How to administer Mesna (sodium 2-mercaptoethanesulfonate) for tracheostomy suctioning?

Mesna Administration for Tracheostomy Suctioning

Critical Clarification: Mesna is NOT Indicated for Routine Tracheostomy Suctioning

Mesna (sodium 2-mercaptoethanesulfonate) is not approved or recommended for routine tracheostomy suctioning. The FDA-approved indications for mesna are exclusively for preventing hemorrhagic cystitis in patients receiving ifosfamide or cyclophosphamide chemotherapy 1.

Evidence Review

FDA-Approved Uses Only

• Mesna is FDA-approved solely as a uroprotective agent administered intravenously or orally to prevent bladder toxicity from chemotherapy agents 1
• The standard dosing involves IV bolus at 20% of ifosfamide dose, followed by additional doses at specific intervals 1
• No FDA approval exists for airway or tracheostomy applications 1

Historical Mucolytic Research (Not Current Practice)

• One 1981 study examined mesna as a mucolytic agent via bronchial lavage (5-10% solution), instillation (15-20 mL of 5-10% solution), or continuous nebulization in 80 intensive care patients 2
• This research predates modern evidence-based airway management guidelines and has not been validated in contemporary practice 2
• Current guidelines explicitly recommend against administering non-approved medications via tracheostomy due to unknown distribution, absorption, toxicity, and efficacy 3

Guideline Recommendations Against Off-Label Airway Use

• The American Thoracic Society consensus statement clearly advises avoiding administration of medications not approved for aerosol use through tracheostomy unless appropriate studies are performed 3
• Drugs that are safely nebulized in mouth-breathing patients may achieve toxic concentrations when administered via tracheostomy due to complete respiratory tract absorption without first-pass metabolism 3
• Instillation of saline before suctioning is avoided given increased risk of coughing and aerosolization with little evidence of benefit 3

Recommended Approach for Tracheostomy Suctioning

Proper Suctioning Technique

• Use closed-circuit suctioning systems with inline suction catheters for both mechanically ventilated and non-ventilated patients to decrease aerosolization 3
• Pass a soft suction catheter beyond the tracheostomy tube tip to establish airway patency and perform therapeutic suction 3
• Apply appropriate negative pressure (100-200 cmH₂O) during suctioning 3

Managing Thick Secretions

• Maintain adequate hydration (1-2 liters of fluid daily) to thin secretions naturally 1
• Perform frequent suctioning to prevent mucus buildup and airway obstruction 3
• For mechanically ventilated patients with thick secretions requiring inhaled medications, use vibrating mesh nebulizers that maintain closed-circuit systems 3
• For non-ventilated patients, use a spacer for metered-dose inhaled medications via tracheostomy 3

Safety Considerations

• Avoid jet nebulizers as they can aerosolize particles up to 80 cm 3
• Use appropriate PPE during all suctioning procedures 3
• If thick secretions cause recurrent inline circuit occlusion, place patients in negative pressure rooms or rooms with HEPA filters 3

Common Pitfalls

• Do not instill any medications into the tracheostomy for suctioning purposes unless they are FDA-approved for this specific indication 3
• Avoid using stiff introducers or bougies during suctioning as they may create false passages 3
• Do not attempt vigorous hand ventilation through a potentially displaced tracheostomy tube, as this can cause surgical emphysema 3