What can be done to help remove secretions in a partial quadriplegic patient with excessive secretions and facial fractures?

Secretion Management in a Partial Quadriplegic Patient with Facial Fractures

In a partial quadriplegic patient with excessive secretions and facial fractures, oropharyngeal suctioning under direct vision using a laryngoscope should be performed every 2-4 hours, combined with active physiotherapy, mechanically-assisted insufflation/exsufflation devices (Cough-Assist), and nebulized acetylcysteine to thin secretions. 1, 2

Immediate Secretion Removal Techniques

Direct Suctioning Approach

• Remove oropharyngeal secretions using a suction device under direct vision with a laryngoscope to avoid soft tissue trauma, particularly critical given the facial fractures 1
• Perform suctioning every 2-4 hours as a minimum frequency, though some patients may require more frequent intervention 3
• Use sterile technique during open suctioning procedures 2
• Limit suction application to maximum 15 seconds per suctioning procedure to prevent hypoxemia 2
• Keep suction pressure below -200 mm Hg in adult patients 2

Critical Considerations for Facial Fractures

• Special vigilance is necessary with blood in the airway due to risk of the "coroner's clot" where aspiration of blood can lead to fatal airway obstruction 1
• Laryngoscopy should be performed with adequate depth if the patient is sedated, and may need to be repeated 1
• Suction of the lower airway using endobronchial catheters may also be necessary 1

Pharmacological Secretion Management

Mucolytic Therapy

• Nebulized acetylcysteine (10-20% solution) should be administered to thin viscid secretions 4
• Dosing: 3-5 mL of 20% solution or 6-10 mL of 10% solution, 3-4 times daily via nebulization 4
• For direct instillation into tracheostomy (if present): 1-2 mL of 10-20% solution every 1-4 hours 4
• Acetylcysteine is specifically indicated for abnormal, viscid, or inspissated mucous secretions and post-traumatic chest conditions 4

Bronchodilator Therapy

• Aerosol therapy combining beta-2 mimetics and anticholinergics should be used as part of a comprehensive secretion management bundle 1

Mechanical Secretion Clearance

Assisted Cough Techniques

• Active physiotherapy combined with mechanically-assisted insufflation/exsufflation devices (Cough-Assist type) are essential for patients with impaired cough due to quadriplegia 1
• These devices simulate a cough by providing positive pressure followed by rapid negative pressure to mobilize secretions 5
• This approach is particularly important in quadriplegic patients who lack the respiratory muscle strength for effective spontaneous cough 1

Positioning and Support

• An abdominal contention belt should be worn during periods of spontaneous breathing to increase inspiratory capacity and improve secretion clearance 1
• Position the patient appropriately to facilitate drainage, though lying down may be better tolerated than sitting in tetraplegic patients due to effects of gravity on abdominal contents 1

Humidification Strategy

• Heated humidification is superior to heat and moisture exchangers in patients with thick, copious secretions 5
• Adequate humidification is the foundation of secretion management and helps maintain mucociliary function 5
• Continue humidified oxygen delivery to prevent secretion inspissation 5

Monitoring and Frequency

Assessment Indicators

• Breath sounds, visual secretions in the artificial airway (if intubated), and increased airway resistance are key indicators for suctioning 2
• Perform as-needed suctioning rather than rigid scheduled intervals, though minimum every 4 hours for oropharyngeal suctioning is recommended 3
• Patients with higher secretion volumes (>11 mL at 2-hour intervals) require more frequent suctioning 3

Common Pitfalls to Avoid

• Never instill normal saline before suctioning as this practice is not supported by evidence and may worsen outcomes 2, 5
• Avoid blind suctioning in patients with facial fractures due to risk of further trauma 1
• Do not rely solely on scheduled suctioning; assess clinical indicators continuously 2
• Ensure adequate humidification before resorting to aggressive mechanical techniques 5
• Three suctioning passes are typically needed to adequately clear secretions, with mean time of approximately 48 seconds 3

Advanced Considerations

If Secretion Retention Persists

• Consider insufflation-exsufflation for impaired cough mechanism 5
• Intrapulmonary percussive ventilation may be considered, though evidence is limited 5
• Early tracheostomy (within 7 days) may be indicated for upper cervical injuries (C2-C5) to facilitate secretion management and ventilatory weaning 1

Airway Protection

• Given the combination of quadriplegia (impaired cough) and facial fractures (risk of blood/secretions), maintain high vigilance for aspiration risk 1
• Keep the patient NPO if laryngeal competence is impaired 1
• Consider laryngeal mask exchange (Bailey manoeuvre) if intubated and protection from blood/secretions in the mouth is needed 1