What treatment is recommended for vomiting caused by tracheostomy-related throat pain and coughing?

Management of Vomiting Due to Tracheostomy-Related Throat Pain and Coughing

For vomiting caused by tracheostomy-related throat pain and coughing, a combination of antiemetic medication and pain management is recommended, with dopamine receptor antagonists such as metoclopramide being the first-line treatment option.

Antiemetic Management

• Dopamine receptor antagonists are the first-line treatment for tracheostomy-related vomiting, with metoclopramide being particularly effective for delayed gastric emptying that may occur with tracheostomy patients 1
• For persistent nausea and vomiting, consider adding 5-HT3 receptor antagonists (such as ondansetron) which can be administered in sublingual form if the patient is actively vomiting 1
• Promethazine may be particularly useful as it provides both antiemetic effects and sedation, which can help reduce coughing-induced vomiting 1
• For severe cases, consider a combination of medications rather than monotherapy, as this approach is more effective for breakthrough emesis 1

Pain Management Considerations

• Adequate pain control is essential as throat pain from the tracheostomy can trigger coughing and subsequent vomiting 1
• Local medications may be administered through the tracheostomy for pain relief, but should be limited to approved inhaled medications to avoid potential systemic side effects 1
• When administering medications via the tracheostomy, be aware that absorption through the airway is not subject to first-pass metabolism, potentially increasing systemic side effects 1

Positioning and Prevention

• Keep the patient propped up at least 30° during and for 30 minutes after feeding to minimize risk of reflux and aspiration 1
• Consider using promotility drugs such as metoclopramide to reduce gastric pooling and delayed gastric emptying 1
• For patients receiving enteral feeding, use iso-osmotic feeds rather than high osmotic feeds to reduce delayed gastric emptying 1

Special Considerations for Tracheostomy Patients

• Ensure the tracheostomy tube is properly positioned and not causing excessive irritation that could trigger coughing and vomiting 2
• Maintain proper tracheostomy care to prevent infection, which can exacerbate throat pain and coughing 2
• For patients with persistent vomiting, assess for potential tracheostomy complications such as tracheoesophageal fistula, which can cause recurrent aspiration and vomiting 3

Management Algorithm

1. First-line treatment: Metoclopramide for its dual antiemetic and promotility effects 1
2. If vomiting persists:
   • Add ondansetron (available in sublingual form) 1
   • Consider promethazine for added sedation effect 1
3. For refractory cases:
   • Use multiple concurrent agents in alternating schedules or routes 1
   • Consider haloperidol or corticosteroids as additional options 1
   • Ensure adequate hydration and electrolyte balance 1

Common Pitfalls and Caveats

• Avoid administering non-approved medications through the tracheostomy as their distribution, deposition, and systemic absorption are unknown and may lead to toxicity 1
• Be cautious with sedating antiemetics in patients with respiratory compromise, as they may further depress respiratory drive 1
• When using antiemetics, administer on a routine around-the-clock schedule rather than PRN dosing for better control of symptoms 1
• For patients with active vomiting, oral administration may not be feasible; consider rectal or IV therapy instead 1
• Always check for and correct any electrolyte abnormalities that may be contributing to or resulting from vomiting 1

By addressing both the vomiting and the underlying causes of throat pain and coughing, most tracheostomy patients can achieve significant symptom relief and improved quality of life.