RESPIRATORY ASSESSMENT

EXAMINATION

AND

A. Abnormal patterns of breathing 1. Sleep Apnea - Cessation of airflow for more than 10 seconds more than 10 times a night during sleep Causes: obstructive (e.g. obesity with upper narrowing, enlarged tonsils, pharyngeal soft tissue changes in acromegaly or hypothyroidism) 2. Cheyne-Stokes - Periods of apnea alternating with periods of hyperpnoea pathophysiology: delay in medullary chemoreceptor response to blood gas changes Causes brain damage hemorrhage) (e.g. trauma, cerebral,

2. Central cyanosis = abnromal amout of deoxygenated haemoglobin in arteries and that blue discoloration is present in parts of body with good circulation such as tongue 3. Peripheral cyanosis = occurs when blood supply to a certain part of body is reduced, and the tissue extracts more oxygen from normal from the circulating blood, e.g. lips in cold weather are often blue, but lips are spared 4. Causes of cyanosis Central cyanosis high altitude massive pulmonary embolism hunt (cyanotic congenital heart disease) methaemoglobinaemia, sulphaemoglobinaemia Peripheral cyanosis

3. Kussmaul's (air hunger) - deep rapid respiration due to stimulation of respiratory centre Causes: metabolic acidosis mellitus, chronic renal failure) 4. Hyperventilation complications: alkalosis and tetany causes: anxiety 5. Ataxic (Biot) irregular in timing and deep causes: brainstem damage 6. Apneustic post-inspiratory pause in breathing causes: brain (pontine) damage 7. Paradoxical the abdomen sucks with respiration (normally, it pouches uotward due to diaphragmatic descent) causes: diaphragmatic paralysis B. Cyanosis 1. Refers to blue discoloration of skin and mucous membranes, is due to presence of deoxygenated hemoglobin in superficial blood vessels (e.g. diabetes

cyanosis c output: left ventricular failure or shock Position: patient sitting over edge of bed General appearance Dyspnea normal respiratory rate < 14 each minute tachypnea = rapid respiratory rate are accessory muscles being used (sternomastoids, platysma, strap muscles of neck) - characteristically, the accessory muscles cause elevation of shoulders with inspiration and aid respiration by increasing chest expansion Cyanosis Character of cough ask patient to cough several times lack of usual explosive beginning may indicate vocal cord paralysis (bovine cough) muffled, wheezy ineffective cough suggests airflow limitation Very loose productive cough suggests excessive bronchial secretions due to: - Chronic bronchitis

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- Pneumonia - Bronchiectasis Dry irritating cough may occur with: - Chest infection - Asthma - Carcinoma of bronchus - left ventricular failure - Interstitial lung disease - ACE inhibitors Sputum Volume

Clubbing Commonly cause by respiratory disease (but NOT emphysema or chronic bronchitis) Occasionally, clubbing is associated with hypertrophic pulmonary osteoarthropathy (HPO) characterized by periosteal inflammation at distal ends of long bones, wrists, ankles, metacarpals and metatarsals Swelling and tenderness over wrists and other involved areas Staining

Type (purulent, mucous, mucopurulent) Presence or absence of blood? Stridor Croaking noise loudest on inspiration Is a sign that requires urgent attention? Causes: (obstruction of larynx, trachea or large bronchus) - Acute onset (minutes) Staining of fingers - sign of cigarette smoking (caused by tar, not nicotine) Wasting and weakness Pulse rate Flapping tremor (asterixis) - unreliable sign Ask patient to dorsiflex wrists and spread out fingers, with arms outstretched Flapping tremor may occur with severe carbon dioxide retention (severe chronic airflow limitation)

Acute epiglottitis Anaphylaxis Toxic gas inhalation - Gradual onset (days, weeks) Laryngeal and pharyngeal tumors -arytenoid rheumatoid arthritis Bilateral vocal cord palsy Tracheal carcinoma Paratracheal compression by lymph nodes -tracheostomy or intubation granulomata Hoarseness Causes include: - Laryngitis - Laryngeal nerve carcinoma of lung - Laryngeal carcinoma The Hands palsy associated with

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The Face Eyes Horner's syndrome? (Constricted pupil, partial ptosis and loss of sweating which can be due to apical lung tumor compressing sympathetic nerves in neck) Nose Polyps? (Associated with asthma) Engorged turbinates? conditions) (Various allergic

causes: hyperinflation due to asthma, emphysema Pigeon chest (pectus carinatum) localized prominence (outward bowing of sternum and costal cartilages) causes: manifestation of chronic childhood illness (due to repeated strong contractions of diaphragm while thorax is still pliable) rickets

Deviated septum? (Nasal obstruction) Mouth and tongue Look for central cyanosis Evidence of upper respiratory tract infection (a reddened pharynx and tonsillar enlargement with or without a coating of pus) Broken tooth - may predispose to lung abscess or pneumonia Sinusitis is indicated by tenderness over the sinuses on palpation Some patients with obstructive sleep apnea will be obese with a receding chin, a small pharynx and a short thick neck The Trachea Kyphosis, exaggerated forward curvature of spine toward the side of the lung lesion Scoliosis, lateral bowing Kyphoscoliosis: causes: Funnel chest (pectus excavatum) localized depression of lower end of sternum in severe cases, lung capacity may be restricted Harrison's sulcus inner depression of lower ribs just above costal margins at site of attachment of diaphragm causes: severe asthma in childhood rickets

involving grey matter of cord) upper mediastinal masses, such as retrosternal goiter s it move inferiorly with each inspiration) is a sign of gross overexpansion of the chest because of airflow obstruction The Chest: inspection Shape and symmetry of chest Barrel shaped compared with lateral diameter rformed to remove TB, but no longer is because of effective ant tuberculosis chemotherapy) involved removal of large number of ribs on one side to achieve permanent collapse of affected lung reduce lung capacity and increase work of breathing) Lesions of chest wall - previous thoracic operations or chest drains for a previous pneumothorax or pleural effusion

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radiotherapy; there is a sharp demarcation between abnormal and normal skin Diffuse swelling of chest wall and neck

causes: pneumothorax rupture of esophagus Prominent veins cause: superior vena cava obstruction Asymmetry of chest wall movements looking down the clavicles during moderate respiration - diminished movement indicates underlying lung disease show delayed or decreased movement causes of reduced chest wall movements on one side are localized: localized pulmonary fibrosis consolidation collapse pleural effusion pneumothroax causes of bilateral movements are diffuse: reduced chest wall

diffuse pulmonary fibrosis

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The Chest: palpation chest expansion place hands firmly on chest wall with fingers extending around sides of chest (fugyre 4.5) as patient takes a big breath in, the thumbs should move symmetrically apart about 5 cm reduced expansion on one side indicates a lesion on that side note: lower lobe expansion is tested here; upper lobe is tested for on inspection (as above) apex beat (discussed in cardiac section) for respiratory diseases: - can be caused by: collapse of lower lobe localized pulmonary fibrosis - can be caused by: pleural effusion tension pneumothorax

finger is pressed firmly against the chest; pad of right middle finger is used to strike firmly the middle phalanx of middle finger of left hand percussion of symmetrical areas of:

posterior (back) (ask patient to move elbows forward across the front of chest - this rotates the scapulae anteriorly, i.e. moves it out of the way)

percussion over a solid structure (e.g. liver, consolidated lung) produces a dull note percussion over a fluid filled area (e.g. pleural effusion) produces an extremely dull (stony dull) note percussion over the normal lung produces a resonant note percussion over a hollow structure (e.g. bowel, pneumothorax) produces a hyperresonsant note liver dullness: percussing down the anterior chest in midclavicular line llness is 6th rib in right mid-clavicular line

is hyper expanded secondary to chronic airflow limitation vocal fremitus palpate chest wall with palm of hand while patient repeats "99" front and back of chest are each palpated in 2 comparable positions with palms; in this way differences in vibration on chest wall can be detected causes of change in vocal fremitus are the same as those for vocal resonance (see later) ribs gently compress chest wall anteroposteriorly and laterally localized pain suggests a rib fracture (may be secondary to trauma or spontaneous as a result of tumor deposition or bone disease) The Chest: percussion with left hand on chest wall and fingers slightly separated and aligned with ribs, the middle sign of hyperinflation emphysema, asthma cardiac dullness: usually present on left side of chest decrease in emphysema or asthma The Chest: auscultation breath sounds introduction one should use the diaphragm of stethoscope to listen to breath sound in each area, comparing each side remember to listen high up into the axillae remember to use bell of stethoscope to listen to lung from above the clavicles quality of breath sounds usually due to

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normal breath sounds chest, produced in airways rather than alveoli (although once they had been thought to arise from alveoli (vesicles) and are therefore called vesicular sounds) and longer on inspiration than on expiration; and there is no gap between the inspiratory and expiratory sounds bronchial breath sounds being filtered by the alveoli, and therefore produce a different quality; they are heard over the trachea normally, but not over the lungs there is a gap between inspiration and expiration solid lung conducts the sound of turbulence in main airways to peripheral areas without filtering

wheezes both - airway narrowing narrowing - asthma (often high pitched) - due to muscle spasm, mucosal edema, excessive secretions - chronic airflow diseases - due to mucosal edema and excessive secretions - carcinoma causing bronchial obstruction tends to cause a localized wheeze which is monophonic and does not clear with coughing crackles pitched crackles) and creptitations (high pitched crackles) airways on expiration and sudden opening on inspiration

- lung consolidation (lobar pneumonia) common - localized pulmonary fibrosis - uncommon - pleural effusion (above the fluid) - uncommon - collapsed lung (e.g. adjacent to a pleural effusion) - uncommon large cavity have an exaggerated bronchial quality)

- suggests disease of small airways - characteristic of chronic airflow limitation - are only heard in early inspiration

- suggests disease confined to alveoli intensity of breath sounds - may be fine, medium or coarse causes of reduced breath sounds include: - fine crackles - typically caused by pulmonary fibrosis emphysema) - medium crackles - typically caused by left ventricular failure (due to presence of alveolar fluid) orax - coarse crackles - tend to change with coughing; occur with any disease that leads to retention of secretions; commonly occur in bronchiectasis pleural friction rub added (adventitious) sounds two types of added sounds: continuous (wheezes) and interrupted (crackles) surfaces rub together, a continuous or intermittent grating sound may be heard

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secondary to pneumonia

pulmonary

infarction

or pulmonale)

edema or cyanosis (clues of cor thrombosis

vocal resonanance Respiratory rate on exercise and positioning gives information about lungs' ability to transmit sounds consolidated lung tends to transmit high frequencies so that speech heard through stethoscope takes a bleeting quality (aegophony); when a patient with aegophony says "bee" it sounds like "bay" listen over each part of chest as patient says "99"; over consolidated lung, the numbers will become clearly audible; over normal lung, the sound is muffled whispering pectoriloquy - vocal resonance is increased to such an extent that whispered speech is distinctly heard The Heart lay patient at 45 degrees measure jugular venous pulse for right heart failure examine pericardium; pay close attention to pulmonary component of P2 (which is best heard at 2nd intercostals space on left) and should not be louder than A2; if it is louder, suspect pulmonary hypertension cor pulmonale (also called pulmonary hypertensive heart disease) may be due to: chronic airflow limitation (emphysema) pulmonary fibrosis pulmonary thromboembolism marked obesity sleep apnea severe kyphoscoliosis The Abdomen palpate liver for enlargement due to secondary deposits of tumor from lung, or right heart failure Other Permberton's sign infected or has been exposed to the TB bacillus. PPD (Purified Protein Derivatives). intradermally usually in the inner aspect of the lower forearm about 4 inches below the elbow. 48 to 72 hours after injection. (+) Mantoux Test is induration of 10 mm or more. about 5 mm is considered positive exposure Tubercle bacilli to Mycobacterium dyspnea should have their respiratory rate measured at rest, at maximal tolerated exertion and supine dyspnea is not accompanied by tachypnea when a patient climbs stairs, one should consider malingering abdomen during inspiration when patient is supine (indicating diaphragmatic paralysis) Temperature: fever may accompany any acute or chronic chest infection DIAGNOSTIC EVALUATION 1. Skin Test: Mantoux Test or Tuberculin Skin Test

inspiratory stridor, and non-pulsatile elevation of jugular venous pressure cava obstruction Feet

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2. Pulse Oximeter chest in motion -invasive method of continuously monitoring the oxygen saturation of hemoglobin forehead, earlobe or bridge of the nose 2 sat levels by monitoring light signals generated by the oximeter and reflected by the blood pulsing through the tissue at the probe - 100% - tissues are not receiving enough O2 radiopaque medium is instilled directly into the trachea and the bronchi and the outline of the entire bronchial tree or selected areas may be visualized through x-ray. anomalies of the bronchial tree and is important in the diagnosis of bronchiectasis. Nursing interventions BEFORE Bronchogram vasoconstrictors sea foods or iodine or anesthesia monoxide Level 3. Chest X-ray -invasive procedure involving the use of x-rays with minimal radiation. on cue to hold his breath and to do deep breathing Nursing interventions AFTER Bronchogram remove metals from the chest. out pregnancy first. 5. Computed Tomography (CT Scan) and Magnetic Resonance Imaging (MRI) CT scan is a radiographic procedure that utilizes x-ray machine. MRI uses magnetic field to record the H+ density of the tissue. It does NOT involve the use of radiation. The contraindications for this procedure are the following: patients with implanted pacemaker, patients with metallic hip prosthesis or other metal implants in the body. This chest CT scan shows a cross-section of a person with bronchial cancer. The two dark areas are the lungs. The light areas within the lungs represent the cancer. Clear MRI images of lung airways during breathing. 6. Fluoroscopy client 8. Bronchoscopy direct inspection and observation of the larynx, trachea and bronchi through a flexible or rigid bronchoscope. lighted bronchoscope into the bronchial tree for direct visualization of the trachea and the tracheobronchial tree. -lying position -op meds: atropine SO4 and valium, topical anesthesia sprayed; followed by local anesthetic injected into larynx. The nurse must have oxygen and anti spasmodic agents ready. continuous observation of an image reflected on a screen when exposed to radiation in the manner of television screen that is activated by an electrode beam. the X-ray beam are visualized on the screen in silhouette 7. Indirect Bronchography

and collect specimen for biopsy

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indicate perforation of bronchial tree. Refer the patient immediately! 9. Lung Scan surgically a radioisotope, scans is taken with a scintillation camera. tracheobronchial tree distribution and blood flow in the lungs. (Measure blood perfusion) Confirm pulmonary embolism or other blood- flow abnormalities obstructing the tracheobronchial tree procedure: -operative atelectasis procedure Bronchoscopy

re to the patient, tell him what to expect, to help him cope with the unknown Atropine (to diminish secretions) is administered one hour before the procedure 10. Sputum Examination Valium is given to sedate patient and allay anxiety. Topical anesthesia is sprayed followed by local anesthesia injected into the larynx NPO for 6-8 hours lenses supine with hyperextended neck during the procedure Early morning sputum specimen is to be collected (suctioning or expectoration) plain water sterile container. Bronchoscopy before Side lying position with. cough and gag reflex. lung tissue cyanosis, hypotension, tachycardia, arrhythmias, hemoptysis, and dyspnea. These signs and symptoms the first dose of anti-microbial therapy. for three consecutive mornings. 11. Biopsy of the Lungs sputum: Gross appearance, Sputum C&S, AFB staining, and for Cytological examination/ Papanicolaou examination ed.

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- Transbronchoscopic biopsydone during bronchoscopy, - Percutaneous needle biopsy - Open lung biopsy procedure:

Residual volume (1200 mL) ains in the lungs after forceful exhalation LUNG CAPACITIES: Functional Residual Capacity (ERV 1100 mL + RV 1200 mL = 2300 mL ) after normal, quiet exhalation

the patients chart.

Inspiratory Capacity (TV 500 mL + IRV 3000 mL = 3500 mL) maximally after a normal expiration

Pneumothorax and air embolism hemoptysis and hemorrhage

Vital capacity (IRV 3000 mL + TV 500 mL + ERV 1100 mL = 4600 mL) exhaled after a maximum inhalation

Total Lung Capacity (IRV 3000 mL + TV 500 mL + ERV 1100 mL + RV 1200 mL = 5800 mL ) 12. Lymph Node Biopsy 14. Arterial Blood Gas

13. Pulmonary Function Test / Studies -invasive test diffusing capacity able to reabsorb or excrete bicarbonate. chodilators or narcotics used before testing rformed on areas where good pulses are palpable (radial, brachial, or femoral). Radial artery is the most common site for withdrawal of blood specimen arterial blood for tissue oxygenation, ventilation, and acid-base status re able to provide adequate oxygen and remove CO2

LUNG VOLUMES: (ITER) reserve volume (3000 mL) following a normal quiet inhalation. Tidal volume (500 mL) normal quiet breathing

Inspiratory

10-ml. Pre-heparinized syringe to prevent clotting of specimen container with ice to prevent hemolysis Allens test to assess for adequacy of collateral circulation of the hand (the ulnar arteries) 15. Pulmonary Angiography

Expiratory reserve volume (1100 mL) following the normal quiet exhalation

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-ray pictures of the pulmonary blood vessels (those in the lungs). seen in an X-ray, a contrast material is injected into one or more arteries or veins so that they can be seen.

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16. Ventilation - Perfusion Scan nuclear scan test that is performed to measure the supply of blood through the lungs. detect the location of the radioactive particles as blood flows through the lungs. ability of air to reach all portions of the lungs. The perfusion scan measures the supply of blood through the lungs. performed to detect a pulmonary embolus. It is also used to evaluate lung function in people with advanced pulmonary disease such as COPD and to detect the presence of shunts (abnormal circulation) in the pulmonary blood vessels. 17. Thoracentesis ocedure suing needle aspiration of intrapleural fluid or air under local anesthesia

unaffected side to prevent leakage of fluid in the thoracic cavity

RESPIRATORY CARE MODALITIES 1. Oxygen Therapy dry gas that supports combustion 21% oxygen from the environment in order to survive Hypoxemia

o Increased pulse rate fluid o Rapid, shallow respiration and dyspnea o Increased restlessness or lightheadedness o Flaring of nares o Substernal or intercostals retractions o Cyanosis insertion of the needle pressure sensation will be felt on insertion of needle Low flow oxygen provides partial oxygenation with patient breathing a combination of supplemental oxygen and room air. Low-flow administration devices: o Nasal Cannula 24-45% 2-6 LPM o Simple Face Mask 0-60% 5-8 LPM roper position: Upright or sitting on the edge of the bed Lying partially on the side, partially on the back o Partial Rebreathing Mask 60-90% 6-10 LPM o Non-rebreathing Mask 95-100% 6-15 LPM o Croupette o Oxygen Tent High flow oxygen provides all necessary oxygenation, with patients breathing only oxygen supplied from the mask and exhaling through a one-way vent. High flow administration devices the patient on the affected side, as ordered, for at least 1 hour to seal the puncture site o Venturi Mask 24-40% 4-10 LPM provides accurate amount of oxygen.

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o Face Mask o Oxygen Hood* o Incubator / isolette* Note: * can be used for both low and high flow administration checking nares, nose and applying gauze or cotton as necessary COPD patients receive only LOW flow oxygen because these persons respond to hypoxia, not increased CO levels.

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2. Tracheobronchial suctioning towel to prevent burns due to dripping of condensate from the steam. Assess for redness on the side of the face which indicates first degree burns. semi or high Fowlers position sterile gloves, sterile suction catheter Hyperventilate client with 100% oxygen before and after suctioning -5 length of catheter insertion) without applying suction. Three passes of the catheter is the maximum, with 10 seconds per pass. during withdrawal of catheter bronchodilators or mucolytic-expectorants. than 120 mmHg rotate while applying intermittent suction take only 10 seconds (maximum of 15 seconds) of the chest. 3. Bronchial Hygiene Measures . c. Medimist inhalation minister bronchodilators or mucolytic-expectorants. 4. Chest Physiotherapy (CPT) and vibration, and breathing retraining. Effective coughing is also an important component. l secretions, improved ventilation, and increased efficiency of respiratory muscles. use gravity to assist in the removal of secretions. a. Steam inhalation follows: - to liquefy mucous secretions - to warm and humidify air - to relieve edema of airways - to soothe irritated airways - to administer medication dependent nursing function t and explain the purpose of the procedure -Fowlers position prevent irritation secretions. promote flow of drainage from different lung segments using gravity. lung segments to promote drainage. surface. 12 18 inches away from the clients nose or adjust distance as necessary minutes depending on tolerability. Percussion -15 percussion or vibration. eathing exercises and breathing retraining improve ventilation and control of breathing and decrease the work of breathing. respiratory disorders like COPD, cystic fibrosis, lung abscess, and pneumonia. The therapy is based on the fact that mucus can be knocked or shaken from airways and helped to drain from the lungs. Postural drainage and coughing exercises after the procedure to facilitate expectoration of mucous secretions. procedure. -care of equipment. b. Aerosol inhalation therapy for 15 20 minutes

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through the chest wall to the bronchi. hands over the areas were secretions are located. ne, kidneys, breast or incision and broken ribs. Areas should be percussed for 1-2 minutes Vibration are placed on clients chest and gently but firmly rapidly vibrate hands against thoracic wall especially during clients exhalation. stimulate cough. -7 times during patient exhalation. Medical and Surgical Nursing Respiratory System Lecture Notes Prepared by: Mark Fredderick R. Abejo RN,, MAN MS Abejo 13

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Suctioning Nursing Interventions in CPT chest wall at the level of 2nd to 3rd intercostals space to release air or in the fourth intercostals space to remove fluid. Types of Bottle Drainage secretions. secretions by gravity -3 cm of sterile -10 to 15 minutes mucus secretions hypotension expectorate sputum est done 60 to 90 minutes before meals or in the morning upon awakening and at bedtime. tube. The fluctuation synchronizes with the respiration. continues bubbling means presence of air-leak 5. Incentive Spirometry Types: volume and flow Device ensures that a volume of air is inhaled and the patient takes deep breaths. Used to prevent or treat atelectasis To enhance deep inhalation Nursing care Positioning of patient, teach and encourage use, set realistic goals for the patient, and record the results. 6. Closed Chest Drainage (Thoracostomy Tube) drainage bottle; the mediastinum or pleural space into a collection chamber to help re-establish normal negative pressure for lung re-expansion. Purposes ural space expand the lungs 2. The second bottle is suction control bottle. Procedure 1. The first bottle is the drainage and water-seal bottle; water-seal bottle (water-seal bottle or the second bottle) and intermittent bubbling with each respiration. NOTE! IF connected to suction apparatus allows the nurse to milk the tube) expansion; (validated by chest x-ray) In the absence of fluctuation: Suspect obstruction of the device -3 feet below the level of the chest to allow drainage from the pleura by gravity. heart to prevent reflux of air or fluid. NSS to create water-seal. One-bottle system -seal

Two-bottle system

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3. Expect continuous bubbling in the suction control bottle; 4. Intermittent bubbling and fluctuation in the water-seal 5. Immerse tip of the tube in the first bottle in 2 to 3 cm of sterile NSS 6. Immerse the tube of the suction control bottle in 10 to 20 cm of sterile NSS to stabilize the normal negative pressure in the lungs. 7. This protects the pleura from trauma if the suction pressure is inadvertently increased

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Three-bottle system is the drainage bottle; water seal bottle suction control bottle. intermittent bubbling and fluctuation with respiration in the water- seal bottle GENTLE bubbling in the suction control bottle. These are the expected observations. continuous bubbling in the WATER seal bottle or if there is VIGOROUS bubbling in the suction control bottle. t the observation at once. Never clamp the tubing unnecessarily. If there is NO fluctuation in the water seal bottle, it may mean TWO things lungs have expanded or the system is NOT functioning appropriately. se refers the observation to the physician, who will order for an X-ray to confirm the suspicion. Important Nursing considerations drainage:

bubbling in the water seal bottle stops, the leak is likely in the lungs, bubbling continues, the leak is between the clamp and the bottle chamber. Next, the nurse moves the clamp towards the bottle checking the bubbling in the water seal bottle. clamp and the distal part including the bottle. tent bubbling, it means that the drainage unit is leaking and the nurse must obtain another set. the nurse temporarily kinks the tube and must obtain a receptacle or container with sterile water and immerse the tubing. as replacement. She should NEVER CLAMP the tube for a longer time to avoid tension pneumothorax. out, the nurse obtains vaselinized gauze and covers the stoma.

Removal of chest tubedone by physician

Petrolatum Gauze Suture removal kit Sterile gauze Adhesive tape -Fowlers position and do valsalva maneuver as the chest tube is removed. -ray may be done after the chest tube is removed emphysema; respiratory distress

ar basis

intervals tube to prevent tension pneumothorax What the nurse should do if: continuous bubbling: 7. Artificial Airway a. Oral airways- these are shorter and often have a larger lumen. They are used to prevent the tongue form falling backward. b. Nasal airways- these are longer and have smaller lumen Which causes greater airway resistance c. Tracheostomy- this is a temporary or permanent surgical opening in the trachea. A tube is inserted to allow ventilation and removal of secretions. It is indicated for emergency airway access for many conditions. The nurse must maintain tracheostomy care properly to prevent infection.

the chest for a few seconds.

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