What is the treatment for severe mucous plugging?

From the Guidelines

Severe mucous plugging is best treated with a combination of airway clearance techniques and medications, starting with nebulised isotonic or hypertonic saline to loosen mucus, followed by bronchodilators and mucoactive treatment, as recommended by the British Thoracic Society guideline for bronchiectasis in adults 1. To manage severe mucous plugging, it is essential to follow a stepwise approach to airway clearance.

• First, evaluate the effectiveness of nebulised isotonic (0.9% saline) or hypertonic saline (3% saline and above) pre-airway clearance, especially in patients with viscous secretions or evidence of sputum plugging 1.
• Individuals should be advised to complete airway clearance in the following order, if prescribed:
  • Bronchodilator
  • Mucoactive treatment
  • Airway clearance
  • Nebulised antibiotic and/or inhaled steroids (if applicable) 1.
• Airway clearance techniques such as active cycle of breathing techniques (ACBT) and physiotherapy management, including stepwise airway clearance, can be beneficial in managing severe mucous plugging 1.
• While nonpharmacologic airway clearance therapies, such as postural drainage, percussion, and vibration, may provide some benefits, their additional value is questionable, and their effect on long-term outcomes is not well established 2.
• Medications, including mucolytics and bronchodilators, can help break down thick mucus and open airways, making it easier to clear mucus 1.
• In severe cases, direct bronchoscopic suctioning may be necessary to physically remove mucus plugs.
• It is crucial to prioritize the patient's morbidity, mortality, and quality of life when managing severe mucous plugging, and to promptly treat the condition to prevent complications such as atelectasis, respiratory distress, and infection.

From the FDA Drug Label

Acetylcysteine solution, USP is indicated as adjuvant therapy for patients with abnormal, viscid, or inspissated mucous secretions in such conditions as: Chronic bronchopulmonary disease (chronic emphysema, emphysema with bronchitis, chronic asthmatic bronchitis, tuberculosis, bronchiectasis and primary amyloidosis of the lung) The mucolytic action of acetylcysteine is related to the sulfhydryl group in the molecule This group probably “opens” disulfide linkages in mucus thereby lowering the viscosity.

Treatment for severe mucous plugging involves the use of acetylcysteine (INH) as an adjuvant therapy to help loosen and clear abnormal mucous secretions. The medication works by breaking down disulfide linkages in mucus, thereby reducing its viscosity and making it easier to expel.

• Key points: + Acetylcysteine is indicated for patients with abnormal, viscid, or inspissated mucous secretions. + The medication's mucolytic action is related to its sulfhydryl group. + Significant mucolysis occurs between pH 7 and 9. 3, 4

From the Research

Treatment Options for Severe Mucous Plugging

• Chest physiotherapy, including bedside chest percussion, has been shown to be effective in resolving acute mucus plugging in urgent situations 5.
• Mucus clearance strategies, such as airway clearance therapies, have been used to ameliorate disease progression in patients with cystic fibrosis and non-cystic fibrosis bronchiectasis, and may also be beneficial for patients with respiratory failure requiring mechanical ventilation 6.
• Mucoactive agents, such as dornase alfa, N-acetylcysteine, and ambroxol, have been used to enhance airway clearance, but their efficacy and safety in adults with acute respiratory conditions are unclear 7.
• Inhibition of the IL-1 signaling pathway has been suggested as a promising anti-inflammatory strategy in patients with cystic fibrosis and potentially other muco-obstructive lung diseases 8.

Considerations for Treatment

• The role and efficacy of conventional measures, such as mechanical percussive therapies, are uncertain 5.
• The use of adjunctive mucoactive agents and other therapies to facilitate secretion clearance in mechanically ventilated patients is not well defined 6.
• More data are required to support the use of mucoactive agents, such as N-acetylcysteine, ambroxol, and heparin, during acute illness 7.

Patient-Specific Factors

• High-risk patients, such as those undergoing fluid removal with dialysis therapies, require careful attention to respiratory status 5.
• Patients with moderate to severe asthma and mucus plugging may have worse airflow obstruction and greater type 2 inflammation, and may require more frequent exacerbations 9.