Management of Tracheostomy-Related Throat Pain and Coughing
The most effective approach to managing tracheostomy-related throat pain and coughing includes proper humidification with Heat Moisture Exchangers (HMEs), closed-circuit suctioning, and avoiding saline instillation before suctioning. 1, 2
Initial Assessment and Management
- Remove any attachments to the tracheostomy tube that could be causing obstruction, such as speaking valves, caps, or humidifying devices that may have become blocked with secretions 1
- Inspect and if necessary, remove and clean the inner cannula to prevent tube occlusion from secretions 1
- Use closed-circuit suctioning with an inline suction catheter to manage secretions while minimizing the risk of aerosolization 1
- Avoid instillation of saline before suctioning as it increases the risk of coughing and provides little benefit while potentially increasing aerosolization 1, 2
Humidification Management
- Use Heat Moisture Exchangers (HMEs) with viral filters rather than heated humidification (HH) or nebulized treatments to reduce coughing and secretion buildup 1
- For patients with thick secretions, consider HMEs with viral filters that have filtration efficiency >99.9% and bidirectional design 1
- Inspect HME filters daily and whenever there is deterioration in ventilation 1
- If secretions become thicker over time, consider transitioning to active, water-based humidification, though this increases the risk of aerosolization 1, 3
Pain Management
- Consider spraying the airways with 4% lidocaine before tube changes or procedures to decrease coughing, being mindful of proper dosing especially in pediatric populations 1
- For patients on antiplatelet therapy, avoid medications with sedative properties that could compromise respiratory function 2
- Maintain proper cuff inflation (20-30 cmH2O for air-filled cuffs) to ensure integrity of the ventilation system while preventing tracheal injury 1, 2
Advanced Interventions for Persistent Symptoms
- For patients with neuromuscular disease and ineffective cough, mechanical insufflation and exsufflation should be used in addition to standard physiotherapy techniques 1
- Consider mini-tracheostomy to facilitate secretion clearance in patients with weak cough or excessive secretions 1
- For patients being weaned from ventilation with persistent cough, high-flow therapy via the tracheostomy tube with an in-line one-way valve (HFT-T-OWV) may provide humidification while allowing speech 3
Equipment and Supplies
Ensure the following equipment is readily available at the bedside:
- Humidification equipment 1
- Suction with appropriate suction catheters 1, 4
- Spare tracheostomy tubes (one the same size and one smaller) 1
- Clean pot for spare inner cannula 1
- Sterile water for cleaning 1
- Water-soluble lubricating jelly 1
- Tracheostomy dressings and tapes 1
- Personal protective equipment (gloves, aprons, eye protection) 1
Preventing Complications
- Perform regular assessment to identify potential complications early 1
- Avoid overtightening of masks if using NIV in conjunction with tracheostomy 1
- Monitor for signs of infection, tracheomalacia, skin breakdown, and tracheoesophageal fistula 4
- Be prepared for emergencies such as hemorrhage, tube dislodgement, or tube obstruction by having all necessary supplies readily available 4
Special Considerations
- For patients on dual antiplatelet therapy following percutaneous coronary intervention, continue standard antiplatelet therapy to prevent thrombotic events 2
- Early tracheostomy (≤14 days after intubation) may be associated with decreased ventilator days and improved outcomes 5
- Percutaneous tracheostomy techniques may be associated with faster weaning and decreased ventilator-associated pneumonia compared to surgical techniques 5
By following these guidelines, healthcare providers can effectively manage tracheostomy-related throat pain and coughing while minimizing complications and improving patient comfort.