THORACENTESIS – Purpose, General Instructions, Preliminary Assessment, Preparation of the Patient and Environment, Equipment, Procedure, After Care and Complications

Thoracentesis is defined as introducing a hollow needle into pleural cavity and aspirating fluid or cur, using aseptic technique

Thoracentesis refer to the puncture by needle through the chest wall into the pleural space for the purpose of removing pleural fluid (blood, serous fluid, pus, etc) and or air (pneumothorax)

Thoracentesis or pleural aspiration or pleural tap is the insertion of needle into the pleural space through the chest wall to remove the pleural fluid or possibly air

PURPOSE

• To remove excessive pleural fluid (serous fluid, blood or pus)
• To drain fluid/air from pleural cavity for diagnostic or therapeutic purposes
• To introduce medications
• To aid in full expansion of lung
• To obtain specimen for biopsy
• To take pleural biopsy for diagnostic examination
• To relieve pain
• To relieve breathlessness caused by accumulation of fluid or air in the pleural space
• To aid in diagnosis and treatment (chemical, bacteriological, cellular, composition and malignancy)

GENERAL INSTRUCTIONS

• The patient should be prepared physically and psychologically for the procedure
• Thoracentesis is indicated in case of pleural effusion due to infection, traumatic injury, cancer or cardiac diseases, etc
• Common site for thoracentesis is just below the scapula at the seventh or eighth intercostals space
• The patient should be warned that any sudden movements during the procedure may cause injury to the lungs, blood vessels, etc
• The level of the aspiration needle should be short to prevent pricking of the lungs
• Usually upright position is used during the procedure as it helps to collect the pleural fluid at the base of the pleural cavity and hence facilitates to remove the fluid easily
• Maintain strict aseptic technique to prevent introduction of infection into the pleural space
• The three way adaptor should be fitted with the needle before it is introduced into the chest cavity.  The adaptor should be in a closed position to prevent the entry of air into the pleural cavity
• The nurse should check the syringes and needle for air-tightness; air may be entering the pleural cavity and collapse
• Remove the fluid slowly and not more than 1000 ml at a time, if the tap is therapeutic to prevent mediastinal shift
• Use water-seal drainage system, if pleural fluid is purulent and difficult to drain
• The specimen should be sent to the laboratory soon after it collected
• The aspiration should be discontinued if any signs of complications are noted such as sharp pain, respiratory distress, excessive coughing, crepitus, hemoptysis, circulatory collapse, etc

PRELIMINARY ASSESSMENT

• Doctors order for any specific instructions
• Written informed consent of the patient or relatives
• General condition and diagnosis of the patient
• Review fresh erect chest X-ray
• Confirm the diagnosis, location and extent of the pleural air/fluid/pus
• Acute respiratory insufficiency (tension pneumothorax, rapidly developing thoracentesis without dsypnea) may demand thoracocentesis without X-ray

Mental status of the patient to follow the instructions

Articles available in the unit

PREPARATION OF THE PATIENT AND ENVIRONMENT

• Explain the sequence of the procedure
• Provide privacy
• Chest X-ray should be taken before thoracentesis is done to diagnose the location
• Check the vital signs and record it on the nurse’s record for reference
• A mild sedation may be given to the patient before starting the procedure
• Maintain the desired position during the procedure
• The nurse should remain near the patient to observe him and to remind him not to move during the procedure
• Premedication – injection atropine sulfate 0.65 mg intramuscularly or intravenously half an hour before procedure

EQUIPMENT

A sterile tray containing:

• Sponge holding forceps – 1
• Dissecting forceps – 1
• Syringe (5ml) and 2 needles for giving local anesthesia
• 20 ml syringe with 1 lock to aspirate the fluid
• Aspiration needle No. 16 (long and short)
• Three way stop clock
• Small bowls (2) to take the cleaning lotions
• Specimen bottles and slides
• Cotton swabs, gauze pieces and cotton pads
• Gown, masks and gloves for the doctor
• Sterile dressing towels/slits

An unsterile/clean tray containing:

• Mackintosh and towel
• Kidney tray and paper bag
• Spirit, iodine and tincture benzoin
• Lignocaine 2%
• Suction apparatus with water-seal drainage system

PROCEDURE

• Position the patient in fowler’s. Bring patient to one side of bed with feet support, arms and head leaning forward on cardiac table with pillows
• Untie gown to expose site for aspiration
• Instinct patient to avoid coughing and to remain immobile during procedure
• Explain that a feeling of deep pressure will be experienced while fluid is being aspirated from pleural space
• Provide sterile gloves to doctor
• Open sterile set and assemble 20 ml, 50 ml syringes, 20-22 G needles and aspiration needle
• Pour antiseptic solution to clean it
• After showing label to doctor clean top of local anesthetic bottle and assist to withdraw mediation
• Reassure patient and instruct to hold breath during insertion of aspiration needle
• As physician does procedure, observe for signs and symptoms of complication
• After fluid is withdrawn from – pleural space, transfer to specimen container
• After needle is withdrawn, apply pressure over puncture site. Assist in sealing site with tincture benzoin swab

AFTER CARE

• Instruct patient to lie on non/affected site for 1 hour. Ensure bed rest for 6 to 8 hours
• Monitor vital signs every half hour until stable
• Observe patient for signs and symptoms of hemothorax, tension pneumothorax, subcutaneous emphysema and air embolism
• Administer analgesics and antibiotics as prescribed
• Instruct patient to carry out deep breathing exercises
• A chest X-ray may be taken to determine the effects of the procedure
• The puncture site should be treated aseptically to prevent contamination of the wound
• The container with aspirated fluid should be labeled and sent to the laboratory with requisition form
• Replace the articles after cleaning
• Wash hands thoroughly
• Record the procedure in the nurse’s record sheet

COMPLICATIONS

• Pneumothorax and hemothorax: sudden rise of sharp pain in the chest, persistent cough, shortness of breath, fall in blood pressure, rapid pulse, anxiety, restlessness and faintness, profuse sweating, pallor cyanosis
• Tension pneumothorax: marked dyspnea, cyanosis, reduced or absence of breath sounds and decreased movement of chest on respiratory rates. Shifting of the trachea to the unaffected side
• Mediastinal shift: cyanosis, severe dyspnea, deviation of larynx and trachea from their normal midline position towards the unaffected side, shifting of the heart heat position of maximum impulse and distended neck veins
• Pulmonary edema: blood tinged frothy sputum, cough, rates, wheezing severe dyspnea, cyanosis, tachycardia, tachypnea, distended neck veins, signs of heart failure, peripheral edema and altered level of consciousness

PULMONARY FUNCTION TEST – (Abnormal Findings, Description, Calculation of Total Lung Capacity, Calculation of Vital Capacity, Age Related Changes, Client Preparation, Procedure, Gas Exchange/Diffusing Capacity of the Lung, Inhalation Tests (Bronchial Provocation Studies), Post-Procedural Tests and Contraindications

Pulmonary function test are done using a spirometer that measures the amount of air a patient can move in and out and how fast he or she can process it. The patient breathes into a mouthpiece and performs several different breathing maneuvers that are explained by the technician performing the test.

By measuring the patient’s airflow and comparing the results with predicted values for each patient’s height, weight, age, and gender, valuable information can be obtained concerning whether the patient has mild, moderate or severe obstructive or restrictive lung disease

ABNORMAL FINDINGS

• Pulmonary fibrosis
• Interstitial lung diseases
• Tumor
• Chest wall trauma
• Emphysema
• Chronic bronchitis
• Asthma
• Inhalant pneumonitis
• Postpneumonectomy
• Bronchiectasis
• Airway infection
• Pneumonia
• Neuromuscular disease
• Hypersensitivity bronchospasm

DESCRIPTION

Pulmonary function test (PFT) is performed in a pulmonary function laboratory. After preparing the client, a nose clip is applied and the unsedated client breathes into spirometer or body plethysmograph, a device for measuring and recording lung volume in liters versus time in seconds. The clients is instructed how to breathe for specific tests; for example, to inhale as deeply as possible and then exhale to the maximal extent possible. Using measured lung volumes, respiratory capacities are calculated to assess pulmonary status

CALCULATION OF TOTAL LUNG CAPACITY

The total lung capacity (TLC) is the total volume of the lung at their maximum inflation. The four values are used to calculate TLC

• Total volume (TV): the volume inhaled and exhaled with normal quite breathing (also called tidal volume)
• Inspiratory reserve volume (IRV): the maximum amount that can be inhaled over and above a normal inspiration
• Expiratory reserve volume (ERV): the maximum amount that can be exhaled following a normal inhalation
• Residual volume (RV): the amount of air remaining in the lungs after maximal exhalation

ABBREVIATIONS USED IN PULMONARY FUNCTION TEST

• FEV₁ – Forced expiratory volume in one second
• FVC – Forced vital capacity
• VC – Vital capacity (forced or relaxed)
• PEF – Peak (maximum) expiratory flow rate
• TLC – Total lung capacity
• FRC – Functional residual capacity
• RV – Residual volume
• TCO – Gas Transfer factor for carbon monoxide
• DCO – Diffusing capacity for carbon monoxide
• KCO – Transfer Coefficient for carbon monoxide (TCO/liter lung volume)

CALCULATION OF VITAL CAPACITY

Vital capacity (VC) is the total amount of air that can be exhaled after a maximal inspiration; it is calculated by adding together the IRV, TV and ERV

• Inspiratory capacity: it is the amount of the air can be inhaled following a normal quiet exhalation. It is calculated by adding the TV and IRV
• Functional residual capacity (FRC): it is the volume of air left in the lungs after a normal exhalation. The ERV and RV are added to determine
• Forced expiratory volume (FEV₁): it is the amount of air that can be expelled in 1 second
• Forced vital capacity (FVC): it is the amount of air that can be exhaled forcefully and rapid after maximum air intake
• Minute volume (MV) is the total amount or volume of air breathed in minute. In older clients, residual capacity is increased and vital capacity is decreased. These age-related changes result from the following

AGE RELATED CHANGES

• Calcification of the costal cartilage and weakening of the intercostals muscles, which reduce movement of the chest wall
• Vertebral osteoporosis, which spinal flexibility and increases the degree of kyphosis, further increasing the anterior posterior diameter of the chest
• Diaphragmatic flattening and loss of elasticity

CLIENT PREPARATION

• Explain the test to the client
• Inform the client that cooperation is necessary to obtain accurate results
• Instruct the client not to use bronchodilators or smoke for 6 hours after this test (if required by physician)
• Tell the client to withhold the use of small-dose meter inhalers and aroused therapy before this study
• Measure and record the client’s height and weight before this study to determine the predicted values
• List on the laboratory slip any medications the client is taking

PROCEDURE

Spirometry and Airflow Rates

• The unsedated client is taken to the pulmonary function laboratory
• The client breaths through a sterile mouthpiece and into a spirometer to measure and record the desired values
• The client is asked to inhale as deeply as possible. This is repeated several times (usually two to three times). The two best are used for calculations. This test may be repeated with bronchodilators if the client’s values are deficient
• From this, the machine computes FVC, FEV₁, FEV₁/FVC, PIFR, PEFR and MMEF
• The client is asked to breathe in and out as deeply and frequently as possible for 15 seconds. The total volume breathed is recorded and multiplied by 4 to obtain the MVV
• The client is asked to breathe in and out normally into the spirometer and then exhale forcibly from the end tidal volume expiration point. This provides measurement of ERV
• The client is asked to breathe in and out normally into the spirometer and then inhale forcibly from the end tidal volume expiration point. This provides measurement of IC
• The client is asked to breathe in and out maximally (but not forced). This is a measure of VC and the calculated TLC

GAS EXCHANGE/DIFFFUSING CAPACITY OF THE LUNG (D₁)

• The D₁ of CO is usually measured by having the client inhale a CO mixture
• D₁ CO is calculated with an analysis of the amount of CO exhaled compared with the amount inhaled. Some procedures require arterial blood gas to be performed at the same time as the gas exchange maneuvers

INHALATION TESTS (BRONCHIAL PROVOCATION STUDIES)

• These tests also may be performed during pulmonary function studies to establish a cause-and-effort relationship in some clients with inhalant allergies
• The methacholine or histamine challenge test is typically used to detect the presence of hyperactive airway diseases. This test would not be indicative for a client known to have asthma
• Care is taken during the challenge test in reverse any severe bronchospasm with prompt administration of an inhalant bronchodilator (e.g. isoproterernol)

POST-PROCEDURAL CARE

Note that clients with severe respiratory problems are occasionally exhausted after the testing and will need rest

CONTRAINDICATIONS

• Clients who are in pain because of the inability to cooperate by deep inspiration and expiration
• Clients who are unable to cooperate because of age or mental incapacity

PULMONARY ANGIOGRAPHY – Indications, Client Preparation, Procedure, Post-Procedural Care, Contraindications and Potential Complications

Pulmonary angiography done through an injection of a radiography contrast material into the pulmonary arteries, pulmonary angiography permits visualization of the pulmonary vasculature.

When congenital embolism is suspected, lung scanning should be performed first. If the lung scan is normal, pulmonary embolism is ruled out first. Definitive diagnosis of pulmonary embolism may require pulmonary angiography. Bronchial angiography is now being in some facilities to identify bleeding sites in the lungs

INDICATION

• Angiography is used to detect pulmonary embolism
• Congenital and acquired lesions of the pulmonary vessels

CLIENT PREPARATION

• Explain the procedure to the client
• Ensure that written and informed consent for this procedure is obtained
• Inform the client that a warm flash will be felt when the dyes is injected
• Check the client for allergies to iodinated dyes and shellfish
• Determine if the patient has ventricular arrhythmias
• Keep the client NPO after midnight on the test
• Administer preprocedural medications as ordered. Atropine may be given to decrease secretions. Meperidine may be used for sedation and relaxation

PROCEDURE

• The clients are placed on an X-ray table in the supine position
• Electrocardiography electrodes are attached for cardiac monitoring
• The catheter is placed into the femoral vein and passed into the inferior vena cave
• With fluoroscopic visualization, the catheter is advanced to the right atrium and the right ventricle
• The catheter is manipulated into the main pulmonary artery, where the dye is injected
• X-ray films of the chest are immediately taken in timed sequence. This allows all vessels visualized by the injection to be photographed. If filling defects are seen in the contrast-filled vessels, pulmonary emboli are present
• If bronchial artery is performed, the femoral artery is cannulated instead of the vein
• During injection of dye, inform the client that he or she will feel a burning sensation and flush throughout the body

POST-PROCEDURAL CARE

• Observe the catheter insertion site for inflammation, hemorrhage and hematoma
• Assess the client’s vital signs for evidence of bleeding (decreased blood pressure, increased pulse)
• Apply cold compress to puncture site if needed to reduce swelling or discomfort
• Inform the client that coughing may occur after this study
• Educate the client regarding the need for bed rest for 12 to 24 hours after the rest

CONTRAINDICATIONS

• Clients with allergies to shellfish of iodinated dye
• Clients who are pregnant, unless the benefits outweigh the risks
• Clients with bleeding disorders

POTENTIAL COMPLICATIONS

• Allergic reaction to iodinated dye
• Hypoglycemia or acidosis may occur in clients who are taking metformin (glucophage) and receive iodine dye
• Cardiac arrhythmia: premature ventricular contractions during right-sided heart catheterization may lead to ventricular tachycardia and ventricular fibrillation

PLEURAL BIOPSY – Pre-Procedural Care, Procedure, Post-Procedural Care and Complications

Biopsy specimens may be taken from various respiratory tissues for examination. As mentioned previously, specimens from tracheobronchial structures may be obtained during bronchoscopy. Biopsy specimens of scalene and mediastinal nodes may be obtained (with local anesthesia for pathologic study, culture or cytological assessment)

PRE-PROCEDURAL CARE

• Obtain inform consent, and instruct the client about the need for and purpose of the rest
• Preparation and positioning of a client for pleural biopsy are similar to those for thoracentesis
• Inform the client, the test is painful, and the client must hold still
• Assist and reassure the client. The test takes 15-30 minutes to complete

PROCEDURE

• Pleural biopsies can be performed surgically through a small thoracotomy incision or during thoracentesis, with the use of a cope needle
• Needle biopsy is a relatively safe, simple diagnostic procedure that can help to determine the cause of pleural effusion
• The needle removes a small fragment of parietal pleura, which is used for microscopic cellular examination and culture
• If bacteriologic studies are needed, the biopsy specimen should be obtained before chemotherapy is begun

POST-PROCEDURAL CARE

• After the biopsy procedure, observe the indications of complications (dyspnea, pallor, diaphoresis, excessive pain)
• Follow-up chest X-ray studies are usually done after the procedure

COMPLICATIONS

• Rare complications include temporary pain associated with intercostals nerve injury and pneumothorax

LUNG BIOPSY – Purpose, Indication, Procedure, After Care, Contraindications and Possible Complications

This invasive procedure is used to obtain a specimen of pulmonary tissue for a histological examination by using either an open or a closed technique. The open method involves a limited thoracotomy. The closed technique includes methods such as transbronchial lung biopsy, transbronchial needle aspiration biopsy, transcatheter bronchial brushing, percutaneous needle biopsy and video-assisted thoracotomy

PURPOSE

• To identify or examine the abnormal cellular structure and bacteria of lung tissues
• To identify the pulmonary tumors or parenchymal changes (acidosis)

INDICATION

• Lung biopsy is indicated to determine the pathology of pulmonary parenchymal diseases
• Carcinomas
• Granulomas
• Sarcoidosis
• Client preparation

Explain the procedure to the client

Ensure that informed consent is obtained

Instruct the client that fasting is usually ordered. The client may be kept NPO after midnight on the day of the rest

• Administer the preprocedural medications 30-60 minutes before the test as ordered
• Instruct the client to remain still during the lung biopsy. Any movement or coughing could cause laceration of the lung by the biopsy needle

PROCEDURE

• Needle puncture (aspiration) biopsy of the chest lesion is done with fluoroscopy
• After a lesion is identified on a chest film and localized by fluoroscopy, topical anesthesia is administered and the needle is administered and the needle is inserted through the chest wall into the lung tissue and lesion
• A small sample of cell is aspirated for microscopic study, and the needle is withdrawn
• Aspiration biopsy may enable definitive diagnosis of nonmalignant neoplasms, granulomas, other nonmalignant growths
• Transbronchial lung biopsy

This technique is performed via flexible fiberoptic bronchoscopy, using cutting forceps

Fluoroscopy is used to ensure proper opening and positioning of the forceps on the lesions

Fluoroscopy also permits visualization of the tug of the lung as the specimen is removed

• Transbronchial needle aspiration

The needle is inserted through the bronchoscope and into the tumor or desired area, where aspiration is performed with the attached syringe

The needle is retracted within its sheath, and the entire catheter is withdrawn from the fiberoptic scope

• Transbronchial brushing

A small brush is moved back and forth over the suspicious area in the bronchioles or its branches

The cells adhere to the brush, which is then removed and used to make microscopic slides

• Percutaneous needle biopsy

In this method for obtaining a closed specimen, the biopsy is obtained after using fluoroscopic X-ray or CT scan determination of the desired site

The procedure is carried out by using a cutting needle or by aspiration with a spinal type needle to obtain a specimen

• Open lung biopsy

The client is taken to the operating room, and general anesthesia is provided

The client is placed in the supine or lateral position and an incision is made into the chest wall

After a piece of lung tissue is removed, the lung is sutured

Chest tube drainage is used for approximately 24 hours after an open lung biopsy

• Transcopic lung biopsy

The lung is collapsed a with a double lumen end tracheal tube placed during induction of general anesthesia

With the use of a thoracoscope, the lung is grasped and piece is cut off with the use of a cutting/stapling device. Large wedge lung resections can be obtained

The scope and trocars are removed, and small chest tube is left in place

The tiny incision is closed, and the procedure is completed

This procedure is performed by the surgeon in 30-60 minutes

During the lung biopsy procedure, assess the client carefully for signs of respiratory distress (e.g. shortness of breath, rapid pulse, and cyanosis)

AFTER CARE

• After the procedure, examine any sputum closely for evidence of blood
• Observe the respiratory distress (may indicate pneumothorax)
• Monitor the client’s vital signs, breath sounds, skin color and temperature
• Place the biopsy specimen in appropriate container for histological and microbial examination
• Assess the client’s breath sound and report any decrease on the biopsy site
• Obtain a chest X-ray film to cheek for complications (e.g. pneumothorax)

CONTRAINDICATIONS

• The client with bullae or cysts of the lung
• Clients with suspected vascular anomalies
• Clients with bleeding abnormalities
• Clients with pulmonary hypertension
• Clients with respiratory insufficiency

POSSIBLE COMPLICATIONS

• Hemoptysis
• Hemothorax
• Pneumothorax
• Empyema

BRONCHOSCOPY – Definition, Purpose, Principle, General Instruction, Preliminary Assessment, Preparation of the Patient Unit, Articles Needed, After Care, Findings and Complications

Bronchoscopy is a endoscopic diagnostic procedure involving the inspection and observation of the trachea, larynx, and bronchi. Bronchoscopy is ordered when clients have unexplained pulmonary signs and symptoms or when nonspecific radiological abnormalities exist

DEFINITION

• Bronchoscope is an endoscopic diagnostic procedure involving the inspection and observation of the trachea, larynx and bronchi. Bronchoscopy is ordered when clients have unexplained pulmonary signs and symptoms or when nonspecific radiological abnormalities exist

PURPOSE

Diagnostic Purpose

• To visualize tumors, obstructions secretions, bleeding sites and foreign objects in the tracheobronchial system
• Collection of secretions for cytological and bacteriologic study
• Assessing tumors for potential resection
• Tissue for lung biopsy may be obtained

Therapeutic Purpose

• To remove secretions that obstructing the air passages
• To fulgurate (electrodesiccate) and excise lesions

PRINCIPLE

• The knowledge of the anatomy and physiology of the body is essential for the safe administration of the injection
• Microorganism are present everywhere so strict aseptic technique should be practiced
• Any unfamiliar situation produces anxiety
• Organization and planning results in the economy of time material and effort

GENERAL INSTRUCTION

• Proper explanation about the procedure should be given to the patient
• Sedation should be given 30-60 minutes before the procedure
• Procedure is done in a darkened room
• Instruction should be given to the patient to keep his mouth clean
• Nothing should be given to the patient 6-8 hours before the procedure
• Loose teeth and artificial dentures should be removed
• The patient should be positioned on his back with neck hyperextended
• The patient should be informed that his eyes will be covered during the procedure to reduce anxiety
• The patient should be told that the doctor and his assistants will be masked and gloved

PRELIMINARY ASSESSMENT

• Identify the patient with name, bed no: etc
• Check the physician’s order
• Check the general condition of the patient
• Assess the abilities and limitations of the patient
• Check the article available in the patient’s unit

PREPARATION OF THE PATIENT UNIT

• Ensure that a signed consent form has been obtained
• Obtain a medication history to determine whether the patient is receiving anticoagulation therapy or aspirin preparations
• Explain the purpose and procedure of the test. Warn the patient that the local anesthetic may taste bitter
• Record baseline vital signs
• Check for articles available in the unit
• The client should be NPO for 6 to 8 hours before the test
• Oral hygiene should be given the night before the test and in the morning
• Postural drainage is performed for 3 days before the test

ARTICLES NEEDED

Bronchoscope (flexible fiberoptic bronchoscope)

A sterile tray containing

• Gown
• Gloves
• Mask

An unsterile tray containing: Normal saline

Procedure

• A sedative and atropine are usually given 1 hour before the test. The sedative/tranquilizer is to promote relaxation; atropine is to reduce secretions during the test
• A topical anesthetic is sprayed into the pharynx and trachea
• A rigid or flexible fiber optic bronchoscope may be used
• The bronchoscope is inserted through the nose (most common) or through the mouth
• The tube is inserted as the physician observes the condition of the upper airways through the eyepiece and guides the tube to the area of the lung to be evaluated

Parts of flexible fiberoptic bronchoscope:

• Eyepiece
• Open channel
• Fiberoptic tube connected to cold light source
• Section tubing
• In-line sputum trap

AFTER CARE

• If bronchoscope is done under general anesthesia, position the patient in a head low position, flat with head turned to one side
• If not under general anesthesia semi-Fowler’s position
• Save all the sputum for laboratory studies
• Observe the patient for impaired respiration laryngeal spasm and laryngeal edema
• Laryngeal strider, dyspnea and shortness of breath should be notified to the doctor
• Provide emergency resuscitation as necessary
• Give treatment as prescribed
• Give nothing by mouth until his gag reflex returns
• Give warm, soothing, soft fluids
• Observe the patient for toxicity of anesthetic drugs
• Treat the sore throat
• An ice collar may; be used to minimize edema and soreness
• Lozenges and smooth gargles are given to the patient
• Instruct the patient not to clear his throat, cough or talk

FINDINGS

• Atelectasis
• Bleeding
• Bronchial adenomas
• Foreign bodies
• Infection
• Lung cancer
• Sarcoidosis
• Secretions
• Tuberculosis
• Tumors

COMPLICATIONS

• Bleeding
• Drug reactions
• Hypotension
• Laryngospasm
• Bronchospasm
• Hypoxia
• Dysrhythmia
• Cardiopulmonary arrest

BRONCHOGRAPHY – Purpose, Client Preparation, Procedure, Post-Procedural Care, Contraindications and Factors Affecting Diagnostic Results

Bronchography is a X-ray test to visualize the trachea, bronchi and entire bronchial tree after a radiopaque iodine contrast liquid is injected through a catheter into the tracheobronchial space. The bronchi are coated with the contrast dye, and a series of X-ray is then taken

PURPOSE

To detect bronchial obstruction such as foreign bodies and tumors

Indications: bronchial obstructions (e.g. foreign bodies, tumors, cysts or cavities, bronchiectasis)

CLIENT PREPARATION

• Obtain a signed consent form. Check that the consent form is signed premeditation is given
• Explain the procedure of the test. Gradually clients are extremely apprehensive about this test and are fearful that they may be unable to breath
• Reassure the client that airway will not be blocked. Inform the patient that he or she may have a sore throat after the test as the result of catheter irritation
• Obtain history of hypersensitivity to anesthetics, iodine and X-ray dyes. Usually the client will receive an expectorant several days before the test to loose secretions
• Record the vital signs

PROCEDURE

• A consent form should be signed
• The client should be NPO for 6 to 8 hours before the test
• Oral hygiene should be given the night before the test and in the morning. This will decrease the number of bacteria that could be introduced into the lungs
• Postural drainage is performed for 3 days before the test. This procedure aids in the removal of bronchial mucus and secretions
• A sedative and atropine are usually given 1 hour before the tests. The sedative/tranquilizer is to promote relaxation; atropine is to reduce secretions during the test
• A topical anesthetic is sprayed into the pharynx and trachea. A catheter is passed through the nose into the trachea, and a local anesthetic and iodized contrast liquid are injected through the catheter
• The client is usually asked to change body positions so that the contrast dye can reach most areas of the bronchial tree
• Following the bronchography procedure, the client may receive nebulization and should perform postural drainage to remove contrast dye. Food and fluids are restricted until the gag (cough) reflex is present

POST-PROCEDURAL CARE

• Assess for signs and symptoms of laryngeal edema (e.g. dyspnea, hoarseness, apprehension). This could be caused by a traumatic insertion of the catheter
• Assess for allergic reaction to the anesthetic and iodized contrast dye (e.g. apprehension, flushing, rash, urticaria, dyspnea, tachycardia and hypotension)
• Check the gag reflex to see that it has returned before offering food and fluids. Have the client swallow and cough or tickle the posterior pharynx will a cotton swab; if gag reflex is present, offer ice chips or sips of water before food
• Monitor vital signs. The temperature may be slightly elevated for 1 or 2 days after the test
• Checks breathe signs. If bronchi and fever are  present, notify the health care providers and record on the client’s chart
• Have the client perform postural drainage post-test? This procedure helps with the removal of the contrast dye. Physiologic damage will not occur if some of the dye remains in the lungs for a period of time
• Offer throat lozenges or an ordered medication for answer their questions
• Be supportive of the client and family. Be available to answer their questions

CONTRAINDICATIONS

• Bronchoscopy is contraindicated during pregnancy
• Client is hypersensitive to anesthetics, iodine or X-ray dyes

FACTORS AFFECTING DIAGNOSTIC RESULTS

• Secretions in the trace bronchial tree can prevent the contrast dye from coating the bronchial walls

WATER SEAL CHEST DRAINAGE – Indications, Objectives, Mechanism, Factors Affecting the Chest Drainage, Water Seal Drainage System, Types of Chest Drainage

Water seal chest drainage means that a column of water in a bottle seals off the atmospheric air preventing from entering the chest drainage tube and thereby in the pleural sac

Water seal drainage system or so called “closed chest drainage” is indented to allow air and flew to escape from the pleural space with each exhalation and to prevent that return flow with each inhalation

Water seal acts as a one way valve, permitting the unit directional flow of air and fluid out of the pleural space, but permitting none to enter from the drainage system

INDICATIONS

• After thoracic or thoracoabdominal surgeries
• Chest injuries involving the pleura
• Spontaneous pneumothorax

OBJECTIVES

• To remove air and fluid from the pleural space
• To re-establish normal negative pressure in the pleural space
• To promote re-expansion of the lungs which apposition and cohesion of the parietal and visceral pleura
• To restore the normal pulmonary ventilation
• To prevent the reflex (return flow) of air and fluid back into the pleural space from the drainage apparatus
• To prevent shifting of the mediastinum and collapse of the lung tissue by equalizing pressure on both sides

MECHANISM

• In a thoracic surgery the parietal pleura is incised and pleural space is opened
• Atmospheric air rushes into the pleural space and the lungs collapse
• When the chest wall is closed, the air is enclosed in the pleural space thus causing to have a pneumothorax in the operated site
• Additional air may continue to leak into the pleural space through the openings in the pulmonary pleural incision
• Trauma of surgery causes serosanguineous fluid to collect in the patient’s chest until healing occurs
• Negative pressure has been lost inside the space owing to pneumothorax
• The body’s ability to absorb air from the pleural cavity is limited
• Therefore, a closed drainage must be established to remove the collecting fluid and air from the pleural cavity and to prevent additional air and fluid entering the pleural cavity
• A closed drainage system is used postoperatively to remove air and serosanguineous fluid form the pleural cavity

FACTOR AFFECTING THE CHEST DRAINAGE

• Proper placement of chest catheters – usually two catheters are placed in the chest, one of them is placed anteriorly through the second intercostals space to permit the escape of air rising in the pleural space. The lower catheter is placed posteriorly through the eighth or ninth intercostals space in the maxillary line to drain off serosanguineous fluid accumulating in the lower portion of the pleural space
• Proper placement of drainage apparatus – the drainage apparatus for closed chest drainage must always locate at a level lower than the patient’s chest. Thus, this helps drainage by gravity. At the same it prevents backflow of air and fluid in pleural space
• Length of the drainage tubing – drainage tubing which connect the chest catheters to the drainage apparatus should be neither too long nor too short. It should fall in a straight line to the drainage apparatus with no dependent loops. Dependent loops of the tubing, that contain fluids obstruct the flow of air and water into the drainage bottle and create back pressure thus impairing the drainage of air or fluid

WATER SEAL DRAINAGE SYSTEM

• Maintaining the patency of the drainage tubing: patency of the drainage tubing and the chest catheter are checked frequently. Kinks and pressure on the tubing will cause obstruction in the flow of drainage. Observe the amount of drainage per hour to make sure that the tube is not internally plugged with pus or blood clots. Milking the tube helps to dislodge any clot that is formed in the drainage tubes
• Maintenance of an air tight drainage system. Closed drainage system must be maintained air-tight. The bottles are sealed with tight stoppers and all connection of the tubes is taped to ensure its air tightness
• Position of the patient: the patient is placed in a Fowler’s position. This position helps to locate the fluid in the lower portion of the pleural space and drainage thorough the chest tubes, which are placed in the lower chest
• Activity of the patient: the movement of the patient in bed helps to drain the chest. Coughing and deep breathing exercises help the patient to promote lung expansion and expulsion of air and fluid from the pleural space by increasing the intrapulmonic and intrapleural pressure.
• Application of mechanical suction on the water and drainage system

Continuous and gentle cough and respirations are too weak to force the air and fluid out of the pleural space through the chest catheters

In the treatment of empyema thoracic in which the drainage is too thick to drain

In those patients where air is leaking into the pleural space faster than it can be removing by a water seal apparatus and or to speed up the removal of air or fluid out of the pleural space

TYPES OF CHEST DRAINAGE

The One-Bottle Water-Seal System

The end of the drainage tube from the patient’s chest is covered by a layer of water which permits drainage and prevents lung collapse by sealing out the atmosphere. Functionally, drainage depends on gravity, on the mechanics of respiration and, if desired, on suction by the addition of controlled vacuum

The tube from the patient extends approximately 2.5 cm below the level of the water in the container. There is a vent for the escape of any air that might be leaking from the lung. The water level fluctuates as the patient exhales. At the end of the drainage tube, bubbling may or may not be visible. Bubbling can mean either persistent leakage of air from the lung or other tissues or a leak in the system

The Two-Bottle Water-seal System

The two bottle system consists of the same water seal chamber plus a fluid-collection bottle. Drainage is similar to that of a single unit, except that when pleural fluid drains, the underwater seal system in not affected by the volume of drainage

Effective drainage depends on gravity or on the amount of suction added to the system. When vacuum is added to the system from a vacuum source, such as wall suction, the connection is made at the vent stem of the underwater-seal bottle. The amount of suction applied to the system is regulated to the wall gauge

The Three-Bottle Water-seal System

This system is similar in all respect to the two-bottle system, except for the addition of a third bottle to control the amount of suction applied. The amount of suction is determined by the depth to which the tip of the venting glass tube is submerged. In the three-bottle system, drainage depends on gravity or the amount of suction applied. The amount of suction in the system is controlled by the manometer bottle. The mechanical suction motor or wall suction creates and maintains a negative pressure throughout the entire closed drainage system

The manometer bottle regulates the amount of the vacuum in the system. This bottle contains three tubes:

• A short tube above the water level comes from the water seal bottle
• Another short tube leads to the vacuum or suction motor or wall suction
• The third tube is a long tube which extends below the water level in the bottle and which is open to the atmosphere outside the bottle. This is in the tube that regulates the amount of vacuum in the system. This is regulated by the depth to which this tube is submerged the usual depth is 20 cm

When the vacuum in the system becomes greater than the depth to which the tube is submerged, outside air is sucked into the system. This result in constant bubbling in the manometer bottle, which indicates that the systems is functioning properly

COMMMERCIALLY PREPARED DISPOSAL DRAINAGE SYSTEMS

Combine drainage collection, water seal and suction control in one unit. These systems ensure patient safety with positive and negative pressure relief valves and have a prominent air leak indicator. Some systems produce no bubbling sound. System allows air and fluid to escape from the pleural cavity but does not allow the air to re-enter. The system may include one, two or three bottles to collect drainage, create a water seal, and control suction. Or it may be a self-contained disposable system. That combines the features of a multi bottle system in a compact, one piece unit

Equipment: thoracic drainage system which can function as gravity drainage systems to be connected to suction to enhance chest drainage

PREPARATION OF THE EQUIPMENT

Check the doctor’s order to determine the type of drainage system to be used and specific procedural details. If appropriate, request the drainage system and suction system from the central supply department. Collect the appropriate equipment and take it to the patient’s bedside

Implementation

• Explain the procedure to the patient and wash your hands
• Maintain sterile technique throughout the entire procedure and whenever you make changes in the system or alter any of the connections to avoid introducing pathogens into the pleural space

SETTING UP A COMMERCIALLY PREPARED DISPOSABLE SYSTEM

• Open the packaged system and place it on the floor in the rack supplied by the manufacture to avoid accidental knocking it over or dislodging the components. After the system is prepared, it may be hung from the side of the patient’s bed
• Remove the plastic connector from the short tube that is attached to the water-seal chamber. Using a 50 ml catheter tip syringe instill sterile distilled water into the water-seal chamber
• If suction is ordered, remove the cap on the suction-control chamber to open the vent. Next instill sterile distilled water until it reaches the 20 cm mark or the ordered level and recap the suction-control chamber
• Using the long tubes connect the patient’s chest tube to the closed drainage system to the suction source, and turn on the suction. Gentle bubbling should begin in the suction chamber, indicating that the correct suction level has been reached

MANAGING CLOSED CHEST UNDERWATER-SEAL DRAINAGE

• Repeatedly note the character, consistency and amount of drainage collection chamber
• Mark the drainage level in the drainage collection chamber by noting the time and date at the drainage level on the chamber every 8 hours
• Check the water level in the water-seal chamber every 8 hours, if necessary, carefully add sterile distilled water until level reaches the 2 cm mark indicated on the water-seal chamber of the commercial system
• Check for fluctuation in the water-seal chamber as the patient breathes. To check for fluctuation when a suction system is being used, momentary disconnect the suction system
• Check the water level in the suction-control chamber. Detach the chamber from the suction chamber when the bubbling ceases, observe the water level. If necessary add sterile distilled water to bring the level to the 20 cm line or as ordered
• Check the gentle bubbling in the suction control chamber because it indicates that the proper suction level has been reached
• Periodically check that the air vent in the system is working properly. Occlusion of the air vent results in a build-up of pressure in the system that could cause the patient to develop a tension pneumothorax
• Coil the systems tubing and secure it to the edge of the bed with a rubber band or tape and a safety pin. Avoid creating dependent loops, kinks or pressure on the tubing
• Be sure to keep two rubbers tipped clamps at the bedside to clamp the chest tube if a bottle breaks or the commercially prepared system cracks or to locate an air leak in the system
• Encourage the patient to cough frequently and breathe deeply to help drain the pleural space and expand the lungs
• Check the rate and quality of the patient’s respirations and auscultate his lungs periodically to assess air exchange in the affected lung
• Tell the patient to report any breathing difficulty immediately. Notify the doctor immediately if the patient develops cyanosis rapid or shallow breathing, sub-cutaneous emphysema chest pain or excessive bleeding
• When clots are visible you may be able to strip the tubing depending on your facility policy. This is a controversial procedure because it creates high negative pressure that could suck viable lung tissue into the drainage
• Check the chest tube dressing at least every 8 hours. Palpate the area surrounding that dressing for crepitus or subcutaneous emphysema, which indicates that air is leaking into the subcutaneous tissue surrounding the insertion site
• Encourage active or passive range of motion (ROM) exercises for the patient’s arm or the affected side if he has been splint his arm to decrease his discomfort
• Remind the ambulatory patient to keep the drainage system below chest level and to be careful not to disconnect the tubing to maintain the water seal

ASSESSMENT OF PROPER FUNCTIONING

• Observing the oscillating movements of the fluid up and down in the water-sealed tube
• Observing the intermittent bubbling in the water seal bottle
• Observing the collection of drainage in the water seal or drainage bottles
• Observing the periodic emptying of the suction control tube and bubbling in the suction control bottle when a mechanical suction is attached to the under-water seal drainage system
• Ascertain the status of the patient by assessing vital signs and the appearance frequently

PRECAUTIONS TO BE TAKEN WHILE REPLACING CHEST DRAINAGE BOTTLES

• Assemble the bottle with tight stopper and tubes and check for their proper functioning
• Double clamp the chest catheters close to the patient’s chest to prevent entry of air into the pleural cavity
• Clamps are applied at the end of a full inspiration to prevent the air being sucked into the pleural space
• Disconnect the bottle to be replaced along with the drainage tubing and attach to new set, taking care not to contaminate the end of the chest catheters
• Be certain that the bottle is placed well before the chest level and is fixed safely to prevent falling or being kicked over accidentally
• Unclamp the patient’s chest catheter and make certain that the system is functioning properly before leaving the patient
• Watch the patient’s vital signs for few minutes to see any changes in the general conditions

CHEST CATHETER REMOVAL

• The chest catheter is removed only on the return order of the physician, and is removed by the physician
• Usually the chest catheters are removed in two or three days, provided the remaining lung tissue is well expanded, the air leaks are absent and fluid drainage is less than 75 ml per day
• A chest X-ray may be taken before the chest catheters are removed to make sure that the lungs are fully expanded
• After removal of the chest catheters, the wound is covered with sterile petrolatum gauze and a firm dressing is applied over the wound which is secured with wide strips of adhesive tapes
• After removal of the catheters the patient is observed closely for the development of respiratory distress

DISCHARGE TEACHING

The following advice is given to these patients on discharge from the hospital

• To have deep breathing and coughing exercise
• To maintain good nutrition
• To maintain good hygiene especially oral hygiene
• To avoid activities or environment that can cause irritation of trachea bronchial tree
• They are advised not to smoke, to avoid dusty place and to avoid exposure to the persons having respiratory infections
• To consult the physician if symptoms of upper respiratory infections or other ailments develop
• To obtain a fitness certificate before they join their duty

COMMON PROBLEMS AND SUGGESTED ACTIONS

• Lack of drainage

Causes: kinking, looping or pressure on the tubing may cause reflux of fluid into the intrapleural space or may impede drainage, causing blocking of the intrapleural drain

Nursing action: check the system and straighten tubing as required. Secure the tubing to prevent a recurrence of the problem

• No fluctuation of fluid in tubing from the underwater seal

Causes – re-expansion of the lung, tubing is obstructed by blood clots fibrin, failure of the suction apparatus

Nursing action: ask medical staff if the drain may be removed following chest X-ray. The purpose of the drain has been fulfilled. Keeping the drain in any longer than necessary may lead to hazards from infection or air re-entry. “milk” the tubing towards the drainage bottle to try to dislodge the obstruction and re-establish potency. Straighten tubing as required. Secure the tubing to prevent a recurrence. Disconnect the suction apparatus and ensure drain is patent

• Constant bubbling of fluid in the drainage

Causes: an air leak in the system

Nursing action: clamp the intrapleural drain momentarily close to the chest wall and establish whether there is a leak in the rest of the system. Clamping the tubing shows whether the leak is below the level of the clamp

• Patient shows signs of rapid shallow breathing, cyanosis, pressure in the chest, subcutaneous emphysema or hemorrhage

Causes: tension pneumothorax, mediastinal shift, postoperative hemorrhage, severe incision pain, pulmonary embolus or cardiac temponade

Nursing action: observe record and report, any of these signs to a doctor immediately

• Incision pain:

Nursing actions: provide analgesia as prescribed to reduce the patient’s discomfort and to enable deep breathing exercises to be performed and mobilization to ensure adequate drainage and to avoid complications

• Accidental disconnection of the drainage tubing from the intrapleural drain:

Nursing action: apply an artery clamp to the drain immediately in order to avoid air entering the pleural space. Re-establish the connection as soon as possible in order to re-establish drainage. If necessary use cleans sterile drainage tube tubing may have been contaminated when it became disconnected

• Patient needs to be moved to another area:

Nursing action: place the drainage bottle below the level of the intrapleural drain as close to the floor as possible in order to prevent reflux of fluid into the pleural space. Do not clamp the drain unless the doctor has ordered it

• Intrapleural brain falls out

Nursing action: pull the purse string suture immediately to close the wound. Cover the wound with an occlusive sterile dressing. Inform a doctor. The objective is to minimize the amount of air entering the pleural space. The drain will probably need reinserting. Reassure the patient with appropriate explanations.

TRACHEOSTOMY SUCTIONING – Definition, Purpose, Equipment, Preliminary Assessment and Procedure

DEFINITION

Tracheostomy is an artificial airway which requires being maintained secretion free, thereby insuring adequate ventilation for the patient

PURPOSE

• To clear secretions from the artificial airway or tracheobronchial tree
• To maintain the patency of the tracheostomy tube
• To ensure maximum ventilation of the patient
• To reduce maximum ventilation of the patient
• To reduce the risk of respiratory infection

EQUIPMENT

• A clean tray
• Sterile suction catheters size 14, 16 adult, 10, 12 pediatric with thumb control
• Sterile gloves
• Sterile towel
• Sterile container and water or normal saline for flushing the catheter and tubing
• Normal saline for installation
• Sterile syringe 2 ml, 5 ml
• Resuscitation bag with reservoir connected to 100% oxygen source. Add positive end expiratory pressure valve to exhalation valve on resuscitation bag in an amount equal to that on the ventilator or (PAP, CPAP device)
• Receptacle for disposables
• Suction apparatus, e.g. portable machine or wall suction set at 80 to 120 mm Hg

PRELIMINARY ASSESSMENT

• Check physician’s order, progress notes and nursing care plan
• Explain the procedure to the patient. Include instructions on how to splint the surgical incision as coughing will be induced during the procedure
• Ensure the patient’s privacy
• Position the patient in suitable position
• Monitor heart rate, respiration rate and type and arterial blood pressure. If blood gases are ordered, know baseline values
• Collect and assemble equipment. Check function of suction and resuscitation bag connected to 100% oxygen source
• Wash and dry hands

Procedure

• Open sterile towel and place in bib like fashion on patient’s chest
• Open sterile gloves and place on sterile field
• If the patient is attached to ventilator test to ensure that disconnection of ventilator may be with one hand
• Fill the sterile container with sterile water
• Open the end of the pack containing the suction catheter and connect it to the tubing of the suction machine
• Using the contaminated hand disconnect the patient from the ventilator CPAP device or other oxygen source
• Ventilate and oxygenate the patient with the resuscitator bag 5 to 6 times
• In the spontaneously breathing patient coordinate ventilation with patients own respiratory effort
• Slide the cover off the catheter and rinse it through with sterile water/saline to lubricate it
• Insert the catheter into the tracheostomy as for as possible without applying suction
• Apply suction and quickly rotate the catheter while it is being withdrawn
• Limit suction time 10 to 15 seconds. Discontinue if heart rate decreases by 20 beats per minute or if cardiac ectopy is observed
• Ventilate the patient between suction with 4-5 manual ventilation
• Sterile normal saline 2 to 3 ml may be instilled into the airway followed by manual ventilation then suction
• Rinse catheter between suctioning. Procedure with sterile water/saline
• Continue procedure as necessary to a maximum of 4 suction passes
• Give the patient 6 to 8 ‘sigh’ breaths with the bag
• Return the patient to the ventilator or apply CPAP or other oxygen delivery device
• Suck oral secretions from the oropharynx above the artificial cuff
• Deliver tracheostomy care as required
• If patient is not an respiratory assistance apply filter or humidifier as indicated
• Check vital signs
• Leave the patient as comfortable as possible
• Clear and clean equipment
• Wash and dry hands
• Document the procedure including patient’s response in appropriate nursing notes

TRACHEOSTOMY CARE – Definition, Use of Tracheostomies, Parts of the Tracheostomy, Indications for Tracheostomy, Complications of Tracheostomy, Care of the Tracheostomy Patient and Cleansing the Inner Cannula

DEFINITION

A tracheostomy is an incision into the trachea the 2^nd, 3^rd, or 4^th tracheal ring

USE OF TRACHEOSTOMIES

• To facilitate prolonged artificial ventilation
• To bypass serious upper respiratory obstructions
• To prevent aspiration of blood, secretions or food into the lungs
• To provide easier access to the lower airways than that is possible through nose or mouth

PARTS OF THE TRACHEOSTOMY TUBE

• Outer tube or outer cannula
• The inner tube or inner cannula
• The obturator or pilot. It is used as a guide to the outer tube

INDICATIONS FOR TRACHEOSTOMY

• Apnea
• Respiratory obstruction
• Circulatory arrest
• Exsanguinating hemorrhage
• Carcinoma of the larynx
• Diphtheria, Ludwig’s angina
• Head injury, neck injury or chest injuries
• Respiratory failure
• Fracture of the larynx or trachea
• In case of foreign body in hypopharynx or larynx
• Patient with severe burns, especially around hand, neck, and face
• Patients who have had thyroidectomy or radical neck resection
• Patients with neurological disorders, drug overdose, bulbar paralysis, or cerebrovascular accidents
• Patients with severe pulmonary edema
• Patients with severe emphysema
• Weak, feeble patients
• Canine biting

COMPLICATIONS OF TRACHEOSTOMY

• Subcutaneous emphysema
• Pneumothorax
• Mediastinal emphysema
• Obstruction of tracheostomy tube
• Respiratory insufficiency
• Displacement of the tube from its position on the tracheal turner
• Hemorrhage
• Pulmonary infection
• Atelectasis
• Tracheoesophageal fistula

Tracheomalacia

Constant pressure exerted by the cuff causes tracheal dilation and erosion

Signs and Symptoms

• An increased amount of air is required in the cuff to maintain the seal
• A large tracheostomy tube is required to prevent air leak at the stone
• Food particles are seen is tracheal secretions
• The client does not receive the set tidal volume of the ventilator

Management

No special management is needed unless bleeding occurs

Prevention

• Use and uncuffed tube as soon as possible
• Monitor cuff pressure and air volumes closely and detect changes

Tracheal Stenosis

Narrowed tracheal lumen is due to scar formation from irritation of tracheal mucosa by the cuff

Signs and Symptoms

Stenosis usually is seen after the cuff is deflated or the tracheostomy tube is removed. The client has increased coughing, inability to expectorate secretions or difficulty in breathing or talking

Management

Tracheal dilation or surgical intervention is used

Prevention

• Prevent pulling of and traction on the tracheostomy tube
• Properly secure the tube in the midline position
• Maintain proper cuff pressure
• Minimize oronasal intubation time

Tracheoesophageal fistula (TEF)

Excessive cuff pressure causes erosion of the posterior wall of the trachea. A hole is created between the trachea and the anterior esophagus. The client at highest risk also has a nasogastric tube present

Signs and Symptoms

• Manually administer oxygen by mask to prevent hypoxemia
• A small soft feeding tube is used instead of a nasogastric tube for tube feedings
• A gastrostomy or jejunostomy may be performed
• Monitor the client with a nasogastric tube closely; assess for TEF and aspiration

Prevention

• Maintain cuff pressure
• Monitor the amount of air needed for inflation and detect changes
• Progress to a deflated cuff or cuffless tube as soon as possible

Trachea-innominate artery fistula

A malpositioned tube causes its distal tip to push against the lateral wall of the tracheostomy. Continued pressure causes necrosis and erosion of the innominate artery. This is a medical emergency

Signs and Symptoms

The tracheostomy tube pulsates in synchrony with the heartbeat. There is heavy bleeding from the stoma. This is a life-threatening complication

Management

• Remove the tracheostomy tube immediately
• Apply direct pressure to the innominate artery at the stoma site
• Prepare the client for immediate surgical repair

Prevention

• Use correct tube size and maintain tube in midline position
• Prevent pulling or tugging on the tracheostomy tube immediately notify the physician of the pulsating tube

CARE OF THE TRACHEOSTOMY PATIENT

• Maintain an open airway. Suction and clean the tube as indicated. Prevent aspiration, e.g. of water, solutions, etc. through the tracheostomy. Keep materials which may occlude the tracheostomy, away from the opening, e.g. clothing, bedsheets
• Observe the patient carefully for indication of respiratory difficulty, e.g. noisy respirators, restlessness, cyanosis, intercostals and substernal retraction, alternations in respiratory rate, labored respiration
• Practice asepsis. Strict aseptic technique should be followed while suctioning, cleaning and dressing the wound
• Observe for complications of tracheostomy. If the airway is obstructed, do suctioning, if the tracheostomy outer tube has come out, put the tracheal dilator inside and inform the doctor. Never try to push a blown out tracheostomy tube back into its place. Tracheal dilator and tracheal hook, sterile, should be present near the patient all the time
• Ensure maximal humidification of the inspired air and approximately warm inspired air. Sterile wet gauze covering the tracheostomy will help in humidification
• Provide adequate hydration to help liquefy pulmonary secretions. At least 3,000 ml of intravenous fluids are ordered daily if adequate oral intake is not possible
• Maintain fluid and electrolyte balance. Keep an accurate intake and output chart
• Be gentle. The tracheal mucosa is easily traumatized during suctioning
• Keep the necessary articles like extra sterile inner tracheostomy tube, tracheal dilator, tape, Vaseline, gauze, sterile gauze pieces, suction nozzles, sterile water and suction apparatus nearby
• Prevent pressure and trauma to the tracheobronchial tree. If a cuffed tube is being used, see that the cuff is deflated, as ordered, to relieve pressure periodically on the tracheal wall
• Periodically inspect the tracheostomy for trauma or infection
• Ensure use of a fresh tracheostomy tube as needed. Clean the inner cannula of mucus and encrustations as indicated. The inner tube is changed by nurses and outer tube by doctors
• Change the dressings and tracheostomy tube as necessary
• Provide appropriate skin care. Keep skin clean and dry
• Provide adequate nourishment
• Provide frequent mouth care to minimize possible infection. Plenty of water should be given orally
• Administer medications as ordered. Narcotics and sedatives are usually avoided. To minimize apprehension, only mild tranquilizers are given
• For long-term cases, the patient and his relatives are taught how to take care of the tube
• Alleviate the patient’s apprehension by closely observing him, providing care in a calm but efficient manner and helping him communicate by providing a call bell

The suction procedure is as follows:

• Auscultate the chest before and after suctioning
• Wash hands and use sterile gloves
• Place a sterile towel across the patient’s chest just below the tracheostomy tube
• Clean the skin around the tube and the adaptors with a recommended antiseptic
• Select the catheter, attach it to the suction apparatus and lubricate it with sterile normal saline, gently insert into the tracheostomy tube and do the suctioning. It should not be continued more than 5 seconds at a time
• After suctioning, discard the catheter and gloves and also the saline. Note the amount and the character of the secretions aspirated
• Wash hands after completion of the procedure

Cleansing the Inner Cannula

It is changed every 2 to 4 hour, but in some cases, only twice. It can be cleaned with cold water and soap and also with hydrogen peroxide solution. After cleaning, it can be sterilized and can be used again. Do not leave the inner cannula out for longer than 5 to 10 m while removing or cleaning it

If left out for longer periods, secretions and crust begin to form in the outer cannula, making it difficult to reinsert the inner cannula

The following conditions should be reported to the doctor if they occur during the postoperative period:

• Tube displacement
• Indications of shock, hemorrhage, respiratory insufficiency and hypoxia
• Respiratory obstruction
• Excessive restlessness or apprehension
• Cyanosis, in case of cyanosis, oxygen should be given
• Rhinorrhea
• Development of tracheoesophageal fistula