What are safe medications to loosen secretions in a child with a tracheostomy (trach)?

From the Guidelines

For children with a tracheostomy, normal saline (0.9% sodium chloride) is the first-line option to loosen secretions, typically administered as 1-3 ml nebulized treatments or direct instillation into the trach 3-4 times daily or as needed. This recommendation is based on the principle of adding moisture to thin secretions, which is a crucial aspect of secretion management in children with a tracheostomy 1. Other options for loosening secretions include sterile water, which can be used similarly to normal saline. For thicker secretions, mucolytics like acetylcysteine (Mucomyst) may be prescribed at 3-5 ml of a 10-20% solution via nebulizer 3-4 times daily. Dornase alfa (Pulmozyme) is effective for very thick secretions, especially in children with cystic fibrosis, used as 2.5 mg nebulized once or twice daily. Hypertonic saline (3-7%) can be used as 3-4 ml nebulized treatments 2-4 times daily but may cause airway irritation in some children.

Some key points to consider when managing secretions in children with a tracheostomy include:

• Adequate hydration and humidification of the tracheostomy are essential components of secretion management
• The use of premarked catheters and twirling the catheter between fingertips during suctioning can help prevent trauma to the tracheal mucosa 1
• Regular daily cleansing of the peristomal area and neck skin is necessary to prevent infection and pressure necrosis
• The routine use of ointments and creams should be avoided, and petroleum-based products are contraindicated 1

It is essential to follow the healthcare provider's specific instructions, as dosing may vary based on the child's age, weight, and condition. Additionally, caregivers should be aware of the importance of suctioning, skin care, and safety measures to prevent complications and ensure the best possible outcomes for children with a tracheostomy 1.

From the FDA Drug Label

Acetylcysteine is indicated as adjuvant therapy for patients with abnormal, viscid, or inspissated mucous secretions in such conditions as: ... Tracheostomy care When used for the routine nursing care of patients with tracheostomy, 1 to 2 mL of a 10% to 20% solution may be given every 1 to 4 hours by instillation into the tracheostomy

Pediatric safe drugs to loosen secretions in a kid with a trach:

• Acetylcysteine (INH) is a safe medication to loosen secretions in a child with a tracheostomy, and can be administered directly into the tracheostomy 2.
• The recommended dose for tracheostomy care is 1 to 2 mL of a 10% to 20% solution every 1 to 4 hours by instillation into the tracheostomy 2.
• Acetylcysteine is indicated for tracheostomy care as an adjuvant therapy for patients with abnormal, viscid, or inspissated mucous secretions 2.

From the Research

Pediatric Safe Drugs to Loosen Secretions in a Kid with a Trach

• Acetylcysteine is a mucolytic agent that has been shown to reduce sputum viscosity, making expectoration easier and improving oxygenation in patients with retained secretions following thoracotomy 3.
• Dornase alfa (Pulmozyme®) is an inhaled mucus-active drug that decreases viscoelasticity of sputum, improves lung function, and reduces respiratory exacerbations in cystic fibrosis patients, including those as young as 5 years old 4.
• There is limited information available on pediatric-specific medications for loosening secretions in children with a tracheostomy, and most established standards and procedures have been developed through trial and error rather than controlled studies 5.

Suctioning and Secretion Management

• Artificial airway suctioning is a key component of airway management, and clinicians should be familiar with the most effective and efficient methods to perform the procedure 6.
• Indicators for suctioning in pediatric patients include breath sounds, visual secretions in the artificial airway, and a sawtooth pattern on the ventilator waveform 6.
• As-needed suctioning is sufficient for neonatal and pediatric patients, rather than scheduled suctioning 6.
• The use of normal saline solution should generally be avoided during suctioning, and suction catheters should occlude less than 70% of the endotracheal tube lumen in neonates and less than 50% in pediatric and adult patients 6.

Tracheostomy Care and Complications

• Effective mobilization of secretions is crucial in tracheostomy care, and a suction catheter is the most important tool for this purpose 7.
• Complications of tracheostomy care include infection, tracheomalacia, skin breakdown, and tracheoesophageal fistula, and tracheostomy emergencies such as hemorrhage, tube dislodgement, and tube obstruction require prompt management 7.