 4-

14 LPM

| Fit dependent; Closed mask causes feelings of claustrophobia leading to poor compliance; must be removed to drink, eat, talk, take pills; risk of aspiration of emesis; add aerosol ring-adapter to protect venturi-ports to allow for room-air entrainment, high-flow room-air entrainment can be noisy; must change adapters for correct FiO2 delivery.| **YES| ****YES-ONLY PEDIATRIC SIZE
---|---|---|---|---|---
COOL AEROSOL MASK| 28-90%| 15+LPM| Aerosol mask attached to corrugated tubing and large O2 Nebulizer. Fits over nose and mouth. Low gas-flow at higher FiO2s.| ****YES| ****YES
FACE TENT| 28-90%| 15+LPM| Under-the-chin style aerosol mask attached to corrugated tubing and large O2 Nebulizer. This style mask is used when a regular aerosol mask can’t be used to sit on the face. Low gas-flow at higher FiO2s.| ****YES| ****YES
TRACH COLLAR| 28-90%| 15+LPM| Aerosol mask that fits over tracheostomy tube with corrugated tubing and large O2 Nebulizer. Low gas-flow at higher FiO2s.| ****YES| ****YES
** OXYMASK*| 24-90%| 1-15LPM| Aerosol mask that fits over nose and mouth, Openings for fluids and oral medication, No buildup of heat or humidity under the mask, Unrestricted communication, FIO2 dependent on work of breathing.| **YES| ****NO**

Attachment C: Oxygen Tank Flow Rate and Capacity

Example : If a cylinder has 1600 PSI remaining and the flow ts 6 liters per minute, the cylinder will last 84 minutes.

References

• bcove.video/3Pu1GQW
• bcove.video/3ZrTkxR
• Skills
• Proofpoint Targeted Attack Protection

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